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Discharge summary
|
report
|
Admission Date: [**2119-6-19**] Discharge Date: [**2119-6-24**]
Date of Birth: [**2082-5-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
Coronary artery disease s/p CABG x urgent CABG x4 with IABP
preop (LIMA>LAD, SVG>Ramus, SVG>OM, SVG>PDA) [**6-20**]
History of Present Illness:
37 year old male with history of exertional chest pain over last
2-3 months. He has since stopped exercise as it consistantly
causes pain.
Admitted for cardiac cath which revealed 3 vessel disease. He
continued to have angina during catheterization, cardiac surgery
was consulted, an IABP was placed and he was brought to the
operating room emergently
Past Medical History:
HTN
Dyslipidemia
thumb surgery
Social History:
works as graphic designer
Lives with wife and 4 children
Tobacco-remote-quit 2 years ago
ETOH- occaisional
no recent recreational drug use, frequent in his 20's
Family History:
strong history of early CAD
Physical Exam:
v/s: 118/63 - 80 - 16
Gen: well developed, well nourished and well groomed.
Neuro: oriented to person, place and time. The patient's mood
and affect were appropriate. ,
Skin: warm and dry. no stasis dermatitis, ulcers, scars, or
xanthomas.
HEENT: no xanthalesma. conjunctiva were pink. no pallor
or cyanosis of the oral mucosa. neck was supple with JVP of
6 cm. There was no thyromegaly.
Chest: no chest wall deformities, scoliosis or kyphosis.
respirations unlabored and there were no use of accessory
muscles. The lungs were clear to ascultation bilaterally with
normal breath sounds and no adventitial sounds or rubs.
CV: Palpation of the heart revealed the PMI to be located in the
5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart sounds revealed a normal
S1 and the S2 was normal. There were no rubs, murmurs, clicks or
gallops.
ABDM: no hepatosplenomegaly or tenderness. The abdomen was
soft nontender and nondistended.
Ext: no pallor, cyanosis, clubbing or edema. There were no
femoral or carotid
bruits. Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2119-6-19**] 07:05PM PTT-42.6*
[**2119-6-19**] 07:05PM CK-MB-NotDone cTropnT-0.08*
[**2119-6-19**] 07:05PM CK(CPK)-46
[**2119-6-21**] 02:41AM BLOOD WBC-12.9* RBC-3.62* Hgb-11.5* Hct-31.9*
MCV-88 MCH-31.8 MCHC-36.1* RDW-13.5 Plt Ct-210
[**2119-6-21**] 02:41AM BLOOD Plt Ct-210
[**2119-6-20**] 03:21PM BLOOD PT-14.0* PTT-33.4 INR(PT)-1.2*
[**2119-6-21**] 02:41AM BLOOD Glucose-116* UreaN-12 Creat-1.0 Na-139
K-4.7 Cl-107 HCO3-25 AnGap-12
[**2119-6-20**] 09:15AM BLOOD ALT-22 AST-19 CK(CPK)-39 AlkPhos-36*
Amylase-30 TotBili-1.1
[**2119-6-20**] 09:15AM BLOOD Albumin-4.0
[**2119-6-20**] 09:15AM BLOOD %HbA1c-5.5
=================================
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83325**] M 37 [**2082-5-23**]
Cardiology Report C.CATH Study Date of [**2119-6-20**]
BRIEF HISTORY: This 37 year old man with hypertension,
hyperlipidemia
and strong family history of CAD presents to the lab with
cresendo chest
pain / NSTEMI and ETT at OSH revealing for inferior ST
depressions.
INDICATIONS FOR CATHETERIZATION: NSTEMI.
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French angled pigtail catheter,
advanced
to the left ventricle through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Intra-aortic balloon counterpulsation: was initiated with an
introducer
sheath using a Cardiac Assist 9 French 30cc wire guided
catheter,
inserted via the right femoral artery.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: m2
HEMOGLOBIN: gms %
REST
**PRESSURES
LEFT VENTRICLE {s/ed} 126/25
AORTA {s/d/m} 125/82/102
**CARDIAC OUTPUT
HEART RATE {beats/min} 87
RHYTHM SINUS
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
LEFT VENTRICULOGRAPHY:
Volumetric data:
LV ejection fraction (nl 50%-80%). 60
Qualitative wall motion:
[**Doctor Last Name **]:
1. Antero basal - normal
2. Antero lateral - hypokinetic
3. Apical - normal
4. Inferior - normal
5. Postero basal - normal
Other findings:
Mitral valve was normal.
Aortic valve was normal.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 100
2) MID RCA DIFFUSELY DISEASED
2A) ACUTE MARGINAL DIFFUSELY DISEASED
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD DISCRETE 90
8) DISTAL LAD NORMAL
9) DIAGONAL-1 DISCRETE 80
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 DISCRETE 99
15) OBTUSE MARGINAL-2 NORMAL
16) OBTUSE MARGINAL-3 NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 0 hour47 minutes.
Arterial time = 0 hour44 minutes.
Fluoro time = 6.2 minutes.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 30 ml,
Indications - Renal
Premedications:
Midazolam 1 mg IV
Fentanyl 25 mcg IV
ASA 325 mg P.O.
Clopidogrel 600
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 5000 units IV
Other medication:
Metoprolol 5 mg IV
Nitroglycerin 20 mcg per min IV gtt
Cardiac Cath Supplies Used:
8FR ARROW, IABP ULTRA FIBEROPTIX CATHETER 40CC
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
5.0MM [**Company **], MULTIPACK
COMMENTS:
1. Selective coronary angiography in this right dominanat system
revealed severe three vessel coronary disease. The LMCA was free
of
angiographically apparent disease. The mid LAD had a 90%
stenosis and
a high diagonal, a 80% stenosis in its lower pole. A large OM
was
sutoally occluded. The RCA had a proximal total occlusion with
left to
right collaterals.
2. Resting hemodynamics revealed normal systemic arterial blood
pressure. There was elevated left sided filling pressures with
LVEDP of
25 mmHg.
3. There was no evidence of aortic stenosis upon pullback from
LV to
ascending aorta.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Mild left ventricular diastolic dysfunction.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 1955**] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) 2878**] I.
[**Last Name (LF) **],[**First Name3 (LF) **] S.
ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] E.
===========================================
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 83326**]
(Complete) Done [**2119-6-20**] at 10:55:42 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2082-5-23**]
Age (years): 37 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for emergent CABG.
ICD-9 Codes: 413.9, 410.91, 424.0
Test Information
Date/Time: [**2119-6-20**] at 10:55 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Ascending: 2.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. Mild
(1+) MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Emergency study. Results were personally
Conclusions
PRE-BYPASS: 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%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
Mild mitral regurgitation is seen. There is no pericardial
effusion. The IABP appears to be in good position approximately
3cm distal to the takeoff of the left subclavian artery.
Post-Bypass:
There is preserved biventricular systolic function. The study is
otherwise unchanged from prebypass.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2119-6-21**] 07:51
====================================
[**Known lastname **],[**Known firstname **] [**Medical Record Number 83325**] M 37 [**2082-5-23**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2119-6-21**] 9:18
AM
[**Hospital 93**] MEDICAL CONDITION:
37 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
s/p ct removal ? ptx
Final Report
INDICATION: 37-year-old male status post CABG and chest tube
removal.
Evaluate for pneumothorax.
COMPARISON: [**2119-6-20**].
SINGLE UPRIGHT AP VIEW OF THE CHEST: There is no pneumothorax,
overt
pulmonary edema or mediastinal widening. There is minimal
bibasilar
atelectasis as expected post- CABG. Unchanged median sternotomy
wires appear intact. The only remaining cardiopulmonary support
device is right IJ with the distal tip projecting over the mid
SVC.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2119-6-21**] 9:48 PM
======================================
Brief Hospital Course:
Mr [**Known lastname 41698**] was admitted to [**Hospital1 18**] on [**6-19**] for cardiac
catheterization after positive ETT. The cardiac catheterization
revealed severe 3 vessel disease with mild diastolic dysfunction
of the left ventricle. He had continuing angina during the
catheterization, cardiac surgery was consulted, an IABP was
placed and he was brought emergently to the operating room for
coronary bypass grafting. Please see OR report for details, in
summary he had coronary bypass graft times 4 with left internal
mammary artery to left anterior descending artery, saphenous
vein graft to Ramus artery, saphenous vein graft to obtuse
marginal, saphenous vein graft to posterior diagonal artery. His
bypass time was 94 minutes with a crossclamp of 74 minutes. He
tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
In the immediate post-op period he remained hemodynamically
stable, he woke and was extubated. By the morning of POD1 his
IABP was weaned and removed and he later that day was
transferred to the stepdown floor. He continued to do well
post-operatively, all tubes lines and drains were removed
according to cardiac surgery protocols. His activity was
advanced with the assistance of nursing and physical therapy, he
was agressively diuresed. Bactrim DS was started for slight
erythema at his mediastinal incision and improvement was seen by
the second day of treatment. On post-operative day four he was
discharged home with visiting nurses.
Medications on Admission:
No outpatient medications prior to admission
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days: for sternal incision erythema.
Disp:*14 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Coronary artery disease s/p CABG x urgent CABG x4 with IABP
preop (LIMA>LAD, SVG>Ramus, SVG>OM, SVG>PDA) [**6-20**]
Dyslipidemia
hypertension
Discharge Condition:
good
Discharge Instructions:
Keep wounds clean and dry.
Take all medications as prescribed
Call for any fever redness or drainage from wounds.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**Last Name (STitle) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] (cardiologist) in [**2-14**] weeks ([**Telephone/Fax (1) **])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2093**] (PCP) in [**1-13**] weeks ([**Telephone/Fax (1) 50208**])
Completed by:[**2119-6-24**]
|
[
"414.01",
"272.4",
"401.9",
"429.9",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.13",
"39.63",
"36.17",
"36.15",
"88.53",
"37.61",
"88.56",
"38.93",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
14422, 14478
|
11716, 13257
|
343, 461
|
14664, 14671
|
2356, 3380
|
14833, 15257
|
1090, 1119
|
13353, 14399
|
10815, 10845
|
14499, 14643
|
13283, 13330
|
6716, 10775
|
14695, 14810
|
1134, 2337
|
5349, 6699
|
3414, 5330
|
282, 305
|
10877, 11693
|
489, 842
|
864, 896
|
912, 1074
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,526
| 100,001
|
42102
|
Discharge summary
|
report
|
Admission Date: [**2117-9-11**] Discharge Date: [**2117-9-17**]
Date of Birth: [**2082-3-21**] Sex: F
Service: MEDICINE
Allergies:
Levaquin
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
35F w/ poorly controlled Type 1 diabetes mellitus w/ neuropathy,
nephropathy, HTN, gastroparesis, CKD and retinopathy, recently
hospitalized for orthostatic hypotension [**2-3**] autonomic
neuropathy [**Date range (1) 25088**]; DKA hospitalizations in [**6-12**] and [**7-12**], now
returning w/ 5d history of worsening nausea, vomiting with
coffee-ground emesis, chills, and dyspnea on exertion. Last
week she had a fall and hit her right face. she also had 1 day
of diarrhea, which resolved early last week. Found to be in DKA
with AG 30 and bicarb 11.
.
In the ED inital vitals were 09:00 0 98.2 113 181/99 22 100% RA.
K 4.7, HCO3 11, Anion Gap 30, Cr. 2.7 (baseline 1.6-2.0) She is
on her 3rd L NS. Insulin srip at 5 units/hr. On home at 22
levemir in am and 12 at with difficult to control sugars. BPs
have been high. Given 30 mtroprolol tartrate in ED.
She was started on an insulin drip at 5 units/hr and 3L NS
boluses. Also aspirin 325mg PO and Morphine 4mg IVx1 for pain.
CXr was clear. EKG NAD.
.
Review of systems: otherwise negative.
Past Medical History:
Type 1 diabetes mellitis w/ neuropathy, nephropathy, and
retinopathy - 2 episodes of DKA in [**6-12**] and [**7-12**]
HTN - 5 years
gastroparesis - 1.5 years
CKD - stage III, baseline Cr 2.4-2.5, proteinuria
L1 vertebral fracture - [**2117-7-17**]
Systolic ejection murmur
Social History:
Patient lives at home in [**Location (un) **] with her 8 y/o daughter and
boyfriend. She has no history of EtOH, tobacco, or illicit drug
use. She is currently unemployed and seeking disability.
Family History:
Both parents have HTN and T2DM. Grandfather had an MI in his
40s.
Physical Exam:
GEN: Awake, alert, and oriented
HEENT: PERRLA. MMM. no JVD. neck supple. No cervical LAD
Cards: RRR, S1/S2 normal. II/VI systolic ejection murmur heard
best at the L upper sternal border.
Pulm: CTABL with no crackles or wheezes.
Abd: BS+, soft, NT, no rebound/guarding, no HSM, no [**Doctor Last Name 515**]
sign
Extremities: wwp, no edema. radials, DPs, PTs 2+.
Skin: no rashes or bruising. no skin tenting.
Neuro: CNs II-XII intact. Upper extremities: Power [**5-6**]
bilaterally. Le: left power: 4.5/5 right: power [**3-6**]. Bilateral
symmetric, reduced sensation distal LE to ankles.
Pertinent Results:
Admission Labs: [**2117-9-11**] 09:22AM
WBC-11.9* RBC-4.58 HGB-13.0 HCT-36.5 MCV-80* PLT COUNT-466*
LIPASE-22 ALT(SGPT)-10 AST(SGOT)-16 ALK PHOS-105 TOT BILI-0.5
GLUCOSE-260* UREA N-48* CREAT-2.7* SODIUM-137 POTASSIUM-4.9
CL-101 CO2-11*
LACTATE-1.9
Discharge Labs: [**2117-9-16**] 07:10AM
WBC-6.8 RBC-3.67* Hgb-10.4* Hct-30.2* MCV-82 Plt Ct-298
Glucose-118* UreaN-20 Creat-2.3* Na-137 K-3.7 Cl-104 HCO3-23
AnGap-14
Calcium-8.7 Phos-3.5 Mg-2.0
Radiology:
CXR: No evidence of pneumonia or other pathological
abnormalities. No
pleural effusions. No pulmonary edema. Normal size of the
cardiac
silhouette.
Microbiology: Urine culture negative, blood cultures no growth
to date, stool for C.difficile negative
Brief Hospital Course:
35 yo F with HTN & poorly controlled type I DM, c/b neuropathy,
gastroparesis, nephropathy ?????? CKD, retinopathy presents with DKA
and hypertension SBP to 200s.
.
# Diabetic ketoacidosis: Patient controls diabetes at home with
Humalog SS and long acting Levemir. Sugars at home recently
have been in 250s. In the ED, glucose was 466. UA was +ve for
ketones ?????? corrected to 200s, but rose again to 300s. She was
treated with an insulin drip which was transitioned to subq when
she tolerated POs. Her electrolytes were repleted and she
received aggressive volume resuscitation. [**Last Name (un) **] saw her and
gave sliding scale recommendations which were implemented. No
source for DKA found, beleived to be [**2-3**] gastroparesis. Nausea
managed with ativan, compazine, and promethazine. She was
discharged on her home Insulin and sliding scale with
instructions to follow-up with [**Last Name (un) **].
# HTN: Hypertensive with SBP in 190s initially, attributed to
DKA, as she has experienced in the past. As she improved her
blood pressures normalized and she was re-started on her home
Lopressor and Midodrine regimen.
# Coffee grounds emesis: Emesis started off as clear, then with
prolonged wretching, she started having coffee-grounds vomiting.
This had also occurred on prior admissions for DKA with
associated vomiting. Her hematocrit remained stable and her
hematemesis self-resolved, and so work-up was deferred to the
outpatient setting.
# Acute on chronic kidney disease, Stage III: Patient's Cr on
admission was 2.7, trending down to 2.1-2.3 following fluids,
consistent with her known CKD secondary to diabetic nephropathy.
Medications on Admission:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levemir 100 unit/mL Solution Sig: Twenty Two (22) units
Subcutaneous every AM.
3. Levemir 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
4. Humalog 100 unit/mL Solution Sig: sliding scale as directed
Subcutaneous four times a day: Please use sliding scale as
directed by MD [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) **].
5. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily): take in the evening.
6. promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) as needed for nausea.
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
Disp:*60 Capsule(s)* Refills:*2*
8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily): Please take
only 1 capsule daily (30 mg) for first 2 weeks of treatment.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain.
10. midodrine 5 mg Tablet Sig: 1.5 Tablets PO every four (4)
hours: Can hold while sleeping.
Disp:*270 Tablet(s)* Refills:*2*
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
Once Daily at 6 PM.
5. midodrine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Levemir 100 unit/mL Solution Sig: As directed by [**Last Name (un) **] units
Subcutaneous As directed.
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic keotacidosis
Hematemesis (blood in your vomit)
Hypertension
Chronic renal insufficiency
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 DKA, hypertension, and
blood in your vomit. You were initially treated in the ICU with
an insulin drip, and your blood sugars improved. Your blood
pressure medications were adjusted to better control your blood
pressure while you were in DKA, but you were re-started on your
home regimen at discharge. The blood in your vomit was likely
secondary to mechanical trauma from repeated wretching, but you
should follow-up with your primary care doctor to discuss
whether you should undergo further evaluation such as an upper
endoscopy. Given your complaints of chronic cough and heartburn,
you should also discuss beginning a trial of a proton pump
inhibitor such as Nexium or Prilosec to see if this helps your
symptoms.
Your insulin regimen was adjusted by the [**Last Name (un) **] team while you
were here. You should continue to follow-up with them with any
questions or concerns regarding your insulin management.
Followup Instructions:
Please call Dr.[**Last Name (STitle) 805**]' office to schedule a follow-up
appointment within 7-10 days of discharge. Her office number is
[**Telephone/Fax (1) 85219**].
You should also continue to follow-up with your [**Last Name (un) **] doctors
as needed.
|
[
"536.3",
"V58.67",
"584.9",
"403.90",
"250.63",
"585.3",
"707.8",
"250.53",
"337.1",
"578.0",
"458.0",
"250.83",
"362.01",
"V13.51",
"250.43",
"250.13"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6745, 6751
|
3326, 4979
|
287, 293
|
6891, 6891
|
2592, 2592
|
8022, 8285
|
1898, 1965
|
6211, 6722
|
6772, 6870
|
5005, 6188
|
7041, 7999
|
2859, 3303
|
1980, 2573
|
1352, 1373
|
230, 249
|
321, 1333
|
2608, 2843
|
6906, 7017
|
1395, 1669
|
1685, 1882
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,086
| 126,710
|
53358
|
Discharge summary
|
report
|
Admission Date: [**2185-5-28**] Discharge Date: [**2185-6-8**]
Service: MEDICINE
Allergies:
Penicillins / Metoprolol
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
Left hip replacement
Picc line
Intubation
Trans esophageal echocardiogram
History of Present Illness:
HPI: 88 yoM w/ Parkinson's disease, history of AF (on coumadin),
h/o CHF (EF 35-40%) presents with hypotension in the setting of
bleeding s/p fall. Patient was in USOH when he got up from a
chair to walk into the next room, felt a little lightheaded, and
fell on his left side, striking his left elbow and left hip. No
head trauma, LOC, or assoacited chest pain, palpitations, N/V,
loss of bowel/bladder control. The fall was unwitnessed, but
within several minutes, his family called EMS and he was
transported to [**Hospital 882**] hospital. There, a Head CT was (-) for
bleed, and he was noted to have a left femoral neck fracture and
a left elbow skin tear/abrasion. He was transferred to [**Hospital1 18**] for
further management. There, elbow plain films were without
fracture or dislocation. He was seen by orthopedics, who plan
surgery to repair the left hip on Tuesday. He was noted to be
bleeding copiously from left elbow abrasion, requiring ~12
dressing changes. He became progressively hypotensive to sbp
60s, and his HCT was noted to be 23 from 26.6 (baseline 32-35).
He received 1L NS and 2u PRBC with good response. His INR was
2.8. Currently, the patient reports left elbow and left hip
pain. He denies chest pain, shortness of breath,
lightheadedness, numbness/tingling. Reports baseline left facial
droop. Reports baseline episodes of intermittent
lightheadedness/vertigo, which have been attributed to PD/PD
meds.
Past Medical History:
PMHx:
1) Parkinson's disease
2) BPH
3) Large left hernia
4) s/p appy
5) s/p hernia repair 20 yrs ago
6) AF: dx [**1-1**]
- Holter [**1-1**] AF 80-100
7) h/o CHF: TTE [**1-1**] EF 35-40%, [**11-28**]+ AR, [**11-28**]+ MR, 3+ TR, global
hypoK w/ distal lateral and inferolateral hypokinesis and apical
akinesis.
8) Fe def anemia
9) Hypothyroidism
10) CRI: baseline Cr 1.5-1.7
Social History:
Pt lives at home with his wife and daughter. [**Name (NI) **] is retired. No
ETOH, tobaccol, or drugs. Did occasionally smoke a pipe but quit
greater than 20 years ago.
Family History:
[**Name (NI) 1094**] father had DM. Unclear what medical problems his mother
had. She was over 90 at her death and died of "old age".
Physical Exam:
PE:
T: 98.4, P: 88, BP: 101/50, R: 20, 97% 2L NC
GEN: elderly, chronically-ill appearing male, alert x 2
HEENT: anicteric, normal conjunctivea, pupils equal and
minimally reactive to light bilaterally, EOMI, OMM dry, OP
clear, neck supple, no JVD, masked facies, mild faical droop
Cardiac: irregulary irregular rhythm, II/VI SEM at apex, II/VI
DM at RLSB
PUlm: min crackles at bases b/l
ABD: NABS, soft, NT/ND, left sided hernia, no HSM
Ext: LLE shortened and externally rotated, left elbow with 5cm
skin tear and associated abrasion, actively dripping blood. 2+
radial pulses bilaterally, trace DP left, 1+ DP right, LLE
slightly cooler than RLE, sensation intact to light touch and
able to wiggle digits distally in upper and lower extremities
bilaterally. No significant hematoma noted at left hip. 1+ LE
edema 1/3 up calves bilaterally.
Pertinent Results:
EKG: AF @ 94 bpm, RBBB, TWF II, III, avF, no sig change [**2185-1-13**]
.
CXR: Mild RLL atelectasis, stable minimal right diaphragmatic
elevation. No acute cardiopulmonary process.
.
L elbow plain films: No fracture, normal alignment, soft tissue
disruption over ulner with densities (likely FB present); obtain
true lateral view to r/o effusion
U/S of left fem region: no hematoma
UA: neg
[**2185-5-28**] 04:00AM PT-20.7* PTT-27.7 INR(PT)-2.8->1.9->2.1
[**2185-5-28**] 04:00AM WBC-10.7 HCT-26.6->23->24.5-> 25.4
[**2185-5-28**] 04:00AM cTropnT-0.03->.01
[**2185-5-28**] 04:00AM CK(CPK)-94->126
[**2185-5-28**] 04:00AM GLUCOSE-116* BUN-58* CR-1.9* NA-138 K-4.8
CL-104 CO2-24
[**2185-5-28**] 09:41PM CK-MB-6
Brief Hospital Course:
A: 88 yoM w/ h/o PD, AF on coumadin presents s/p fall with left
femoral fracture and hypotension.
1) Hypotension: [**12-29**] dehydration and blood loss from large left
elbow skin tear in setting of elevated INR. Patients blood
pressure was managed with fluids and blood transfusions. Was
stable and did not need pressors. Other than admission he did
not have any further problems with hypotension.
.
2) Bacteremia: [**12-29**] left forearm tear: grew MRSA from swab of
left elbow. Patient spiked temp on [**6-1**], ID w/u was done but
vancomycin was not started until [**6-3**] once blood cultures
revealed GPC's. He was being covered in the interim for skin
flora with clindamycin as per recommendations of Ortho. He was
started on vancomycin empirically on [**2185-6-3**] and cultures 2 days
later grew MRSA bacteremia. 3/4 bottles on [**7-18**] on [**6-3**] all
other bottles NGTD. ID came to see patient and recommended 6
weeks of antibiotics. Left hip was not imaged due to metal
prosthesis. CT would show artifact and MRI CI with metal in hip.
Bone scan and White cell scan would give false positive given
recent surgery. Dr. [**First Name (STitle) 1022**] from ortho had recommended tap of joint
for fluid collection, gram stain and culture but given risks of
procedure (CT guided tap of left hip) and risk of infection with
procedure, the teams (ID, Ortho, Medicine team) in agreement
with the family, decided that the best course of action was to
treat with Vancomycin for 6 weeks with therapeutic trough levels
above 15. Follow up with Dr. [**First Name (STitle) 1022**] and ID as outpatient and follow
ESR for infection. TEE was done and was negative for
endocarditis. Left elbow was imaged with films and was negative
for [**Last Name (un) 2043**] destruction/erosion. Patient had been afebrile since
spike on [**6-1**], white count since then was within normal range.
Left elbow: improved throughout hospital course. Pitting edema,
redness and tenderness improved throughout hospital stay. Good
granulation tissue in the wound, no pus or foul smelling odor.
3)Respiratory failure: [**12-29**] anesthetics from surgery, patient
intubated for airway protection, admitted to MICU for [**12-30**] day
and extubated successfully on day 2 of admission.
4) Anemia: blood loss superimposed on h/o Fe def anemia
Patient received 4u PRBC (last transfusion [**5-27**]), his
anticoagulation was reversed with FFP ad vitamin K. His
hematocrit has been stable since. The source of the bleed was
from the large skin tear on the left forearm/elbow area.
.
5) UTI: when patient spiked a fever on [**2185-6-1**], w/u of fever
revealed UTI with pansensitive proteus mirabilus. He was treated
with Bactrim DS [**Hospital1 **] for 7 days, remainder of days to be
continued at rehab.
6) Left femoral neck fracture: Seen by ortho in the ED who
recommended surgery for hip fracture. [**2185-5-31**] had
hemiarthroplasty, Surgery was uncomplicated. Placed metal
prosthesis in the left hip. Patient being seen by PT while
hospitalized.
.
7) Fall: Given lightheadedness prior to fall, the ddx includes
PD sx/PD meds (which patient attributes prior episodes of LH),
orthostais, vasovagal, myocardial ischemia, volume depletion
(given home lasix, spironolactone). No new neurological deficit
to suggest stroke. Patient ruled out for MI, ECG without any
acute changes, unclear whether this was purely a mechanical
fall. Telemetry without any other arrythmia other than atrial
fibrillation. PT saw patient post op and recommended further
rehab. No further c/o lightheadedness.
.
8) h/o CHF: Although no known h/o CAD, findings on TTE
concerning for prior ischemia. Patient was euvolemic here w/o
c/o shortness of breath on exam. c/w with all his cardiac meds
with the exception of his lasix an spironolactone which will
need to be added back on as an outpatient.
.
9) AF: stable, rate controlled. INR reversed given bleed,
hematocrits stable and started on lovenox post op. Starting
coumadin at rehab for goal INR [**12-30**].
.
10) ARF on CRF: Cr 1.9 from baseline 1.5-1.7. Pre renal in
nature since it corrected afterward with fluid hydration. Stable
at 1.7. Meds were renally dosed and factor 10a was checked to
asses that lovenox levels were within normal therapeutic range.
.
11) Parkinson's disease: Continue home meds, stable.
.
12) F/E/N: low fat, low salt diet
- monitor electrolytes and replete as needed
[**Name (NI) 109766**] Pt seems to be eating. Getting puree diet. Pt was
NPO yesterday possibly NPO today as well for aspiration of
joint.
-pt on high calorie (BOOST), low salt, fluid restricted (1.5L)
diet
-pt tolerating full diet no signs of aspiration
.
13) Ppx: pneumoboots, lovenox, protonix
.
14) Dispo: MICU
.
15) Code: confirmed with patient and family
.
16) Comm: patient, wife [**Name (NI) 8817**] [**Name (NI) **] [**Telephone/Fax (1) 109767**]
17) Pain control- pain well controlled right now. On PRN
tyleonol
Medications on Admission:
carbidopa/levodopa 25/100 1.5 tabs TID
Entacapone 200mg TID
Mirapex 1.5mg, 2.5 tab [**Hospital1 **]
Proscar 5mg po qam
hytrin 5mg po qpm
levothyroxine 12.5mg po qam
alphagen 0.15% to OS [**Hospital1 **]
Centrum
coumadin 2.5mg T/W/Th, 3mg M/F
Spironolactone 12.5mg po q am
lasix 60mg po qd
asa 81mg q d
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
8AM, 2PM, 8PM ().
2. Entacapone 200 mg Tablet Sig: One (1) Tablet PO 8am, 2pm, 8pm
().
3. Mirapex 1.5 mg Tablet Sig: Two (2) Tablet PO 8am, 2pm, 8pm
(): total 3.75mg at 8am, 2pm, 8pm.
4. Mirapex 0.25 mg Tablet Sig: Three (3) Tablet PO at 8am, 2pm,
8pm: total 3.75mg at 8am, 2pm, 8pm.
5. Proscar 5 mg Tablet Sig: One (1) Tablet PO qAM.
6. Hytrin 5 mg Capsule Sig: One (1) Capsule PO qPM.
7. Levothyroxine Sodium 25 mcg Tablet Sig: 0.5 Tablet PO QAM
(once a day (in the morning)).
8. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. Centrum Silver Tablet Sig: One (1) Tablet PO once a day.
10. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO at
bedtime: Prior to admission was on 2.5mg T/W/TH, 3mg M/F. Load
then change back to old regimen.
11. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 6 weeks: start [**2185-6-7**].
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Primary
1. Left femoral hip fracture s/p left hip prosthesis
2. Large skin tear on the left forearm
3. Respiratory failure
4. acute blood loss anemia
5. coagulopathy
6. MRSA bacteremia
7. Acute Renal Failure
8. Hypotension
9. Malnutrition
10. Pansensitive Proteus UTI
Secondary
1. Congestive Heart Failure
2. Chronic Renal Insufficiency
3. Parkinsons Disease
4. Benign Prostatic Hypertrophy
5. Atrial Fibrillation
6. Hypothyroidism
7. Iron deficiency anemia
Discharge Condition:
stable, afebrile
Discharge Instructions:
Please take all your medication as prescribed and follow up with
all your recommended appointments.
Please call your primary care physician or seek medical
attention if you develop: fevers, chills, nausea/vomiting,
swelling in the left hip area with redness and pain with
palpation, swelling in the left elbow with redness and pain,
lower extremity edema that does not resolve, shortness of
breath, chest pain, no urine output or other concerning
symptoms.
Followup Instructions:
1. Please follow up with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 2204**] in [**12-30**] weeks. Please call his office to set up an
appointment [**Telephone/Fax (1) 2936**].
2. Please follow up with Dr. [**First Name (STitle) **] in Infectious Disease
Clinic, here are the details of the appointment:
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Where: LM [**Hospital Unit Name 4341**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2185-7-6**] 11:30
3. Please follow up with Dr. [**First Name (STitle) 1022**] in 2 weeks. Please call his
office to schedule an appointment. ([**Telephone/Fax (1) 46169**]
These are other appointments that appear in your records:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2185-8-5**] 12:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2185-11-4**] 4:00
|
[
"518.5",
"585",
"V09.0",
"286.9",
"285.1",
"263.9",
"244.9",
"786.1",
"584.9",
"280.9",
"599.0",
"E888.9",
"276.5",
"913.0",
"790.7",
"276.2",
"332.0",
"820.8",
"458.9",
"428.0",
"427.31",
"425.4",
"881.10",
"041.11",
"041.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"96.04",
"99.04",
"88.72",
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
11096, 11169
|
4143, 9075
|
242, 318
|
11671, 11689
|
3396, 4120
|
12196, 13385
|
2383, 2518
|
9427, 11073
|
11190, 11650
|
9101, 9404
|
11713, 12173
|
2533, 3376
|
191, 204
|
346, 1782
|
1804, 2180
|
2196, 2367
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,507
| 107,977
|
37858
|
Discharge summary
|
report
|
Admission Date: [**2158-11-28**] Discharge Date: [**2158-12-6**]
Date of Birth: [**2091-9-13**] Sex: M
Service: SURGERY
Allergies:
Equine Protein / Penicillins
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD, pre-emptive Living related kidney transplant
Major Surgical or Invasive Procedure:
[**2158-11-28**]: living related kidney transplant
History of Present Illness:
67M with longstanding diabetes maintained on oral agents for 17
years. Approximately one year ago, his creatinine was
increasing. In [**2158-4-14**], his creatinine went up fairly acutely
to 7.4. Since that time, he has had some
problems with edema, but this has been managed recently with
Lasix. He feels remarkably well for someone with advanced renal
disease. He has no pain and is
able to perform his daily activities without any problem. This
includes a fairly rigorous teaching schedule as well as other
activities. He now presents for kidney transplant.
Past Medical History:
HTN, [**Doctor Last Name **] [**Location (un) **] exposure in [**Country 3992**], anemia, diabetic
retinopathy, s/p lens procedure, granulomatous disease of the
bone marrow.
Social History:
He is a former hospital administrator. He was the former
president and CEO of [**Hospital 84680**] Hospital. He is married with
three children ages 38, 34 and 34.
Family History:
His father died of congestive heart failure at age 83. Mother
died of myocardial infarction at age 66. She also had diabetes.
Physical Exam:
On day of discharge:
Afebrile, vital signs stable and within normal limits.
Gen: alert and oriented, no obvious discomfort.
Pulm: CTA b/l
CVS: RRR
Abd: soft / min distended / non tender / bowel sounds present
Incision: minimal swelling with ecchymosis, minimal
serosanginous drainage
Pertinent Results:
[**2158-12-6**] 02:52PM BLOOD Hct-26.9*
[**2158-12-6**] 04:52AM BLOOD PT-17.3* PTT-26.5 INR(PT)-1.5*
[**2158-12-6**] 04:52AM BLOOD Glucose-61* UreaN-30* Creat-1.3* Na-139
K-5.0 Cl-113* HCO3-21* AnGap-10
[**12-5**] Renal transplant u/s: normal blood flow and normal
resistive indices, large fluid collection adjacent to the upper
pole of the transplant kidney measuring 13 x 6 x 9 cm, no mass
effect on kidney
Brief Hospital Course:
The patient was admitted to the PACU following his surgery. He
tolerated the procedure well. Following the procedure, he had a
PCA for pain control, foley in place, IVF at 50cc per hour plus
cc per cc replacement of urine output, MMF [**12-15**] started, bactrim,
valcyte, tacrolimus [**1-16**] started, lopressor, hydralazine given,
diet advanced to clear liquids.
[**11-29**]: vancomycin and levofloxacin x 1, diet advanced to a
regular diet, replacement fluid discontinued, ATG 100 mg given,
ASA 81 mg started, Tacro [**1-16**], steroid taper started
[**11-30**]: the patient reported chest pain, EKG performed
demonstrating atrial fibrillation, lopressor and nitroglycerin
given without relief, digoxin 0.25 mg IV x1 given, 2 units RBC
transfused, ATG 100 mg IV x 1, tacro [**3-18**], transferred to the ICU
for continued monitoring. Cardiology consult obtained
[**12-1**]: ATG 100 mg IV x1, ASA increased to 325 mg, continued
digoxin, tacrolimus [**3-18**]
[**12-2**]: coumadin 4 mg started, heparin drip started, tacro [**3-18**],
foley discontinued, PCA stopped, PO medication started,
transferred to the floor, amiodarone started
[**12-3**]: continued coumadin and heparin drip, continued regular
diet, amio continued, tacro [**3-18**]
[**12-4**]: transfused 2 units RBC, continued heparin drip and
coumadin, tacrolimus [**2-14**], continued valcyte
[**12-5**]: renal ultrasound performed which demonstrated a hematoma,
heparin drip stopped, continued coumadin 1 mg, tacro [**12-15**],
transfused one unit rbc
[**12-6**]: ambulating without assistance, cont coumadin, tacrolimus
[**12-15**], discharged to home
Medications on Admission:
amlodipine 10', lipitor 20', epo, vit D2, pepcid 20', lasix 40',
glipizide 5', hydralazine 100''', lopressor 100", renagel 1600",
januvia 25'. asa
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
6. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg daily x 1 week
200 mg daily x 1 month
[**Hospital 1326**] clinic will assist with transition off amiodarone.
Disp:*60 Tablet(s)* Refills:*2*
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
Disp:*2 bottles* Refills:*1*
11. Insulin Syringe Ultrafine [**12-16**] mL 29 x [**12-16**] Syringe Sig: One
(1) Miscellaneous once a day.
Disp:*1 box* Refills:*1*
12. Januvia 50 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*2*
13. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
14. Outpatient Lab Work
Trough Prograf level
PT/INR
Results to transplant coordinator (pager [**Numeric Identifier 28794**])
15. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
16. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
17. Insulin/finger sticks
Increase Lantus by 2 units every 3 days for fasting blood sugars
> 150.
Monitor finger stick blood sugars at least twice daily Fasting
and 4 PM. More often as necessary. Bring record to [**Hospital **] clinic
and transplant clinic appointments
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD now s/p living related kidney transplant
atrial fibrillation
Hyperglycemia post transplant
Discharge Condition:
Stable/Good
A+Ox3
Ambulatory
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, inability to
take or keep down food, fluids or medications
Monitor the incision for redness, drainage or bleeding
Labwork will be done every Monday and Thursday at the [**Hospital **]
Medical Building lab until further notice. Labs to be drawn are
CBC, Chem 7, Ca, Phos, AST, T Bili, UA and trough Prograf level,
PT/INR.
Bring Prograf with you and take once the blood is drawn.
No heavy lifting, nothing heavier than a gallon of milk
Increase your phosphorous intake with whole grains, skim milk,
nuts.
Drink enough fluids to keep urine light yellow. Several liters
of fluid daily are recommended.
No driving if taking narcotic pain medication
[**Month (only) 116**] not shower due to hemodialysis line being in place. [**Month (only) 116**] use
handheld shower below the waist. Do not spray directly on
incision.
Pat incision dry. You may leave the incision open to air or
cover for comfort with a dry gauze. Staples will be removed in
clinic.
Labs will be additionally drawn on Saturday [**12-9**] at 8AM in the
[**Hospital Ward Name 1826**] Lab ([**Hospital Ward Name 516**])
**** Please follow the amiodarone taper as prescribed:
400 mg daily x 1 week
200 mg daily x 1 month
[**Hospital 1326**] clinic will assist with transition off amiodarone due
to interaction with Prograf and Coumadin
INR per transplant clinic recommendations. [**Hospital 1326**] clinic
will prescribe coumadin dosing
Follow [**Last Name (un) **] recommendations for insulin regime/ oral
medication for blood sugar control and monitoring and recording
blood sugars
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-12-7**] 10:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2158-12-11**]
1:10
[**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2158-12-18**] 10:00
[**Last Name (un) **] Appointment: Dr [**Last Name (STitle) **] [**2157-12-18**] 2:00
|
[
"V87.2",
"275.3",
"733.99",
"427.31",
"414.01",
"997.1",
"599.70",
"362.01",
"V58.67",
"E878.0",
"403.91",
"585.6",
"250.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"00.91"
] |
icd9pcs
|
[
[
[]
]
] |
6023, 6029
|
2267, 3898
|
340, 393
|
6169, 6200
|
1833, 2244
|
7917, 8394
|
1384, 1513
|
4095, 6000
|
6050, 6148
|
3924, 4072
|
6224, 7894
|
1528, 1814
|
250, 302
|
421, 989
|
1011, 1186
|
1202, 1368
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,183
| 111,139
|
43719
|
Discharge summary
|
report
|
Admission Date: [**2166-3-27**] Discharge Date: [**2166-4-1**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Atrial fibrillation with RVR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an 86F with PMH HTN, hyperlipidemia,
hypothyroidism sent from PCP office for evaluation of afib with
RVR. The patient has complained of nonproductive cough and
fatigue x 1 week. No f/c, SOB. + sick contacts in [**Name2 (NI) **]. The
patient presented to her PCP office the day of admission for
these symptoms and was found to have new afib with RVR 130s and
was sent to the ED for further evaluation. She denied
[**Name2 (NI) 15420**], CP, SOB, or dizziness.
.
In the ED, vitals: T: 97.2 BP: 127/76 P: 86 RR: 16 SpO2: 97%RA.
Initial EKG showed atrial fibrillation with rapid ventricular
rate 170s that resolved without intervention. She had one
epidose of SSCP with cough lasting seconds and resolving without
intervention. Given aspirin 325 mg and levofloxacin 750 mg.
.
ROS: Denied headache, rhinorrhea or congestion. No orthopnea,
PND, LE edema. Denied nausea, vomiting, diarrhea, constipation
or abdominal pain. No melena or BRBPR. No dysuria. Denied
arthralgias or myalgias. No rash.
Past Medical History:
1. History of depression
2. Dementia
3. Hypothyroidism
4. Osteoarthritis
5. Hypertension
6. Hyperlipidemia
7. Gait disorder with high falls risk
8. Status post right humerus fracture
9. Right hip replacement
10. Left inguinal hernia repair
Social History:
The patient lives at [**Location **] Crossing [**Hospital3 **] facility.
Daughter involved in care and lives in area. Non-smoker, no
EtOH.
Family History:
NC
Physical Exam:
Vitals: T: 96.4 BP: 158/80 P: 87 RR: 16 SpO2: 97%2L
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI, sclera anicteric. MMM, OP without
lesions
Neck: Supple, no JVD or carotid bruits appreciated
Pulm: Decreased BS bases, good air flow, increased expiratory
phase, scattered expiratory wheeze
Cardiac: RRR, nl S1/S2, 2/6 systolic diamond-shaped murmur to
carotids
Abdomen: Soft, NT/ND, + BS, no masses or hepatomegaly noted
Ext: No edema b/t, 2+ DP and PT pulses b/l
Lymphatics: No cervical, supraclavicular LAD
Skin: No rashes or lesions noted.
Neurologic: Alert & Oriented x 2, CN II-XII grossly intact, MAEW
Pertinent Results:
[**2166-3-27**] 04:30PM BLOOD WBC-8.1 RBC-4.12* Hgb-12.6 Hct-38.6
MCV-94 MCH-30.6 MCHC-32.7 RDW-14.3 Plt Ct-277
[**2166-3-27**] 04:30PM BLOOD Glucose-90 UreaN-15 Creat-1.4* Na-141
K-4.4 Cl-104 HCO3-24 AnGap-17
[**2166-3-27**] 04:30PM BLOOD CK(CPK)-98 cTropnT-<0.01
[**2166-3-28**] 03:28AM BLOOD CK(CPK)-83 cTropnT-<0.01
[**2166-3-27**] 04:30PM BLOOD TSH-3.0
.
EKG 1 14:08 Atrial fibrillation with RVR, rate 179, NA, LBBB
(old), TWI V5-V6
EKG 2 16:38 NSR rate 93, NA, LBBB, TWI V5-V6
.
Radiologic Data:
[**2166-3-27**] CHEST (PORTABLE AP): IMPRESSION: Mild pulmonary edema and
moderate bilateral effusions and atelectasis.
.
[**2166-3-28**] Echo: The left atrium is moderately dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is moderate global left ventricular
hypokinesis (LVEF = 30-40 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. There is moderate thickening of the mitral valve
chordae. Mild to moderate ([**12-25**]+) mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is no pericardial
effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2158-11-8**], the left
ventricular ejection fraction is reduced.
.
IMPRESSION: moderately reduced left ventricular contractile
function; heavy calcification of mitral annulus and support
structures
.
MICRO:
[**3-27**] BCx: P x 2
[**3-29**] UCx: P
Brief Hospital Course:
The patient is a 86F with PMH of HTN, hyperlipidemia, and
hypothyroidism presenting with cough and fatigue, found to be in
pAF with new systolic heart failure.
.
Paroxysmal atrial fibrillation: Patient was admitted with AF in
rate of 130s in ED, but had spontaneous conversion to NSR. This
was the first documented episode of afib for this patient.
Infectious w/u negative. TSH was WNL. There was no e/o acute MI,
with negative cardiac enzymes x 2 and no acute ST-T changes
consistent with ischemia on EKG. She remained in NSR during
much of her hospital course; however, she did have several
recurrent episodes of AF requiring IV medications for rate
control. On [**3-30**], the patient was transferred to the CCU for
altered mental status and AF with RVR to 140s despite IV BB and
CCB. She was started on an amiodarone load with amiodarone 400
[**Hospital1 **]. She should be continued on amiodarone 400 [**Hospital1 **] for a 7 day
course ([**Date range (1) 13500**]), followed by 200 [**Hospital1 **] x 7 days, then 200 daily
for maintenance dose. She was also started on a BB which she
tolerated well. Her CHADS2 score was 3; however, after
discussion of risks and benefits with the patient and her family
they declined anticoagulation given her high fall risk. She was
continued on ASA 325mg. She was scheduled a follow up
appointment with Cardiology clinic prior to discharge.
.
CHF: She was noted to have a new global hypokinesis with EF
30-40% on this admission. As above, there was no e/o acute MI
on admission given negative cardiac enzymes and no acute ST-T
changes consistent with ischemia on EKG. Echo showed no WMA.
She was diursed to euvolemia during this hospitalization. She
should have a repeat ECHO in [**1-27**] months to reassess with her
LVEF.
.
Chronic renal failure: Likely due to long-standing HTN. Renal
function stable.
.
Hypertension: Continued on BB and ACEI.
.
Hyperlipidemia: Continued on home dose of simvastatin.
Medications on Admission:
Buspirone 15 mg [**Hospital1 **]
Lisinopril 10 mg DAILY
Olanzapine 2.5 mg [**Hospital1 **]
Simvastatin 20 mg DAILY
Synthroid 75 mcg DAILY
Venlafaxine 225 mg DAILY
Aspirin 81 mg DAILY
Calcium-Vitamin D3-Vitamin K 500 mg-100 unit-[**Unit Number **] mcg [**Hospital1 **]
Multivitamin DAILY
Lorazepam 0.5 mg PRN
Lactulose [**Hospital1 **] PRN
Discharge Medications:
1. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
7. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days: until [**4-6**].
9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days: [**4-7**] until [**4-13**].
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
from [**4-14**].
11. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO QID (4
times a day).
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 1036**] - [**Location (un) 620**]
Discharge Diagnosis:
Primary
Atrial Fibrillation
Secondary
Congestive Heart Failure
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with fatigue and cough. You were noted to
have a new atrial fibrillation (an abnormal heart rhythm). You
were also found to have heart failure.
You were treated with several agents for your heart conditions,
including amiodarone, high dose aspirin and metoprolol. You
should take all of your medication as directed.
Your effexor was decreased.
If you have any of the following symptoms you should return to
the emergency room or see your PCP:
[**Name10 (NameIs) **], chest pain, shortess of breath, fever, chills or
any other serious concerns.
Followup Instructions:
We have scheduled the following appointments for you. Please
attend them as directed:
Cardiology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 4451**]
Date/Time:[**2166-4-16**] 9:40
Primary Care Provider:
[**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8708**], M.D. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2166-5-29**] 2:30
Completed by:[**2166-4-1**]
|
[
"427.31",
"403.90",
"428.21",
"428.0",
"244.9",
"715.90",
"272.4",
"585.9",
"V43.64"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7858, 7935
|
4251, 6210
|
246, 252
|
8055, 8063
|
2375, 4228
|
8679, 9162
|
1720, 1724
|
6599, 7835
|
7956, 8034
|
6236, 6576
|
8087, 8656
|
1739, 2356
|
178, 208
|
280, 1285
|
1307, 1548
|
1564, 1704
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,031
| 186,744
|
1096
|
Discharge summary
|
report
|
Admission Date: [**2175-1-5**] Discharge Date: [**2175-1-10**]
Date of Birth: Sex: F
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
Russian-speaking female with a past medical history
significant for hepatitis C cirrhosis, diabetes, and coronary
artery disease who presents with fever and hypotension.
On the day prior to admission, the patient had a routine
cystoscopy. She had taken Bactrim prophylaxis with this
cystoscopy, but otherwise no antibiotic prophylaxis. The
next day, she noted a fever to 102. She also had nausea and
vomiting with emesis times one, and abdominal pain, and
diarrhea. She also noted fevers and chills with a
temperature to 102. She then presented to the Emergency
Department.
Her primary complaint at the time of Emergency Department
evaluation was hematuria.
A review of systems was significant for dysuria and frequency
for the previous few days. She also notes exercise-induced
angina over the previous few months, but no active change in
this. She is otherwise without any complaints; including no
cough or shortness of breath or chest pain.
Upon arrival to the Emergency Department, the patient was
noted to be febrile and mildly hypotensive. She was enrolled
in a sepsis protocol given her fever, leukocytosis, and a
lactate greater than 4. She was aggressively fluid
resuscitated and received a total of 4 liters of normal
saline. Her blood pressure initially responded to fluid
boluses but then trended down to the 90s systolic. She was
then started on Levophed for pressor support which had to be
titrated up to 4 mcg a minute to maintain mean arterial
pressures of greater than 60. She was given ceftriaxone, and
vancomycin, and levofloxacin as per sepsis protocol. Her
lactate did trend down to 1.4 following aggressive fluid
resuscitation. Her mixed venous oxygen saturations ranged
from 82% to 89%. Her central venous pressure was 10 cm when
placed. It subsequently ranged from 9 to 18, and at the time
of Medical Intensive Care Unit evaluation was 8. The patient
was subsequently admitted to the Medical Intensive Care Unit
for management given her presumed septic shock.
PAST MEDICAL HISTORY:
1. Hepatitis C cirrhosis (Child's class B).
2. Portal hypertension with grade II varices.
3. History of Escherichia coli urosepsis in [**2174-4-12**].
4. Depression.
5. History of upper gastrointestinal bleed.
6. History of psychosis.
7. Status post cholecystectomy.
8. History of hepatic encephalopathy.
9. Asthma.
10. Coronary artery disease.
11. Hypertension.
12. Diabetes mellitus.
13. Iron deficiency anemia.
MEDICATIONS ON ADMISSION: Zyprexa, Protonix, nadolol,
Celexa, Sonata, and Bactrim prophylaxis.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies any tobacco or alcohol
use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.5
with a temperature maximum of 101.9, her blood pressure was
119/37, her pulse was 65, her respiratory rate was 22, and
her oxygen saturation was 99% on 2 liters of oxygen via nasal
cannula. In general, a chronically ill-appearing and
disheveled female. Alert and conversant. In no acute
distress. Head, eyes, ears, nose, and throat examination
revealed positive scleral icterus. The mucous membranes were
moist. The pupils were reactive. Neck examination revealed
no jugular venous pressure. Positive telangiectasias. A
right internal jugular in place. Lung examination revealed
decreased breath sounds in the left base. Cardiovascular
examination revealed a regular rate, normal first heart
sounds and second heart sounds, with no murmurs, rubs, or
gallops. The abdomen had positive bowel sounds and
distended. Mildly tenderness to palpation in the umbilical
area with a reducible umbilical hernia. A large right upper
quadrant scar. Difficult to palpate liver given significant
distention. Positive umbilical vein prominence. Extremities
revealed trace lower extremity edema bilaterally, warm, left
radial artery line in place. Neurologic examination revealed
alert and oriented times three. She responded appropriately
to questions and moved extremities times four.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 21, her hematocrit was 34.2, and her platelets
were 106. Sodium was 138, potassium was 3.8, chloride was
106, bicarbonate was 21, blood urea nitrogen was 16,
creatinine was 1, and her blood glucose was 110.
Differential with 83% neutrophils, 7% band, 4% lymphocytes,
and 6% monocytes. Urinalysis revealed large blood, nitrite
positive, protein of 30, small bilirubin, with 6 to 10 red
blood cells, 21 to 50 white blood cells, a few bacteria, and
0 to 2 epithelial cells.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray revealed
questionable hazy left cardiac silhouette and questionable
anterior effusion on lateral film.
A KUB revealed no obstruction or other acute process.
SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. INFECTIOUS DISEASE ISSUES: The patient was admitted in
acute septic shock, with primary source being urosepsis. The
patient with a history of urosepsis, admitted following a
cystoscopy with only Bactrim prophylaxis with probable
bacteria feeding her blood. She did develop temporal sepsis
and did require Levophed for pressure support. The patient
initially received vancomycin, Levaquin, and ceftriaxone.
This was sepsis clinically tailored to only Levaquin and
vancomycin.
The patient was initially started on Levophed for pressure
support in the Emergency Department given her hypotension
despite aggressive fluid resuscitation. On the day of
admission to the Medical Intensive Care Unit, the patient's
blood pressure did stabilize and she was weaned off pressure
support within one day.
She continued to remain hemodynamically stable and was
subsequently called out to the floor where she completed an
empiric course of Levaquin. Her vancomycin was subsequently
discontinued as her cultures remained negative for any
vancomycin-sensitive organisms.
2. CIRRHOSIS ISSUES: The patient with hepatitis C cirrhosis
(Child's class B). Initially, her cirrhotic medications were
held given her acute septic shock. She was subsequently
started back on her Aldactone at a low dose which was slowly
titrated up. She was placed on a low-sodium diet with strict
ins-and-outs.
The Hepatology team did follow the patient throughout her
hospital course. She was thought to require long-term
spontaneous bacterial peritonitis prophylaxis with plans to
start her on ciprofloxacin for prophylaxis when she did
complete her course of Levaquin for her urosepsis.
3. DIABETES MELLITUS ISSUES: The patient was maintained on
glyburide with an insulin sliding-scale for coverage.
4. PSYCHIATRIC ISSUES: The patient on Celexa and olanzapine
as per her outpatient regimen. She also received Sonata for
sleep.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To home with [**Hospital6 407**]
services.
DISCHARGE DIAGNOSES:
1. Urosepsis.
2. Septic shock.
3. Hepatitis C cirrhosis.
4. Portal hypertension with grade II varices.
5. Ascites.
6. Diabetes mellitus.
7. Urinary tract infection.
MEDICATIONS ON DISCHARGE:
1. Levaquin 500 mg once per day (times 10 days).
2. Albuterol meter-dosed inhaler as needed.
3. Olanzapine 10 mg at hour of sleep.
4. Citalopram 20 mg once per day.
5. Timolol eyedrops once per day.
6. Zaleplon 5 mg at hour of sleep.
7. Glyburide 2.5 mg in the morning.
8. Nadolol 80 mg once per day.
9. Spironolactone 100 mg once per day.
10. Lactulose 30 mg q.6h. as needed.
11. Pantoprazole 40 mg once per day.
12. Lasix 40 mg once per day.
13. Ciprofloxacin one tablet by mouth every week; to be
started following completion of Levaquin.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 7123**]
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2175-4-13**] 16:17
T: [**2175-4-15**] 09:40
JOB#: [**Job Number 7124**]
|
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13,806
| 184,142
|
2212
|
Discharge summary
|
report
|
Admission Date: [**2125-1-17**] Discharge Date: [**2125-3-22**]
Date of Birth: [**2052-4-9**] Sex: F
Service: SURGERY
Allergies:
Meperidine / Erythromycin Base / Oxycodone / Fentanyl / Levaquin
/ Cephalosporins
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
acute left groin bleed
Major Surgical or Invasive Procedure:
[**2125-1-17**] Debridement of left groin and thrombectomy of left
femoral-popliteal bypass.
[**2125-1-29**] Removal of infected left femoral to above-the-knee
popliteal polytetrafluorethylene bypass graft, excision of
pseudoaneurysm and saphenous vein patch profundaplasty.
[**2125-2-1**] Left above knee amputation
[**2125-2-25**] EGD, endoscopic cauterization bleeding duodenal erosion
[**2125-2-28**] Flexible bronchoscopy, tracheostomy tube (7.0 Portex),
20-French percutaneous endoscopic gastrostomy tube
History of Present Illness:
acute left groin bleed s/p left fem-[**Doctor Last Name **] bpg [**11-25**] day of
admisssion.
Past Medical History:
Past Medical History
- CAD s/p PCI
- CHF
- Hypothyroidism
- Diabetes mellitus type 2
- COPD
- mild CRI
- elev. chol
- prior GI bleed on ASA/plavix
Past Surgical History:
- Aorto-bifem bypass [**2111**]
- Pseudoaneurysm repair '[**17**]
- 5V CABG '[**21**]
- Bilateral cataract surgery
- Left profunda femoris endarterectomy, leftfemoral to above
the knee popliteal bypass using PTFE [**2124-11-29**]
- ICD placement for nonsustained VT & LV
Social History:
She lives with her sister. [**Name (NI) **] etOH. Ex-smoker, stopped smoking 9
years ago (smoked [**12-20**] ppd X 35 yrs).
Family History:
Noncontributory.
Physical Exam:
96.0 70 61/40 10 93%RA
after 3L IV
96.0 62 105/31 14 100%4L
NAD. Pale. A&Ox3.
No carotid bruit.
RRR.
CTAB.
Soft. NT. ND.
Dried blood L groin. Sinus tract in L groin. Serosanguinous
drainage. No active bleeding.
LLE slightly cooler than RLE.
Pulses fem [**Doctor Last Name **] pt dp graft
R +2 nd tri nd
L +2 nd nd nd nd
Pertinent Results:
[**2125-1-17**] 11:52PM GLUCOSE-75 UREA N-37* CREAT-1.3* SODIUM-146*
POTASSIUM-3.9 CHLORIDE-120* TOTAL CO2-18* ANION GAP-12
[**2125-1-17**] 11:52PM cTropnT-1.96*
[**2125-1-17**] 11:52PM CALCIUM-7.8* PHOSPHATE-3.1 MAGNESIUM-1.9
[**2125-1-17**] 11:52PM WBC-9.8 RBC-3.33* HGB-9.9* HCT-29.0* MCV-87
MCH-29.8 MCHC-34.2 RDW-17.1*
[**2125-1-17**] 11:52PM PLT COUNT-125*
[**2125-1-17**] 11:30PM TYPE-ART TEMP-38.9 RATES-/16 TIDAL VOL-570
PEEP-10 O2-40 PO2-147* PCO2-35 PH-7.33* TOTAL CO2-19* BASE XS--6
INTUBATED-INTUBATED VENT-SPONTANEOU
[**2125-1-17**] 10:17PM CK(CPK)-277*
[**2125-1-17**] 10:17PM CK-MB-39* MB INDX-14.1*
[**2125-1-17**] 02:12PM ALT(SGPT)-8 AST(SGOT)-15 CK(CPK)-58 ALK
PHOS-174* AMYLASE-37 TOT BILI-0.3
[**2125-1-17**] 02:12PM LIPASE-14
[**2125-1-17**] 02:12PM ALBUMIN-2.5* CALCIUM-7.1* PHOSPHATE-4.5
MAGNESIUM-2.0
[**2125-1-17**] 02:12PM TRIGLYCER-151*
[**2125-1-17**] 02:12PM PT-15.2* PTT-38.7* INR(PT)-1.3*
[**2125-1-17**] 01:00PM GLUCOSE-253* LACTATE-0.9 NA+-139 K+-4.0
CL--119*
Brief Hospital Course:
The patient was intially evaluated in emergency room @ [**Location (un) **]
and subsequently transferred to [**Hospital1 18**] for further care. Her
hospitalization was prolonged and complicated, as outlined below
by systems.
Neuro: The patient was awake and alert upon admission. Her
mental status has since been variable given the multiple
interventions and prolonged hospitalization she has endured. Her
pain has been controlled with Tylenol and PRN IV narcotics. She
is able to follow commands, but remains weak and in need of
significant rehabilitation. She is unable to phonate given her
prolonged intubation and now tracheostomy. She is to progressed
to a Passe-Muir valve, however her respiratory failure limited
her ability to performed PMV trials.
Vascular: The patient was admitted on [**1-17**] with an acutely
bleeding L fem-[**Doctor Last Name **] bypass ([**2124-11-29**]) and an infected L groin.
Her Hct was 18 at the time of presentation. Non-contrast CT
demonstrated air and fluid in the L groin wound. Bleeding was
initially controlled with pressure, however she later developed
decreased pulses in her LLE. Of note, the aortobifemoral bypass
([**2111**]) was not exposed during the most recent procedure. She was
taken to the OR for debridement of the L groin and thrombectomy
of L femoral-popliteal bypass. She was having an acute MI at the
time of surgery, and after Cardiology consultation, there was no
recommended intervention to improve her cardiac function. She
tolerated the procedure relatively well. Postoperatively she was
maintained on a heparin gtt. She was covered with broad spectrum
antibiotics for her infected groin/graft. Her groin was treated
initially with a VAC dressing.
On [**1-29**] the patient had another brisk epsiode of bleeding and
she was again taken emergently to the operating room. A
pseudoaneurysm was found at the proximal anastamosis and a
grossly infected graft was noted. She underwent removal of the
infected L fem-AK [**Doctor Last Name **] PTFE bpg, excision of pseudoaneurysm, and
saphenous vein patch profundaplasty. Over the following days,
her LLE became progressively more ischemic and she eventually
was brought back to the operating room on [**2-1**] for a L BKA given
her lack of revascularization options. Her excised graft grew
[**Female First Name (un) **] and she was maintained on Fluconazole for the remainder
of her hospitalization. Her BKA stump was opened laterally on
[**2-5**] for suspected infection and swab cultures were taken, which
eventually grew VRE. She was treated with a full course of
Linzeolid and wet to dry dressing changes were use to maintain
the opened portion of the stump.
Her Vascular exam remained stable for the remainder of her
hospitalization with dopplerable signals in her distal RLE. Her
L BKA stump has adequately closed and without signs of continued
infection. Multiple CT scans of the stump and L groin were
obtained for suspected infection. However, combined with the
lack of external signs of infection, the small fluid
collections/hematomas appeared stable and not infected.
Cardiac: On admission the patient was having a symptomatic
STEMI. Troponins peaked at 1.96. Cardiology was consulted and
determined that there was no further therapy to improve her
coronary status given she had previously undergone CABG and
subsequent coronary arteriography showing extensive disease
without reconstruction options. An ECHO was performed on [**1-18**],
which showed an LVEF of 50%. This was repeated later in the
course given her poor renal function and hypotension on [**1-/2046**],
which showed that overall left ventricular systolic function was
severely depressed (LVEF= 20-30 %) secondary to severe
hypokinesis of all segments except the basal inferior,
posterior, and lateral segments. This was thought to be due to
her recent MI and remodeling. She did require pressors
(intropes) multiple times to maintain her cardiac output. She
did not require pressors during the last 2 weeks of her
hospitalization. She was over-diuresed and did require some
volume resuscitation the week prior to transfer, but eventually
was hemodynamically stable with acceptable SBP in the 90-120
range. Her volume status was very difficult to assess and there
was an unsuccessful attempt at PA catheter placement. Her
troponins did trend down and did not spike again during her
course. Her last troponin was 0.12 on [**2-17**]. During the final
week, her blood pressure was increasingly difficult to maintain,
despite volume resuscitation. Sepsis and the resulting
inflammation made it essential impossible for her to maintain
adequate intravascular volume. Pressors were reinstitued on [**3-21**]
to maintain her blood pressure, but requirements gradually
increased without signs of improvement.
Pulmonary: The patient required multiple intubations during her
hospitalization. Initially this was mainly due to the multiple
procedures she underwent, however following her 2nd MI she had
significant difficult weaning from the ventilator. Given her
lack of progression in weaning from the vent she underwent
tracheostomy placement on [**2-28**]. On [**3-2**] & [**3-4**] she grew
enterobacter from her sputum and CXR were equivocal for
infiltrates given her large effusions. Given her lack of
progress in vent-wean, she was treated with a course of
Meropenem for ventilator associated pneumonia. Her pulmonary
status has gradually improved with diuresis. She was evaluated
for a Passe-Muir valve and recommendations were made on [**3-7**] to
do trials while on pressure support and to continue with trach
collar trials. During the final weeks of [**Month (only) 958**], she spent
variable lengths of time on trach-collar trials, at times
lasting up to 12 hours without ventilator support. However, as
her overall status gradually deteriorated thoughout the last
week of [**Month (only) 958**] and early [**Month (only) 547**], she required increasing
ventilatory support. Sputum cultures again grew Enterobacter on
[**3-18**] and she was again started on Meropenem. Her respiratory
failure contributed significantly to her multisystem organ
failure.
GI/Nutrition: When the patient remained extubated, she had poor
oral intake. She also was intubated for a large portion of her
hospitalization. She was maintained on enteral tube feedings
starting [**1-/2046**] via OGT and eventually a PEG. A PEG was placed on
[**2-28**] with the tracheostomy given the lack of progress in weaning
and the need for more permanent enteral access. Tube feeds were
tolerated well and she was tolerating goal feeds of 25cc/h of
Nutren Renal full-strength with Beneprotein, 10 gm/day and
Banana flakes, 3 packets per day. The patient did have a minor
UGI bleed, described below in the Heme section. She was
maintained on GI prophylaxis with a PPI. Multiple CT scans of
the patient's abdomen and pelvis were obtained throughout her
course. The CT scan done [**2-5**] and the other studies there after
demonstrate multiple areas of hypoattenuation in the the spleen
consistent with infarction. It was postulated that this may
account or contribute to her intermittant fevers. It was decided
that no treatment was necessary for the infarcted areas of the
spleen and that this likely occured during periods hypoperfusion
that occured throughout her course from the acute hemorrhaging
and myocardial ischemia. During the final weeks of [**Month (only) 958**] and
early [**Month (only) 547**], the patient developed diarrhea with daily stool
outputs reaching 1L at times. Stool samples were analyzed during
this period were negative for C. difficile, including the B
toxin. Tube feedings were changed to an elemental formula,
Vivonex, but were discontinued as she developed sepsis and
multisystem organ failure. A CT of the torso and lower
extremities failed to show an intra-abdominal source of sepsis,
but did show increased splenic infarction, likely due to global
hypoperfusion due to her septic shock.
GU/Renal: The patient was admitted with some degree of CRI and
her renal function was variable throughout her hospitalization.
Aggressive diuretic therapy was utilized on multiple occasions
given her poor cardiac function. Her creatinine peaked at 2.1
and had decreased to normal ranges in her final weeks. Her
normal Cr despite her oliguric renal failure may be explained by
her decreased muscle mass at this time. Following her
transfusions she became uremic with BUN's in the 120 range,
however the patient remained asymptomatic. Her uremia may have
contributed somewhat to her GI bleed. BUN had stabilized in the
70-80 range. Without the aid of diurectics, the patient was
significantly oliguric. She was maintained on a Bumex gtt on
multiple occasions throughout her course to try maintain
euvolemia, however her diuresis was limited numerous times by
hypotension. Nephrology was consulted and followed the patient
during her course. No dialysis was ever required, though this
was considered. Throughout her final week, agressive diuresis
was attempted as her progressively worsening hypotension
required volume resuscitation and pressors to maintain SBP
greater than 90. Her daily weights gradually rose to above 80kg
as she became more anasarcic. Despite the use of Duirel and
Bumex, her urine output had decreased to only few hundred cc's
per day during the final week.
Heme: The patient was maintained on a heparin gtt after the
initially bleeding from her groin was controlled. However this
was discontinued after her 2nd bleed and the graft was excised.
She has been maintained on aspirin 81mg daily. The patient was
transfused with multiple blood products during her
hospitalization for the acute hemorrhage from her L groin, as
well as a minor UGI bleed confirmed on EGD. The patient had an
acute drop in her hematocrit on [**2-23**] for which she was tranfused
a total of 6 units of pRBC's over the next 3 days. Her stool was
guiaic positive. A tagged-RBC scan was negative on [**2-24**], so an
EGD was performed on [**2-25**], which showed a linear erosion in the
duodenum with slow bleeding and required endoscopic
cauterization. Her hematocrit responded appropriately to the
transfusions and stabilized in the high 20/low 30 range the
remainder of her hospitalization. The patient had a known Anti-K
antibody, but despite appropriate blood products, she had
another positive Coombs test on [**2-27**], following the most recent
set of transfusions. She is now documented as also having a
Anti-C antibody. This was postulated as a possible reason for
her spiking fevers the few days following the transfusions.
ID: The patient was initially maintained of IV
Vancomycin/Aztreonam/Flagyl for her infected L groin/fem-[**Doctor Last Name **]
bypass. Infectious Disease was consulted early in her hospital
course. On [**1-28**] she began having diarrhea and oral Vancomycin
was initiated. The L bypass that was excised on [**1-29**] eventually
grew [**Female First Name (un) 564**] and she was started on Fluconazole on [**2-2**] and was
to continue it for the remainder of her life given she has
remaining graft (aortobifem). Her BKA stump was opened laterally
on [**2-5**] for suspected infection and swab cultures were taken,
which eventually grew VRE. She was treated with a full course of
Linzeolid. Repeat imaging of the stump following antibiotic
treatment showed a stable hematoma without obvious sign of
infection. Her stool was positive for C. difficile toxin
multiple times throughout her hospitalization and she was
continued on oral Vanco until [**3-6**]. Her diarrhea then appeared
under control. As stated above in the Pulmonary section, the
patient did develop a VAP and is to continue Meropenem until
[**3-17**] to complete a 2 week course. The patient did spike
intermittant fevers in the early 2 weeks of [**Month (only) 958**]. Extensive
work-up only identified a VAP, which we are treating. RUQ US did
not reveal cholecystitis. CT scans of the pelvis and stump
identified stable L groin and stump fluid collections cosistent
with seroma and hematoma respectively with external signs of
infection. Given her positive Coombs test and transfusions in
the period between [**Date range (1) 11768**], it was thought that a delayed
hemolytic tranfusion reaction may be the cause. However, her
labs were not consistent with hemolysis. She was also noted to
have a partially infarcted spleen, which may also have
contributed to the fevers.
Repeat cultures were performed due to a rapidly increasing
leukocytosis, increasing from 16K to 23K on [**3-18**]. Sputum again
grew out Enterobacter. Her WBC peaked at 35K on [**3-20**]. She also
had increasing diarrhea during this time. Antibiotics coverage
was broadened after ID reconsultation to include Daptomycin, PO
Vancomyin, Meropenem, Gentamycin, and Flagyl. Fluconazole was
also changed to Caspfungin for antifungal coverage. Graft
infection remained as a possible explanation for her failure to
improve and increased WBC during her final week, however imaging
never demonstrated signs of peri-graft inflammation and blood
cultures remained negative. Numerous stool samples for C.
difficile toxin were again sent of during the final weeks,
including B toxin, all of which were negative. A clear
explanation for her profound leukocytosis, septic shock, and
gradual decompensation was not discovered.
Despite broad antibiotic coverage and maximal supportive care,
including increasing pressor and ventilatory requirements, Ms.
[**Known lastname **] continued to decompensate. Her decompensation was more
rapid on [**3-21**] and [**3-22**]. A family meeting was held on [**3-22**] and after
extensive discussion and explanation by Dr. [**Last Name (STitle) 1391**] that the
patient's prognosis was very poor given her multi-system organ
failure (Renal, Respiratory, Cardiac), it was decided to change
the goals of care to CMO. Supportive measures were withdrawn
around 12:10 PM on [**3-22**] and change to comfort measures. Time of
death was pronounced shortly thereafter.
Medications on Admission:
- Synthroid 125mcg daily
- Toprol XL 100mg daily
- Lasix 80mg po daily
- Vytorin
- Iron Sulfate 325mg dialy
- Colace 100mg daily
- Aspirin 81mg daily
- Actos 80mg daily
- Cozaar 100mg daily
- Duoneb inh [**Hospital1 **]
- Albuterol PRN
Discharge Medications:
Not applicable, patient deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
PVD: L fem-[**Doctor Last Name **] bpg with PTFE [**11-25**], ABF [**2111**], PSA repair '[**17**]
Acute hemorrhage L groin
Thrombosed L fem-[**Doctor Last Name **] bypass graft
Acute myocardial infarction
L fem-[**Doctor Last Name **] bypass graft infection s/p excision, profundoplasty
L femoral pseuodaneurysm s/p excision
Critical limb ischemia LLE s/p L BKA
Postop UGI bleed (duodenal erosion) s/p endoscopic cauterization
Postop Ventilator associated pneumonia
Postop malnutrition s/p PEG
Postop respiratory failure s/p tracheostomy
Postop Partial splenic infarction
Postop cardiac demand ischemia with elevated troponin, resolved
Multisystem organ failure
Sepsis
history of coronary artery disease s/p multiple RCA
angiioplasties and stenting procedures,s/p CABG"s/AVR (
pericardial )( Lima-lad,svg RCAx2) [**2121**],
history of hypothyroidism
history of anemia- iron supplment
history of hypertension
history of COPD
history of DM2, noninsulin dependant
history of CHF,systolic history of dysarythmias, anticoagulated
history of hyperlipdemia
history of stage 1-2 renal disease creatinine 1.8
postop hyperchloremic metabolic acidosis
postop blood loss anemia,transfused
Discharge Condition:
Deceased.
Discharge Instructions:
Not applicable. Patient deceased.
Followup Instructions:
Not applicable. Patient deceased.
|
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"414.01",
"785.51",
"997.62",
"599.0",
"998.12",
"584.9",
"532.40",
"535.50",
"999.9",
"482.83",
"E947.8",
"996.74",
"530.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"54.0",
"99.04",
"31.1",
"38.48",
"39.49",
"34.04",
"33.23",
"99.15",
"93.59",
"45.34",
"84.17",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17477, 17486
|
3102, 17133
|
363, 877
|
18711, 18723
|
2056, 3079
|
18805, 18841
|
1625, 1643
|
17419, 17454
|
17507, 18690
|
17159, 17396
|
18747, 18782
|
1194, 1467
|
1658, 2037
|
301, 325
|
905, 1001
|
1023, 1171
|
1483, 1609
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,129
| 157,379
|
2073+2074
|
Discharge summary
|
report+report
|
Admission Date: [**2106-6-10**] Discharge Date: [**2106-6-25**]
Date of Birth: [**2036-7-7**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
woman with a sudden onset of blinding headache on the day of
admission with no neck pain, nausea, vomiting, blurry vision
or trauma. She had no chest pain or shortness of breath or
dizziness.
PHYSICAL EXAM:
GENERAL: She is awake, alert and oriented x3.
VITAL SIGNS: Her temperature was 96??????, heart rate 62, blood
pressure 131/72, respiratory rate 18. Saturations were 99%
on room air.
HEAD, EARS, EYES, NOSE AND THROAT: Her pupils equal, round
and reactive to light.
NEUROLOGIC: Cranial nerves II through XII were intact. On
motor strength, she had no pronator drift and she was [**6-6**] in
all muscle groups.
CARDIOVASCULAR: She had a S1 and S2, no S3 or S4.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No cyanosis, clubbing or edema.
CT showed subarachnoid hemorrhage.
HOSPITAL COURSE: She was admitted to the Neurosurgical
Intensive Care Unit for blood pressure control. On
[**2106-6-11**], she underwent a coiling of a right posterior
communicating artery aneurysm. Coiling was successful and
the patient was monitored in the Neurologic Intensive Care
Unit for 10 days to watch for vasospasm. The patient had no
episodes of vasospasm while in the Intensive Care Unit. Her
vital signs remained stable. She was afebrile. She did have
complaints of headache on and off. She was medicated with
Percocet. She had transcranial Dopplers which showed some
mild elevation, but no clinical evidence of vasospasm. She
had repeat arteriogram on [**2106-6-18**] which showed no evidence
of vasospasm.
The patient continued to be monitored for blood pressure
monitoring and was started on Neo-Synephrine to keep her
blood pressure greater than 150. On [**2106-6-19**], the patient
had a temperature of 101.2?????? and she was started on
ceftriaxone for left lower lobe pneumonia. The patient
developed loose stools, most likely it was thought to be
related to her lactose intolerance, however it persisted
after lactose diet was initiated and a Clostridium difficile
toxin was sent. The patient is on a 10 day course of
ceftriaxone and she is day 7 of 10 days. She was transferred
to the regular floor on [**2106-6-23**]. She remains in stable
condition. She was seen by physical therapy and occupational
therapy and found to require rehabilitation.
DISCHARGE MEDICATIONS:
1. Percocet 1 to 2 tablets po q4h prn
2. Ceftriaxone 2 gm intravenous q 24 hours to be continued
until [**2106-6-28**].
3. Heparin 5000 units subcutaneous q 12 hours.
The patient was in stable condition at the time of discharge
and will follow up with Dr. [**Last Name (STitle) 1132**] in two weeks' time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2106-6-24**] 11:25
T: [**2106-6-24**] 12:05
JOB#: [**Job Number **]
Admission Date: [**2106-6-10**] Discharge Date: [**2106-6-25**]
Date of Birth: [**2036-7-7**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
woman with a sudden onset of blinding headache on the day of
admission with no neck pain, nausea, vomiting, blurry vision
or trauma. She had no chest pain or shortness of breath or
dizziness.
PHYSICAL EXAM:
GENERAL: She is awake, alert and oriented x3.
VITAL SIGNS: Her temperature was 96??????, heart rate 62, blood
pressure 131/72, respiratory rate 18. Saturations were 99%
on room air.
HEAD, EARS, EYES, NOSE AND THROAT: Her pupils equal, round
and reactive to light.
NEUROLOGIC: Cranial nerves II through XII were intact. On
motor strength, she had no pronator drift and she was [**6-6**] in
all muscle groups.
CARDIOVASCULAR: She had a S1 and S2, no S3 or S4.
ABDOMEN: Soft, nontender, nondistended.
EXTREMITIES: No cyanosis, clubbing or edema.
CT showed subarachnoid hemorrhage.
HOSPITAL COURSE: She was admitted to the Neurosurgical
Intensive Care Unit for blood pressure control. On
[**2106-6-11**], she underwent a coiling of a right posterior
communicating artery aneurysm. Coiling was successful and
the patient was monitored in the Neurologic Intensive Care
Unit for 10 days to watch for vasospasm. The patient had no
episodes of vasospasm while in the Intensive Care Unit. Her
vital signs remained stable. She was afebrile. She did have
complaints of headache on and off. She was medicated with
Percocet. She had transcranial Dopplers which showed some
mild elevation, but no clinical evidence of vasospasm. She
had repeat arteriogram on [**2106-6-18**] which showed no evidence
of vasospasm.
The patient continued to be monitored for blood pressure
monitoring and was started on Neo-Synephrine to keep her
blood pressure greater than 150. On [**2106-6-19**], the patient
had a temperature of 101.2?????? and she was started on
ceftriaxone for left lower lobe pneumonia. The patient
developed loose stools, most likely it was thought to be
related to her lactose intolerance, however it persisted
after lactose diet was initiated and a Clostridium difficile
toxin was sent. The patient is on a 10 day course of
ceftriaxone and she is day 7 of 10 days. She was transferred
to the regular floor on [**2106-6-23**]. She remains in stable
condition. She was seen by physical therapy and occupational
therapy and found to require rehabilitation.
DISCHARGE MEDICATIONS:
1. Percocet 1 to 2 tablets po q4h prn
2. Ceftriaxone 2 gm intravenous q 24 hours to be continued
until [**2106-6-28**].
3. Heparin 5000 units subcutaneous q 12 hours.
The patient was in stable condition at the time of discharge
and will follow up with Dr. [**Last Name (STitle) 1132**] in two weeks' time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2106-6-24**] 11:25
T: [**2106-6-24**] 12:05
JOB#: [**Job Number **]
|
[
"401.9",
"430",
"997.3",
"486",
"599.0",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"39.79",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5555, 6117
|
4063, 5532
|
3456, 4045
|
3218, 3441
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,974
| 101,698
|
53152
|
Discharge summary
|
report
|
Admission Date: [**2161-12-12**] Discharge Date: [**2162-1-5**]
Service: ONCOLOGY
CHIEF COMPLAINT:
Worsening dyspnea.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old
woman with metastatic breast cancer, diagnosed in [**2161-11-13**], presenting to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] on
[**2161-12-12**] for shortness of breath times several
weeks, worsening over the last few days. She does have two
pillow orthopnea but negative paroxysmal nocturnal dyspnea,
no chest pain or palpitations. She has noted increasing
lower extremity edema over the last week. She has cough
which is productive of white sputum but no night sweats or
weight loss. She denies fever, chills, nausea or vomiting.
She has been using inhalers but does not feel that they have
been effective with regard to her dyspnea. She is not on any
oxygen at home.
The patient's previous workup for shortness of breath has
included a CT angiogram on [**2161-12-2**] which was
negative for pulmonary embolism but notable for bilateral
ground-glass opacities. A transthoracic echocardiogram
showed a left ventricular ejection fraction of greater than
70% with mild aortic and mitral regurgitation. She has
moderate pericardial effusion as noted by the transthoracic
echocardiogram.
PAST MEDICAL HISTORY:
1. Pernicious anemia.
2. Chronic obstructive pulmonary disease.
3. Depression.
4. Bilateral total knee replacements.
5. Pelvic mass found in the left adnexal region measuring
6 x 4 cm, which is likely metastatic versus primary ovarian
in origin.
6. Infiltrating ductal carcinoma, ER positive, HR2/neu
negative with omental metastases, retroperitoneal lymph
nodes. MRI of the head revealed no metastatic disease,
however, bone scan indicated thoracic metastases.
SOCIAL HISTORY: The patient lives alone on the third story
of an apartment building and is independent. Her daughter
and son-in-law live nearby and are very supportive.
FAMILY HISTORY: Family history is significant for coronary
artery disease in the patient's father, however, no family
history of cancer.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Zoloft 100 mg p.o.q.d., Lasix 40
mg p.o.b.i.d., Combivent one to two puffs q.i.d., AeroBid
four puffs b.i.d., vitamin B12 q. month, Femara 2.5 mg
p.o.q.d.
PHYSICAL EXAMINATION: On physical examination on admission,
the patient had a temperature of 97, blood pressure 162/82,
heart rate 88, respiratory rate 28, and oxygen saturation 98%
on three liters nasal cannula. General: Patient in no acute
distress, resting comfortably in bed, appears younger than
her stated age. Head, eyes, ears, nose and throat:
Oropharynx clear, moist mucous membranes, jugular venous
pulsation not elevated, neck supple, anicteric sclerae,
extraocular movements intact, no lymphadenopathy present in
the cervical region. Chest: Bilateral basilar crackles
without wheezing, left axillary lymphadenopathy.
Cardiovascular: Regular rate, normal S1 and S2, no S3 or S4,
II/VI murmur at left sternal border. Abdomen: Soft,
nontender, nondistended, positive bowel sounds, no
hepatosplenomegaly. Extremities: 2+ bilateral pitting
edema, no cyanosis or clubbing, 2+ dorsalis pedis pulses
bilaterally, skin warm and dry. Neurologic examination:
Alert and oriented times three, cranial nerves II through XII
intact, [**5-17**] motor strength in bilateral upper and lower
extremities.
LABORATORY DATA: Admission white blood cell count 6.1,
hematocrit 32.2, platelet count 263,000, sodium 137,
potassium 4.1, chloride 106, bicarbonate 18, BUN 34,
creatinine 1.3, glucose 109.
STUDIES DURING HOSPITALIZATION:
1. Chest x-ray, [**2161-12-12**] revealed bilateral
interstitial infiltrates, bilateral pleural effusions, mild
congestive heart failure.
2. Transthoracic echocardiogram, [**2161-12-16**] showed
mild left ventricular hypertrophy, hyperdynamic left
ventricular function with a moderate pericardial effusion, no
change from echocardiogram on [**2161-12-8**].
3. Transthoracic echocardiogram, [**2162-1-4**] showed
left ventricular ejection fraction greater than 55% with
loculated moderate sized 1.5 cm pericardial effusion with
fibrin deposits on the surface of the heart; no
echocardiographic signs of tamponade; compared with prior
echocardiogram, the pericardial effusion appears loculated at
this point.
4. Electrocardiogram on admission showed normal sinus
rhythm, Q waves in III and AVF which were old and T wave
abnormalities in V2 through V6 which were nonspecific.
HOSPITAL COURSE: The patient is a [**Age over 90 **] year old female with
chronic obstructive pulmonary disease, breast cancer and
anemia, who presents with acute worsening of chronic
shortness of breath.
1. Cardiovascular: The patient was initially thought to be
in congestive heart failure and was aggressive diuresed until
her creatinine bumped. She was ruled out for a myocardial
infarction by negative cardiac enzymes on numerous occasions
during her hospitalization. Serial echocardiograms were
performed times four, which showed moderate sized pericardial
effusion without signs of tamponade but evidence of diastolic
dysfunction.
As the patient's dyspnea did not improve, there was concern
that the effusion was compromising cardiac output and her
ability to mobilize fluid. Therefore, a pericardial window
was placed on [**2162-1-1**] with greater than 200 cc of
bloody fluid out, and the drain was left in until [**2162-1-5**]. There was no improvement in the patient's dyspnea
after the window was placed and the pericardial drainage tube
was pulled.
As the pericardial fluid was bloody, there was concern for a
malignant effusion, however, cytology revealed no malignant
cells. It was significant for reactive mesothelial cells,
red blood cells, lymphocytes and neutrophils.
The patient also had occasional episodes of ectopy, both
atrial fibrillation and supraventricular tachycardia, which
was thought to be related to the pericardial window and
drain, with resulting irritation. She was started on
metoprolol 25 mg twice a day for both rhythm abnormalities
and for improvement of congestive heart failure.
2. Pulmonary: The patient's main complaint on admission was
acute worsening of chronic dyspnea over the last month. Upon
medical record review, it appears that the patient has had
complaints of dyspnea since [**2161-7-13**] and, during her
previous admission at the beginning of [**Month (only) **], she was
noted to have oxygen saturation of 91% in room air.
The cardiologic etiologies of the dyspnea was extensively
investigated but, as she had no improvement with diuresis,
pericardial window and multiple rule outs for myocardial
infarction, it was felt that there was a pulmonary etiology
as the most likely explanation for her dyspnea.
Given the patient's history of chronic metastatic breast
cancer, lymphatic spread of the cancer was thought to be the
source of her dyspnea. A thoracentesis was performed on
[**2161-12-30**] and 600 cc of yellow straw colored fluid
was removed. The fluid was later found to be positive for
malignant cells, consistent with adenocarcinoma.
The patient was ruled for pulmonary embolism just prior to
admission. Although she was not on oxygen at home, she had a
consistent three to four liter nasal cannula oxygen
requirement throughout the hospitalization.
The patient was transferred to the Medical Intensive Care
Unit following pericardial window placement and consideration
for Swan-Ganz catheter was undertaken, however, the patient
and family opted to pursue a less aggressive treatment
course. The Swan-Ganz was not placed and her volume status,
instead, was estimated per clinical examination and
radiograph evidence that was available.
3. Renal: On admission, the patient's creatinine was 1.3
and bumped to as high as 2.1 with diuresis. With fluid
hydration after the pericardial window was placed, the
creatinine trended down and is currently at 1.6 at the time
of discharge.
4. Infectious disease: The patient was treated with a ten
day course of antibiotics for presumed pneumonia, which did
not improve her pulmonary status.
5. Hematology: The patient has a baseline pernicious anemia
and received B12 injection on admission. She is to continue
these injections monthly.
6. Gastrointestinal: The patient is chronically constipated
but had worsening of her constipation throughout her
hospitalization. Her abdomen became progressively more
distended and tender during the end of her hospital course
while she was in the MICU. Liver function tests were
performed and found to be normal on several occasions. An
abdominal x-ray showed a distended large bowel, however, she
was eventually able to move her bowels two to three days
prior to discharge. Her abdominal exam did not significantly
improve after the bowel movements and, given her elevated
lactate, there was concern for bowel wall ischemia, ileus or
obstruction from her previous known large pelvic mass. The
option of a CT abdomen was discussed with the patient and
family, who both agreed not to perform the study given the
risks of worsening renal function from contrast load and
their wish not to pursue surgical intervention. The etiology
of her abdominal pain was most likely functional constipation
and she was continued on an aggressive bowel regimen with per
rectum medication and enemas as needed.
7. Fluids, electrolytes and nutrition: Throughout her
hospitalization, the patient had a minimal appetite secondary
to cancer anorexia and had a few episodes of nausea and
emesis. Her emesis was thought secondary to functional
constipation. She was able to tolerate fluids and pureed
food on occasion and was able to take most of her oral
medications. During a family meeting, a nasogastric tube was
discussed with the possibility of starting tube feeds. The
family, however, did not think this was consistent with the
patient's wishes and, therefore, no nasogastric tube was
placed. Likewise, the option of a percutaneous endoscopic
gastrostomy tube was also felt by the family not to be
consistent with the patient's wishes.
8. Oncology: On admission, the patient had a known
diagnosis of metastatic breast cancer, which was recently
diagnosed in [**2161-11-13**]. Her outpatient oncologist, Dr.
[**First Name (STitle) **], did not feel chemotherapy was indicated at the time of
diagnosis. She was instead started on Femara given that the
tumor was estrogen receptor positive.
9. Code status: A family meeting was held on [**2162-1-4**] and, after a long discussion of the progression of the
patient's disease and lack of response to medical management,
it was decided by both the patient and her family that she
would be "Do Not Resuscitate", "Do Not Intubate" and not to
pursue aggressive medical treatment at this point. Her
medications were simplified and she was prepared for
transition to a skilled nursing facility with the possibility
of hospice care in the near future. At this time, she was
not "Comfort Measures Only", however, future medical decision
making would be contingent upon optimizing the quality of
life.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Metastatic breast cancer, bone, retroperitoneal lymph
nodes and omentum.
2. Pelvic mass thought secondary to breast cancer metastases
or primary ovarian tumor.
3. Diastolic congestive heart failure.
4. Chronic obstructive pulmonary disease.
5. Acute renal failure/chronic renal insufficiency.
6. Constipation.
7. Status post pericardial window, [**2162-1-1**].
8. Status post thoracentesis, [**2161-12-30**].
9. Chronic dyspnea, thought secondary to lymphangitic spread
of carcinoma.
10. Paroxysmal atrial fibrillation.
11. Pernicious anemia.
DISCHARGE MEDICATIONS:
Metoprolol 25 mg p.o.b.i.d.
Pepcid 20 mg p.o.b.i.d.
Reglan 10 mg p.o.q.i.d.
Dulcolax p.r.p.r.n.
Senna two tablets p.o.q.d.
Colace 100 mg p.o.b.i.d.
Lactulose 30 cc p.o. or 300 cc p.r.t.i.d.p.r.n.
Combivent q.6h.
Flovent 110 mcg two puffs b.i.d.
Zoloft 100 mg p.o.q.d.
Femara 2.5 mg p.o.q.d.
Roxanol p.r.n.
Supplemental oxygen, three to four liters.
Tylenol p.r.n.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to
[**Location (un) **] Skilled Nursing facility with the possibility of
transition to hospice. Her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **],
[**First Name3 (LF) **] continue to follow the patient after discharge.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 16520**]
Dictated By:[**Last Name (NamePattern1) 18697**]
MEDQUIST36
D: [**2162-1-9**] 22:07
T: [**2162-1-14**] 17:24
JOB#: [**Job Number **]
|
[
"197.2",
"427.31",
"560.1",
"599.0",
"423.9",
"174.8",
"496",
"428.0",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"37.12",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2058, 2234
|
11316, 11872
|
11895, 12260
|
2261, 2417
|
4648, 11261
|
12285, 12814
|
2440, 3365
|
109, 129
|
158, 1377
|
3389, 4630
|
1399, 1869
|
1886, 2041
|
11286, 11295
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,563
| 136,946
|
7295
|
Discharge summary
|
report
|
Admission Date: [**2118-7-28**] Discharge Date: [**2118-8-5**]
Date of Birth: [**2067-7-28**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
back pain, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 yo male with history of HIV on HAART (CD4 413, VL 50 in [**5-26**])
and IVDU who complains of atraumatic acute onset low back pain
x1 week and fevers to 101 x2 days. Pain became worse last night.
Associated with nausea and loss of appetite. Denies lower
extremity weakness, numbness/tingling, urinary or bowel
incontinence, urinary retention, saddle anesthesia. Denies
abdominal pain. Denies headache, neck pain.
He was seen by Dr. [**Last Name (STitle) 724**] and could not sit comfortably in his
office secondary to pain. He has a history of IVDU with last use
in [**6-25**]. He had a routine colonoscopy last week, but was fine
until yesterday. In his office, exam was significant for Temp
100.5, SBP 98/60 (normally 120s/80s); several fractured teeth
(new); shoddy cervical adenopathy. Clear lungs; RRR s1/s2 with
soft grade 1-2 SEM LSB that's stable; abd is benign. Cannot sit;
walking difficult, cannot reproduce pain with palpation. + psoas
sign.
In the ED, initial VS: Pain 10 102 96 101/55 19 97% ra. Blood
cultures x3 were obtained. Rectal exam done noted normal tone.
CXR revealed increased interstitial markings. MRI spine prelim
read was negative for epidural abscess. UA was sent and is
pending. He was given 5mg iv morphine given for pain, ativan
given prior to mri, 1gm tylenol for temp 102.2, 650mg po tylenol
given for temp on admission, and 1gm iv vanco given. Most recent
vitals prior to transfer: Most Recent Vitals: 102.6, 97, 24,
110/72, 94%RA.
Currently, he is somnolent and unable to provide more than basic
answers to questions.
ROS: unable to obtain
Past Medical History:
HIV diagnosed in [**2101**]; no ARVs for many years. Sees Dr. [**Last Name (STitle) 724**]
HCV+ Genotype 1 infection, not on therapy
hx b/l MRSA + buttock abscesses
Right epididymo-orchitis w/ assoc right pyocele
Hx syphills
Hx chlamydia
Hx gonorrhea
IVDU, last use [**6-25**]
Multiple prior UTI's
MEDICATIONS: per OMR
citalopram 20 mg Tablet daily with ARVs
darunavir [Prezista] 400 mg Tablet 2 Tablet(s) by mouth once
daily
emtricitabine-tenofovir [Truvada] 200 mg-300 mg Tablet daily
ritonavir [Norvir] 100 mg Tablet daily with darunavir
sildenafil [Viagra] 100 mg Tablet 0.25-0.5 prn
terbinafine 1 % Cream apply to soles of feet daily after
showering
Social History:
Born in [**Male First Name (un) 1056**], moved to the US 29 yrs ago. Sexually active
with males, contracted HIV in [**2101**] from unprotected intercourse.
Has a HIV+ boyfriend with whom he is currently sexually active
(without protection), who may not be monogamous. Denies tobacco
use, occasional EtOH ([**4-17**] drinks/wknd) and marijuana use. Last
IVDU one month ago. Used to work in a hotel. Never been in
prison, never been homeless.
Family History:
No h/o HIV.
Physical Exam:
Admission physical exam:
VS - 98.8 right 86/57 left 94/59 78 16 95% on RA 69.4kg
GENERAL - somnolent male in NAD, comfortable, only responds to
sternal rub, clear when responding
HEENT - NC/AT, dilated pupils at 6mm bilat, PERRLA, EOMI,
sclerae anicteric, MMM, OP clear
NECK - supple, neg B/K signs, no thyromegaly, shotty LAD in
right submandibular area
LUNGS - crackles right base > left base
HEART - PMI non-displaced, RRR, no MRG, nl S1, split S2
ABDOMEN - +BS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no [**Last Name (un) **] lesions or osler nodes on fingers or toes
SKIN - no rashes or lesions
BACK - marked CVA tenderness bilaterally, no tenderness over
spinous processess from cervical spine to sacrum, no abscesses
or fistulas apparent on external rectal exam
NEURO - somnolent, with sternal rub: A&Ox3, CNs II-XII grossly
intact, muscle strength 5/5 throughout
Pertinent Results:
MRI C-T-L spine
IMPRESSION: Multilevel degenerative changes in the cervical,
thoracic and lumbar spine as described above with severe
foraminal narrowing and canal stenosis at multiple levels. No
evidence of epidural abscess seen.
.
Renal Ultrasound:
IMPRESSION:
1. Perinephric fluid collection of unclear etiology. Correlation
with CT is recommended.
2. Pericholecystic fluid without evidence of gallbladder
dilatation or wall thickening is consistent with pericholecystic
edema secondary to impeded venous return (such as in portal
hypertension) or edema secondary to hypoproteinemia as in
anasarca.
3. Ascites.
.
CXR: [**2118-7-30**]
There is a left retrocardiac opacity and consolidation within
the left mid and lower lung fields. There is mild improved
aeration at the right base.
Findings are most likely due to pulmonary edema as opposed to
focal
consolidation. Left sided pleural effusion is also seen. There
are no
pneumothoraces.
.
CXR: [**2118-7-28**]
IMPRESSION: Increased interstitial markings most pronounced at
the lung
bases, which are nonspecific and may reflect atelectatic changes
but mild
pulmonary vascular congestion, or an atypical infection are not
excluded. No overt pulmonary edema is seen. A repeat
radiograph with improved inspiratory effort may be helpful for
further evaluation.
.
Chest CT [**2118-8-1**]
IMPRESSION:
1. Multifocal pneumonia.
2. Bilateral pleural effusions and bibasilar consolidations,
unchanged since CT abdomen and most likely reflecting areas of
atelectasis.
3. Anasarca.
.
Echocardiogram [**2118-8-1**]
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) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are structurally normal. No
mass or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
.
Abd CT [**2118-7-30**]:
IMPRESSION:
1. Bilateral pleural effusions with overlying atelectasis.
2. The previously noted perinephric fluid actually represents
perihepatic
fluid extending anterior to the right lobe of liver and inferior
to the left
lobe of liver. Both kidneys are normal in appearance without
evidence of
pyelonephritis. The constellation of bilateral pleural
effusions,
intra-abdominal fluid, and anasarca suggests fluid overload.
3. Thick-walled bladder suggestive of cystitis.
4. Moderately enlarged prostate.
.
Renal ultrasound [**2118-7-29**]:
IMPRESSION:
1. Small amount to right perinephric fluid, which in the
setting of ascites
could represent fluid in [**Location (un) 6813**] pouch.
2. Findings of right pleural effusion, ascites, GB mural edema,
distended IVC
all suggestive of cardiac decompensation/third spacing.
Correlate clinically.
.
MRI C/T/L Spin [**2118-7-28**]:
FINDINGS:
MR CERVICAL SPINE: Cervical vertebrae appear normal in height,
marrow signal
intensity and alignment. Craniocervical junction appears
normal. There are
discogenic endplate changes seen at multiple levels, most
prominent at C4-C5.
The cervical spinal cord shows normal morphology and signal
intensity.
At C2-C3, there is no disc herniation, spinal canal or neural
foraminal
narrowing.
At C3-C4, there is posterior disc osteophyte complex indenting
the thecal sac
without significant spinal canal narrowing. There is mild
bilateral neural
foraminal narrowing from uncovertebral and facet joint
osteophytes.
At C4-C5, there is posterior disc osteophyte complex effacing
the thecal sac
and remodeling the cervical spinal cord without focal cord
signal abnormality.
Uncovertebral and facet joint osteophytes result in moderate
right and mild
left neural foraminal narrowing.
At C5-C6, posterior disc osteophyte complex indenting the thecal
sac but no
significant canal narrowing is seen. Uncovertebral and facet
joint
osteophytes result in moderate right and mild left neural
foraminal narrowing.
At C6-C7, posterior disc osteophyte complex is effacing the
thecal sac and
remodeling the cervical spinal cord causing mild canal
narrowing.
Uncovertebral and facet joint osteophytes result in moderate
bilateral neural
foraminal narrowing.
At C7-T1, there is no disc herniation, spinal canal or neural
foraminal
narrowing.
Visualized pre- and para-vertebral soft tissues appear
unremarkable. There is
no abnormal enhancement concerning for epidural abscess.
MRI THORACIC SPINE: Thoracic vertebrae appear normal in height,
marrow signal
intensity and alignment. The thoracic spinal cord shows normal
morphology and
signal intensity. There is no abnormal enhancement seen in the
thoracic spine
concerning for epidural abscess. There are disc protrusions
seen at multiple
levels in the thoracic spine, most prominent at T6-T7 and T8-T9
levels with
indentation of the thoracic cord, but no cord signal abnormality
is seen.
There is no significant neural foraminal narrowing seen.
MRI LUMBAR SPINE: Lumbar vertebrae are normal in height, marrow
signal
intensity and alignment. Discogenic endplate marrow changes are
seen at L3-L4
level. The spinal cord terminates at mid L1 level. Conus
medullaris and
cauda equina have normal morphology and signal intensities.
At L2-L3, there is disc bulge, ligamentum flavum thickening and
facet joint
osteophytes causing mild spinal canal narrowing. Combination of
disc bulge
and facet joint osteophytes results in moderate left neural
foraminal
narrowing.
At L3-L4, there is disc bulge, ligamentum flavum and bilateral
facet joint
osteophytes resulting in mild canal stenosis. Disc bulge and
facet joint
osteophytes result in moderate-to-severe left neural foraminal
narrowing.
At L4-L5, there is a disc bulge with broad-based posterior
central and right
paracentral and foraminal disc protrusion causing severe
narrowing of the
subarticular recess, impinging the traversing right L5 nerve
root.
Combination of disc bulge and ligamentum flavum thickening
resulting in
moderate spinal canal stenosis.
At L5-S1, there is disc bulge which along with ligamentous
thickening results
in severe narrowing of the right subarticular recess impinging
the traversing
right S1 nerve root. Combination of disc bulge and ligamentum
flavum
thickening and facet joint osteophytes resulting in narrowing of
the left
neural foramen.
IMPRESSION: Multilevel degenerative changes in the cervical,
thoracic and
lumbar spine as described above with severe foraminal narrowing
and canal
stenosis at multiple levels. No evidence of epidural abscess
seen.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
====================================
Mr. [**Known lastname 26958**] is a 51M w/ HIV on HAART (last cd4 410 on [**2118-5-26**],
hep C (not treated), and IVDU (active) who presented with sepsis
from pyelonephritis and who then developed hypoxia and was found
to have multifocal pneumonia. Infectious Diseases followed him
during this admission.
ACTIVE ISSUES:
=======================
# Klebsiella Sepsis/UTI: Patient was admitted to the general
medicine floor for pyelonephritis and IV antibiotics. The
patient subsequently had Klebsiella growing in [**5-18**] bottles and
was transferred to the MICU twice in the setting of hypotension
and hypoxemia. He was briefly on pressors. He was covered
broadly with Cefepime while in the MICU but cultures later
returned as pansensitive and he was narrowed to ciprofloxacin.
- Patient will receive 7 more days of ciprofloxacin PO after
discharge to complete a 2 week course of antibiotics from first
negative blood culture ([**2118-7-29**])
- consider outpatient workup for why patient has recurrent UTIs.
- Patient advised to wear condoms every time
# Multifocal pneumonia: During the hospitalization the patient
developed worsening respiratory status. He subsequently had a CT
of his chest which showed multifocal pneumonia. He was covered
for Community Acquired pneumonia pathogens with 7 days of
cefepime and 5 days of azithromycin. He does has HIV, although
his last CD4 count was in the 400s in [**Month (only) 547**] (and 637 during this
admission) so felt to be unlikely to have PCP or other
opportunistic infection.
# Low back pain: Patient has chronic low back pain worse on the
left lumbar area, mildly tender to touch. No neurologic
deficits. Because of fevers and severe back pain at time of
admission the patient underwent MRI of spine. It did not show
any acute process but showed degenerative changes in the
cervical, thoracic and lumbar spine with severe foraminal
narrowing and canal stenosis at multiple levels.
- Outpatient follow-up for chronic back pain
# Substance Abuse: admission urine tox positive for amphetamines
and opioids. Patient reports actively using crystal meth prior
to admission.
- patient given information on drug treatment facilities
# Ascites seen on U/S: Unclear if patient has cirrhosis but does
have history of hepC which has not been treated. Recent
hepascore done outpatient was 0.96 which puts him at 54% of
cirrhosis. Patient had evidence of anasarca on CT which may have
been the cause. Patient also has portosystemic shunt in liver
segment seen on imaging since [**2116**] of uncertain significance.
- will follow-up with ID after discharge to consider treatment
for hepC
RESOLVED ISSUES:
=======================
# Thrombocytopenia: likely was secondary to sepsis as it
normalized as patient improved.
# Coagulopathy: Most likely nutritional given that INR improved
from 1.5 to 1.1 with vitamin K. Patient might also have early
cirrhosis as discussed above.
CHRONIC ISSUES:
=======================
# Depression:
- continued citalopram
# HIV:
- continue emcitritabine-tenofovir, darunavir, ritonavir
- f/u with Dr. [**Last Name (STitle) 724**]
# Hep C: currently not treated
- outpatient follow-up with Dr. [**Last Name (STitle) 724**]
TRANSITIONAL ISSUES:
==========================
# CODE STATUS: confirmed full
# CONTACT: Former Partner [**First Name8 (NamePattern2) **] [**Name2 (NI) **] designated as
HCP([**Telephone/Fax (1) 26959**]
# Notable labs on last check here: Hct 34.1, Retics 0.4, Albumin
2.4, CD4 637 on [**2118-8-1**]. These can be followed as an outpatient
after discharge.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Citalopram 20 mg PO DAILY
2. Darunavir 800 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Ritonavir (Oral Solution) 100 mg PO DAILY
to be given with darunavir
5. sildenafil *NF* 25-50 Oral prn
6. Terbinafine 1% Cream 1 Appl TP DAILY showering
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Darunavir 800 mg PO DAILY
3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
4. Ritonavir (Oral Solution) 100 mg PO DAILY
to be given with darunavir
5. Sildenafil *NF* 25-50 mg ORAL PRN erectile dysfunction
6. Terbinafine 1% Cream 1 Appl TP DAILY showering
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *Cipro 500 mg 1 Tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
8. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pyelonephritis
Multifocal Pneumonia
Severe sepsis
SECONDARY DIANOGSIS:
HIV
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 26958**], it was a pleasure taking care of you here at [**Hospital1 1535**].
You were hospitalized with an infection in your blood, kidney,
and lungs. You were seriously ill and required intensive care.
You improved with treatment with antibiotics.
You will need to take a few more days of antibiotics after you
leave to be sure you get rid of the infection completely.
It is VERY important for your health that you stop using drugs.
Followup Instructions:
Name: [**Last Name (LF) 724**], [**Name8 (MD) **] MD
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 18406**]
Phone: [**Telephone/Fax (1) 3581**]
When: Thursday, [**2116-9-9**]:30 AM
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73,941
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48264
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Discharge summary
|
report
|
Admission Date: [**2112-5-18**] Discharge Date: [**2112-5-25**]
Date of Birth: [**2032-12-4**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine / Clindamycin / Dilaudid
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
dyspnea, hypoxemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79yo F with h/o COPD (gold iv on home o2) and recent admission
for pneumonia who presents with dyspnea and hypoxemia. Her
husband died suddenly last thursday of an intracranial hemmorage
and she has not had anything to eat or drink since then. The
wake was yesterday and the funeral today. She arrived to the ED
from her husbands [**Name (NI) 101683**] via limo. She states that she has
had worsening dyspnea and increased oxygen requirement. She does
not have cough or change in sputum production. She had one fever
at home. She has also had nausea and vomiting which has been a
chronic problem and vomited the azithromycin she was given. She
was recently admitted (discharged on [**4-21**]) with weakness and was
treated with 8 day course of vanc/cefepime and azithro x 5 days
for HCAP. Per PCP notes, she has had fradually worsening dyspnea
over the past several months with several courses of prednisone
initiated in [**State 108**]. She was also hospitalized here in
[**Month (only) 956**].
.
In the ED, initial vs were: 114 139/71 19 84RA, 100% neb. A CXR
showed LUL PNA. She was given nebs, 4L NS, ceftriaxone,
azithomycin, vancomycin, methylprednisolone 125, zofran,
kayexylate and tylenol.
.
Vitals on transfer 97.4, 110, 140/54, 28, 96% 4L
.
On the floor, she is breathing comfortably. She denies chest
pain now but did say she had a brief pain at her left costal
margin that was associated with coughing. She states that she
was improving from her last discharge steadily until her husband
passed away and then began to feel dyspneic and very weak with
symptoms most noteable with exertion and less with rest. She has
had some weight loss of about 15 pounds over the past several
months which she attributes to poor appetite from recurrent
illnesses.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, diarrhea, dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
# COPD on 2L O2 at home: FEV1 0.43 L on [**2111-11-2**], FEV1/FVC 46%
# CAD, status post remote inferior MI at age 45 per pt report
# Hypertension
# Hypercholesterolemia
# Hyperglycemia in the setting of steroid use
# Osteoporosis
# Lung nodules seen on CT in [**2103**], which have been followed
# Restless leg syndrome
# Insomnia
# s/p carpal tunnel release
Social History:
She has 4 children and 4 grandchildren. She is a retired travel
[**Doctor Last Name 360**]. Tobacco: quit tobacco 14 years ago, 80-plus-pack-year
history. ETOH: occasional ethanol.
Family History:
No family history of lung problems.
Physical Exam:
Admission exam:
Tmax: 35.9 ??????C (96.7 ??????F)
Tcurrent: 35.9 ??????C (96.7 ??????F)
HR: 101 (101 - 102) bpm
BP: 136/58(77) {136/58(77) - 136/58(77)} mmHg
RR: 20 (20 - 21) insp/min
SpO2: 93%
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, dry MM
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Breath Sounds: Wheezes : , Diminished: )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Discharge exam:
Pertinent Results:
Admission labs:
[**2112-5-18**] 01:45PM BLOOD WBC-27.0*# RBC-3.83* Hgb-10.5* Hct-33.9*
MCV-89 MCH-27.3 MCHC-30.8* RDW-20.9* Plt Ct-355
[**2112-5-18**] 01:45PM BLOOD Neuts-93* Bands-2 Lymphs-2* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2112-5-18**] 01:45PM BLOOD Glucose-316* UreaN-16 Creat-0.7 Na-128*
K-6.7* Cl-88* HCO3-26 AnGap-21*
[**2112-5-18**] 01:45PM BLOOD cTropnT-<0.01
[**2112-5-18**] 08:05PM BLOOD cTropnT-<0.01
[**2112-5-18**] 02:02PM BLOOD Glucose-304* Lactate-3.7* Na-129* K-6.9*
Cl-87* calHCO3-29
[**2112-5-18**] 02:26PM BLOOD K-5.4*
[**2112-5-18**] 05:45PM BLOOD Lactate-4.4*
[**2112-5-18**] 03:20PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2112-5-18**] 03:20PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
[**2112-5-18**] 03:20PM URINE RBC-1 WBC-5 Bacteri-FEW Yeast-NONE Epi-2
TransE-<1
[**2112-5-18**] 03:20PM URINE CastGr-4* CastHy-29*
Chest X-Ray:
IMPRESSION: Significantly progressed/new consolidation in the
left upper and lower lung worrisome for extensive pneumonia.
Possible left pleural effusion.
Brief Hospital Course:
Ms. [**Known lastname 26172**] is a 79 year-old woman with a history of COPD who
presented with dyspnea, hypoxemia, CXR consistent with left
multifocal pneumonia.
# Pneumonia/Respiratory Distress: Patient with marked
leukocytosis with bandemia, tachypnea, tachycardia initially
thought to be secondary to pneumonia. Her oxygen requirement
improved with antibiotic treatment with vancomycin, cefepime and
ciprofloxacin, however her chest x-ray continued to worsen,
concerning for a possible malignancy. With her deteriorating
lung function over the past several months and her goals of
care, a meeting was held with her daughters and outpatient
providers the final decision was made to continue antibiotic
treatment for a full 14 day course since we were unable to
obtain a sputum culture, along with supplemental oxygen therapy
but otherwise to focus on comfort. She was started on an
increased dose of klonopin, along with dilaudid 1-2mg Q2h prn
breathlessness, zyprexa QHS and prn ativan, the dilaudid was the
most helpful for her symptoms. Her antibiotic course will be
completed on [**2112-6-1**]. She will also be continued on prednisone
35mg daily and standing nebulizer treatments to help with her
breathing.
.
.
#COPD: Gold stage IV on home O2. Patient was treated for COPD
exacerbation with prednisone 60 mg daily for 5 days, standing
nebs and then tapered back to her home dose of prednisone 35mg
daily.
.
#CAD: Continued aspirin.
.
#HTN: continue her home verapamil
.
#Dyslipidemia: discontinued her home Lipitor given her goals of
care
.
#Osteoporosis: discontinued her home regimen
.
#Diabetes: currently treating with glargine 8units QHS and
checking blood sugars in the morning
.
#Seasonal Allergies: continued on astelin and montelukast
.
#Insomnia/anxiety/recent stressers: Patient recently lost
husband. Social work was consulted for support, her medication
regimen was changed as above and she should be continued to be
followed by the palliative care team
.
Transition Issues:
1. Should be continued to be followed by the palliative care
team at the MACU
2. Patient is DNR/DNI
Medications on Admission:
-Albuterol 90 mcg HFA inhaler 2 puffs QID prn
-Advair 500mcg/50mcg 1 puff [**Hospital1 **]
-Ipratropium 17mcg HFA inhaler 1 puff Q6h
-Ipratropium/albuterol 2.5mg-0.5mg/3mL nebs Q6-8h prn
-Tiotropium 18mcg inhaled once daily
-Prednisone taper: currently 35mg once daily, tapering by 5mg
every Sunday.
-Bactrim ss 1 tablet po daily
-ASA 162mg once daily
-Verapamil XR 120mg once daily
-Lipitor 80mg once daily
-Omeprazole 40mg once daily
-Docusate 100mg [**Hospital1 **]
-Novolog sliding scale: BG 250-299 - 4 units, 300-349 - 6 units,
350-399 - 8 units, >400 - 10 units and [**Name8 (MD) 138**] MD.
-Metformin 500mg [**Hospital1 **]
-Astelin 137mcg 2 sprays in each nostril [**Hospital1 **]
-Montelukast 10mg QHS
-Clonazepam 0.5mg [**Hospital1 **] (typically in the afternoon and at
bedtime)
-Melatonin OTC - dosage unclear.
-Ascorbic acid 250mg once daily
-Ferrous sulfate 325mg once daily
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Puff Inhalation [**Hospital1 **] (2 times a day).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for shortness of breath or wheezing.
9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
10. verapamil 120 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q24H (every 24 hours).
11. prednisone 10 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
13. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO four times a
day: Hold for sedation, RR<12.
14. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety: Please try dilaudid first .
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
17. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
18. Dilaudid 2 mg Tablet Sig: 0.5-1 Tablet PO q2h as needed for
shortness of breath or wheezing.
19. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours) for 7 days.
21. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 7 days.
22. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: Four
Hundred (400) mg Intravenous Q12H (every 12 hours) for 7 days.
23. insulin glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous HS (at bedtime): Have been checking blood sugar
with morning labs.
24. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection TID (3 times a day): Please offer TID, patient may
refuse.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY: Pneumonia, COPD exacerbation, Anxiety
SECONDARY: Hypertension, Osteoporosis
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:
It was a pleasure to participate in your care Ms. [**Known lastname 26172**]. You
were admitted to the hospital with difficulty breathing and you
were found to have a pneumonia. We treated your pneumonia with
antibiotics and gave you medications to help your breathing.
After a discussion with your family and pulmonologist, Dr.
[**Last Name (STitle) **] we decided to continue treat your pneumonia and give you
oxygen but wanted to focus on comfort as the main goal, using
medications to help treat your breathlessness.
Please make the following changes to your medications:
1. Add vancomycin for seven more days
2. Add cefepime for seven more days
3. Add cipro for seven more days
4. Add ativan
5. Add zyprexa
6. Add dilaudid
Followup Instructions:
You will follow-up with the doctor at the extended care
facility.
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2112-6-8**] at 2:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2112-6-8**] at 3:00 PM
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2112-6-8**] at 3:00 PM
With: DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"486",
"249.00",
"401.9",
"518.89",
"V58.67",
"780.52",
"285.9",
"412",
"V49.86",
"V46.2",
"733.00",
"511.9",
"300.00",
"V15.82",
"E932.0",
"491.21",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
10714, 10780
|
4998, 7107
|
334, 341
|
10909, 10909
|
3860, 3860
|
11840, 12665
|
2898, 2935
|
8047, 10691
|
10801, 10888
|
7133, 8024
|
11085, 11635
|
2950, 3824
|
3841, 3841
|
11664, 11817
|
2152, 2295
|
276, 296
|
369, 2133
|
3876, 4975
|
10924, 11061
|
2317, 2678
|
2694, 2882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,466
| 112,577
|
34279
|
Discharge summary
|
report
|
Admission Date: [**2154-8-13**] Discharge Date: [**2154-8-19**]
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
consulted for Subdural hematomas
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87M with a history of Parkinson's disease and atrial
fibrilliation on coumadin, who presented to OSH after he was
found down in his yard by a neighbor. The patient was able to
describe that he was getting his mail and tripped and fell,
hitting his head but no loss of concsciousness, although he does
not recall exactly what happened. Per EMS, he had
perserveration, but denied headache, neck pain, extremity pain
or
parasthesias. He was A+Ox 3 at OSH and upon arrival to [**Hospital1 18**] ED
this afternoon. CT scan at OSH demonstrated bilateral subdural
hematomas, L frontal hematoma 13mm and R frontal hematoma 4mm,
with subarachnoid hemorrage extending into parietal convexities,
without midline shift. INR 1.9. Received 2u FFP and Vit k prior
to transfer.
Of note, patient was offered surgery for his valvular disease a
few months ago, but decided against it and made himself DNR
status.
Past Medical History:
AFIB, parkinsons, CHF, aortic valvular disease
Social History:
lives alone. Occasionally smokes, no ETOH.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM upon admission:
T: 97.6 BP: 149/70 HR: 98 AF R 19 O2Sats 99% 4LNC
Gen: WD/WN, comfortable, NAD.
HEENT: MM dry, no teeth. Abrasion to central occiput, no
hematoma. face is atraumatic
Pupils: equal reactive to light 3->2mm
Neck: Supple, non tender
Lungs: course B/L, decreased bases.
Cardiac: irregularly irregular
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake but drowsy, cooperative with exam, normal
affect.
Orientation: Oriented to person only. Was A+O x 3 earlier, now
cannot name date or place
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 2mm
bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally.
Strength full power [**6-3**] throughout. No pronator drift
Sensation: Intact to light touch.
Toes downgoing bilaterally
Pertinent Results:
CHEST RADIOGRAPH [**2154-8-15**]
INDICATION: Intraparenchymal hemorrhage.
COMPARISON: [**2154-8-13**].
FINDINGS: There is no relevant change. Moderate cardiomegaly,
mild
distension of the pulmonary vasculature. No evidence of pleural
effusion, no focal parenchymal opacities suggestive of
pneumonia.
Head CT [**2154-8-14**]:
FINDINGS: There is no significant change in multi-compartmental
blood 13 hours after the most recent scan. There is slightly
more intraventricular blood, but no evidence of obstruction. No
new hemorrhage is seen. No evidence of herniation or other short
interval change is seen.
IMPRESSION:
1. No significant change in multi-compartmental blood 13 hours
after the most recent scan.
2. Slight increase in intraventricular blood, but no evidence of
obstructive hydrocephalus.
Head CT [**2154-8-13**]: Final Report
INDICATION: Fall and subdural hematoma, transferred from outside
hospital.
COMPARISON: Outside hospital study obtained at approximately 10
a.m. on
[**2154-8-13**] Hospital.
TECHNIQUE: Non-contrast head CT with additional bone algorithm
reconstructions.
FINDINGS: There is marked interval worsening of bifrontal
subdural,
subarachnoid, and intraparenchymal hemorrhage. A large focus of
intraparenchymal hemorrhage in the left inferior frontal lobe
measuring 2.3 x 3 cm was not noted on the prior study. There is
also increased hemorrhagic component layering along the
interhemispheric fissure and falx cerebri.
Multiple bilateral foci of subarachnoid hemorrhage involving
left inferior
temporal, bilateral frontal, posterior frontoparietal are noted.
There is
mild perihemorrhagic edema most prominently noted in the left
inferior frontal lobes without significant mass effect or shift
of normally midline structures.
There is no intraventricular hemorrhage, entrapment or
hydrocephalus.
Bilateral basal ganglia and insular cortex demonstrates old
lacunar infarct.
The basilar cisterns are preserved without evidence of downward
transtentorial herniation. There is posterior soft tissue
thickening with scalp hematoma noted superiorly. Air-fluid
levels and mucosal thickening is noted in the left sphenoid and
right maxillary antrum. There is also mucosal thickening in
bilateral anterior and posterior ethmoid air cells, left
maxillary sinus and middle sphenoid sinus. Small amount of air
is noted in the cavernous sinus which could be iatrogenic.
Additionally, there is also minimal opacification of bilateral
mastoid air cells. Impacted right upper molar is noted in the
right maxillary antrum.
Osseous structures demonstrate nondisplaced midline frontal bone
fracture.
IMPRESSION:
1. Mild interval worsening of bifrontal subdural, subarachnoid
and
intraparenchymal hemorrhage. Additional foci of subarachnoid
hemorrhage are also noted bilaterally involving the
frontoparietal and inferior temporal regions. There is no
intraventricular hemorrhage on the current study.
2. Small amount of air in the cavernous sinus could be
iatrogenic.
3. Nondisplaced midline frontal bone fracture.
4. Mucosal thickening in multiple paranasal sinuses, and
bilateral mastoid
air cell opacification as described above.
Brief Hospital Course:
The patient was admitted on [**8-13**] to the ICU. He received FFP and
factor IX to reverse his INR as well as vitamin K. He was put on
mannitol to decrease swelling in the brain. He was also put on
dilantin. The patient was DNR/DNI when he arrived to the
hospital. Cardiology was consulted who agreed with giving him
additional lasix due to his CHF history after receiving FFP. On
[**8-14**] there was a family meeting and they decided to all him to
be intubated if necessary for short-term. The patient's exam
remained stable. He received FFP again on [**8-15**] and [**8-16**] for
elevated INR. On [**8-16**] he was transferred to the stepdown unit.
Over the weekend the patient's neuro exam became worse. The
family decided to make him DNR/DNI again and to make him comfort
measures only. Geriatrics was also consulted to help with his
management. He was unresponsive on [**8-19**] in the morning but his
pupils were reactive. He did have a grasp bilaterally and
withdrew with the lower extremities. Palliative care was
consulted and they recommended adding a morphine bolus in
addition to the morphine drip. During the afternoon of [**8-19**] the
patient's respirations were increasing and he received a
morphine bolus. He expired at 3:45 on [**8-19**] and both his sons
were notified shortly afterwards.
Medications on Admission:
coumadin 3mg daily,
carbidopa/levo 25/250 QID, furosimide 40mg daily, lopressor 25mg
daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
SDH
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2154-8-19**]
|
[
"427.31",
"585.9",
"414.01",
"801.21",
"332.0",
"E885.9",
"424.1",
"403.90",
"V66.7",
"428.0",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7206, 7215
|
5723, 7035
|
265, 271
|
7263, 7273
|
2544, 5700
|
7326, 7362
|
1347, 1365
|
7177, 7183
|
7236, 7242
|
7061, 7154
|
7297, 7303
|
1380, 1396
|
193, 227
|
299, 1199
|
1948, 2525
|
1410, 1772
|
1787, 1932
|
1221, 1270
|
1286, 1331
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,922
| 121,235
|
53176
|
Discharge summary
|
report
|
Admission Date: [**2186-8-20**] Discharge Date: [**2186-8-31**]
Service: SURGERY
Allergies:
Advil
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
1. Laparoscopic cholecystectomy.
2. Laparoscopic lysis of adhesions approximately 2.5 hours.
History of Present Illness:
[**Age over 90 **] yo F with one day of epigastric abdominal pain, nausea,
vomiting, and diarrhea. Non-bloody, non-bilious vomitus.
Non-bloody, brown, watery diarrhea. A CT scan of the abd/pelvis
shows a large, distended gallbladder with a small amount of
pericholecystic fluid. US notes the presence of sludge within
the
gallbladder, however the patient's pain is clearly centered over
the epigastrium and not in the RUQ.
Her LFTs were elevated as listed below, raising concern for a
common duct stone (Tbili 1.6, baseline 0.3-0.5), and
transaminitis concerning for perhaps some other primary liver
disease. Her lipase is elevated, though, which could account for
the n/v/d and abdominal pain.
Past Medical History:
Type II DM--diagnosed in [**2165**]'s, diet controlled
HTN
Left breast CA s/p lumpectomy and RT-[**2180-3-16**]
Gastric cancer--Stage III, s/p gastrectomy [**2169**]
GERD
osteoporosis
arthritis
tinnitus
Fe deficient anemia
cataract
Social History:
The patient lives in [**Location 686**] with her sister, two daughters,
and a son. She had 14 children, but many are deceased. She moved
to the US from [**Location (un) **] in [**2155**]. She denies alcohol, smoking, and
recreational drug use.
Family History:
Her mother died at age 53 from an unspecified cancer. Her father
died at 43 of "natural causes". No family history of CAD, but
sister has Type II DM.
Physical Exam:
PE:
99.6 90 107/47 24 982L
NAD, lying comfortably in bed
RRR
CTA B
S/ND/tender in the epigastrium
WWP
Pertinent Results:
[**2186-8-19**] 08:15PM WBC-8.0# RBC-3.97* HGB-12.6 HCT-38.9 MCV-98
MCH-31.8 MCHC-32.4 RDW-14.3
[**2186-8-19**] 08:15PM NEUTS-91.8* LYMPHS-6.1* MONOS-1.1* EOS-0.2
BASOS-0.8
[**2186-8-19**] 08:15PM PLT COUNT-175
[**2186-8-19**] 08:15PM ALT(SGPT)-371* AST(SGOT)-944* ALK PHOS-130*
TOT BILI-1.6*
[**2186-8-19**] 08:15PM LIPASE-211*
[**2186-8-19**] 08:15PM GLUCOSE-194* UREA N-18 CREAT-1.2* SODIUM-141
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
[**2186-8-20**] 06:40AM ALT(SGPT)-569* AST(SGOT)-1071* ALK PHOS-130*
TOT BILI-2.2* DIR BILI-2.1* INDIR BIL-0.1
[**2186-8-20**] 06:40AM LIPASE-689*
[**2186-8-20**] 06:40AM GLUCOSE-147* UREA N-16 CREAT-1.3* SODIUM-142
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-27 ANION GAP-14
[**2186-8-19**] CT Abd : . Distended gallbladder with minimal
pericholecystic fluid and likely gallbladder sludge. Correlation
to physical examination, clinical history and liver function
tests is recommended. If this correlation is equivocal, these
findings could be further evaluated via son[**Name (NI) 867**].
2. Atherosclerotic disease.
3. Cardiomegaly.
4. Periportal edema likely reflecting overhydration.
5. Bilateral renal hypodensities, some of which are cysts,
others of which
are too small to characterize.
6. Central uterine hypodensity, likely endometrial and unchanged
from
previous studies. If patient has vaginal bleeding, consider
outpatient
ultrasound.
[**2186-8-20**] Liver US : Large gallbladder with mobile sludge and
stones as well as mild mural edema and trace pericholecystic
fluid. The common bile duct is normal measuring 3 mm.
[**2186-8-22**] ERCP : Evidence of a prior Roux-en-Y surgery was seen.
Both limbs were evaluated.
The ampulla could not be reached due to the patient's surgical
anatomy.
[**2186-8-24**] Cardiac echo : The left atrium is normal in size. There
is moderate symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Overall left ventricular
systolic function is normal (LVEF 75%). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is a mild resting left ventricular outflow
tract obstruction. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall is hypertrophied. Right ventricular
chamber size is normal. with normal free wall contractility. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2186-8-19**] 10:45 pm BLOOD CULTURE
**FINAL REPORT [**2186-8-26**]**
Blood Culture, Routine (Final [**2186-8-26**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE.
FUSOBACTERIUM SPECIES. BETA LACTAMASE NEGATIVE.
UNABLE TO FURTHER SPECIATE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Ms. [**Name13 (STitle) **] was evaluated by the ACS service in the Emergency
Room and admitted to the hospital with gallstone pancreatitis.
She was made NPO, hydrated with IV fluids and cultured. She had
one positive blood culture for Klebsiella and was placed on
Unasyn.
She underwent ERCP to clear the CBD but the procedure was
aborted due to her prior Roux En Y and subsequent inability to
reach the ampulla. Although she was a high risk operative
candidate due to her age and heart disease, she was also at a
high risk for recurrent pancreatitis.
The Cardiology service evaluated her and a cardiac echo revealed
a normal EF with no new wall motion abnormalities. Her blood
pressure and heart rate was controlled with beta blockers and
although a high surgical risk she was cleared for surgery.
She was taken to the Operating Room on [**2186-8-25**] and underwent a
laparoscopic cholecystectomy. She tolerated the procedure well
and returned to the PACU in stable condition. She maintained
stable hemodynamics and her pain was well controlled. Following
transfer to the surgical floor she made very good progress. Her
diet was gradually resumed on post op day # 2 after following a
gradual decline in her LFT's. Her surgical ports were healing
well and her pain was controlled with Tylenol alone.
The Physical Therapy service worked with her daily and she was
up and ambulating independently with a rolling walker. She had
no chest pain or shortness of breath and her pre op medications
were resumed with good blood pressure control. After an
uneventful recovery she was discharged to home on [**2186-8-31**] and
will follow up with the [**Hospital 2536**] Clinic in [**1-18**] weeks.
Medications on Admission:
Vitamin B-12 1 mg', Triamcinolone 0.1 % [**Hospital1 **] prn, Acetaminophen
500'''prn, Atenolol 50'', Clonazepam 0.5-1 qhs prn, Lisinopril
10', Omeprazole 20', Mylanta prn, nitroglycerin 0.4 SL q5" x 3
prn, Colace 100'', Sucralfate 1 tid, Multivitamin Tab 1
Tablet(s) by mouth once a day
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO three times a
day.
7. Vitamin B-12 500 mcg Tablet Sig: Two (2) Tablet PO once a
day.
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Gallstone pancreatitis, status post
total gastrectomy
Gram negative bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* 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 [**9-29**] 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:
Call the [**Hospital 2536**] Clinic at [**Telephone/Fax (1) 600**] for a follow up appointment
in [**1-18**] weeks.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2186-9-6**] 3:00
Completed by:[**2186-8-31**]
|
[
"427.1",
"250.00",
"388.30",
"562.10",
"577.0",
"041.3",
"V10.3",
"530.81",
"280.9",
"568.0",
"401.9",
"574.90",
"366.8",
"577.1",
"716.90",
"790.7",
"V10.04",
"733.00",
"V15.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.51",
"51.23",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
8351, 8408
|
5662, 7362
|
227, 322
|
8531, 8531
|
1875, 5639
|
9984, 10284
|
1582, 1733
|
7701, 8328
|
8429, 8510
|
7388, 7678
|
8682, 9614
|
1748, 1856
|
173, 189
|
9626, 9961
|
350, 1048
|
8546, 8658
|
1070, 1304
|
1320, 1566
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,909
| 175,121
|
49709
|
Discharge summary
|
report
|
Admission Date: [**2182-10-27**] Discharge Date: [**2182-10-30**]
Date of Birth: [**2125-9-30**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Gentamicin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Right lower quadran pain
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
Mr. [**Known lastname **] is a 57 year old man with a history of type I
diabetes mellitus, status post pancreas-[**Known lastname **] transplant
(failed), coronary artery disease, s/p multiple stents,
congestive heart failure with EF: 50-55%, hepatitis B and C who
p/w RLQ pain.
The patient states that he had onset of severe (can't rate),
sharp, RLQ pain 1d prior to admission that woke him from sleep.
The pain was non-radiating worse w/ any movement and
non-positional. He reports that the pain is essentially
constant. He had 2 bowel movements that were normal and large
yesterday. He did not strain, and they were formed and of
normal consistency.
The pain was unchanged after the bowel movement. He has had no
bowel movement today. The stool is non-bloody, and normal in
color (not tarry or [**Male First Name (un) 1658**] colored). He has had minimal PO intake
[**1-2**] anorexia. No change in pain w/ p.o. intake. Denies
n/v/diarrhea. Denies fever/chlls/rash. +chills, no rigors.
In the emergency department transplant surgery evaluated him and
felt he had no surgical issues. He received synthroid,
amiodarone, toprol xl, prednisone, prontonix, lipitor, phoslo,
renagel, regular insulin (doses as listed in med list), dilaudid
2mg iv x4, vanc/levo/flagyl, and decadron 8mg iv (given as
stress dose because ED thought pt would need surgery). Noted to
be hypoglycemic to 20s in ED, and he was given 1amp D50.
Past Medical History:
1. ESRD: status pancreas-kidney transplant [**2164**], status post
cadaveric [**Year (4 digits) **] transplantation in [**2172**], now requiring dialysis
3x/wk
2. CAD: s/p myocardial infarction in [**2164**], s/p LCX stenting in
[**2174**], s/p LCX and OM3 stenting in [**2175**], s/p mid-LCX stenting on
'[**78**], s/p OM3 restenting in '[**78**]
3. DM
4. Hypothyroidism
5. Hypercholesterolemia
6. Hep C (dx in '[**75**]), viral load and Hep B
7. CVA in [**2174**] with residual left-sided weakness
8. PVD
9. Diverticulitis, status post colostomy and Hartmann's pouch in
[**2175**],
status post reversal in [**6-3**], last Colonscopy ([**12-4**]): Erythema,
friability and granularity in the very distal portion of the
colon, just inside the afferent limb of the stoma, with
overlying clot. Brown stool with no bleeding proximal to this.
10. PVD s/p multiple digit amputations
11. GERD
12. Wheelchair bound after gentamicin related vertigo
13. PAF: diagnosed in [**2175**], continued on CCB and started on Amio
at that time
14. Benign prostatic hypertrophy, status post transurethral
resection of the prostate.
15. SBP [**1-31**]
16. CHF with an EF:50-55%
Social History:
Patient lives with his wife. They have two children who live
nearby. He previously worked as a plummer but is now retired. He
has a 30pk year smoking hx but quit 10 years ago. He denies IVDU
and alcohol use.
Family History:
[**Name (NI) 1094**] father died at age 56 of MI, with DM and a "big heart".
Mother died age 84 of "old age" s/p CVA, with DM and HTN. Sister
has Grave's dz and brother died of 56 with DM.
Physical Exam:
t97.3, bp 142/37, p 60, r 14, 97% ra
Well appearing male in NAD
Pupils: L 1mm- surgical, R 3mm reactive.
OP clr, dry MM
Neck supple, 7cm JVP
Regular s1,s2. no m/r/g. L chest HD catheter w/o
erythema/swelling.
b/l basilar rales R>L
R 5 cm subchondral scar, 7cm midline laparotomy scar. +bs. soft.
+exquisite RLQ tenderness, moderate RUQ tenderness. +guarding.
no rebound.
guiac neg by ED note.
no le edema/cyanosis/clubbing
+mult digital amputations.
alert and oriented x3
Pertinent Results:
EKG: sinus brady, LAD/ LAFB, QTC prolonged at 516
.
cxr: No radiographic evidence of acute cardiopulmonary process.
No free air under the diaphragm
.
ct: No evidence of appendicitis or other focal fluid
collections.
ADMISSION LABS:
[**2182-10-27**] 02:32PM GLUCOSE-100 UREA N-40* CREAT-7.8*# SODIUM-135
POTASSIUM-5.1 CHLORIDE-95* TOTAL CO2-24 ANION GAP-21*
[**2182-10-27**] 02:32PM ALT(SGPT)-14 AST(SGOT)-24 ALK PHOS-433*
AMYLASE-21 TOT BILI-0.3
[**2182-10-27**] 02:32PM WBC-5.1# RBC-4.37*# HGB-14.2# HCT-42.6#
MCV-98# MCH-32.5* MCHC-33.4 RDW-14.6
[**2182-10-27**] 02:32PM PLT COUNT-134*
[**2182-10-27**] 02:32PM PT-12.9 PTT-33.1 INR(PT)-1.1
[**2182-10-27**] 02:37PM LACTATE-1.9
Brief Hospital Course:
Patient is a 55 year-old gentleman with history of DMI,
pancreas/[**Month/Day/Year **] transplant (failed), ESRD, CAD s/p multiple
stents, CHF (EF 50-55%), Hep B/C who was initially admitted on
[**10-27**] for RLQ pain. Pt reported RLQ pain to be sharp ([**9-9**])and
consistent exacerbated by movement. Pt reports similar pain in
[**2179**] that resulted in colostomy for perforated colon. Pt reports
intermittent episodes of chills since [**10-26**] but denies
F/N/V/BRBPR/diarrhea/constipation. CT negative for obstruction
or appendicitis. Evaluated by transplant team but determine not
to have any surgical issues. While on floor, patient became
bradycardic to 30s, hypotensive to systolic 90s, and developed
chest pain on [**10-28**]. EKG revealed ventricular escape rhythm. EP
was consulted and patient received pacer, placed in right
cephalic vein.
.
# Cardiac
= Rhythm: Patient received pacer [**2182-10-28**]. Unknown etiology of
arrhythmia, most likely secondary to extensive CAD. Pt back on
beta-blocker and amiodorone
= PUMP: EF >60% per ECHO [**7-5**]. Fluid overloaded per CXR and labs
but dry on exam - dealt with via dialysis.
= ISCHEMIA: Patient with chest pain in setting of bradycardia.
Pt found to have elevated 0.20 trop, likely due to [**Month/Year (2) **] failure
.
# RLQ pain - unclear etiology. ruled out for appendicitis,
perforation. pyelonephritis a possibility but no stranding
related to either native or transplant kidneys. in d/w
radiology, not clearly related to constipation as not impressive
amts of stool. symptoms not c/w mesenteric/colonic ischemia and
pt is guiac neg. possible infectious etiology, ? c.diff, but nl
wbc so not high suspicion. Patient with history of abdominal
pain in past- could be hepatic or splenic infarct vs. atypical
chest pain. At this point pt describes that pain has decreased
signficantly and now has a good appetite.
- PRN Dilaudid for pain control
- Check [**Last Name (un) 104**] stim, could be related to adrenal insufficiency
# ESRD s/p [**Last Name (un) **] transplant
- continued on HD, monitor electrolytes
- HD M/W/F , this wk, pt received HD on Tuesday as well
continue renagel/phoslo
- increase phoslo to 3 pills TID, send PTH
- check ionized calcium
- pt found to be hyperkalemic with a potassium of 6 given 15 of
kayexalate and 1 amp of bicarb.
# ? ANEMIA - at goal
- continue epo 10,000
- iron studies TIBC decreased at 216 ,Ferritin levels wnl at
315, TRF decreased at 166.
# s/p transplant
- can stop t-plant meds per transplant team (bactrim,
prednisone)
# DM
- cont lantus and humalog SS
Medications on Admission:
Renagel
Phoslo
synthroid 200mcg qday
prednisone 5mg qday
toprol xl 12.5 mg qday
amiodarone 400 mg qday
asa 325mg qday
protonix 40mg qday
lipitor 10mg qday
lantus 15 hs, humalog ss
bactrim TIW
Discharge Medications:
1. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous once a day.
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed: no substituion.
Disp:*20 Tablet(s)* Refills:*0*
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 2646**]
Discharge Diagnosis:
Bradycardia
Type I diabetes mellitus complicated by [**Last Name (un) **] failure
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please take your medications as directed.
Followup Instructions:
1) Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2182-11-5**] 10:30
2) Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 14200**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2182-11-14**] 8:35
|
[
"789.03",
"428.0",
"585.6",
"414.01",
"V45.82",
"996.86",
"250.41",
"996.81",
"427.81",
"401.9",
"427.31",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"39.95",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
8820, 8876
|
4621, 7200
|
307, 329
|
9002, 9011
|
3905, 4122
|
9202, 9464
|
3207, 3397
|
7443, 8797
|
8897, 8981
|
7226, 7420
|
9035, 9179
|
3412, 3886
|
243, 269
|
357, 1785
|
4138, 4598
|
1807, 2965
|
2981, 3191
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,507
| 132,742
|
24799
|
Discharge summary
|
report
|
Admission Date: [**2144-11-9**] [**Month/Day/Year **] Date: [**2144-11-12**]
Date of Birth: [**2099-1-29**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**Known firstname 1257**]
Chief Complaint:
EtOH intoxication, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 45 yo M with hx of EtOH abuse, withdrawal/DTs
with seizures (last 6 months ago in setting of withdrawal) who
presented to ED with chest pressure 2-3 days described as
similar to past pericarditis: dull pressure in center of chest,
non-radiating, + pleuritic. No f/c, no SOB but + dry cough.
Recent admission [**10-22**] for similar chest pain as well as active
withdrawal, admitted to MICU.
.
In [**Name (NI) **], pt was placed on a CIWA scale. He stated, "I feel like
I'm coming off the booze." CIWA score 11, given 2mg Ativan IV x
1. Received total of 3 L NS, including a banana bag. EKG with
new TWI anteriorly compared with prior so enzymes sent.
Past Medical History:
- EtOH abuse x 20 years (withdrawal/seizures 6 months ago)
- Hx of pericarditis (s/p window ~[**2139**]-[**2140**] per notes)
- Depression
- GERD
Social History:
Homeless, searching for apt. Recently divorced. Drinks [**2-5**]
pints vodka daily. Hx tobacco in past, none recently. No IVDU.
Family History:
Mother - healthy. Father - unknown. Aunts and uncles with
alcoholism
Physical Exam:
Per MICU Admission note:
VS (on arrival to MICU): T 97 HR 106 Bp 116/68 RR 11 Sat 95 RA
GEN: Sleepy but arouses easily, conversant, + EtoH halitosis
HEENT: PERRL; + lateral nystagmus that fatigues; poor dentition
Neck: Supple
Lungs: CTAB
Heart: s1s2 tachy, no m/r/g
Abd: +BS, soft, NT/ND
Ext: WD/WP; radial & DP 2+,
Neuro: MAE, speech fluent but slightly slurred
.
Pertinent Results:
[**2144-11-9**] 09:36PM WBC-4.9# RBC-3.48* HGB-11.6* HCT-32.7* MCV-94
MCH-33.2* MCHC-35.3* RDW-14.5
[**2144-11-9**] 09:36PM NEUTS-48.2* LYMPHS-45.7* MONOS-3.9 EOS-1.6
BASOS-0.6
[**2144-11-9**] 09:36PM PLT COUNT-229#
.
[**2144-11-9**] 09:36PM GLUCOSE-99 UREA N-11 CREAT-0.6 SODIUM-142
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-28 ANION GAP-17
[**2144-11-9**] 09:36PM ALT(SGPT)-28 AST(SGOT)-38 CK(CPK)-155 ALK
PHOS-77 AMYLASE-159* TOT BILI-0.4
[**2144-11-9**] 09:36PM LIPASE-39
[**2144-11-9**] 09:36PM ALBUMIN-4.8 CALCIUM-9.5 PHOSPHATE-4.4
MAGNESIUM-1.9
.
[**2144-11-9**] 09:36PM [**Month/Day/Year **]-NEG ETHANOL-340* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2144-11-9**] 09:36PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2144-11-9**] 09:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
.
[**2144-11-9**] 09:36PM BLOOD cTropnT-<0.01
[**2144-11-9**] 09:36PM BLOOD CK-MB-3
[**2144-11-9**] 09:36PM BLOOD CK(CPK)-155
[**2144-11-10**] 06:15AM BLOOD CK-MB-3 cTropnT-<0.01
[**2144-11-10**] 06:15AM BLOOD CK(CPK)-120
[**2144-11-10**] 01:04PM BLOOD CK-MB-2 cTropnT-<0.01
[**2144-11-10**] 01:04PM BLOOD CK(CPK)-129
.
CXR: IMPRESSION: No acute cardiopulmonary process.
.
EKG: Sinus tach at 122, NA/NI, TWI V3-V4 (new), + LVH
EKG repeat on Day of [**Month/Day/Year **]: NSR, NA/NI, + LVH, T-waves
returned to baseline, unchanged from earlier ECG\
.
[**2144-11-12**] 12:45PM BLOOD ALT-27 AST-48* LD(LDH)-169 AlkPhos-68
TotBili-0.8
[**2144-11-12**] 12:45PM BLOOD CRP-2.6, ESR-12
[**2144-11-12**] 12:45PM BLOOD [**Doctor First Name **]-PND dsDNA-PND
Brief Hospital Course:
A/P: 45 yo man with h/o EtOH abuse, withdrawal, and pericarditis
p/w intoxication and chest pain, but ruled out for MI.
.
# EtOH Abuse: Patient with significant history of withdrawal
with seizures/DT's. Presented with EtOH level of 340, was given
banana bag, thiamine, folate, MVI, and detoxed appropriatley in
MICU. By day 2 patient was transferred to floor and his
Benzodiazepine requirement gradually decreased.
.
# Chest Pain: Patient ruled out for MI and bedside echo without
pericardial effusion per MICU note. Presumed recurrence of
pericarditis - patient states it has happened so often that he's
lost count. He was treated with scheduled ibuprofen for
pain/inflamation and was given PPi while on NSAIDs to protect
against gastritis. On day of [**Doctor First Name **], his chest pain was
minimal. He may benefit from treatment with [**Doctor First Name **] as
indicated by the CORE trial (Arch Intern Med [**2141**], 165:[**2123**]).
I've ask him to bring this up with his PCP [**Last Name (NamePattern4) **] [**2144-11-24**].
.
[**Doctor First Name **] and DS-DNA pending
.
Medications on Admission:
Seroquel 50 qHS
[**Doctor First Name **] Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for chest pain.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
[**Doctor First Name **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
[**Doctor First Name **] Disposition:
Home
[**Doctor First Name **] Diagnosis:
Primary: EtOH intoxication, chest pain
.
[**Doctor First Name **] Condition:
Good, VSS, no symptoms of withdrawal, on RA
[**Doctor First Name **] Instructions:
You came to the hospital for ethanol intoxication and chest
pain. Blood test show you did not have a heart attack and you
were given medications to prevent seizures and alcohol
withdrawal. For your recurrent pericarditis, you should ask
your doctor [**First Name (Titles) **] [**Last Name (Titles) **] treatment.
.
Please take your medications as prescribed
.
Call your doctor or return to the ED if you have fevers/chills,
tremors, increasing chest pain, shortness of breath, nausea,
vomitting, diarrhea, numbness/tingling in your extremities or
other concerns.
Followup Instructions:
You have an appointment with your PCP: [**Name10 (NameIs) 4322**],[**Name11 (NameIs) 1569**] [**Name Initial (NameIs) **].
[**Telephone/Fax (1) 4326**] on [**2144-11-26**] at 9:30. Please call to reschedule if
you cannot make this.
Completed by:[**2144-11-13**]
|
[
"291.81",
"311",
"530.81",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3514, 4606
|
311, 318
|
1822, 3491
|
6097, 6362
|
1347, 1420
|
4632, 6074
|
1435, 1803
|
242, 273
|
346, 1016
|
1038, 1185
|
1201, 1331
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,020
| 117,007
|
23642
|
Discharge summary
|
report
|
Admission Date: [**2200-5-7**] Discharge Date: [**2200-5-13**]
Date of Birth: [**2169-5-3**] Sex: F
Service: PSU
SERVICE: Plastic surgery
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 31-year-old
female with a history of right breast cancer. She is
otherwise quite healthy. She presents for right mastectomy
with [**Last Name (un) 5884**] flap reconstruction.
PAST MEDICAL HISTORY: Right breast cancer.
PAST SURGICAL HISTORY:
1. Cholecystectomy.
2. Excision of the a cyst in the right wrist.
ALLERGIES: Penicillin.
MEDICATIONS AT HOME: None.
PHYSICAL EXAMINATION: Blood pressure 122/56, heart rate 93,
oxygen saturation 100% on room air. The patient is alert,
oriented, in no apparent distress. Heart is regular rate and
rhythm with no murmurs, rubs or gallops. Lungs are clear to
auscultation bilaterally. Abdomen is soft, nontender,
nondistended with no masses. The right breast is significant
for a 2 cm mass in the upper lateral pole.
HOSPITAL COURSE: The patient was admitted to the plastic
surgery service on [**2200-5-7**]. She underwent a total
mastectomy by the breast surgery service and a deep flap
reconstruction by the plastic surgery service. For further
information on these procedures, please see associated
operative note. The patient tolerated the procedure well,
and was observed overnight in the ICU. The pulses in her
flaps were checked every half an hour to hour initially after
surgery. Her flap maintained good blood flow, and was pink
and warm. On postoperative day #1 she was able to be
transferred to the floor. Her flap continued to be monitored
carefully. There was a question of a small hematoma on
postoperative day #3, but this was observed and did not
increase in size. On postoperative days #4 and #5, the
patient was feeling dizzy and had trouble ambulating. Her
hematocrit was checked and was 26.1. On postoperative day
#5, the decision was made to transfuse 1 unit of autologous
red blood cells for symptomatic anemia. After the
administration of the blood, the patient began to feel much
better. Her lightheadedness went away and she was able to
ambulate. She was then able to tolerate a regular diet, as
well as oral pain medications. On postoperative day #6, the
patient's symptoms had improved dramatically and she was
doing quite well clinically. The decision was made to
discharge her to home with [**Hospital 269**] nursing care to assist with
her drains.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home with services.
DISCHARGE DIAGNOSIS: Right breast cancer.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 mg tablet 1-2 tablets p.o. q.4-6h. p.r.n.
for pain.
2. Clindamycin 300 mg p.o. t.i.d. time 7 days.
3. Colace 100 mg capsule 1 capsule p.o. b.i.d. while taking
Percocet.
4. Aspirin 81 mg tablet 2 tablets p.o. daily.
FOLLOW-UP PLANS: The patient will follow up with Dr. [**First Name (STitle) **]
this Friday. She will call the office for appointment. The
patient will also follow-up with Dr. [**Last Name (STitle) 364**] on [**2200-5-15**]
at 9:30.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 39103**]
Dictated By:[**Last Name (NamePattern1) 11988**]
MEDQUIST36
D: [**2200-5-13**] 09:41:50
T: [**2200-5-14**] 10:20:11
Job#: [**Job Number 60482**]
|
[
"E878.6",
"174.8",
"196.3",
"998.12",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.89",
"99.02",
"85.41",
"40.23"
] |
icd9pcs
|
[
[
[]
]
] |
2615, 2856
|
2570, 2592
|
1012, 2473
|
583, 590
|
468, 561
|
613, 994
|
2874, 3365
|
190, 400
|
423, 445
|
2498, 2548
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,660
| 107,310
|
54076
|
Discharge summary
|
report
|
Admission Date: [**2115-3-12**] Discharge Date: [**2115-3-20**]
Date of Birth: [**2054-3-15**] Sex: F
Service: MEDICINE
Allergies:
Thorazine / Penicillins
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
60F with schizoaffective disorder and COPD presents with
increased SOB x1 day. Patient has h/o chronic cough and SOB
(able to walk ~15 minutes on level ground, says she "can't climb
stairs"). Cough has been increasing over the last several days,
worsened last evening. Abdomen hurts with deep coughing. Cough
is productive, but patient hasn't noticed change in quality of
sputum. Has been wheezing as well, took friend's albuterol
nebulizer which helped her SOB. No sick contacts or recent
travel, did not receive influenza vaccination this year. No leg
pains, h/o thrombosis, recent travel. Denies
dizziness/lightheadedness, does feel thirsty.
Review of systems otherwise negative for fevers, chills, sweats,
headache, rhinitis, sore throat, myalgias,
diarrhea/constipation, dysuria. Denies h/o cardiac disease, HTN,
high cholesterol, or family h/o cardiac disease. Does have h/o
chronic dysphagia with regurgitation.
In the ED, vitals were T 98.5, P 88, BP 124/66, RR 38, O2 87% on
RA. She was given solumedrol 125mg IV, azithromycin 500mg PO,
combivent, ceftriaxone, and ASA 325mg once. She was put on CPAP
briefly with good effect. ABG obtained showed 7.25/60/72.
Past Medical History:
* COPD - patient denies h/o intubation, no PFTs availble in OMR
* Schizoaffective disorder, bipolar
* Chronic low back pain, followed at pain clinic
* duodenal polyp, adenoma on bx [**9-/2114**]
* esophageal stricture s/p dilatation
* h/o urinary retention
* h/o ovarian cysts
* s/p ccy
Social History:
Lives alone, long history of smoking ~1ppd since age 14, denies
EtoH or ilict drug use.
Family History:
no h/o cardiac or pulmonary disease
Physical Exam:
Vitals T 96F P 74 BP 142/45 RR 24 O2 92% 2L
BP 110/60 P 80 supine and sitting without significant change
General Anxious appearing, tachypneic but able to speak in full
sentences
HEENT Sclera white, conjunctiva pink, dry mucus membranes
Neck JVP flat
Pulm resonant to percussion, bilateral wheezing and few right
sided crackles
CV distant regular S1 S2 no m/r/g
Abd Soft, nontender +bowel sounds
Extrem Warm, no edema
Neuro/psych Suspicious affect but answers appropriately
Pertinent Results:
Data
CBC 8.0>13.8/39.3<178 N88.7% L 7.2% M 3.8% E 0.1% Baso 0.1%
Chem 122/4.1/86/27/11/0.9<168
Ca 8.8, Mg 1.9, Phos 3.0
CK 748 MB 14 Tropn <0.01
proBNP 345
ABG 7.25/60/72/28 lactate 1.9
Micro
[**3-12**] blood cx [**2-16**] NGTD
Imaging
[**3-12**] CXR
CHEST, SINGLE VIEW: Heart size and mediastinal borders are
normal. No focal consolidation, pneumothorax, or pleural
effusion. No gross osseous abnormality.
IMPRESSION: No acute cardiopulmonary process.
EKG noisy baseline but apparent SR @91bpm, normal axis and
intervals, no s1/q3/t3, no evidence of acute ischemia or strain
Brief Hospital Course:
60 yo F longtime smoker with h/o COPD and schizoaffective
disorder per records presented with increased SOB and cough x1
day without fever.
1. Dyspnea: Symptoms were most consistent with COPD
exacerbation. ABG suggested acute respiratory acidosis.
Pneumonia was less likely in absence of fever. Clinically did
not appear volume overloaded, and BNP<450 making CHF
exacerbation less likely. Chest CTA ruled out PE. MI was ruled
out by enzymes. She was treated with BiPAP and found to be
optimal respiratory-wise with O2 saturation in the mid-to-high
80s. She finished a 7-day course of azithromycin and
ceftriaxone. She was given nebulizers and started on prednisone,
which was tapered by discharge. By discharge, she was breathing
comfortably on room air with O2 saturation in mid-to-high 80s.
She underwent pulmonary tests the results of which were still
pending by discharge.
2. Altered mental status: might be due to hypercarbic
respiratory failure on admission versus worsening psychiatric
disorder. She was continued on outpatient thioridazine and
chlordiazepoxide. Her mental status improved to orientation x 3
by discharge.
Medications on Admission:
Meds (per patient):
mellaril 50mg PO BID
topamax 25mg PO BID
librium 10mg PO BID
no inhalers
Discharge Medications:
1. Chlordiazepoxide HCl 10 mg Capsule Sig: One (1) Capsule PO
once a day.
2. Thioridazine 100 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
3. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 7 days.
Disp:*7 Patch 24 hr(s)* Refills:*0*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*30 doses* Refills:*0*
6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
Disp:*30 doses* Refills:*0*
7. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a day
for 16 days: 40mg x 4 days
30mg x 4 days
20mg x 4 days
10mg x 4 days.
Disp:*42 Tablet(s)* Refills:*0*
8. Oxygen
Titrate oxygen, via nasal cannula to 88-90%.
9. Nebulizer
One nebulizer machine.
Discharge Disposition:
Home With Service
Facility:
Caregroup home
Discharge Diagnosis:
Primary:
1. Chronic obstructive pulmonary disease
2. Hypercarbic respiratory failure
Secondary:
1. Schizoaffective disorder
Discharge Condition:
Hemodynamically stable. Oxygen saturation 88% on 2 liters of
oxygen via nasal cannula.
Discharge Instructions:
You were admitted after experiencing a worsening of your COPD.
Your oxygen levels are quite low and you would benefit from home
oxygen therapy.
For your safety, YOU MUST QUIT SMOKING. If you do continue
smoking, you CANNOT use the oxygen, nor can you use the nicotine
patch.
If you continue to experience worsening shortness of breath with
exertion, chest pains, wheezing, fevers/chills, please be sure
to call your primary care doctor or go to an emergency room.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 2903**] on Monday [**3-25**] at 11:15.
You would also benefit from an outpatient sleep study. The
phone number is [**Telephone/Fax (1) 6856**].
|
[
"276.2",
"276.1",
"724.2",
"295.70",
"491.21",
"338.29",
"305.1",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
5332, 5377
|
3080, 3970
|
287, 295
|
5546, 5636
|
2471, 3057
|
6151, 6348
|
1925, 1962
|
4356, 5309
|
5398, 5525
|
4239, 4333
|
5660, 6128
|
1977, 2452
|
244, 249
|
323, 1494
|
3985, 4213
|
1516, 1804
|
1820, 1909
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,447
| 190,049
|
32749
|
Discharge summary
|
report
|
Admission Date: [**2191-6-12**] Discharge Date: [**2191-6-16**]
Date of Birth: [**2112-1-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Right lower extremity weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79yo male w/ h/o CAD s/p MI, COPD, ankylosing spondylitis s/p
back surgery comes in s/p fall at home with right-sided
hemiparesis. He had a mechanical fall at home, tripping over
oxygen tubing at home onto his hands. He did not have pain
immediately following the fall. He had been feeling well
otherwise, and denies preceding dizziness, chest pain or
shortness of breath.
.
He went to [**Hospital3 3583**], arriving 11:30pm [**6-11**], where he had
stable vital signs and got Dilaudid 1mg x2, Zofran 8mg and 500cc
NS. He was found to have RLE paresis and was sent [**Hospital1 18**] for
spine surgery eval.
.
In the emergency room, initial vitals T 97.1 HR 83 BP 156/52 RR
16 98% 3L Nasal Cannula. Patient given multiple doses of
morphine for pain. MR spine showed C7-T1 fracture with
anterolisthesis and hematoma extending down to T10. Ortho spine
(Dr. [**Last Name (STitle) 1007**] felt that he was too high of surgical risk to go to
the OR. On [**Last Name (LF) **], [**First Name3 (LF) **] given one dose of DDAVP. UA positive for
glucose but no bacteria. Trop 0.01.
.
Per ortho: Has disruption of C7-T1 and hematoma extends down to
T10. Would have to decompress nearly entire. Would probably lose
3-4 liters of blood in the best case scenario. Surgery could be
lethal. Has previously refused CABG, saying he "never wants to
go under the knife again". Neuro exam currently stable. Has
potential, with brace and log-rolls, of avoiding surgery with
only RLE deficit. If neuro exam worsens, might alter
risk-benefit and may risk massive surgery.
.
On the floor, the patient is sleepy but arousable after multiple
doses of morphine. He is tired and does not want to discuss his
prognosis or decisions regarding surgery. He refers all
decisions regarding his care to his wife, [**Name (NI) **]. [**Name2 (NI) **] denies recent
cough, dyspnea, chest pain, N/V, F/C, diarrhea or constipation.
He did have a recent COPD flare [**2191-6-3**] for which he was treated
with antibiotics and steroids. He is currently on 10mg
prednisone daily, and was to go to 5mg daily tomorrow.
Past Medical History:
1. Coronary artery disease s/p MI [**2191-3-17**] with "60% blockage" of
left main?, recommended to have CABG, but patient declined.
2. Chronic obstructive pulmonary disease on 2L home O2.
3. Ankylosing spondylitis, s/p T11-T12 fracture requiring
surgical reduction [**2187-12-9**]. Post-op course c/b difficulty
weaning from the vent, resulting in trach/PEG and prolonged
rehab course.
4. Systolic congestive heart failure, daily weights have been
stable, last EF in [**2186**] 35-40%
5. Insulin-dependent diabetes mellitus
6. Peripheral vascular disease, chronic pain with walking
7. Hypercholesterolemia
8. Obstructive sleep apnea, not on home CPAP
9. s/p cholecystectomy
Social History:
Lives with his wife. At baseline can walk up a flight of stairs,
recently had to pause half way up.
- Tobacco: Quit 10yrs ago, smoked for about 50yrs prior
- Alcohol: occasional
- Illicits: none
Family History:
adopted
Physical Exam:
On admission:
Vitals: 98.7, 73, 111/45, 96/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: scattered wheezes but good air movement.
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
At discharge: same as above except:
Neuro: Able to dorsiflex L foot and move some toes of R foot,
otherwise no motor function in lower extremities
Pertinent Results:
WBC 23.4-> 15.4 during admission, Hct 35.8->27, platelets
234->181
N92, B1
coags remained normal INR 1.0, PTT 24.8
ESR 8, CRP 10.2
139/5.6/93/38/43/1.2<440 at admission BUN/Cr 44/1.1 at discharge
Trop 0.01-.03
Ca/Mg/Phos: 9.1/2.4/4.8 at admission, phos normalized to 2.7 at
discharge
lactate 1.7
VBG 7.24/35/100 [**6-13**]
C-spine [**6-13**] pending
MR spine [**6-12**]
MR CERVICAL, THORACIC AND LUMBAR SPINE.
HISTORY: Difficulty moving right lower extremity status post
fall.
Sagittal imaging was performed through the entire spine using
long TR, long TE
fast spin echo, STIR, and short TR, short TE spin echo
technique. Axial
imaging was performed with gradient echo technique in the
cervical spine and
long TR, long TE fast spin echo technique in the thoracic and
lumbar spines.
Comparison to T-spine CT studies of [**2191-6-12**].
FINDINGS: There appears to be a fracture of the superior portion
of the T1
vertebral body, also involving the inferior C7 body. There is
wedging of the
T1 and discontinuity of the anterior margins of the vertebral
bodies at this
location. There is hyperintensity in the C6 vertebral body on
the STIR images
without definite evidence of fracture. There is hyperintensity
in the C6-C7
and C7-T1 intervertebral discs, compatible with acute trauma.
There is faint
hyperintensity on STIR images in the posterior ligamentous
complex at C6,
compatible with the spinous process fracture seen on the CT.
There is
extensive prevertebral fluid, presumably hemorrhage. There
appears to be
intraspinal hemorrhage posterior to the spinal cord at the level
of the
ligamentous injury, with unclear extent within the spinal canal.
At a
minimum, this appears to be present at the C5 through C7 levels,
but may
extend farther inferiorly into the thoracic spinal canal.
The patient has classic imaging findings of ankylosing
spondylitis and has
undergone posterior fusion with rods and pedicle screws from
T7-T12.
Images of the lumbar spine demonstrate changes of ankylosing
spondylitis with no evidence of fracture or abnormalities
encroaching on the spinal canal.
There appears to be a defect in the T11 vertebral body. There is
no evidence of encroachment on the spinal canal or spinal cord
at this level and no evidence of hemorrhage.
CONCLUSION:
1. Unstable-appearing cervical spine fracture with disruption of
the C6-C7
intervertebral level, the C7 inferior vertebral body, and the
superior T1
body. Extensive prevertebral soft tissue fluid. Hyperintensity
in the
posterior ligamentous complex suggesting fracture. Intraspinal
fluid
collection, presumably epidural hematoma, posterior to the
spinal cord at this
level.
2. Hyperintensity and apparent fracture of the superior portion
of the T11
body, without evidence of hemorrhage.
3. Ankylosing spondylitis, status post lower thoracic spine
fusion.
ECG
Baseline artifact. Probable sinus rhythm. P-R interval
prolongation.
Intraventricular conduction delay of right bundle-branch block
type with marked left axis deviation. Consider left anterior
fascicular block. Since the previous tracing of [**2191-6-12**]
differences may be due to artifact. Otherwise, findings are
unchanged.
[**6-15**] CXR: Portable AP radiograph of the chest was reviewed in
comparison to [**2191-6-13**]. The patient's head obscures lung
apices . Heart size, mediastinal contours are unremarkable.
There is interval resolution of pulmonary edema. Multiple
noncalcified pleural plaques are noted bilaterally.
Discharge Labs:
CBC: 12.1/9.2/26.8/183
Chem7: Glc 231 BUN 40 Cr 1 Na 140 K 4.4 HCO3 39
Brief Hospital Course:
79yo man w/ CAD s/p MI, sCHF, COPD on home O2 and IDDM here s/p
mechanical fall with C7-T1 fracture, paraspinal hematoma and RLE
paralysis.
.
# Spinal fracture and hematoma: Patient initially admitted to
MICU with right lower extremity paresis. Patient received Q1h
neuro checks. Paresis of left lower extremity developed
overnight. Rest of neuro exam remained stable with the exception
of some improvement in ability to move left toes with time. MRI
showed unstable C6-T1 spinal fracture with posterior epidural
hematoma. Given dexamethasone 8mg Q8hrsX1 day. Per ortho spine
team, he would require an extensive surgery with decompression
from C6 down to the end of the thoracic vertebrae where he had
his previous surgery[Per the Revised [**Doctor Last Name **] cardiac risk index
(RCRI), the patient has 4 risk factors: high-risk surgery,
history of ischemic heart disease, heart failure, and
pre-operative treatment with insulin. This puts his
intraoperative risk of MI at >5.4%. He is also at considerable
risk of pulmonary disease]. Estimated blood loss would be [**3-22**]
liters and it would be very high risk. Patient and family have
decided not to pursue surgery. Patient given [**Location (un) 36323**] cervical
collar, which should be worn when out of bed and put on while
supine. [**Location (un) **] held during stay in the MICU due to epidural
hematoma and not restarted at time of discharge. Pain controlled
with Percocet.
.
# UTI: UA from [**6-14**] grossly positive, culture grew >100K S.
aureus, sensitive to Bactrim. Started planned 7 day course of
Bactrim on [**6-16**]. Foley should be removed as tolerated.
.
# sCHF: per wife, has been at baseline weights. CXR showed
resolution of pulm edema. Lasix 40mg PO daily restarted at time
of discharge.
.
# COPD: had a recent exacerbation. Prednisone tapered to 5mg
daily, should continue to taper to off as resp status allows.
Continued home advair, spiriva.
.
# IDDM: held nateglinide during admission, restarted at time of
discharge. Continued glargine 20 units daily.
.
# Communication: Patient and wife [**Name (NI) **]
([**Telephone/Fax (3) 76292**])
# Code: DNR/DNI (discussed with proxy)
.
TRANSITIONAL ISSUES:
-continue PT/OT as tolerated
-brace while out of bed
-monitor for skin breakdown
-taper prednisone to off
Medications on Admission:
- Lantus 20 units daily
- Spiriva 18mcg daily
- Tylenol PRN
- Lasix 40mg daily
- Metoprolol 25mg daily
- Starlix (nateglinide) 120mg TID
- [**Telephone/Fax (3) **] 75mg daily
- Simvastatin 40mg QHS
- Vitamin D 1,000 units daily
- Advair 230/21 2 puffs [**Hospital1 **]
- Prednisone 10mg daily (from recent COPD flare, to titrate to
5mg tomorrow)
Discharge Medications:
1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. insulin glargine 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous once a day.
4. fluticasone-salmeterol 230-21 mcg/Actuation Aerosol Sig: Two
(2) Inhalation twice a day.
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. nateglinide 120 mg Tablet Sig: One (1) Tablet PO three times
a day.
9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
11. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] HealthCare/Pediatric Center at [**Location (un) 3320**]
Discharge Diagnosis:
Cervical spine fracture: disruption of the C6-C7 level, the C7
inferior vertebral body, and the superior T1 body.
Epidural hematoma
Urinary tract infection
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital for a fall at home with
right-sided weakness. You were transferred here for spine
evaluation. You underwent MRI which showed unstable cervical
spine fracture with disruption of the C6-C7 level, the C7
inferior vertebral body, and the superior T1 body. The surgeons
felt that given the disruption from C7-T1, the hematoma which
extends down to T10, and the extent of morbidity during the
procedure, surgery could be lethal. As such, conservative
management in the form of a brace was pursued. You are also
being treated for an infection in your urine. You are being
discharged to rehab.
.
Medication changes:
STOP [**Location (un) **] (clopidogrel)
STOP acetaminophen
START oxycodone/acetaminophen as needed for pain
DECREASE prednisone to 5mg daily
.
You should continue to take all of your other meds as
prescribed.
Followup Instructions:
Name: White, [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**] ORTHOPEDICS/Spine Center
Address: [**Location (un) **], [**Hospital Ward Name **] 2, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3736**]
Appt: [**6-29**], 2:30 PM
You should make an appointment to see your PCP upon leaving
rehab.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"440.21",
"V15.51",
"720.0",
"428.0",
"V58.67",
"428.22",
"250.00",
"272.0",
"496",
"805.07",
"599.0",
"E885.9",
"V45.4",
"V46.2",
"852.41",
"344.30",
"327.23",
"414.01",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11317, 11418
|
7636, 9799
|
343, 349
|
11656, 11656
|
4055, 7522
|
12666, 13209
|
3380, 3389
|
10324, 11294
|
11439, 11635
|
9953, 10301
|
11791, 12413
|
7538, 7613
|
3404, 3404
|
3901, 4036
|
9820, 9927
|
12433, 12643
|
272, 305
|
377, 2452
|
3418, 3887
|
11671, 11767
|
2474, 3151
|
3167, 3364
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
989
| 130,009
|
20260
|
Discharge summary
|
report
|
Admission Date: [**2161-11-7**] Discharge Date: [**2161-11-17**]
Date of Birth: [**2090-12-12**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
70M acute cholecystitis x4days
Major Surgical or Invasive Procedure:
s/p open cholecystectomy and liver biopsy
s/p ERCP with biliary stent placement
s/p placement of central venous catheter
History of Present Illness:
70 y/o M with several day history of abdominal pain ??fevers,
nausea, etc
Past Medical History:
- diabetes type 2
- neuropathy
- retinopathy
- gilberts syndrome
Social History:
married and lives with wife
Pertinent Results:
[**2161-11-17**] 06:20AM BLOOD WBC-11.5* RBC-3.05* Hgb-9.8* Hct-29.3*
MCV-96 MCH-32.3* MCHC-33.6 RDW-15.8* Plt Ct-257
[**2161-11-7**] 12:20PM BLOOD Neuts-79.9* Bands-0 Lymphs-12.4*
Monos-5.7 Eos-1.4 Baso-0.6
[**2161-11-17**] 06:20AM BLOOD Plt Ct-257
[**2161-11-17**] 06:20AM BLOOD PT-13.6* PTT-64.8* INR(PT)-1.2*
[**2161-11-17**] 06:20AM BLOOD Glucose-98 UreaN-30* Creat-1.4* Na-140
K-4.3 Cl-105 HCO3-29 AnGap-10
[**2161-11-17**] 06:20AM BLOOD ALT-111* AST-225* LD(LDH)-341*
AlkPhos-682* Amylase-145* TotBili-13.4* DirBili-11.0*
IndBili-2.4
[**2161-11-16**] 07:09AM BLOOD ALT-106* AST-204* LD(LDH)-309*
AlkPhos-646* Amylase-112* TotBili-13.3* DirBili-9.9* IndBili-3.4
[**2161-11-15**] 12:30AM BLOOD ALT-112* AST-224* AlkPhos-582*
Amylase-102* TotBili-12.0*
[**2161-11-14**] 04:07AM BLOOD ALT-116* AST-246* AlkPhos-536* Amylase-96
TotBili-11.4*
[**2161-11-13**] 02:01AM BLOOD ALT-101* AST-180* CK(CPK)-527*
AlkPhos-449* Amylase-84 TotBili-12.7*
[**2161-11-17**] 06:20AM BLOOD Lipase-215*
[**2161-11-16**] 07:09AM BLOOD Lipase-158*
[**2161-11-15**] 12:30AM BLOOD Lipase-125*
[**2161-11-14**] 04:07AM BLOOD Lipase-103*
[**2161-11-13**] 02:01AM BLOOD Lipase-118*
[**2161-11-17**] 06:20AM BLOOD Albumin-2.6* Calcium-8.0* Phos-2.4*
Mg-2.4
[**2161-11-9**] 03:44PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE IgM
HBc-NEGATIVE
[**2161-11-11**] 02:25PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2161-11-9**] 03:44PM BLOOD HCV Ab-NEGATIVE
Cardiology Report ECHO Study Date of [**2161-11-11**]
Conclusions:
1.The left atrium is mildly dilated. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly
depressed. Resting regional wall motion abnormalities include
basal and mid
inferolateral severe hypokinesis-akinesis.
3. Right ventricular chamber size is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet
excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. The mitral
valve leaflets
are elongated. No mitral regurgitation is seen.
6.There is no pericardial effusion. There is an anterior space
which most
likely represents a fat pad.
SPECIMEN SUBMITTED: GALLBLADDER, LIVER BIOPSY.
Procedure date Tissue received Report Date Diagnosed
by
[**2161-11-8**] [**2161-11-9**] [**2161-11-12**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 18795**]/cma??????
DIAGNOSIS:
I. Gallbladder (A-B):
Acute necrotizing cholecystitis superimposed on a background of
chronic cholecystitis.
II. Wedge biopsy of liver (C):
1. Cirrhosis (confirmed by trichrome stain).
2. Parenchyma:
a. Steatosis, large and small droplet forms, involving 5-10% of
hepatocytes.
b. Multiple single apoptotic hepatocytes.
c. Foci of hepatocytes with cytoplasmic hyalin.
3. Portal areas/fibrous tracts:
Variable active and chronic inflammation with focal bile duct
proliferation.
4. Iron stain:
Focally increased iron (2+/4+) in hepatocytes and Kupffer cells.
Note: The findings are consistent with some type of
toxic-metabolic liver injury with progression to cirrhosis. The
specimen contains numerous lobular neutrophils, but it is
difficult to determine whether these simply represent so-called
"surgical hepatitis" or an aspect of toxic-metabolic hepatitis.
In addition, subcapsular specimens such as this biopsy may be
more fibrotic than deeper areas of the liver. Clinical
correlation is necessary to determine the etiology of the liver
findings.
Clinical: Cholecystitis, acute. Fibrotic liver noted at
surgery.
Brief Hospital Course:
Mr. [**Known lastname **] is a diabetic with a history of an
unknown liver disease thought to be [**Doctor Last Name **]-[**Location (un) 54397**] syndrome
with an elevated bilirubin up to 5.9. He was admitted with 4
days of abdominal pain in the right upper quadrant, nausea
and vomiting. The ultrasound was quite difficult but did show
a normal size common duct at 5 mm sludge and a very difficult
to visualize gallbladder. It was felt that percutaneous
cholecystostomy tube was not possible. ERCP was not warranted
after consultation with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of GI. It was
thought that his elevated bilirubin was due to his [**Doctor Last Name **]-
[**Location (un) 54397**] syndrome. He was brought to the operating room
The procedures performed on [**2161-11-8**] were
1. Total cholecystectomy with oversew of cystic duct.
2. Liver biopsy.
3. Drainage of right upper quadrant.
4. Laparoscopy.
Post op the patient was extubated in the PACU and then
transferred directly to the ICU for increasing bilirubin and
creatinine. The patient was kept on Unasyn. Hepatology was
consulted for input into the patient's underlying liver disease.
In the ICU the patient had worsening renal function and a
decreased HCT. He was given albumin and a unit of PRBC. He also
had PVC's and V-tach runs. Cardiology was consulted and an Echo
was performend. The echo revealed and akinetic area of left
ventricle. The patient improved and was transferred to the floor
on POD3. On POD5 the patient had elevated LFT's and bilirubin.
He was taken for an ERCP. A stent was placed and sludge was
drained. During the procedure the patient became hypoxic and
bradycardic. He was transferred to the ICU intubated. The
patient improved and was extubated and transferred to the floor.
The patient continued to improve and tolerated a diet. He was
seen by PT and cleared for home. He was discharged on POD8 to
home with VNA services.
Medications on Admission:
amaryl
neurontin
zestril
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ursodiol 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
acute cholecystitis
s/p open cholecystectomy and liver biopsy
s/p ERCP with biliary stent placement
history of diabetes
history of gilberts syndrome w/baseline bili of 1.7
Discharge Condition:
stable
Discharge Instructions:
- you will be discharged to home with VNA services to help with
dressing changes
- you may shower
- you should continue the diet you began in the hospital
- you should take all medications as instructed
- do not lift anything heavier than a gallon of milk for the
next six weeks
- no soaking in baths, hot tubs, or swimming pools until cleared
at a follow-up appointment
- you will have several follow-up appointments you will need to
make - these are very important
- [**Name8 (MD) 138**] MD or return to ED if T>101.5, chills, nausea, vomiting,
chest pain, shortness of breath, severe abdominal pain, redness
or smelly drainage from around your incision, or any other
concern
-please restart your home medications
Followup Instructions:
**You will need to call to confirm the following appointments.
They are very important**
- Dr. [**Last Name (STitle) **]: ([**Telephone/Fax (1) 33502**] -> you need to see her Monday [**11-23**].
- Cardiology clinic: ([**Telephone/Fax (1) 2037**] -> you will need to schedule
a follow-up appointment as well as an outpatient ECHO and stress
test.
- ERCP with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10532**]- please call for
appointment next week
- Hepatology with Dr. [**Last Name (STitle) 54398**] ([**Telephone/Fax (1) 54399**]
- Please call [**Last Name (un) **] Diabetes center for blood sugar management
([**Telephone/Fax (1) 54400**]
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**2161-11-17**]
|
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icd9cm
|
[
[
[]
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[
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[
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6761, 6844
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|
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|
278, 310
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499, 574
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596, 662
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678, 707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,488
| 160,553
|
17652
|
Discharge summary
|
report
|
Admission Date: [**2170-3-31**] Discharge Date: [**2170-4-13**]
Date of Birth: [**2130-2-9**] Sex: M
Service: MEDICINE
Allergies:
Ampicillin / Ancef
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
urosepsis, Cdiff
Major Surgical or Invasive Procedure:
endotrachial intubation
left internal jugular central line placement
PICC placement x 2
History of Present Illness:
40 y/o man with h/o C5-quadriplegia, multiple admissions for
urosepsis, who presented originally to [**Hospital1 **] [**Location (un) 620**] from rehab 3
days ago with hypotension. He had been found to have ESBL UTI
and C. diff colitis. His infections were initially responding to
IV fluids and antibiotics but on [**3-29**] he developed increasing
abdominal pain and distention. A CT abdomen was done that showed
a fluid collection in his right lower abdomen. Surgery was
consulted and recommended IR-guided drainage. He was then
transferred to [**Hospital1 **] [**Location (un) 86**] for IR evaluation. Per report, at time
of transfer his systolic pressures were 120-130s with HR 50-60s.
His mental status was altered (confirmed by his mother and HCP),
who said that this is what usually happens when he develops
infections.
.
Review of systems is difficult to obtain from patient given that
he has altered mental status and is a poor historian.
.
Of note, patient has a complicated urologic history and is
followed by Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**Hospital1 18**]. Per a recent urology note, patient
is "s/p appendicovesicostomy and ACE which have not been used in
some time due to indwelling Foley and rectal tube."
Past Medical History:
-C5 quadriplegia
-MDS
-recurrent UTIs and urosepsis
-OSA on biPAP with settings of [**10-31**] at night
-seizure disorder
-baclofen pump placed by Dr. [**First Name8 (NamePattern2) 1116**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 49143**])
-CKI with baseline Cr=1.5
-h/o C diff
-h/o bradycardia thought to be secondary to baclofen
-depression
-s/p appendicovesicostomy
-s/p Ace-[**Location (un) **] (antegrade continent enema) procedure
-s/p right eye prosthesis
Social History:
The patient lives at home with 24 hour care. His mother is very
involved but lives out of state. Used to work at UPS in
Marketing. Had MVA at age 17 resulting in quadriplegia.
- Tobacco:none
- Alcohol:none
- Illicits:none
Family History:
Father had [**Name2 (NI) **] in 50s.
Physical Exam:
Vitals: BP 71/32, HR 65, sat 97%
General: awakens to voice, disoriented
Neuro: perseverates on words or phrases, not responsive to
simple commands
HEENT: prosthetic right eye, dilated left eye (unchanged per OSH
records)
Heart: RRR, normal s1/s2
Chest: clear bilaterally anterior fields
Abdomen: obese, soft, no rebound or guarding; there is a
subcutaneous pump in the left lower quadrant; there are surgical
incisional scars over the umbilicus and midline
Extremities: wwp, b/l 2+ lower extremity pitting edema
Pertinent Results:
Admission labs:
[**2170-3-31**] 12:31AM BLOOD WBC-1.9* RBC-2.79* Hgb-8.7* Hct-26.1*
MCV-94 MCH-31.3 MCHC-33.5 RDW-21.1* Plt Ct-27*
[**2170-3-31**] 12:31AM BLOOD PT-11.1 PTT-33.1 INR(PT)-0.9
[**2170-3-31**] 12:31AM BLOOD Glucose-106* UreaN-54* Creat-2.3* Na-134
K-4.4 Cl-104 HCO3-17* AnGap-17
[**2170-3-31**] 03:48AM BLOOD ALT-19 AST-24 LD(LDH)-163 AlkPhos-124
Amylase-25 TotBili-0.1
[**2170-3-31**] 12:31AM BLOOD Calcium-7.6* Phos-5.9*# Mg-2.1
[**2170-3-31**] 03:48AM BLOOD TSH-8.4*
[**2170-3-31**] 03:59PM BLOOD Free T4-1.0
[**2170-3-31**] 03:48AM BLOOD Cortsol-45.2*
.
Discharge labs:
[**2170-4-13**] 05:40AM BLOOD WBC-3.5* RBC-2.83* Hgb-8.3* Hct-26.4*
MCV-93 MCH-29.2 MCHC-31.3 RDW-20.3* Plt Ct-484*
[**2170-4-13**] 05:40AM BLOOD Glucose-102* UreaN-27* Creat-1.1 Na-141
K-5.1 Cl-104 HCO3-32 AnGap-10
[**2170-4-13**] 05:40AM BLOOD Calcium-8.2* Phos-3.9 Mg-2.3
[**2170-4-12**] 05:45AM BLOOD Phenyto-2.8*
.
Urine studies:
[**2170-4-3**] 03:04PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.010
[**2170-4-1**] 10:41AM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.008
[**2170-4-3**] 03:04PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2170-4-1**] 10:41AM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2170-4-1**] 10:41AM URINE Hours-RANDOM UreaN-200 Creat-17 Na-57 K-9
Cl-52
[**2170-3-31**] 02:27AM URINE Hours-RANDOM UreaN-184 Creat-45 Na-82
[**2170-4-1**] 10:41AM URINE Osmolal-212
.
CSF studies:
[**2170-4-4**] 01:48PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-0
Lymphs-72 Monos-28
[**2170-4-4**] 01:48PM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-79
[**2170-4-4**] 01:48PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-negative
Microbiology:
.
[**2170-3-31**] MRSA screen: negative
[**2170-3-31**] Blood cultures x 2: no growth
[**2170-4-3**] Blood cultures x 2: no growth
[**2170-4-4**] Blood cultures x 2: no growth
[**2170-4-3**] Urine culture: GRAM NEGATIVE ROD(S). ~[**2159**]/ML
.
[**2170-4-1**] Urine culture:
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
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
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2170-4-4**] Cerebrospinal fluid:
GRAM STAIN (Final [**2170-4-4**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2170-4-7**]): NO GROWTH.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
.
Imaging:
.
CXR (portable AP) [**2170-3-31**]:
1. Increased retrocardiac density, consistent with left lower
lobe collapse and/or consolidation.
2. Upper zone redistribution and mild vascular blurring, could
reflect mild CHF.
3. Improvement in parenchymal opacities -- please see comment.
.
CT pelvis [**2170-4-1**]:
1. Diffuse colitis with intra-abdominal fat stranding has
slightly
progressed.
2. Contrast passes throughout the large bowel with no
extravasation.
3. Slight decrease in size of the simple fluid collection in the
right iliac fossa which is most likely a locule of free fluid
and not typical for an abscess.
.
CT head w/o contrast [**2170-4-4**]:
1. No intracranial hemorrhage or edema.
2. 4.5-mm hyperdense lesion in the midline, at the level of the
foramen of
[**Last Name (un) 2044**], likely a colloid cyst, unchanged over the series of
previous CTs dating back to [**2162**]. Equivocally increased
prominence anteriorly of the cavum septum pellucidum, of
doubtful significance.
.
Venous ultrasound, left upper extremity [**2170-4-9**]:
Occlusive thrombus in a small segment of the more superficial
anterior basilic vein with no flow and no compressibility.
Brief Hospital Course:
40 y/o man h/o C5-quadriplegia, recurrent UTIs and past
admissions for urosepsis, transferred from [**Hospital1 **] [**Location (un) 620**] with C.
diff colitis, ESBL UTI, and concern of intra-abdominal abscess.
He was initially admitted to the intensive care unit for
hypotension.
.
# ESBL urinary tract infection/sepsis: Patient was initially
septic with hypotension and required pressors in the ICU. He was
started was treated with meropenem from [**3-28**] to [**4-11**] (14-day
course). As his condition improved, he was weaned off of
pressors and transferred to the medical floor. The patient will
need to follow up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] discharge to evaluate the
etiology of his recurrent urinary tract infections.
.
# C. diff colitis: The patient was treated with PO Vancomycin
and IV Flagyl (later changed to PO). The plan is to continue
Flagyl until [**2170-4-18**] (one week after other antibiotics were
discontinued). Vancomycin should be tapered as indicated in the
discharge medication list.
.
# Healthcare-associated pneumonia: On [**2170-4-3**], the patient
developed fever to 100.2. CXR was concerning for pneumonia. IV
vancomycin was added to the patient's other antibiotics on
[**2170-4-3**] and was discontinued until [**2170-4-11**]. The patient needs
chest physical therapy.
.
# Abdominal fluid collection: The patient was noted to have an
intra-abdominal fluid collection. He was evaluated by the
surgical consult service, who felt that the fluid collection did
not need to be drained.
.
# Elective intubation: The patient was intubated electively from
[**2170-3-31**] to [**2170-4-2**] for CT abdomen.
.
# Delirium: At baseline, the patient is completely alert and
oriented. The patient developed confusion hallucinations
following extubation on [**2170-4-2**]. Psychiatry and neurology were
consulted. Theh patient's altered mental status was felt to be
related to delirium in the setting of infection and medications.
LP was unremarkable. The was no evidence of seizures. The
patient continued Keppra and Dilantin (pre-admission
medications), and was briefly on haloperidol. Haloperidol was
stopped on [**2170-4-9**]. The patient's mental status gradually
improved, and he was back to his baseline (normal mental status)
at the time of discharge.
.
# Seizures: The patient continued Keppra and phenytoin.
Neurology was consulted. The patient was discharged on Keppra
1000 mg [**Hospital1 **]. Phenytoin was dosed at 150 mg QAM and 200 mg QPM.
The patient will need to have a phenytoin level checked on
[**2170-4-16**]. The goal level is [**9-12**]. Neurology follow-up with Dr.
[**Last Name (STitle) 43313**] [**Name (STitle) **] was arranged.
# Dysphagia: As the patient's mental status improved, he was
evaluated by video fluoroscopy. This showed mild oropharyngeal
dysphagia characterized primarily by intermittent premature
spillover and swallow delay resulting in silent aspiration of
thin liquids before and during the swallow. Cued cough was
weak/breathy and
ineffective in clearing aspirated material from the trachea. The
use of a chin tuck (single sips and consecutive straw sips) was
effective in preventing and eliminating aspiration of thin
liquids. However when patient was noted to aspirate thin liquids
when attempting to self-feed straw sips of thin liquid [**12-26**]
reduced coordination resulting in poor chin tuck position.
The speech and swallow service recommended a PO diet of thin
liquids and regular solids. The patient will require strict 1:1
supervision to assist with feeding and cue him to use a chin
tuck with ALL sips of thin liquids. If patient attempts to
self-feed he should be downgraded to nectar thick liquids. The
patient should undergo continued monitoring at rehab and repeat
instrumental evaluation once he appears at his baseline and may
be more able to protect his airway despite swallow delay.
.
# Acute kidney injury: The patient's creatinine peaked at 2.5.
This was felt to be prerenal. The patient was treated with IV
fluids. His creatinine was 1.1 at the time of discharge.
.
# Pancytopenia. The patient presented with WBC 1.9, Hct 26, Plt
27. He has a known history of myelodysplastic syndrome. Review
of records shows that he has developed similar pancytopenia in
the setting of acute illnesses (previously during admissions in
[**Last Name (LF) 547**], [**First Name3 (LF) 404**], and [**Month (only) **]). He received 2U PRBC in the ICU.
At the time of discharge, the patient had WBC 3.5, Hct 26, and
Plt 484. The patient's CBC should be followed 2 times weekly
after discharge.
.
# s/p appendicovesicostomy/ACE-[**Location (un) **] (anterograde continence
enema): The patient is followed by Dr. [**Last Name (STitle) **] (urology) as an
outpatient. He has an appendicovesicostomy (leading to the
bladder), and and ACE-[**Location (un) **] (leading to the colon).
The patient needs urinary catheterization times daily through
his appendicovesicostomy (6a/12p/6p/12a), using 8FR straight
catheter (at umbilicus, patient left side). Procedure: (sterile
technique) cleanse bladder ostomy area with chloraprep;
lubricate catheter tip and insert catheter a few inches (does
not need to be inserted the whole length & you may pull back if
no flash of urine once fully inserted); attach catheter end to
urinary leg bag collection bag to capture drainage (drain approx
30 mins); remove catheter, cover ostomy with sterile 2X2, and
apply tegaderm.
Additionally, the patient requires straight urethral
catheterization three times weekly (Monday, Wednesday, Friday)
to remove sediment.
The patient does not currently need continence enemas through
his ACE-[**Location (un) **] (leading to the colon). However, the ACE-[**Location (un) **]
needs to be accessed 1-2 times daily to prevent the tract from
closing up.
.
# Hypertension: Metoprolol was started due to hypertension after
extubation. However, the patient was noted to be bradycardic to
as low as 48 on metoprolol 25 mg TID. On review of past medical
records, it became apparent that the patient had had problems
with bradycardia and long pauses during a recent admission.
Therefore, metoprolol was stopped at the time of discharge.
.
# Depression: Sertraline was initially held. This was restarted
at 50 mg daily at the time of discharge. Consideration can be
given to further titration of the patient's sertraline dose (his
pre-admission dose was 100 mg daily).
.
# Obstructive sleep apnea: CPAP at night.
.
# Communication. Mother [**Name (NI) 382**] at [**Telephone/Fax (1) 49146**]
.
# Code status: Okay to intubate, do not resuscitate.
Medications on Admission:
MEDICATIONS (at time of transfer from [**Hospital1 **] [**Location (un) 620**]):
- Keppra 1000 mg [**Hospital1 **]
- Flagyl 500 mg IV q8h
- Dilantin 100 mg IV bid
- ertapenem 1 g IV q24h
- sertraline 100 mg daily
- lactobacillus nebs around-the-clock
.
MEDICATIONS (per recent discharge summary [**2-/2170**]):
- acetaminophen 325-650 q6h prn
- albuterol nebs
- vitamin B12 500 mcg daily
- flucinolone 0.01% cream [**Hospital1 **] prn
- ipratropium nebs q6h
- Keppra 1000 mg [**Hospital1 **]
- levofloxacin / Flagyl
- Dilantin 100 mg [**Hospital1 **]
- sertraline 100 mg qday
- simvastatin 40 mg qday
Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
2. Phenytoin 50 mg Tablet, Chewable Sig: Three (3) Tablet,
Chewable PO QAM (once a day (in the morning)).
3. Phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO QPM (once a day (in the evening)).
4. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
5. vancomycin taper
vancomycin liquid 250 mg four times daily from [**Date range (1) 49147**];
vancomycin liquid 125 mg four times daily from [**Date range (1) 49148**];
vancomycin liquid 125 mg twice daily from [**Date range (1) 3046**];
vancomycin liquid 125 mg once daily from [**Date range (1) 3047**].
6. Baclofen pump
Baclofen *NF* 1700.2 mcg/day Intrathecal infusion
Concentration: 4000mcg/ml
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units subcutaneous Injection TID (3 times a day).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 5 days: Last day = [**2170-4-18**].
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**]
Discharge Diagnosis:
Primary:
-ESBL Klebsiella UTI, complicated by sepsis
-clostridium difficile
-delirium
-health-care associated pneumonia
-acute on chornic kidney injury
-dysphagia
.
Secondary:
-C5 quadriplegia
-s/p ACE-[**Location (un) **]
-s/p appendicovesicostomy
-seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to [**Hospital1 69**] with a
urinary tract infection, colitis from clostridium difficile, and
a fluid collection in your abdomen. You were treated with
antibiotics. The surgical consult service was consulted due to
the fluid collection in your abdomen, and they felt that no
invasive intervention was required.
.
You were admitted to the intensive care unit, where you
initially required medications to support your blood pressure.
You were electively intubated for a CT scan.
.
Your hospital course was complicated by pneumonia, which was
treated by antibiotics. You also developed confusion, which was
felt to be related to infection and had resolved by the time of
discharge.
.
There are some changes to your medications:
START Flagyl 500 mg every 8 hours for 5 more days
START vancomycin taper
CHANGE phenytoin dose to 150 mg in the morning and 200 mg in the
evening
DECREASE sertraline to 50 mg daily. Talk to your doctors about
increasing this to your previous dose of 100 mg daily.
.
You had a high-normal potassium level and a mildly low white
blood cell count at the time of discharge. You should have a
complete blood count and chemistry panel (chem 7) checked twice
weekly after discharge.
.
You will need to have your phenytoin (Dilantin) levels followed
closely.
Followup Instructions:
Specialty: urology
Dr. [**Last Name (STitle) 49149**] [**Name (STitle) **]
Date and Time: [**2170-5-10**] at 2:30 p.m.
Phone number: [**Telephone/Fax (1) 49150**]
Location: [**Hospital1 18**] [**Location (un) 620**]
.
Department: NEUROLOGY
When: WEDNESDAY [**2170-5-9**] at 1 PM
With: DRS. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Make an appointment to see your primary care doctor after you
leave rehab.
|
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"486",
"584.9",
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"276.2",
"344.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.71",
"03.31",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15893, 15939
|
7400, 14019
|
294, 384
|
16250, 16250
|
3002, 3002
|
17703, 18295
|
2417, 2455
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14670, 15870
|
15960, 16229
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14045, 14647
|
16385, 17099
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3589, 7377
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2470, 2983
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17128, 17680
|
238, 256
|
412, 1662
|
3018, 3573
|
16265, 16361
|
1684, 2161
|
2177, 2401
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,113
| 182,591
|
4893
|
Discharge summary
|
report
|
Admission Date: [**2142-8-15**] Discharge Date: [**2142-8-20**]
Date of Birth: Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: Miss [**Known lastname 19419**] is a 39 year old
female with a complicated past medical history including
diabetes mellitus and end stage renal disease status post
living donor transplant on immunosuppression with a history
of gastroparesis, who presented with five days of nausea and
vomiting with some diarrhea. Her finger stick blood sugars
at home were also upwards of 500. On the day of admission,
the patient went to [**Hospital6 33**] where she was noted
to be hypertensive with an anion gap and positive ketones in
her serum and was transferred to [**Hospital1 190**] because of her kidney transplant.
On admission to the [**Hospital1 69**], the
patient had no further complaints of nausea and vomiting and
had not had a bowel movement for several hours. She also
denied chest pain, shortness of breath, fever, or abdominal
pain.
PAST MEDICAL HISTORY:
1. Type I diabetes mellitus, complicated by gastroparesis,
retinopathy, neuropathy, end stage renal disease status post
living related donor transplant in [**2140-10-31**].
2. Coronary artery disease status post coronary artery
bypass graft in [**5-2**], with left internal mammary artery to
left anterior descending, saphenous vein graft to patent
ductus arteriosus, OM1 and a diagonal. Catheterization on
[**2142-8-11**] with a patent left internal mammary artery to
patent ductus arteriosus, occluded saphenous vein graft to
OM1, ejection fraction 45 to 50%.
3. Peripheral vascular disease status post right profundus,
and femoral-popliteal bypass.
4. Chronic toe and heel ulcers.
5. Depression.
6. Hypertension.
7. Sarcoidosis.
MEDICATIONS:
1. Lantus insulin 26 units qhs plus a regular insulin
sliding scale.
2. Prograf 3 mg po twice a day.
3. Bactrim double strength on Monday/Wednesday/Friday.
4. Zantac 150 mg po twice a day.
5. Metoprolol 100 mg po three times a day.
6. Reglan 10 mg po three times a day with meals.
7. Aspirin 81 mg po once daily.
8. Zoloft 150 mg po qhs.
9. Pravachol 40 mg po qam.
10. Remeron 15 mg po qhs prn.
11. Prednisone 5 mg po qam.
12. Vitamin D 50,000 units intravenous qweek.
13. Calcium and Vitamin D qday.
SOCIAL HISTORY: Smokes one half pack per day for 22 years.
No ethanol use. Occasionally uses marijuana. Lives with her
mother. Not currently sexually active.
PHYSICAL EXAMINATION: Blood pressure 198/80; heart rate 78;
sedimentation rate 100% on room air; generally, she was
lethargic but in no apparent distress; mucous membranes were
dry in the oropharynx; there was no lymph adenopathy; heart
was beating with regular rate and rhythm with a 206 systolic
ejection murmur heard at the left upper sternal border
without radiation; lungs were clear to auscultation
bilaterally; abdomen was soft, non-tender, non-distended,
with normal active bowel sounds; extremities were without
edema; there were 2+ dorsalis pedis pulses bilaterally, the
right ankle was covered with gauze; rectal was of normal
tone; guaiac negative; neurological examination was
non-focal.
LABORATORY DATA: Laboratories were significant for a white
count of 9; hematocrit of 44; blood sugar of 584; BUN and
creatinine 22/1.3; liver function tests were within normal
limits; venous blood gas showed pH 7.28; anion gap was 29.
Chest x-ray was negative for infiltrate in the lungs or free
air in the abdomen; abdominal film showed no obstruction.
Electrocardiogram showed normal sinus rhythm at 88 with
normal axis; T wave flattening in I and L; ST depressions in
II, III and F.
HOSPITAL COURSE: Her hospital course by problem is as
follows:
1. Diabetic ketoacidosis on clear etiology but likely
related to gastroparesis versus gastroenteritis. Patient was
transferred to the medical Intensive Care Unit and initially
treated with an insulin drip until her anion gap closed. She
was then slowly covered with titration of her regular insulin
and long acting insulin regimen, per the regimen she was
given at the [**First Name4 (NamePattern1) 8392**] [**Last Name (NamePattern1) **] on [**2142-7-26**]. She was
discharged on that regimen.
2. Renal transplant. Patient on chronic immunosuppression
per living related donor kidney transplant. She had not
taken her immunosuppression medications for several days
prior to admission. Prograf levels were checked. She was
evaluated by the renal transplant service and she was
discharged on her outpatient regimen of Prograf and
Prednisone.
3. Diarrhea. Patient had recent admission for
Cryptosporidium. Stool studies were sent during this
admission, though her diarrhea had slowed considerably. She
was restarted on her gastroparesis medications. Stool
studies were pending at the time of discharge.
4. Coronary artery disease. The patient was continued on
her outpatient regimen and had no issues during this
hospitalization.
DISCHARGE: The patient was discharged on [**2141-8-21**] with
follow-up with Dr. [**Last Name (STitle) 20416**] at the [**Hospital 8392**] Clinic and Dr.
[**Last Name (STitle) 20417**] of the renal transplant service as scheduled.
DISCHARGE MEDICATIONS: As on admission.
DISCHARGE DIAGNOSIS:
1. Diabetic ketoacidosis.
2. Nausea and vomiting.
3. Electrolyte imbalances.
4. Gastroenteritis.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 4430**]
MEDQUIST36
D: [**2142-8-20**] 11:31
T: [**2142-8-20**] 18:55
JOB#: [**Job Number 20418**]
|
[
"250.13",
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
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5216, 5234
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5255, 5605
|
3664, 5192
|
2477, 3646
|
161, 1004
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1026, 2291
|
2308, 2454
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,479
| 179,959
|
19210
|
Discharge summary
|
report
|
Admission Date: [**2150-12-11**] Discharge Date: [**2150-12-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
NG lavage.
History of Present Illness:
83yo male with Afib on coumadin, CAD on ASA, s/p CVA with
lacunar infarcts and residual dementia, hx of aorto-enteric
fistula repair, EtOH abuse presents with one day of hematemesis.
Pt is demented and most of hx was gotten from family members.
Pt was in his usual state of health until yesterday when he
began coughing up minimal amounts of pink fluid. He has
previously had a chronic cough but this was now accompanied by
pink fluid. One day prior to admission, the patient had an
episode of hematemsis. The emesis was characterized as dark
with clots. The patient had another episode of emesis on the
morning of admission that was similar characteristic prompting a
visit to the ED. The pt had an episode of emesis in the ED
which was characterized as coffee ground. NG suction resulted
in return of more coffee ground material but cleared without
lavage. A type and cross was sent as well as a CBC 2 large bore
IVs were placed in the arms and the patient was transferrd to
the [**Hospital Unit Name 153**].
Past Medical History:
1. CHF/Pneumonia (last [**Hospital1 18**] admit [**2150-7-14**])
2. s/p CVA with lacunar infarcts and resulting dementia
3. Afib with sick sinus syndrome s/p pacemaker VVI type
4. CRF with Cr = 1.5
5. AAA repaired [**2144**] complicated by aorto-enteric fistula in
[**2150**] w/ J-tube placement
6. CAD w/100% occluded RCA
7. HTN
8. COPD
9. Hx EtOH abuse
10. Gout
Social History:
Pt previously lived at a Nursing Home but has lived with
daughter [**Name (NI) **] [**Known lastname 52362**] since end of [**2150-9-30**]. Pt has 4
daughters. Pt quit smoking 20 years ago but admits to having
smoked over 2ppd x 30years. Pt also drinks EtOH - drank Guiness
at NH to inc PO intake of nutrients.
Family History:
NC.
Physical Exam:
PE:
VS: Tc: 97 HR: 100 BP: 150/80 RR: 12 SaO2: 98% on RA
Gen: elderly male lying in bed in NAD. Pt is asleep but
arousable and interacts appropriately.
HEENT: PERRL, EOMI
CV: irregular rhythm, 2/6 SEM at left upper sternal border
Chest: CTA bilaterally
Abd: soft, NT, ND, hypoactive BS
Rectal: guaiac positive by report (as per GI)
Ext: no clubbing, cyanosis, edema
Pertinent Results:
CXR [**2150-12-11**]: no free air; pacemaker present; NG tube in gastic
fundus, ?fibrotic lung disease.
.
ECG [**2150-12-11**]: irregularly irregular at ventricular rate of 97.
nml axis. no P waves identified. LVH with strain pattern.
EGD [**2150-12-14**]: A small amount of red blood with smooth surfaced
mass was seen in the left aspect of the hypopharynx. The area
was not well seen due to overlying mucus.
Impression: ? mass with localized blood in the hypopharynx;
Likely small area of NG tube trauma; small excavated area, with
suture material, was seen on the anterior surface of the gastric
body; otherwise normal egd to second part of the duodenum.
[**2150-12-11**] 01:40PM WBC-11.1* RBC-3.30* HGB-9.2* HCT-28.1* MCV-85
MCH-27.6 MCHC-32.8 RDW-15.5
[**2150-12-11**] 01:40PM NEUTS-80.6* BANDS-0 LYMPHS-13.6* MONOS-4.9
EOS-0.5 BASOS-0.3
[**2150-12-11**] 01:40PM HYPOCHROM-NORMAL ANISOCYT-3+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
SCHISTOCY-OCCASIONAL
[**2150-12-11**] 01:40PM PLT COUNT-307
[**2150-12-11**] 01:40PM PT-41.2* PTT-46.0* INR(PT)-10.7
[**2150-12-11**] 01:40PM LIPASE-28
[**2150-12-11**] 01:40PM ALT(SGPT)-17 AST(SGOT)-20 AMYLASE-60 TOT
BILI-0.8
[**2150-12-11**] 01:40PM GLUCOSE-144* UREA N-50* CREAT-1.9* SODIUM-138
POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-23 ANION GAP-16
[**2150-12-11**] 01:48PM HGB-10.3* calcHCT-31
[**2150-12-11**] 07:54PM PT-17.5* PTT-33.8 INR(PT)-1.9
[**2150-12-11**] 07:54PM HCT-22.3*
[**2150-12-11**] 07:54PM BLOOD Hct-22.3*
[**2150-12-12**] 03:29AM BLOOD WBC-8.2 RBC-3.09* Hgb-9.1* Hct-26.4*
MCV-86 MCH-29.4 MCHC-34.4 RDW-15.8* Plt Ct-213
[**2150-12-12**] 08:47AM BLOOD Hct-28.2*
[**2150-12-13**] 09:30AM BLOOD WBC-8.0 RBC-3.34* Hgb-9.6* Hct-29.3*
MCV-88 MCH-28.8 MCHC-32.9 RDW-15.9* Plt Ct-202
[**2150-12-13**] 09:05PM BLOOD Hct-29.8*
[**2150-12-11**] 01:40PM BLOOD PT-41.2* PTT-46.0* INR(PT)-10.7
[**2150-12-11**] 07:54PM BLOOD PT-17.5* PTT-33.8 INR(PT)-1.9
[**2150-12-13**] 09:30AM BLOOD PT-14.0* PTT-24.0 INR(PT)-1.2
[**2150-12-13**] Urine culture: + E coli and Pseudomonas aeruginosa.
Brief Hospital Course:
1. upper gastrointestinal bleed: pt was admitted to the [**Hospital Unit Name 153**].
NG suction returned more coffee grounds that cleared with
lavage. Pt was transfused with 2 units PRBCs. Pt's hematocrit
remained stable; in the setting of resolution of the acute
bleed, an EGD was performed which showed a questionable
hypopharyngeal mass thought to be the origination of the bleed.
ENT was consulted, and it was thought that this hypopharyngeal
mass was actually the hyoid bone, the configuration of which was
an anatomic variant; no further intervention recommended.
Therefore, the origin of the bleed was not able to be
visualized. In the last few days of hospitalization, pt refused
blood draws, so hematocrit could not continued to be followed.
.
2. Afib: pt previously on anticoagulation with coumadin, and he
was found to be supratherapeutic on admission (INR 10.7).
Coumadin was held, and will be held for the month after
discharge. It is possible at that time that pt will be started
on low dose coumadin (2mg daily), as pt began to refuse blood
draws, and had actually declined blood draws to check his INR
for the 3 weeks before his admission.
.
3. CAD: pt with known CAD; beta blocker, ACE inhibitor, and
statin were given. Aspirin was held in the setting of an acute
GI bleed.
.
4. HTN: as above. Pt maintained on BB and ACE inhibitor. BP
well-controlled while in hospital.
.
5. urinary tract infection - pt was noted to have a UTI per UA.
He was treated in the hospital with levofloxacin (though pt
declined all medications in the last 2 days of hospitalization),
and cultures came back positive for E coli and Pseudomonas. He
was prescribed a 7 day course of ciprofloxacin for after
discharge.
.
6. CRI: pt with known CRI with baseline Cr of 1.5. No acute
issues while in hospital; maintained adequate urine output.
.
7. dementia: pt with baseline dementia. Remained less than
fully oriented, and was thought to be at baseline per family
members.
.
8. Code: DNR/DNI confirmed with attending and HCP.
Medications on Admission:
1. ASA
2. Effexor 75mg once daily
3. Lasix 20mg once daily
4. Lipitor 20mg once daily
5. Synthroid 50mcg once daily
6. Colace 100mg [**Hospital1 **]
7. Metoprolol 50mg [**Hospital1 **]
8. Zantac 170mg once daily
9. Isosorbide 10mg TID
10. Coumadin 5mg once daily - discontinued on [**2150-12-8**]
11. Lisinopril 5mg once daily - discontinued on [**2150-12-8**]
Discharge Medications:
1. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO DAILY (Daily).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
6. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
You should resume your regular dosage.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1)Gastrointestinal Bleed
2)Urinary Tract Infection
3)Elevated INR
4)hypopharyngeal mass (anatomical variant)
Discharge Condition:
Fair
Discharge Instructions:
Please call your doctor if you have more bleeding, increased
confusion, fever or other concerning symptoms.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 16258**] within the next 1-2 weeks
|
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21,830
| 123,054
|
2499+2500
|
Discharge summary
|
report+report
|
Admission Date: [**2108-10-26**] Discharge Date:
Service: C-MEDICINE/CCU/MICU
HISTORY OF PRESENT ILLNESS: The patient is an 82 year old
male with a past medical history of hypertension, peripheral
vascular disease, status post left above the knee amputation,
who does not regularly seek medical care, who presented to
the Emergency Department at [**Hospital1 188**], on [**2108-10-26**], complaining of a two to four week
history of shortness of breath, productive cough, congestion,
brief choking sensation. On arrival to the Emergency
Department, temperature was 98.5, heart rate 90, blood
pressure 139/71, respiratory rate 36, oxygen saturation 76%
in room air.
Of note, the patient's initial laboratories showed a
bicarbonate markedly elevated at 38. Chest x-ray at that
time showed cardiac enlargement with mild upper lung zone
redistribution with small bilateral pleural effusions, left
greater than right, questionable right lower lobe pneumonia.
The patient was admitted to the C-Medicine service for
management of congestive heart failure. Also of note, CT
scan of the chest in the Emergency Department ruled out
pulmonary embolism.
On the C-Medicine service, the patient was diuresed
aggressively with Lasix 40 mg intravenously twice a day,
started on Aspirin and Captopril, and was transiently on a
Nitroglycerin drip for blood pressure control. He was ruled
out for myocardial infarction with three sets of cardiac
enzymes. With these laboratories, the patient's
creatinine-kinase level was relatively flat, but he did have
a slight troponin leak felt to be consistent with heart
strain secondary to congestive heart failure.
While on the regular floor, the patient had issues with
confusion, agitation and refusing to take oral medications.
This required one to one sitter as well as medication with
Haldol and Risperidone. On the evening of [**2108-10-28**], the
patient had increased agitation and confusion. He was
medicated with Haldol and Risperidone. At that time, he
dropped his oxygen saturation to 66% on nasal cannula oxygen
and was noted to have increased respiratory rate and some
gurgling. The patient was placed on face mask and given
Lasix 40 mg intravenously, however, he failed to improve
dramatically. Therefore, he was intubated after rapid
sequence medication with Etomidate and Succinylcholine.
Prior to intubation, his arterial blood gases revealed
7.24/108/164. This was consistent with hypercarbic
respiratory failure.
The patient was therefore transferred to the CCU service
where the thinking was that the patient could possibly have
intermittent pulmonary emboli versus ischemia. As the
patient had elevated blood urea nitrogen and creatinine and
was already over four liters negative for his hospital
course, diuresis was held. Echocardiogram was performed
which showed a left ventricular ejection fraction of greater
than 50%, left ventricular hypertrophy, and evidence of
diastolic dysfunction with E:A ratio of 0.67, and impaired
relaxation. No wall motion abnormalities were found. The
patient was worked up for pulmonary embolism via positive
D-dimer, however, lower extremity ultrasounds were negative.
A repeat CT scan of the chest was not performed. This is in
light of a negative CTA of the chest on admission. The
patient was started on Heparin drip for anticoagulation.
Heparin was later discontinued due to a large nosebleed. The
patient was extubated while in the CCU service on [**2108-10-30**].
Preextubation arterial blood gas was 7.37/81/80 on 50%
nonrebreather face mask. That evening, the patient
demonstrated increased work of breathing. Arterial blood
gases were checked and showed values of 7.20/126/110. The
patient was agitated and received Haldol and Ativan. Repeat
gas was 7.14/131/128 with oxygen saturation 86%. Chest x-ray
was performed which showed a questionable left sided
pneumothorax. A repeat chest x-ray was performed in order to
further evaluate possible pneumothorax. In the interim, the
patient was reintubated and a chest tube was placed by
surgical staff. During chest tube placement, the repeat
chest x-ray was read as no evidence of pneumothorax. Decision
was made to continue chest tube placement and chest tube
drained 220cc of straw colored fluid. All told the patient
tolerated these interventions well.
The patient was then transferred to the Medical Intensive
Care Unit service for further management of his pulmonary
issues including recurrent hypercarbic respiratory failure.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Peripheral vascular disease, status post right carotid
endarterectomy in [**2099**].
3. Left above the knee amputation, status post World War II
injury.
ALLERGIES: The patient reports no known drug allergies.
MEDICATIONS ON ADMISSION; None.
MEDICATIONS ON TRANSFER FROM CCU SERVICE TO MEDICAL INTENSIVE
CARE UNIT SERVICE:
1. Haldol.
2. Fentanyl drip.
3. Levofloxacin 500 mg once daily.
4. Propofol.
5. Albuterol and Atrovent nebulizers.
6. Regular insulin sliding scale.
7. Lorazepam.
8. Famotidine.
9. Aspirin.
SOCIAL HISTORY: The patient reports a positive 50 to 75 pack
year tobacco history, having quit in [**2092**]. There is a remote
history of alcohol. The patient is a retired mechanic. He
is a World War II Veteran. He lived alone prior to
admission. His daughter, [**Name (NI) **], is actively involved in his
medical care and checks up on him frequently. His wife is
deceased status post myocardial infarction approximately one
year ago.
FAMILY HISTORY: No history of early coronary artery disease.
The patient's brother deceased from complications of type 2
diabetes mellitus. Sister deceased from episode of
respiratory distress. The patient's parents lived into their
90s without major medical problems.
PHYSICAL EXAMINATION: On transfer to Medical Intensive Care
Unit service, temperature was 101.0, heart rate 64, blood
pressure 106/40, respiratory rate 14, oxygen saturation 99%.
The patient was being ventilated on assist control with tidal
volume 500 to 560, respiratory rate 10-14, pressure support
of 0, PEEP of 5, FIO2 0.60. On those settings, arterial
blood gas was 7.41/65/186/43. Generally, the patient is well
developed, thin male, opened eyes to voice, somewhat
agitated, in no acute distress, breathing comfortably. Head,
eyes, ears, nose and throat examination - Normocephalic and
atraumatic. The pupils are equal, round, and reactive to
light and accommodation. Positive endotracheal tube,
positive oral gastric tube placed. Neck was supple, no
masses or lymphadenopathy, 1+ carotid pulses, normal carotid
upstroke. Positive faint left carotid bruit. Lungs - Mild
bibasilar crackles; otherwise coarse breath sounds
anterolaterally secondary to ventilation settings.
Cardiovascular is regular rate and rhythm, S1 and S2 heart
sounds auscultated, no murmurs, rubs or gallops. The
abdomen is soft, mildly distended, some left lower quadrant
fullness. Extremities - left above the knee amputation,
right leg with no edema or erythema. Foot warm. Distal
pulses nonpalpable but auscultated via Doppler.
Genitourinary - Right scrotum markedly enlarged compared to
left. No evidence of transillumination. Skin - no rashes or
lesions. Neurologically, awake, open eyes to voice, not
following commands consistently, moving all extremities.
LABORATORY DATA: On transfer to the Medical Intensive Care
Unit service, the patient's complete blood count showed a
white blood cell count of 8.8, hematocrit 37.2, MCV 77,
platelet count 183,000. Coagulation profile showed
prothrombin time 13.5, partial thromboplastin time 34.4, INR
1.2. Serum chemistries showed sodium 148, potassium 3.7,
chloride 101, bicarbonate 46 up from 38 on admission, blood
urea nitrogen 42, creatinine 1.1, glucose 95. Other
laboratories showed calcium 7.8, with free calcium 1.12,
phosphate 4.8, magnesium 2.1, albumin 3.1.
Chest x-ray from [**2108-10-29**], showed positive left sided chest
tube. No evidence of pneumothorax. Heart enlarged.
Positive intubation with endotracheal tube 2.8 centimeters
above carina in good position. Right lung clear. No
evidence of failure. Lower extremity ultrasound from
[**2108-10-29**], showed no evidence of deep vein thrombosis. CT
scan of the chest from [**2108-10-26**], showed no filling defects in
the pulmonary artery vasculature, no pulmonary embolism
identified, moderate bilateral pleural effusions, some
atelectasis at the bases bilaterally. Lingular atelectasis.
Positive hiatal hernia. Degenerative changes throughout the
thoracic spine. Small pericardial effusion.
Echocardiogram from [**2108-10-29**], showed E:A ratio of 0.67, left
ventricular ejection fraction greater than 55%. Left atrium
mildly dilated. Right atrium mildly dilated. Moderate
symmetric left ventricular hypertrophy. Overall systolic
function was normal. Right ventricular chamber size and free
wall motion were normal. Trace aortic regurgitation. Left
ventricular inflow pattern suggestive of impaired relaxation.
Trivial tricuspid regurgitation. Mild pulmonary artery
systolic hypertension. Physiologic pericardial effusion.
HOSPITAL COURSE:
1. Respiratory failure - The patient was reintubated while
in the CCU service on [**2108-10-30**], for recurrent hypercarbic
respiratory failure. At that time, etiology of his acute
decompensation included hypercarbic respiratory failure
secondary to chronic obstructive pulmonary disease.
Evaluation of the patient's laboratories on admission showed
that he came in with elevated bicarbonate of 38. This is
suggestive of the patient being a chronic CO2 retainer with
baseline carbon dioxide levels in the 60 to 80 range.
Although the patient did not come to the hospital with a
diagnosis of chronic obstructive pulmonary disease, it was
felt that he likely had baseline chronic obstructive
pulmonary disease based on extensive smoking history, his
clinical examination and could possibly have additional
pulmonary damage secondary to occupational history. It was
felt possible that the patient's acute decompensation on the
floor while extubated could have been due to excessive
oxygenation, namely, that high flow oxygen blunted the
patient's hypoxic respiratory drive, increased VQ mismatch,
and also heavy effects of elevating the patient's carbon
dioxide level secondary to the [**Last Name (un) 12794**] effect. Therefore,
the patient was treated for the obstruction component of his
chronic obstructive pulmonary disease with Albuterol and
Atrovent nebulizer treatments. He was also maintained on
aggressive pulmonary toilet. He had originally been on
Levofloxacin 500 mg intravenously q24hours started by the CCU
service in light of his history of increased cough and sputum
production. He was also started on pulse dose steroids. In
terms of his most recent arterial blood gas which showed pH
7.41, carbon dioxide 65, oxygen 186, the patient's vent
settings were changed to decrease his level of FIO2. His
current level of ventilation was continued. He was
maintained on Haldol p.r.n. for agitation. Throughout the
following day, the patient was weaned off the ventilator and
had a trial of pressure support ventilation which he
tolerated well. He was extubated on [**2108-10-31**]. Post
extubation, the patient's oxygen settings were maintained
conservatively to keep his oxygen saturation levels between
89 and 93% in light of his history of CO2 retention. He
tolerated this well and was able to maintain adequate
oxygenation and ventilation off the ventilator on low flow
oxygen administered via face mask and cannula. Levofloxacin
as well as steroids were discontinued later in the hospital
course secondary to the patient's mental status changes.
2. Mental status changes secondary to delirium - Throughout
his stay in the Intensive Care Unit, the patient was agitated
and confused. A workup for infectious etiologies including
blood cultures, sputum cultures, and urine cultures were all
negative. A psychiatry consultation was obtained. They
recommended medicating the patient with Seroquel and Haldol
p.r.n. With Haldol and Seroquel administration, the patient
was less agitated but remained confused. Folate, B12 and RPR
laboratories were evaluated and were all negative. The
patient had a CT scan of the head performed to rule out
subdural bleed. At the time of this dictation, results of
that are still pending. In light of the aggressive
administration of Haldol, serial electrocardiograms were
checked to rule out Q-T interval prolongation.
3. Congestive heart failure - Based on the patient's
admission chest x-ray as well as physical examination
findings, as well as improvement in respiratory status with
diuresis, it was felt that the patient most likely was in
mild congestive heart failure on admission. Echocardiogram
showed normal systolic function, but evidence of diastolic
dysfunction. At the time of transfer to the Medical
Intensive Care Unit service, the patient appeared euvolemic
on examination without signs or symptoms of congestive heart
failure. Therefore, additional diuresis was held. He was
started on low dose beta blocker for his congestive heart
failure.
4. Coronary artery disease - In light of the patient's
presentation with congestive heart failure, as well as his
slight troponin leak during this hospitalization, it was felt
that the patient might have a component of ischemia
contributing to his dyspnea. Initially, he was maintained on
Aspirin as well as beta blocker therapy. After stabilization
from this hospital event, the patient should likely undergo
stress testing as an outpatient in order to further evaluate
his cardiac function.
5. Possible pneumothorax - Prior to transfer to the Medical
Intensive Care Unit service, the patient had a chest tube
placed for possible pneumothorax. However, repeat chest
x-ray showed no evidence of pneumothorax. Chest tube was
removed on [**2108-10-31**].
6. Acute renal failure - With diuresis, the patient's
creatinine level peaked at 1.4. This acute increase is
likely secondary to overdiuresis and intravascular volume
depletion resulting in hyperperfusion of kidneys. In light
of his prerenal picture, further diuresis was held after
transfer to the Medical Intensive Care Unit service. All the
patient's medications were renally dosed and nephrotoxic
agents were avoided.
7. Iron deficiency anemia - The patient's admission complete
blood count showed a low MCV and hypochromasia. Iron studies
were performed consistent with iron deficiency anemia. This
raised the question that the patient had an occult bleed,
namely, colon cancer. All his stools were guaiac negative.
It is recommended the patient undergo outpatient colonoscopy
for further workup of his iron deficiency anemia.
8. Code Status - The patient is a full code.
9. Communication/family issues - The patient's daughter,
[**Name (NI) **] [**Name (NI) 12795**], is extremely involved in his medical care.
Should the patient become unable to make medical decisions
for himself, he has appointed Ms. [**Name13 (STitle) 12795**] as his health
care proxy.
10. Disposition - On [**2108-11-3**], the patient was transferred to
the Medicine service from the Medical Intensive Care Unit.
The remainder of his hospital course as well as discharge
condition, discharge status, and discharge medications will
be dictated as a separate addendum to this report.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 257**]
MEDQUIST36
D: [**2108-11-4**] 12:51
T: [**2108-11-4**] 13:33
JOB#: [**Job Number 12796**]
cc:[**Male First Name (un) 12797**] Admission Date: [**2108-10-26**] Discharge Date: [**2108-11-14**]
Service: ACOVE
ADDENDUM: Medicine
HOSPITAL COURSE SINCE PREVIOUS DICTATION: 1. PULMONARY: On
transfer to the ACOVE Service from the MICU, the patient improved
dramatically from a respiratory standpoint. He was continued on
oxygen and his nebulizer treatments with oxygen saturations
approximately 90% on 2 liters. The patient had a chest x-ray
that seemed consistent with aspiration and he was briefly started
on levofloxacin and Flagyl.
On [**2108-11-7**], the patient had an episode of hypoxia
to 68% with an ABG of 7.18/73/57. The patient was placed on
humidified oxygen with saturations around 90-92% and was
suctioned. The patient was noted to have thick tenacious
sputum. A stat chest x-ray was ordered that showed no
changes. The patient had chest PT at this time for
percussive therapy and was noted to have a blood pressure of
80/30 and was subsequently bolused with normal saline.
Given minimal responsiveness to sternal rub, the patient was
again transferred to the ICU for respiratory distress. The
patient was intubated in the SICU and was placed on levo,
ceftazidime, and vancomycin for pneumonia. The patient was
eventually weaned from the ventilator and improved dramatically
from a respiratory standpoint. He was continued on all
nebulizers and received frequent suctioning. The etiology of the
patient's hypoxic respiratory failure was considered likely
multifactorial including his diastolic heart failure, pneumonia,
and COPD. The patient was treated for his mild diastolic heart
failure.
A sputum sent on [**2108-11-7**] grew out MRSA and the
patient's levofloxacin and ceftazidime were stopped and he
was kept on vancomycin IV. He received a PICC line and it is
anticipated that the patient will receive a full 14 day
course of IV vancomycin for MRSA pneumonia.
2. CARDIOVASCULAR: While in the [**Hospital Unit Name 153**], the patient was noted
to have a troponin leak in the setting of respiratory
distress considered secondary to demand ischemia. The
patient was continued on aspirin, Lopressor, and statin and
it is anticipated that he will have a more thorough cardiac
workup as an outpatient. Notably, the patient's CK and CK MB
were normal and stable throughout his stay.
Prior to transfer to the [**Hospital Ward Name 516**], the patient had an
echocardiogram which was significant for an EF of over 55%,
moderate symmetrical LVH, mild pulmonary hypertension, and an
E/A ratio of 0.67. It is likely that the patient has
diastolic dysfunction and in addition to a beta blocker was
kept on Lasix 40 mg q.d. for likely volume overload.
3. INFECTIOUS DISEASE: On discharge from the MICU, the
patient improved from a pulmonary standpoint but could not be
weaned from oxygen. The chest x-ray was significant for a
retrocardiac pneumonia and the patient was started on
levofloxacin and Flagyl for presumed aspiration pneumonia.
The patient subsequently had a hypoxic respiratory distress
and was transferred to the [**Hospital Unit Name 153**] where sputum was sent and
came back with MRSA. The patient was started on vancomycin
and will receive this for 14 days. He remained afebrile
throughout his hospital stay.
4. MENTAL STATUS: The patient was transferred with the
diagnosis of delirium that was considered multifactorial,
potential etiologies include psychotropic medications that
the patient had received, hypercapnic and hypoxic respiratory
arrest as well as baseline dementia. After the patient was
extubated for the third time, his mental status improved
significantly. He was followed by the Psychiatry Team who
felt that his delirium was most likely secondary to his
multiple medical problems and recommended treating his
medical problems and following up in the future with an MRI
once the patient was stable. The patient was noted to have
symptoms consistent with sundowning with an acute increase in
his confusion at night; however, the patient's mental status
was appropriate during the day and he was noted to be alert
and oriented prior to discharge.
5. RENAL: The patient was noted on transfer to have an
elevated creatinine which was thought likely secondary to
dehydration. He was fluid resuscitated but continued to have
increasing creatinine to a maximum of 2.8. The [**Hospital Unit Name 153**] Team
thought that the patient's acute renal failure was secondary
to possible hypoxemia and the patient's creatinine after he
was extubated eventually improved to 1.1 prior to discharge.
6. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
evaluated by the Speech and Swallow Team and had a video
fluoroscopic swallowing evaluation which was negative for
aspiration. Prior to discharge, his diet was advanced to
pureed solids and regular thin liquids. It was anticipated
that the patient's diet will be advanced to a regular diet
after he is transferred to the rehabilitation hospital.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged to the [**Hospital6 7068**].
DISCHARGE DIAGNOSIS:
1. Diastolic dysfunction.
2. Hypercarbic respiratory arrest.
3. Chronic obstructive pulmonary disease.
4. Methicillin-resistant Staphylococcus aureus pneumonia.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Fluticasone two puffs b.i.d.
3. Salmeterol 50 micrograms one inhalation q. 12 hours.
4. Atorvostatin 10 mg p.o. q.d.
5. Ipratropium bromide 0.02% one nebulizer q. six hours
p.r.n.
6. Prednisone 20 mg p.o. q.d. times two days, 10 mg p.o.
q.d. times two days.
7. Metoprolol 25 mg p.o. b.i.d.
8. Vancomycin 1 gram IV q.d. times seven days.
9. Heparin 5,000 units q. eight hours subcutaneously.
10. Pantoprazole 40 mg p.o. q.d.
11. Lasix 40 mg p.o. q.d.
12. Calcium carbonate 500 mg p.o. t.i.d.
FOLLOW-UP: The patient is discharged to [**Hospital6 7068**] where he will continue on medications
as prescribed. He will continue vancomycin for seven days
for MRSA pneumonia. It is hoped at this time that he will
also be placed on an ACE inhibitor for his antihypertensive
regimen. The patient will be followed by the physicians at
the rehabilitation center. He is encouraged to contact Dr.
[**Last Name (STitle) 12798**] at [**Hospital 882**] Hospital to schedule a follow-up
appointment within two weeks of being discharged from
[**Hospital1 **]. If Dr. [**Last Name (STitle) 12798**] is not taking any new patients,
the patient is welcome to follow-up with Dr. [**Last Name (STitle) **] in the
[**Hospital 191**] Clinic.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern4) 12799**]
MEDQUIST36
D: [**2108-11-14**] 10:02
T: [**2108-11-14**] 13:11
JOB#: [**Job Number 12800**]
|
[
"507.0",
"428.0",
"584.9",
"428.30",
"276.5",
"518.0",
"482.41",
"518.81",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"96.04",
"96.71",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
5546, 5802
|
21054, 22563
|
20865, 21031
|
9183, 19032
|
5825, 9166
|
118, 4512
|
19048, 20737
|
4534, 5084
|
5101, 5529
|
20762, 20844
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,921
| 101,317
|
35070+57974
|
Discharge summary
|
report+addendum
|
Admission Date: [**2124-8-18**] Discharge Date: [**2124-8-28**]
Date of Birth: [**2046-8-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass grafts x 3(LIMA-LAD, SVG-RCA,SVG-Cx)
History of Present Illness:
This 78 year old white male was being evaluated for claudication
and revascularization of his left leg. During this workup he
was found to have an abnormal stress test and a catheterization
revealed significant double vessel disease. he was referrred
for coronary revascularization, but had been given Plavix. He
was admitted and begun on Heparin to allow clearance of the
Plavix.
Past Medical History:
Peripheral vascular disease
chronic renal insufficiency
s/p right carotid endarterectomy
hyperlipidemia
hypertension
renal artery stenosis
Social History:
Ex-smoker having quit 25 years ago. Retired engineer. Lives at
home with his wife, Drinks 3-4 [**Name2 (NI) 17963**] a week.
Family History:
No family history of early coronary artery disease or peripheral
vascular disease.
Physical Exam:
T 97.8 BP 139/68 HR 72 RR 20 96% RA 70.4 KG
Neuro: non-focal
Pulmonary: Lungs clear to auscultation bilaterally
Cardiac: regular rate and rhythm.
Sternal incision: sternum stable. No erythema or drainage.
Abdomen: soft and nontender without rebound or guarding.
Normoactive bowel sounds
Extremities: warm with 1+ edema
Pertinent Results:
Date of Birth: [**2046-8-3**] Sex: M
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 6477**]
PREOPERATIVE DIAGNOSIS: Coronary artery disease.
POSTOPERATIVE DIAGNOSIS: Coronary artery disease.
PROCEDURE PERFORMED: Coronary artery bypass grafting x3:
Left internal mammary artery grafted to the left anterior
descending with reverse saphenous vein graft to the posterior
descending artery and reverse saphenous vein graft to first
diagonal branch.
ASSISTANT: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 80112**], MD
ANESTHESIA: General endotracheal anesthesia.
CLINICAL NOTE: Mr. [**Known firstname 1726**] [**Known lastname **] is a 78-year-old male with
symptoms of chest tightness, shortness of breath, status post
right carotid endarterectomy, and known with peripheral
vascular disease with claudication and hypertension. He
underwent catheterization that showed severe 2-vessel disease
presenting for revascularization.
DESCRIPTION OF PROCEDURE: After adequate anesthesia was
achieved and with the patient supine, he was prepped and
draped in the usual sterile manner. Median sternotomy was
performed through which the pericardium was exposed. The left
internal mammary artery was taken down to the level of the
left subclavian vein and divided distally after heparin was
given. Saphenous vein was harvested from the right lower
extremity using endoscopic vein harvesting system and
prepared in the usual fashion. The pericardium was exposed.
The patient was then heparinized. The ascending aorta was
cannulated with a soft-flow ascending aortic cannula. Three
stage venous cannula was placed through the right atrial
appendage. Retrograde coronary sinus cannula was placed
through the right atrial wall. He was placed on bypass and
the aorta was crossclamped. The heart was arrested with cold
antegrade blood cardioplegia followed by multiple retrograde
doses. The posterior descending artery was a small vessel but
was grafted to a segment of vein in end-to-side fashion with
running 7-0 Prolene. The first diagonal branch of the LAD was
a good size branch that was similarly grafted. The left
anterior descending artery was grafted to the mammary artery
in end-to-side fashion with a good size left internal mammary
artery. With the crossclamp in place, the 2 main grafts were
fashioned to the ascending aorta. Two punch aortotomies with
running 6-0 Prolene. Warm cardioplegia was given retrograde.
The crossclamp was released with the patient's head down
while de-airing the root. The grafts were de-aired and open
to flow. Epicardial pacing wires were placed. He was weaned
off bypass, decannulated after protamine administration and
once the field was dry, 1 left pleural and 2 mediastinal
tubes were left in place. The sternotomy was closed with
heavy steel wires and the presternal layers were closed with
Vicryl sutures. The skin was closed with subcuticular
closure. Dry dressing was applied. He tolerated the procedure
well and left the OR in stable condition.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 80113**]
[**Last Name (LF) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2046-8-3**]
Age (years): 78 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraop TEE for CABG
ICD-9 Codes: 402.90, 786.05, 786.51, 440.0
Test Information
Date/Time: [**2124-8-22**] at 13:21 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3319**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm
Aorta - Ascending: 2.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Aortic Valve - LVOT diam: 1.7 cm
Aortic Valve - Pressure Half Time: 143 ms
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Lipomatous hypertrophy of the
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. Moderate regional LV
systolic dysfunction.
RIGHT VENTRICLE: Mild global RV free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Simple atheroma in
aortic arch. Complex (>4mm) atheroma in the descending thoracic
aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Mild to moderate
([**11-24**]+) AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
2. The left ventricular cavity size is normal. There is moderate
regional left ventricular systolic dysfunction with anterior,
antero-septal and antero-lateral hypokinesis.
3. There are simple atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. Mild to moderate ([**11-24**]+) aortic
regurgitation is seen.
5. The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced.
1. Biventricular function is unchanged.
2. Aorta is intact post decannulation.
3. Other findings are unchanged.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2124-8-22**] 14:20
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2124-8-26**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80114**]
Reason: f/u atx, effusion
[**Hospital 93**] MEDICAL CONDITION:
78 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
f/u atx, effusion
Provisional Findings Impression: JRld SAT [**2124-8-26**] 8:33 PM
Increased bibasilar atelectasis more so in the left. Increased
bilateral
pleural effusions more so in the left.
Final Report
REASON FOR EXAM: Status post CABG, assess pleural effusion.
Comparison is made with prior study performed [**2124-8-23**].
Bibasilar atelectasis worse in the left side have increased.
Small bilateral
pleural effusions worse in the left side have also increased.
There is no
CHF. Cardiomediastinal silhouette is unchanged. Sternal wires
are aligned.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: SUN [**2124-8-27**] 2:22 PM
Brief Hospital Course:
78 year old male who was transferred to [**Hospital1 18**] on [**2124-8-18**] for
CABG. He was being evaluated prior to Left fem-[**Doctor Last Name **] bypass. He
had failed a persantine-ett and cath showed severe ostial LAD
disease and 60% RCA disease. He was brought to the OR with Dr
[**Last Name (STitle) **] on [**2124-8-22**] for 3-vessesl CAD (LIMA-LAD, SVG-D1,
SVG-PDA). Please see operative report for full details.
Post-operatively he was transferred to the CVICU for invasive
monitoring.
Patient was noted to be in a junctional rhythm on POD 3 and
nodal blocking agents were held. As a result, he was NOT
restarted on beta blockers.
He was transferred to the step down floor on post-op day 4. He
remained in sinus rhythm from post-op day 4 to discharge. He was
evaluated by PT and cleared to be discharged to home.
Medications on Admission:
Lisinopril 20mg/D,Plavix 75mg/D,ASA81,Zocor 20mg/D, ToprolXL
25mg/D
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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
5. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO Q12H
(every 12 hours) for 5 days.
Disp:*20 Packet(s)* Refills:*0*
6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take this as long as you take the narcotic
pain medicine.
Disp:*60 Capsule(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 11485**] VNA
Discharge Diagnosis:
Coronary artery disease
s/p coronary artery bypass grafting
hypertension
peripheral vascular disease
s/p right carotid endarterectomy
hyperlipidemia
chronic renal insufficiency
renal artery stenosis
Discharge Condition:
good
Discharge Instructions:
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
shower daily, no baths or swimming
no lotions, creams or powders to incisions
report any fever greater than 100.5
report any redness or drainage from incisions
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**Last Name (STitle) **] [**Last Name (STitle) **] [**12-26**] weeks
Dr [**Last Name (STitle) 17025**] 2 weeks
Completed by:[**2124-8-28**] Name: [**Known lastname **],[**Known firstname **] W. Unit No: [**Numeric Identifier 12884**]
Admission Date: [**2124-8-18**] Discharge Date: [**2124-8-28**]
Date of Birth: [**2046-8-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex
Attending:[**First Name3 (LF) 741**]
Addendum:
As per patient request, T#3 prescription was not given. Darvocet
tabs 50/325 mg, 1/2 tabs po q 4hprn pain, dispensed #45 was
administered.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 12885**] VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2124-8-28**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
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icd9pcs
|
[
[
[]
]
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|
9680, 10511
|
295, 357
|
11953, 11960
|
1533, 7273
|
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|
1090, 1174
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|
8808, 8838
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7322, 8768
|
1189, 1514
|
232, 257
|
8870, 9657
|
385, 770
|
792, 932
|
948, 1074
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,648
| 165,385
|
11998
|
Discharge summary
|
report
|
Admission Date: [**2154-1-6**] Discharge Date: [**2154-1-12**]
Date of Birth: [**2108-7-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
alcohol intoxication, chronic pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45 yo F with a long hx of alcohol abuse and withdrawl, chronic
pancreatitis who presented to [**Hospital1 18**] with ETOH intoxication
(level = 350 on arrival), nausea, and abdominal pain. She stated
that this abdominal pain is consistent with prior flares. Pt
reports that most of her care has been at [**Hospital1 112**] and [**Hospital1 2025**]. She has
been admitted once before to [**Hospital1 18**] with ETOH intoxication,
abdominal pain, and suicidal ideation.
.
She reports a pancreatic cyst removal in [**2145**], otherwise has not
had any major complications: no prior ICU stays, no prior
intubation. She is currently drinking approximately 1 pint of
vodka per day.
This 'flare' is different from priors in that she had a small
amount of coffee ground emesis. This occured after 3 hours of
wretching and was not witnessed in the ED.
.
In the ED, initial VS: 99.6, HR=129, 123/92, 18, 99% room air.
She was given two doses of valium 10mg IV as her tachycardia was
thought to represent withdrawal--no reports of any other signs
of withdrawal. Her last drink was 5 hours prior to presentation.
She received 1 banana bag and 3L NS. Labs were notable for a
transaminitis with ALT=167 and AST=750 (HEMOLYZED), normal
lipase, WBC of 3.6 and Hct of 42.1 with MCV of 105.
.
In the ICU, she c/o abdominal pain which radiates from her
epigastrium down to her pelvis and also to her back, stating
that this is similar to her prior episodes. She is still
nauseous and states that she has had chest pain for the last
twelve hours with is retrosternal and needle-like. Denies
radiation of this pain, denies association with exertion.
.
While in the MICU, she was given IVF, pain control, CIWA scale,
CT abd pelvis showing chronic pancreatitis, pseudocyst, fatty
liver and PPD placed. U/S L.clavicle showed no DVT
.
Currently, she reports improved but present sharp/crampy abd
pain as described above. She also reports fleeting retrosternal
CP, that occurs when she develops nausea but is not associated
with diaphoresis, LH/palp/sob or radiation of pain. She also
denies recent
f
e
v
e
r
/
chills/ST/URI/cough/headache/LH/palp/v/d/c/melena/brbpr/dysuria/
joint pain/skin rash/paresthesias/weakness.
Past Medical History:
# EtOH abuse- patient reports previous seizures during
withdrawal
# History of chronic pancreatitis, status-post surgical
pancreatic cyst removal.
# Prior Peptic Ulcer
# Depression
# Anxiety
# Motor vehicle accident with facial trauma 20 years ago
# Left ankle injury
# History of panic attacks.
# Reported history of Hepatitis A in 20's
Social History:
Patient has had long history of alcohol abuse over last 20+
years, with multiple relapses and admissions. Denies illicit
drug use. No tobacco currently.
Family History:
Uncle with CAD s/p CABG at 70. Multiple family members with
alcoholism and depression.
Physical Exam:
VS: afeb, BP 127/102, HR 88, RR 12 sat 98% on RA.
Gen: Ruddy complexion, female appearing stated age, NAD.
Speaking coherently in full sentences. Calm and appropriate.
slightly tremulous.
HEENT: OP clear, EOMI, PERRL
Neck: No JVD, no LAD. RIGHT EJ in place.
Cor: s1s2 rrr no m/r/g
Pulm: CTAB, no w/r/r
Abd: +bs, soft, TTP epigastric area, periumbilical and LUQ, no
guarding or rebound, non distended.
Extrem: no c/c/e, DP/PT 2+. Tender swelling over left clavicle.
Skin: no rashes, however ruddy complexion.
Neuro: CNs symmetric, strength 5/5 throughout. No asterixis.
Speech coherent and fluent. A&Ox3, slight tremor.
Psych: Slightly anxious, but otherwise appropriate. Denies
SI/HI.
Pertinent Results:
[**2154-1-6**] 08:08PM PT-12.8 PTT-24.5 INR(PT)-1.1
[**2154-1-6**] 08:08PM PLT COUNT-399#
[**2154-1-6**] 08:08PM NEUTS-73.0* LYMPHS-21.0 MONOS-5.0 EOS-0.4
BASOS-0.6
[**2154-1-6**] 08:08PM WBC-3.6* RBC-4.01* HGB-13.3 HCT-42.1 MCV-105*
MCH-33.1* MCHC-31.6 RDW-15.6*
[**2154-1-6**] 08:08PM ASA-NEG ETHANOL-349* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-1-6**] 08:08PM OSMOLAL-383*
[**2154-1-6**] 08:08PM CK-MB-1 cTropnT-<0.01
[**2154-1-6**] 08:08PM LIPASE-17
[**2154-1-6**] 08:08PM ALT(SGPT)-167* AST(SGOT)-750* TOT BILI-0.5
[**2154-1-6**] 08:08PM estGFR-Using this
[**2154-1-6**] 08:08PM GLUCOSE-73 UREA N-9 CREAT-0.8 SODIUM-141
POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-17* ANION GAP-30*
[**2154-1-6**] 08:08PM POTASSIUM-5.3*
[**2154-1-6**] 10:22PM LACTATE-3.2*
[**2154-1-6**] 11:09PM K+-3.9
[**2154-1-11**] 06:30AM BLOOD WBC-2.5* RBC-2.73* Hgb-9.5* Hct-28.4*
MCV-104* MCH-34.7* MCHC-33.4 RDW-14.6 Plt Ct-105*
[**2154-1-8**] 06:20AM BLOOD Neuts-41.0* Lymphs-53.0* Monos-2.1
Eos-1.8 Baso-2.1*
[**2154-1-11**] 06:30AM BLOOD PT-12.8 PTT-32.2 INR(PT)-1.1
[**2154-1-11**] 06:30AM BLOOD Glucose-101 UreaN-3* Creat-0.5 Na-135
K-3.6 Cl-102 HCO3-22 AnGap-15
[**2154-1-11**] 06:30AM BLOOD ALT-71* AST-94* LD(LDH)-261* AlkPhos-114
TotBili-0.7
[**2154-1-11**] 06:30AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.5*
[**2154-1-7**] 03:28PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
.
[**1-6**] CXR: No acute cardiopulmonary abnormality.
.
[**1-7**] CT Abdomen/Pelvis:
1. No findings of bowel ischemia.
2. Pancreatic calcifications likely related to history of
chronic
pancreatitis. Sub-3-cm pancreatic tail thick-walled fluid
collection, in the setting of the history of chronic
pancreatitis this likely represents a pseudocyst. Correlation
with any prior imaging is recommended to assess for stability.
3. Severe fatty infiltration of the liver. Esophageal/gastric
varices as
well as intra-abdominal collateral vessels suggestive of
underlying portal
hypertension. Splenic vein patency not established on current
exam due to
poor bolus timing, can consider ultrasound to assess if needed.
.
[**1-7**] Upper Extremity US: No deep vein thrombosis in the left
arm and no subcutaneous fluid collection identified.
Brief Hospital Course:
Ms. [**Known lastname 4401**] is a 45 year old woman with a history of alcohol
abuse and chronic pancreatitis. She presented with abdominal
pain consistent with her previous episodes of pancreatitis. She
also desired withdrawal from alcohol and placement at an alcohol
treatment facility.
.
#. Pancreatitis: Patient had chronic pancreatitis. Her pain was
consistent with previous exacerbations of pancreatitis. She did
not have an elevation of lipase or amylase which is consistent
with chronic pancreatitis. When she was transferred to the MICU,
there was concern about the diffuse and extreme nature of her
pain. A CT of the abdomen and pelvis was performed. There was no
evidence of bowel wall ischemia. There were calcifications of
her pancreas which were consistent with chronic pancreatitis.
She received hydromorphone for pain control in the MICU. She was
switched to oral medications on the floor. Her diet was advanced
to clear liquids. The patient reported receiving adequate pain
relief. However, after speaking on the phone with a friend who
also had chronic pancreatitis, Ms. [**Known lastname 4401**] became very upset
that we were not giving her a high enough dose of pain
medications. She stated that she was having increased pain. Her
pain medication was increased and she was made NPO. Her diet was
slowly advanced as tolerated. She reported a significant
improvement in her pain. She was able to tolerate a regular diet
at the time of discharge. She was restarted on pancreatic
enzymes with meals.
.
# Anion Gap: Patient had an anion gap when seen in the emergency
department. She had a venous lactate of 3.2. Her anion gap was
felt to be secondary to alcohol use. Because of the anion gap,
she was transferred to the MICU. The anion gap resolved the
following day.
.
# GI Bleed: Patient had a history of several months of black,
tarry stool occurring about once a month. She also had one
episode of coffee ground emesis one week prior to admission. NG
lavage and guiac performed during the admission were both
negative. The episode of emesis sounded consistent with a
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear. However, given her varices (seen on CT) and
history of tarry stool, it was felt that she needed an
endoscopy. We attempted to receive records from [**Hospital1 2025**] or [**Hospital1 112**] to
see if her varices had been documented previously. However, we
were unable to retrieve them. Patient had no further episodes
concerning for bleeding during the hospitalization. A follow up
appointment was made for her with GI.
.
# Chest Pain: Patient reported some chest discomfort in the
emergency department. She had negative cardiac enzymes and no
return of her pain.
.
# Tender left neck: Patient reported a tenderness at her left
neck. She had a previous IV during another hospitalization at
that site. An ultrasound did not show any DVT's at the site. The
discomfort improved during the hospitalization.
.
# Transaminitis: AST and ALT ratio was consistent with alcohol
abuse. The elevation improved over the hospitalization, but
remained elevated. Hepatitis serologies were negative. Patient
would benefit from Hep B vaccination as an outpatient. This was
discussed with her.
.
# Alcohol withdrawal: Her last drink was at 3pm on [**9-5**]. She was
placed on the CIWA scale. She had mild withdrawal and required
no more than 3 doses of valium per day on the floor. She
received a banana bag in the emergency department. She received
thiamine, folate and a multivitamin on the floor. On the day of
discharge she had not scored on the CIWA scale in over 48 hours.
Social work assisted her in treatment plans. Patient did not
want to go to an inpatient facility. Arrangements were made to
help with an intensive outpatient program.
.
# PPD: PPD was read on [**1-9**] (48 hours after placement). It was
negative.
.
# Thrombocytopenia: Patient had greater than a 50% drop in her
platelets. Her baseline platelets were unknown. There was
concern over HIT given her frequent hospitalizations and likely
exposure to heparin. A heparin dependent antibody was negative.
Her thrombocytopenia was thought to be related to a low
baseline. She received fonduparinux for prophylaxis when heparin
was stopped.
.
# CODE: Patient was a full code during the admission.
Medications on Admission:
Patient states she was not taking any medications regularly
prior to admission.
We called her pharmacy and was able to get the name of her
pancreatic enzymes (Pancrease MT-10). She had 3 refills left.
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea for 2 weeks.
Disp:*15 Tablet(s)* Refills:*0*
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation: Please use as needed when taking pain medications.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation for 2 weeks: Please take while
you are using pain medications.
Disp:*30 Capsule(s)* Refills:*0*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation for 2 weeks: Please take while
using pain medications.
Disp:*30 Tablet(s)* Refills:*0*
9. Pancrease MT 10 30,000-10,000- 30,000 unit Capsule, Delayed
Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO
three times a day.
10. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain for 2 weeks: Please do not drive or
operate machinery while taking this medication. Do not take with
any other narcotic.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Acute on chronic pancreatitis.
- Alcohol intoxication and withdrawal.
- Alcoholic hepatitis.
- Pancytopenia.
- Coffee ground emesis
- Portal hypertension.
Secondary Diagnosis:
- Alcohol abuse
- Chronic pancreatitis s/p cystectomy
- Depression/anxiety
Discharge Condition:
All vital signs were stable. Patient was afebrile.
Discharge Instructions:
You were admitted to the hospital with pancreatitis and alcohol
withdrawal. You have chronic pancreatitis which caused the pain
in your abdomen. This is most likely caused by your alcohol use.
When you were in the hospital, you were treated with pain
medications and we gave you intravenous fluids to help keep you
hydrated.
When you were admitted to the hospital, you were intoxicated. We
treated you for alcohol withdrawal. You required several doses
of valium to help with your withdrawal.
When you were admitted, you had a CT scan of your abdomen which
showed varices (dilated veins) in your esophagus. It is very
important that you follow up with a gastroenterologist to
monitor these varices. Sometimes they can bleed and cause a
life-threatening condition.
Your alcohol use has caused damage to your liver and pancreas.
It is very important that you stop drinking. You have decided to
not go to an inpatient treatment facility. Instead, you want to
go to an intensive outpatient facility. We have included the
phone number for this program. It is very important that you
follow up on Monday. In the meantime, please go to Alcoholics
Anonymous meetings. You were given a list of meeting times and
places.
Please discuss with your new primary care provider about [**Name Initial (PRE) **]
vaccination for Hepatitis B.
When you were admitted, you told us you were not taking any
medications on a regular basis. You used to take an enzyme
formulation for your pancreas. Please continue to take this as
directed. Your pharmacy says that you still have refills for
this medication. We are giving you pain medication for your
abdominal pain. Please do not combine this with any other pain
medication. You should not take acetaminophen or over the
counter medications like ibuprofen (NSAID's) until told by your
doctor that it is alright to do so. While you are taking
narcotics, it may be necessary to take medications such as
docusate, senna, and bisacodyl to help your bowels move. We are
also giving you ondansetron (Zofran) to help with nausea.
Please come back to the emergency department if you have fevers,
chills, blood in your stool, black stool, blood in your vomit,
constant vomiting, headaches, shortness of breath, chest pain,
or worsening abdominal pain or inability to take in sufficient
food and drink.
Followup Instructions:
We have scheduled the following appointments for you:
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]/ Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**] (PCP)
Specialty: Internal Medicine
Date and time: Monday [**2154-1-21**] at 2:45 PM
Location: [**Hospital1 18**] [**Hospital 516**] [**Hospital3 **] [**Hospital Ward Name 23**]
Building Atrium Suite [**Location (un) **]
Phone number: ([**Telephone/Fax (1) 1300**]
MD: Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) 2161**]
Specialty: Gastroenterology
Date and time: Monday [**2154-1-21**] at 1:30 PM
Location: [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Unit Name 1825**] [**Location (un) **]
Phone number: ([**Telephone/Fax (1) 451**]
On Monday please call the following center to schedule a
structured outpatient addiction's treatment program.
[**University/College 23633**] Mental Health
Noddle's Island
([**Telephone/Fax (1) 24566**]
|
[
"284.1",
"291.81",
"577.0",
"530.7",
"571.1",
"571.2",
"577.2",
"276.2",
"456.21",
"572.3",
"300.4",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12384, 12390
|
6220, 10531
|
355, 361
|
12707, 12760
|
3940, 6197
|
15133, 16114
|
3131, 3219
|
10783, 12361
|
12411, 12411
|
10557, 10760
|
12784, 15110
|
3234, 3921
|
273, 317
|
389, 2584
|
12609, 12686
|
12430, 12588
|
2606, 2945
|
2961, 3115
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,156
| 113,375
|
50933
|
Discharge summary
|
report
|
Admission Date: [**2105-1-26**] Discharge Date: [**2105-2-4**]
Date of Birth: [**2047-2-3**] Sex: F
Service: MEDICINE
Allergies:
Ambien / Percocet
Attending:[**First Name3 (LF) 134**]
Chief Complaint:
admitted for pre-op cath
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
57 y/o F w/CAD s/p CABG [**2098**] (at [**Hospital1 112**], LIMA->LAD, SVG->RCA,
SVG->OM3), CHF [**1-28**] diastolic dysfxn w/EF 50%, and aortic
stenosis, admitted today for pre-op cath, prior to possible redo
CABG and possible AVR. She was noted to have aortic stenosis on
a TTE from an OSH in [**7-30**], with a valve area 1.0 cm2, peak
gradient 59 mm Hg, 1+ MR, and mod pulm htn. Her most recent adm
to the [**Hospital1 **] was [**8-30**], when she presented w/resting CP. EKG at
that time demonstrated old lat TWI. She underwent cath which
revealed patent LIMA->LAD, 80% mid LAD, 80% OM1, and 100% OM3
occlusions. Her EF was noted to be 55%. She had a PTCA of
OM1, c/b dissection with resulting overlying cypher stents
placed.
Since that intervention, she has noted no improvement in her
anginal symptoms, and has been having 3-6 episodes of angina
daily both at rest and with exertion (episodes resolve w/nitro
spray). She also c/o orthopnea and increasing LE edema, but no
PND.
Prior to her cath today, she became hypotensive in the holding
area (72/41, pulse 61). She received 2 L NS, 1 mg atropine,
with a pressure that responded to 108/52. She was also somewhat
hypotensive during her cath, systolics 80s. Today, she
underwent a cath which revealed patent LIMA->LAD, totally
occluded RCA/SVGs, 3+MR, posterobasal/inferior akinesis, and EF
40%. Her CO was 6.3, CI 3.2, PA 44/20, wedge 23, and RA mean 30.
Aortic valve area 1.1 cm2, peak gradient 40 mm Hg (mean 28 mm
Hg). She also had posterobasal and inferior akinesis on left
ventriculography.
Past Medical History:
1. CAD
2. Mitral regurg
3. Aortic stenosis
4. rheumatoid arthritis
5. osteoarthritis
6. fibromyalgia
7. hypothyroidism
8. htn
9. hypercholesterolemia
10. depression
11. iron def. anemia
12. s/p appy
13. s/p TAH
Social History:
single, has daughter, denies EtOH or tobacco
Family History:
Mother had CABG at age 48, died of CAD at age 68
Father had DM, CAD, died of MI
Physical Exam:
T: 97.2 P: 67 BP: 127/53 RR: 12 O2 sat: 97%
Gen: alert & oriented anxious female, in NAD
HEENT: NCAT. no conjunct. pallor. MMM.
Lungs: CTA bilaterally
CV: RRR, III/VI mid-peaking systolic murmur heard throughout,
radiating to carotids
Abd: obese, nontender, nondistended. normoactive bowel sounds.
Ext: no edema. 1+ dorsalis pedis pulses bilaterally.
Pertinent Results:
Admit ECG: NSR, q waves in II, III, avF, and TWI in V4-6.
Cardiac Cath:
COMMENTS: 1. Selective coronary angiography demonstrated
native
three vessel coronary artery disease in this right dominant
circulation.
The LMCA was a short vessel without flow limiting disease. The
LAD was
totally occluded after the first septal branch. The distal LAD
filled
via a patent LIMA graft. The LCX had a 50% tubular proximal
stenosis.
The OM2 had a 70% ostial stenosis and was a large vessel. A
patent stent
was seen between OM2 and OM3. OM3 was a large vessel without
flow
limiting disease. The RCA was totally occluded in the proximal
vessel
with left to right collaterals seen filling the distal vessel.
2. Graft angiography demonstrated a widely patent LIMA-LAD. The
SVG-RCA
and SVG-OM3 were known to be occluded and not engaged.
3. Resting hemodynamics from right and left heart
catheterization
revealed markedly elevated right and left sided filling
pressures
(RVEDP=28mmHg and LVEDP=26mmHg). Cardiac output and index were
preserved
at 6.3L/min and 3.2L/min/m2. There was a 40mmHg peak gradient
and 28mmHg
mean gradient across the aortic valve with calculated aortic
valve area
of 1.1cm2. Moderate pulmonary systolic pressures was seen.
4. Left ventriculography demonstrated posterobasal and inferior
akineses
with LVEF of 40%. 3+ mitral regurgitation was seen.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease. Patent LIMA-LAD.
2. Moderate aortic stenosis.
3. Moderate to severe mitral regurgitation.
4. Focal LV systolic dysfunction.
5. Severe biventricular diastolic dysfunction.
TTE [**2105-1-29**]:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size
is normal. Overall left ventricular systolic function is mildly
depressed
(ejection fraction 40-50 percent) secondary to hypokinesis of
the inferior
free wall. No masses or thrombi are seen in the left ventricle.
There is no
ventricular septal defect. The aortic valve is bicuspid. There
is moderate
aortic valve stenosis, with mild aortic regurgitation. The
mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. At least
mild mitral regurgitation is seen. There is no pericardial
effusion.
Compared with the findings of the prior study (tape reviewed) of
[**2105-1-27**], the transaortic valvular gradient is somewhat lower;
however, moderate
aortic stenosis is still present; otherwise no major change is
evident
(inferior hypokinesis present on prior study).
Pertinent lab results:
[**2105-1-26**] 01:45PM BLOOD WBC-3.1* RBC-3.70* Hgb-7.9* Hct-25.9*
MCV-70* MCH-21.4* MCHC-30.5* RDW-13.8 Plt Ct-215
[**2105-1-26**] 06:43PM BLOOD Hct-27.1*
[**2105-1-27**] 05:05AM BLOOD WBC-4.5 RBC-3.85* Hgb-8.1* Hct-27.2*
MCV-71* MCH-21.1* MCHC-29.9* RDW-14.2 Plt Ct-231
[**2105-1-28**] 06:02AM BLOOD WBC-5.7 RBC-3.81* Hgb-8.3* Hct-26.8*
MCV-70* MCH-21.8* MCHC-31.0 RDW-14.1 Plt Ct-211
[**2105-1-29**] 06:30AM BLOOD WBC-4.9 RBC-4.32 Hgb-9.6* Hct-30.6*
MCV-71* MCH-22.3* MCHC-31.4 RDW-15.3 Plt Ct-209
[**2105-1-30**] 06:10AM BLOOD Hct-29.2*
[**2105-1-31**] 06:50AM BLOOD Hct-29.7*
[**2105-2-1**] 06:40AM BLOOD Hct-30.8*
[**2105-2-2**] 07:00AM BLOOD Hct-30.8*
[**2105-1-26**] 01:45PM BLOOD Glucose-111* UreaN-17 Creat-0.9 Na-140
K-4.5 Cl-111* HCO3-25 AnGap-9
[**2105-1-26**] 06:43PM BLOOD Glucose-143* UreaN-15 Creat-0.8 Na-141
K-4.4 Cl-111* HCO3-26 AnGap-8
[**2105-1-27**] 05:05AM BLOOD Glucose-107* UreaN-12 Creat-0.8 Na-138
K-4.4 Cl-107 HCO3-24 AnGap-11
[**2105-1-28**] 06:02AM BLOOD Glucose-87 UreaN-15 Creat-0.9 Na-139
K-4.3 Cl-108 HCO3-23 AnGap-12
[**2105-1-29**] 06:30AM BLOOD Glucose-78 UreaN-15 Creat-0.7 Na-141
K-3.9 Cl-104 HCO3-26 AnGap-15
[**2105-1-26**] 01:45PM BLOOD ALT-22 AST-22 AlkPhos-108 TotBili-0.3
[**2105-1-29**] 06:30AM BLOOD Mg-1.7 Cholest-232*
[**2105-1-29**] 02:02PM BLOOD %HbA1c-6.4*
[**2105-1-28**] 06:02AM BLOOD TSH-1.5
Brief Hospital Course:
1. Cardiac:
-coronaries: She was continued on ASA, plavix, statin. She was
evaluated by the CT surgery team regarding the possibility of
CABG/valve replacement, and they felt she could follow-up with
them as an outpatient. It was not felt to be an urgent
inpatient matter and f/u was arranged with Dr. [**Last Name (STitle) **].
Throughout her stay, she had numerous episodes of chest pain
which she states were the typical chest pain she has at home
that wake her up at night. EKGs were done for all of these
episodes, and never showed any signs of ischemia. The pain
would resolve on its own or with sublingual nitroglycerin. It
was unclear whether this pain represented angina or not, however
given the lack of EKG changes it seemed unlikely to be angina.
-pump: She has an EF of 40%. Because of her AS, she is
preload-dependent and so was not aggressively diuresed. Her bp
was difficult to control and several medication adjustments were
made throughout her admission. She was eventually discharged on
lisinopril, toprol, isosorbide mononitrate, and HCTZ.
-rhythm: remained in sinus throughout.
2. Hypotension: She was admitted to the CCU for post-cath
hypotension, which resolved by the night of admission. This was
felt to be most likely related to medications, as the patient
was given her meds on a different schedule than her home regimen
(she usually only takes her meds at night).
2. Heme: She has a hx of iron-def anemia and was kept on her
iron supplementation. She was transfused to a hematocrit of 30
given her CAD.
3. Hypothyroidism: continued on levoxyl.
4. Fibromyalgia/Osteoarthritis: She was continued on her home
pain regimen (duragesic, hydrocodone, nambutone). She was also
given prn percocet. However, this was attempted to be limited,
as the pt often appeared to be overly medicated on narcotics
(falling asleep during conversations, etc.)
5. PT: The patient had difficulty ambulating secondary to her
chronic back/leg pain. She was evaluated by PT, who felt she
was safe to go home w/home PT, which was arranged.
Medications on Admission:
crestor 10 mg po daily
nambutone 500 mg po bid
levoxyl 150 mcg po daily
imdur 120 mg po daily
norvasc 50 mg po tid
plavix 75 mg po daily
lopid 600 mg po daily
toprol XL 100 mg po daily
lisinopril 40 mg po daily
effexor XR 150 mg po daily
hydrocodone 7.5-750 2 tabs q4-6 hrs prn
duragesic patch 125 mcg q48hrs
trazodone 150-200mg po qhs
nitro sublingual prn
ASA 325 po daily
iron 325 mg po tid
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
3. Nabumetone 500 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
4. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)).
6. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Venlafaxine HCl 75 mg Capsule, Sust. Release 24HR Sig: Two
(2) Capsule, Sust. Release 24HR PO QHS (once a day (at
bedtime)).
8. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
10. Trazodone HCl 50 mg Tablet Sig: 1-3 Tablets PO HS (at
bedtime) as needed.
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 48HR
Transdermal Q48HRS ().
14. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 48HR
Transdermal Q48HRS ().
15. Rosuvastatin Calcium 20 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
16. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: 1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
18. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease
Aortic Stenosis
Mitral Regurgitation
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or return to the emergency room for
worsening chest pain, chest pain that does not resolve with 5
minutes, shortness of breath, nausea, vomiting, abdominal pain,
lightheadedness, or any other concerns.
Please take all of your medications as prescribed. If some of
your medications are supposed to be taken at intervals during
the day, it is important that you take them at those times. Do
not just take all of your daily dose at night for medications
that are dosed more than once per day.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Last Name (Prefixes) 413**] CARDIAC SURGERY LMOB 2A Where: CARDIAC
SURGERY LMOB 2A Date/Time:[**2105-2-5**] 1:00
f/u with your PCP within one week
You have anemia, which we discussed. You should talk with your
primary care physician about pursuing an upper endoscopy and a
colonoscopy.
|
[
"398.91",
"244.9",
"414.01",
"458.29",
"280.9",
"V45.81",
"396.2",
"729.1",
"413.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.53",
"88.56",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11023, 11078
|
6593, 8655
|
300, 325
|
11183, 11191
|
2710, 4070
|
11755, 12083
|
2235, 2316
|
9098, 11000
|
11099, 11162
|
8681, 9075
|
4087, 6570
|
11215, 11732
|
2331, 2691
|
236, 262
|
353, 1922
|
1944, 2157
|
2173, 2219
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,641
| 109,689
|
34523
|
Discharge summary
|
report
|
Admission Date: [**2144-7-19**] Discharge Date: [**2144-7-21**]
Date of Birth: [**2071-4-13**] Sex: M
Service: NEUROSURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
Right Craniotomy for evacuation of large IPH
History of Present Illness:
HPI: Patient is a 73M with PMH significant for HTN, CAD and
polycythemia who was in his usual state of health this afternoon
when he stumbled over onto the floor. He was taken to OSH where
their work-up revealed a sizable IPH. He was reportedly AOX3 at
the OSH, but upon arrival to [**Hospital1 18**] ED was AOx2.
Past Medical History:
1. CAD
2. HTN
3. Polycythemia; multiple transfusion history secondary to his
condition per family reports.
Social History:
Social Hx: Married, resides at home with wife.
Family History:
Family Hx: non-contributory
Physical Exam:
O: T:afebrile BP: HR: RR: O2Sats:
intubated, mechanically ventillated
Gen: WD/WN elderly male, sedated on Propofol
HEENT: normocephalic, oozing lt frontal laceration.
Pupils: asymmetric Lt 3.5mm, Rt 6.5mm. Non reactive.
EOMs: unable to assess
Extrem: Warm and well-perfused.
Neuro:
Mental status: No response to voice, no commands. Delayed
localization with LEFT upper extremity to noxious stimulus, weak
withdrawal
LLE. Posturing on right side with noxious stimulus. +cough with
deep ET
suctioning.
Cranial Nerves:
I: Not tested
II: Right pupil 6.5mm, Left pupil 3.5mm
III, IV, VI-XII: unable to assess
Toes upgoing bilaterally
Pertinent Results:
[**2144-7-19**] 10:18PM GLUCOSE-229* UREA N-33* CREAT-1.7*
SODIUM-131* POTASSIUM-5.6* CHLORIDE-98 TOTAL CO2-18* ANION
GAP-21*
[**2144-7-19**] 10:18PM ALT(SGPT)-17 AST(SGOT)-33 LD(LDH)-722*
CK(CPK)-64
[**2144-7-19**] 10:18PM CK-MB-NotDone cTropnT-0.12*
[**2144-7-19**] 10:18PM CALCIUM-7.9* PHOSPHATE-7.3*# MAGNESIUM-1.8
[**2144-7-19**] 10:18PM HAPTOGLOB-81
[**2144-7-19**] 10:18PM WBC-55.4* RBC-2.84* HGB-8.9* HCT-24.7* MCV-87
MCH-31.4 MCHC-36.0* RDW-18.6*
[**2144-7-19**] 10:18PM PLT COUNT-83*
[**2144-7-19**] 10:18PM PT-17.2* PTT-36.4* INR(PT)-1.6*
[**2144-7-19**] 10:18PM FIBRINOGE-669* D-DIMER-3512* THROMBN-19.2
[**2144-7-19**] 10:18PM PARST SMR-NEGATIVE
[**2144-7-19**] 08:25PM TYPE-ART RATES-/11 TIDAL VOL-700 O2-66 PO2-90
PCO2-41 PH-7.34* TOTAL CO2-23 BASE XS--3 INTUBATED-INTUBATED
Brief Hospital Course:
Dr. [**First Name (STitle) **] met with family and discussed surgical options for
evacuation of the IPH, prognosis with/without surgery was felt
to be poor. Family wishing to proceed with surgical intervention
in best efforts. Preoperatively pt had CTA imaging to evaluate
for an aneurysmal source for the bleed. Showed Post operative CT
scan showed Iiterval worsening of right frontal parenchymal
hemorrhage and mass effect
with now 17 mm left [**Hospital1 **] subfalcine herniation, compared to
prior comparative
measurement of 14 mm. There is also interval effacement of
basilar and
perimesencephalic cistern, raising concern for impending uncal
herniation. The
preliminary review of the CTA portion of the study, demonstrates
a 4 mm focal
ectatic segment just proximal to the basilar bifurcation into
PCA (3:252), The
right PCA is relatively [**Name2 (NI) 79305**] and a ruptures circle of
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 53283**] or
AVM as a precipitant of fall could not be excluded.
Following surgical evacuation CT imaging was completed on
[**2144-7-20**] which revealed new bleed extending beneath the surgical
bed with worse vasogenic edema. Mannitol therapy continues in an
effort to contain this edema. Physical exam remains consistent
with fixed pupils. Left 3mm, Right 6mm. Corneals + but slowed in
the left cornea. Mechanically ventilated with some spontaneous
respirations. He does not follow commands when pt allowed to
lighten from sedation. Pt localizing in Lt upper extremity to
noxious stimuli, Left LE with withdrawl to stimulus and only
extensor posturing on the right side. Family aware of the
gravity of pts illness and are supportive. Family meeting held
and maintain that Mr. [**Known lastname **] would not like to be maintained
on full time nursing care or would not wish for tracheostomy and
PEG tube placement for nutritional support. It was felt that
comfort measures would be the most appropriate course of care
given his wishes and present condition.He was extubated [**2144-7-20**]
and started on morphine drip. With family present, he expired
14:12 on [**2144-7-21**].
Medications on Admission:
1. Hydrea 1500mg daily
2. Verapamil 180mg daily
3. Elavil 50mg daily
4. Trilafon 4mg daily
5. Niaspan 1gm daily
6. Colchicine 0.6mg daily
7. Toprol XL 100mg daily
8. MVI
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
intraparenchymal hemorrhage
Discharge Condition:
expired
Discharge Instructions:
none
Completed by:[**2144-7-21**]
|
[
"401.9",
"584.9",
"412",
"274.9",
"414.01",
"V66.7",
"V10.83",
"431",
"780.01",
"238.75",
"238.4",
"414.8",
"285.9",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.39",
"96.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
4832, 4841
|
2440, 4582
|
302, 348
|
4913, 4923
|
1604, 2417
|
906, 935
|
4803, 4809
|
4862, 4892
|
4608, 4780
|
4947, 4982
|
950, 1233
|
259, 264
|
376, 694
|
1469, 1585
|
1248, 1453
|
716, 824
|
840, 890
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,792
| 144,955
|
31877
|
Discharge summary
|
report
|
Admission Date: [**2100-8-4**] Discharge Date: [**2100-8-23**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic Pseudocyst
Major Surgical or Invasive Procedure:
IVC filter
Successful CT-guided 12 French pigtail catheter into the
patient's known pancreatic pseudocyst.
Successful CT-guided placement of an 18-French drainage catheter
into the patient's pancreatic pseudocyst.
s/p right thoracentesis (700 cc off) and left chest drainage
History of Present Illness:
This is a 84 year old male who presented to [**Hospital1 1562**] with coffee
ground emesis. On CT he was found to have a pancreatic
pseudocyst. He has a history of A-fib and was on Coumadin.
Past Medical History:
h/o PAF formerly on amiodarone and coumadin
3VD with medical management, CHF EF >60%, HTN, prostate CA, CRI
PSH:
gallstone pancreatitis ([**4-5**]), open CCY ([**4-5**]), s/p resection
prostate.
Social History:
Lives on [**Location (un) **] with Wife.
Daughter [**Name2 (NI) **] is excellent contact - [**Name (NI) **]: [**Telephone/Fax (1) 74759**]. Cell
[**Telephone/Fax (1) 74760**].
Physical Exam:
VS: 99.2, 110, 110/70, 18, 98% 2L
Gen: NAD
Chest: CTAB
CV: RRR
Abd: well-healed abdominal incision, soft, mild distention,
non-tender,
Ext: WWP, trace edema
Guiac positive
Pertinent Results:
[**2100-8-4**] 11:55PM BLOOD WBC-18.6* RBC-3.81* Hgb-11.9* Hct-35.5*
MCV-93 MCH-31.2 MCHC-33.4 RDW-16.5* Plt Ct-409
[**2100-8-6**] 08:50AM BLOOD WBC-21.3* RBC-3.58* Hgb-11.2* Hct-33.8*
MCV-94 MCH-31.4 MCHC-33.2 RDW-16.7* Plt Ct-442*
[**2100-8-11**] 04:37AM BLOOD WBC-14.1* RBC-2.94* Hgb-9.3* Hct-27.8*
MCV-95 MCH-31.7 MCHC-33.4 RDW-17.1* Plt Ct-377
[**2100-8-4**] 11:55PM BLOOD Glucose-65* UreaN-29* Creat-1.5* Na-144
K-4.6 Cl-112* HCO3-20* AnGap-17
[**2100-8-9**] 04:05AM BLOOD Glucose-108* UreaN-41* Creat-1.8* Na-144
K-4.4 Cl-110* HCO3-25 AnGap-13
[**2100-8-11**] 04:37AM BLOOD Glucose-102 UreaN-52* Creat-1.8* Na-141
K-4.0 Cl-101 HCO3-34* AnGap-10
[**2100-8-4**] 11:55PM BLOOD ALT-13 AST-23 CK(CPK)-17* AlkPhos-136*
Amylase-28 TotBili-0.9
[**2100-8-5**] 07:15AM BLOOD ALT-11 AST-22 LD(LDH)-241 CK(CPK)-15*
AlkPhos-142* Amylase-24 TotBili-0.9 DirBili-0.5* IndBili-0.4
[**2100-8-11**] 04:37AM BLOOD ALT-9 AST-26 LD(LDH)-206 AlkPhos-138*
Amylase-23 TotBili-0.6
[**2100-8-4**] 11:55PM BLOOD Lipase-17
[**2100-8-11**] 04:37AM BLOOD Lipase-19
[**2100-8-4**] 11:55PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2100-8-8**] 12:57AM BLOOD proBNP-[**Numeric Identifier 74761**]*
[**2100-8-5**] 07:15AM BLOOD Albumin-2.1* Calcium-7.9* Phos-3.8 Mg-2.0
Iron-15*
[**2100-8-8**] 12:57AM BLOOD TotProt-4.6* Calcium-8.1* Phos-4.0 Mg-1.9
[**2100-8-11**] 04:37AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.1
[**2100-8-5**] 07:15AM BLOOD calTIBC-118* TRF-91*
[**2100-8-6**] 08:50AM BLOOD TSH-2.4
[**2100-8-10**] 10:45AM BLOOD Vanco-26.6*
.
CTA ABD W&W/O C & RECONS [**2100-8-5**] 10:30 AM
IMPRESSION:
1. Heterogeneous peripancreatic fluid collection containing air
as noted above with inferior extension within the
retroperitoneum as detailed.
2. Deep venous thrombosis and suggestion of small pulmonary
embolism and possible pulmonary infarct. These findings are
discussed with the surgical house staff at the time of
dictation.
3. Bilateral pleural effusions.
4. Moderate ascites.
.
Cardiology Report ECHO Study Date of [**2100-8-5**]
IMPRESSION: Normal global and regional biventricular systolic
function. Mild
aortic regurgitation. Mild pulmonary hypertension. Dilated
thoracic aorta.
.
CT GUIDANCE DRAINAGE [**2100-8-6**] 10:38 AM
IMPRESSION:
1. Successful CT-guided 12 French pigtail catheter into the
patient's known pancreatic pseudocyst.
.
CHEST (PORTABLE AP) [**2100-8-9**] 6:41 AM
FINDINGS: Left pigtail pleural drainage catheter is unchanged.
There are moderate bilateral pleural effusions, probably right
greater than left. There is asymmetric right perihilar opacity,
which likely represents asymmetric pulmonary edema, probably the
result of fluid overload.
IVC filter is again seen. Pseudocyst drainage catheter is noted,
overlying the left upper abdomen, unchanged.
IMPRESSION:
1. Moderate bilateral pleural effusions, probably right greater
than left.
2. Probable early asymmetric pulmonary edema, likelyas as a
result of fluid overload.
.
CT ABSCESS CATH CHANGE [**2100-8-9**] 2:23 PM
IMPRESSION:
1. Successful CT-guided placement of an 18-French drainage
catheter into the patient's pancreatic pseudocyst.
.
CHEST (PORTABLE AP) [**2100-8-10**] 9:27 AM
IMPRESSION: No significant interval change.
.
CT ABSCESS CATH CHANGE [**2100-8-13**] 4:08 PM
Through the patient's existing catheter, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was
passed and serial dilation was completed before placing a
24-French Malincot catheter without incident.
No complications ensued. The patient remained stable throughout
his stay in the CT suite. The catheter was attached to a
drainage bag to be drained by gravity. The attending
radiologists were present during the entirety of the procedure.
IMPRESSION:
1. Successful placement of a 24-French drainage catheter. This
catheter is not to be removed before consulting radiology as it
requires removal over a special troca device.
.
CT ABDOMEN W/O CONTRAST [**2100-8-17**] 1:41 PM
IMPRESSION:
1. Status post drainage tube placement for the pseudocyst with
fluid and gas, with surrounding fat stranding, slightly
decreased in size since prior study.
2. Unchanged free fluid in the abdomen and pelvis, with
mesenteric nodes and 1.9-cm focus of another possible
pseudocyst.
3. Moderate amount of bilateral pleural effusion with
atelectasis and moderate-sized hiatal hernia.
.
Brief Hospital Course:
84 yo male with a h/o PAF formerly on amiodarone and Coumadin,
3VD with medical management, CHF EF >60% who presented with
coffee ground emesis and found to have pancreatic pseudocyst.
PE/DVT: His CT on [**8-5**] showed bilateral PE and DVT. A heparin gtt
was started. Vascular was consulted and we stopped the heparin
in order for a filter placement. Vascular successfully placed
IVC filter on [**2100-8-5**].
Atrial fibrillation: He had a history of PAF and also likely
related to PE. Cardiology was consulted. He received 20 mg IV
Lopressor Q4 for rate control. He was deemed a high operative
risk.
He was started on Diltiazem for rate control. The diltiazem gtt
was controlling his rate well.
On [**2100-8-9**], off diltiazem gtt, on lopressor 25 [**Hospital1 **] PO with HR
80s, afib
On [**2100-8-10**], he continued to diuresing 8 liters of urine a day.
His Lasix was decreased and his goal output was -500 to 1 liter
max/day. His Lopressor was increase for HR control, rate 80-90s
afib. His Coumadin will restart when stable.
Pleural Effusion: He was shown to have bilateral pleural
effusion. He had s/p right thoracentesis (700 cc off) and left
chest drainage pigtail placed w/1100ml fluid out; resp status
improved. He then had reaccumulation of fluid on the right.
Pulmonary was consulted. The pigtail on the left was left in
place for 48 hours and then pulled on [**2100-8-10**] due to concern for
infection. The right sided reaccumulation was partly due to
fluid overload, CHF. He required Bipap overnight for some
respiratory distress.
The right side was again taped for 700cc straw colored fluid on
[**2100-8-9**]
He received Albumin due to low albumin (albumin 2 on [**8-5**]).
He then began mobilizing the fluids after initial hypovolemia
and diuresed -5 liters, (1.7 in 2 hours) with Cr 1.5->1.8. He
was receiving Lasix and his goal was -500 to 1 liter. His
proBNP 17,000.
.
Pancreatic Pseudocyst: He was started on broad spectrum
antibiotics.
He went to CT and under anesthesia had successful CT-guided 12
French pigtail catheter into the patient's known pancreatic
pseudocyst on [**2100-8-6**].
This fluid grew out STREPTOCOCCUS MILLERI GROUP. HEAVY
GROWTH. and STAPHYLOCOCCUS, COAGULASE NEGATIVE. MODERATE
GROWTH. He continued on Imipenem (day 15); Vanc/Fluc (day 14)
[**8-9**] CT GUIDED CATHETER UPSIZE
IMPRESSION:
1. Successful CT-guided placement of an 18-French drainage
catheter into the
patient's pancreatic pseudocyst.
He went again for upsizing of his drain catheter on [**2100-8-13**] and
had successful placement of a 24-French drainage catheter. This
catheter is not to be removed before consulting radiology as it
requires removal over a special troca device. The output was
thick, tannish fluid. He continued to have a small volume of
output from the drain. He needs continued drain care, including
forward flushing with 20-30cc of saline and aspirating back.
He will return to see Dr. [**Last Name (STitle) **] in 3 weeks for repeat CT. He
will continue on antibiotics until that time.
FEN: He was NPO with IVF. He was started on TPN on HD 3. His
diet was slowly advanced, starting with sips. On HD 7 he
tolerated a small amount of food, but had some nausea and ~50 cc
of emesis. His diet was eventually liberated, but his intake was
still poor. Calorie counts were only ~300-800 kcal/day. He will
continue to need TPN until his appetite improves.
Hypovolemia: He was requiring several fluid boluses for low
urine output while in the ICU on [**2100-8-7**]. After adequate
hydration, he was restarted on his home Lasix.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours).
10. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours).
11. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): Please check Vanco trough
prior to 4th dose.
12. Insulin Regular Human 100 unit/mL Solution Sig: Sliding
Scale Injection ASDIR (AS DIRECTED).
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
UGI Bleed
Pancreatic Pseudocyst
Left CFV thrombus
Atrial fibrillation
bilateral PE
Pleural Effusion
Malnutrition
Discharge Condition:
Fair
Continue on TPN
Continue with drain care
continue with PT
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
* Continue with drain care.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2100-9-10**] 10:15.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2100-9-10**] 11:30
.
Completed by:[**2100-8-23**]
|
[
"511.9",
"578.9",
"415.19",
"453.41",
"403.90",
"263.9",
"427.31",
"V10.46",
"585.9",
"577.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"38.7",
"34.91",
"52.01"
] |
icd9pcs
|
[
[
[]
]
] |
10666, 10732
|
5752, 9328
|
281, 558
|
10889, 10954
|
1397, 5729
|
12071, 12362
|
9351, 10643
|
10753, 10868
|
10978, 12048
|
1205, 1378
|
220, 243
|
586, 778
|
800, 997
|
1013, 1190
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,680
| 156,870
|
37803
|
Discharge summary
|
report
|
Admission Date: [**2165-11-18**] Discharge Date: [**2165-11-26**]
Date of Birth: [**2096-11-22**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Septra Ds / Lidocaine Hcl/Epinephrine / Shellfish Derived /
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Fusion T11-L3 via thoracotomy
Fusion L3 to S1
Posterior fusion with instrumentation T8 to S1
History of Present Illness:
Ms. [**Known lastname 77743**] has a long history of scoliosis which contributes
to back and leg pain. She has attempted conservative therapy
but has failed. She now presents for surgical intervention.
Past Medical History:
PMH:
1. b/l interstitial fibrosis w/ normal PFTs in [**2165**]
2. recurrent UTI
3. multiple sclerosis
4. severe degenerative disc disease and lumbar canal stenosis
PSH:
1. b/l hip replacements (last replacement in
[**2160**]).
2. cholecystectomy in [**2124**].
3. cosmetic surgery on her upper eyelids.
Social History:
Denies
Family History:
N/C
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
RLE- 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
LLE decreased strength due to MS
Pertinent Results:
[**2165-11-24**] 06:20AM BLOOD WBC-8.8 RBC-3.56* Hgb-10.9* Hct-30.7*
MCV-86 MCH-30.7 MCHC-35.6* RDW-14.7 Plt Ct-141*
[**2165-11-23**] 03:15AM BLOOD WBC-10.2 RBC-3.73* Hgb-11.4* Hct-32.0*
MCV-86 MCH-30.6 MCHC-35.6* RDW-15.1 Plt Ct-110*
[**2165-11-22**] 02:33AM BLOOD WBC-10.7 RBC-2.99* Hgb-9.2* Hct-25.3*
MCV-85 MCH-30.8 MCHC-36.5* RDW-15.0 Plt Ct-80*
[**2165-11-20**] 10:08PM BLOOD WBC-8.5 RBC-3.46* Hgb-10.3* Hct-29.5*
MCV-85 MCH-29.9 MCHC-35.0 RDW-14.6 Plt Ct-63*#
[**2165-11-24**] 06:20AM BLOOD Glucose-106* UreaN-10 Creat-0.4 Na-137
K-4.2 Cl-102 HCO3-29 AnGap-10
[**2165-11-22**] 02:33AM BLOOD Glucose-106* UreaN-22* Creat-0.6 Na-138
K-4.7 Cl-107 HCO3-27 AnGap-9
[**2165-11-19**] 05:55AM BLOOD Glucose-121* UreaN-10 Creat-0.7 Na-138
K-4.5 Cl-102 HCO3-27 AnGap-14
[**2165-11-24**] 06:20AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.9
[**2165-11-21**] 03:16AM BLOOD Calcium-8.5 Phos-2.5* Mg-2.2
[**2165-11-19**] 05:55AM BLOOD Calcium-8.5 Mg-1.7
Brief Hospital Course:
Ms. [**Known lastname 77743**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2165-11-18**] and taken to the Operating Room for T8-L3 anterior
fusion through a thoracotomy. Chest tube was placed
intraoperatively. Please refer to the dictated operative note
for further details. The surgery was without complication and
the patient was transferred to the PACU in a stable condition.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were given per standard protocol.
Initial postop pain was controlled with a PCA. On HD#2 she
returned to the operating room for a scheduled L3-S1 anterior
fusion as part of a staged 3-part procedure. Please refer to the
dictated operative note for further details. The second surgery
was also without complication and the patient was transferred to
the PACU in a stable condition. Postoperative HCT was stable.
Hospital day three she underwent a posterior fusion T8-S1. A
bupivicaine epidural pain catheter placed at the time of the
posterior surgery remained in place until [**2165-11-22**]. She was
transfered to the SICU where she was monitored for hemodynamic
stability. Her left leg appeared weak and this was though to be
due to an MS flare. Neurology was consulted for question of
steroids which they thought was not required. She improved over
her hospital stay. She was transfused multiple units of PRBCs
and platelets. She was kept NPO until bowel function returned
then diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on [**2165-11-25**]. She was fitted with a TLSO brace.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Medications on Admission:
1. Copaxone 20 mg subcutaneously once daily
2. Forteo injections for osteoporosis
3. Wellbutrin 300 mg once daily
4. Baclofen 10 mg q.p.m.
5. Augmentin 250 mg daily
6. cranberry extract
7. vitamin D 4000 units daily
8. calcium 1200 mg daily
9. Nexium 40mg q.a.m.
10. Vicodin p.r.n. pain
11. omega-3 fish oil one to two capsules a day.
Discharge Medications:
1. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for rash.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. bupropion HCl 150 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
5. baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. glatiramer 20 mg Kit Sig: One (1) Kit Subcutaneous DAILY
(Daily).
9. Forteo 20 mcg/dose - 600 mcg/2.4 mL Pen Injector Sig: One (1)
injection Subcutaneous DAILY (Daily).
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasm.
12. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
heartburn.
13. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital [**Location (un) **] CT
Discharge Diagnosis:
Scoliosis
Acute post-op blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
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: Activity as tolerated
TLSO brace for ambulation
Treatments Frequency:
Please continue to change the dressings daily
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2165-11-26**]
|
[
"738.4",
"785.0",
"515",
"338.12",
"293.0",
"V13.02",
"737.34",
"530.81",
"V43.64",
"285.1",
"340",
"733.00",
"721.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.51",
"81.06",
"81.63",
"81.62",
"81.04",
"03.90",
"38.93",
"84.52",
"81.64",
"81.07",
"80.99",
"81.05"
] |
icd9pcs
|
[
[
[]
]
] |
6367, 6443
|
2599, 4504
|
370, 465
|
6529, 6536
|
1638, 2576
|
8668, 8749
|
1065, 1070
|
4892, 6344
|
6464, 6508
|
4530, 4867
|
6560, 6666
|
1085, 1619
|
8516, 8576
|
8598, 8645
|
6702, 6895
|
313, 332
|
6931, 7386
|
7398, 8498
|
493, 698
|
720, 1025
|
1041, 1049
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,905
| 143,877
|
43835
|
Discharge summary
|
report
|
Admission Date: [**2188-2-19**] Discharge Date: [**2188-2-29**]
Date of Birth: [**2112-6-22**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Transferred for evaluation of traumatic intracranial hemorrhage
in the context of anticoagulation.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. [**Known lastname 94161**] is a 75-year-old right-handed woman with CAD (s/p
AMI [**2167**], 2VCABG [**2178**], PCI stents x 2 [**2187**], on ASA, Plavix),
ESRD (dialysis), mechanical mitral valve ([**2178**], Coumadin, goal
INR 2.5), infected left inguinal cath. site, w/ fall on Saturday
striking back of head, now w/ worsening HA and SDH on NCHCT.
Recent admission with myocardial ischemia with two stents place
in [**Month (only) 404**] (records not available to us at this time). She had a
"clot in her femoral artery which burst" per her daughter (which
we took to mean pseudoaneurysm) with continued ooze this month.
She also developed a fever and thus returned to [**Hospital1 2025**]. She was
discharged on Saturday. Arriving home, she was about to climb
the stairs at home when she reached for a rail, missed and fell
backward, fracturing her left wrist and hitting the back of her
head. She was taken to [**Hospital **] hospital where fracture was found
and head CT did not show hemorrhage. She returned home only to
become more confused "for the last couple of days", Mrs.
[**Known lastname 94161**] says. She went to dialysis on Monday morning, where she
developed a severe headache that she described as [**1-31**] (see
mental status below) which was bilateral, posterior and upper
neck and throbbing in character. She would normally call her
family at the end of the session, around 5 p.m., but did not
call by 8 p.m. They called, went to collect her and found her to
be confused and have a somewhat vacant expression. She did not
recall what had happened over the weekend. They again returned
to [**Hospital **] Hospital where NCHCT revealed right occipital falcine
subdural hematoma and left frontoparietal subdural hematoma.
Given elevated INR, FFP and vitamin K were given and she was
transferred to [**Hospital1 18**] for further evaluation by Neurosurgery.
Given no surgical intervention, Neurology was called.
In the ED she was given 0.25 mg Ativan IV, platelets. Dilantin
was stopped so little was given (venous pain was severe and we
considered this was not needed).
She feels that her headache is [**1-31**] and not as bad as before.
She recognizes that she has been confused. Per her family she is
clearly more confused and amnestic than recent baseline, but her
baseline function worsened after admission for cardiac cath and
[**Month/Year (2) **] placement in [**Month (only) 404**]. Prior to that time her family feel
that her memory was excellent.
UTI was treated with Bactrim, course continues. Also receives IV
antibiotic at dialysis (family did not know which). Fracture of
wrist was going to be cast Tuesday (today). Patient has been
constipated. Son-in-law suggests patient also takes significant
opiates at home for pain and that may withdraw if not given.
Prior to transfer to CT en route to the ICU, she again became
agitated and hypertensive to 189. This was 139 on repeat when
settled. Ativan 0.25 mg IV was repeated for CT and transfer.
Past Medical History:
- Thalassemia minor
- Hypertension 'as long as daughter recalls'
- Diabetes II, [**2167**]
- Dyslipidemia
- AMI in [**2167**], family think no angioplasty or [**Last Name (LF) **], [**First Name3 (LF) **]
daughter
- Further CAD, [**2178**] on cath: CAD affecting distal (apical)
portion of the left anterior descending coronary artery,
moderately severe diffuse involvement of the mid LCX and severe
diffuse disease of the right coronary artery with small distal
vessels.
- Mitral regurgitation/prolapse 3+ in [**2178**]
- CABG (2V) + MVR in [**2178**]. CABG: saphenous vein graft to obtuse
marginal branch of circumflex coronary artery, right
coronary artery endarterectomy, saphenous vein graft to right
coronary artery.
- Valvular systolic dysfunction, congestive heart failure, with
heart failure, possible infarctive component.
- ESRD, [**1-23**] DMII, HTN, hemodialysis M/W/F at [**Hospital1 **] location on
Brimble St.
- Left hip replacement
- Mechanical mitral valve, as above.
- Osteoarthritis
- Irritable bowel syndrome
- Gastroesophageal reflux disease
- Depression/anxiety
- Anemia
- PCI [**2187-12-22**] with placement of two stents, unknown type,
unknown anatomy (done at [**Hospital1 2025**])
- Lumbar spinal stenosis
Social History:
Lives with husband. Private nursing spend about 60 hours per
week at their house, depending on needs. No smoking for 13
years, but prior 45 pack years. No alcohol.
Family History:
Mother died young in [**Name (NI) 8751**], no health problems at time.
Father with ESRD on dialysis, HTN.
No siblings.
Son with Crohn's. Daughter with HTN.
Physical Exam:
On Discharge:
Vitals: 98.2 F, 135/78 mmHg, 79 BPM, RR 18, 98 % RA
General physical exam shows a increase in serous drainage from
groin incision with granulation tissue still present (see
hospital course for comment). General physical examination
otherwise unchanged.
Neurologic examination is now only remarkable for right
homonymous hemianopia. The remainder of the examination was
baseline, with baseline impaired gait, unsteady and requiring a
cane. The remaining exam was normal.
On Admission:
Vitals: 98.4 F 79 Beats 139/59 mmHg 20 breaths 97% 2L NC
General Appearance: Initially in pain from initiation of
Dilantin
infusion. Yelling and saying wanted to go home, wanted to die.
Then Dilantin stopped, calmed down, given 0.25 mg IV Ativan and
settled down. Then cooperative with exam.
HEENT: NC, OP clear, MMM.
Neck: Supple. No bruits. Reduced ROM to ~ 60 degrees b/l.
Lungs: CTA bilaterally.
Cardiac: RRR. Mechanical valve click in mitral position.
Abdominal: Soft, NT, BS+
Extremities: Warm and well-perfused. Peripheral pulses 2+. Some
pedal edema.
Groin: Wound healing by secondary intention in left groin is
packed with gauze. Granulation tissue visible.
Neurologic:
Mental status:
Awake and alert, cooperative with exam.
Orientation: Oriented to person, "[**Hospital **] Hospital", but not
date, month, year.
Language: Normal fluency, comprehension, repetition, naming from
left visual field. No paraphasic errors. Able to follow one step
commands, but often with some confusion if these were spatial -
would point to self when asked to point to daughter and would
not
point to right space.
Acalculia even for 2+1.
Registration of three words at one trial and recall of one at
five minutes without hints.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 2 to
1.5 mm bilaterally. Visual fields remarkable for right
homonymous
hemianopia.
III, IV, VI: Extraocular movements intact bilaterally with
sustained nystagmus on left gaze, difficult to evaluate right
gaze - difficult to get past midline.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetric.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Tone increased in legs, symmetrically. Normal in arms.
Power likely full throughout - no weakness noted, but difficulty
following instructions with left hand. Right hand difficult to
evaluate owing to wrist fracture and bandaging.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 0
Left 2 2 2 1 0
Toes downgoing bilaterally
Sensation intact to light touch, vibration, joint position,
pinprick bilaterally. DSS noted.
No intention tremor. Difficulty following instructions, but
coordinated movements rapid.
Gait:
Unable to evaluate
Pertinent Results:
[**2188-2-29**] 06:05AM BLOOD WBC-7.5 RBC-3.87* Hgb-9.5* Hct-30.2*
MCV-78* MCH-24.4* MCHC-31.3 RDW-16.1* Plt Ct-167
[**2188-2-19**] 12:20AM BLOOD Neuts-86.2* Lymphs-8.1* Monos-3.7 Eos-1.7
Baso-0.3
[**2188-2-29**] 03:25PM BLOOD PT-26.4* PTT-54.0* INR(PT)-2.6*
[**2188-2-29**] 06:05AM BLOOD Glucose-90 UreaN-33* Creat-4.2*# Na-139
K-4.5 Cl-101 HCO3-26 AnGap-17
[**2188-2-29**] 06:05AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.0
[**2188-2-22**] 06:10AM BLOOD %HbA1c-5.0 eAG-97
[**2188-2-22**] 06:10AM BLOOD Triglyc-98 HDL-37 CHOL/HD-3.0 LDLcalc-54
[**2188-2-29**] 06:05AM BLOOD Vanco-9.1*
[**2188-2-19**] 04:34PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
[**2188-2-19**] 04:34PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2188-2-19**] 04:34PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
ECG Study Date of [**2188-2-19**] 12:21:28 AM
Sinus rhythm. Left atrial abnormality. Prior inferior myocardial
infarction. Right bundle-branch block. Low precordial lead
voltage. Frequent ventricular ectopy with ventricular couplets.
These findings are new compared to the previous tracing of
[**2179-9-7**]. Followup and clinical correlation are suggested.
Rate PR QRS QT/QTc P QRS T
74 182 164 448/472 -31 100 -22
NCHCT on Arrival
FINDINGS: There is a left convexity subdural hematoma which is
no more than 5 mm in thickness, without associated mass effect,
unchanged compared with prior. There is also a left posterior
parafalcine subdural hematoma, with a hematocrit level
indicating recent bleeding, which measures 2.9 x 3.0 cm, also
unchanged compared with prior. There is also subdural blood
along the left tentorium. There is stable effacement of the left
occipital [**Doctor Last Name 534**], and stable sulcal effacement in the occipital
and posterior parietal lobes. There is no shift of midline
structures and no herniation.
The imaged mastoid air cells and the visualized portions of the
paranasal sinuses appear well aerated. A probable odontogenic
cyst in the left maxillary alveolar ridge is partially imaged.
IMPRESSION: Stable left posterior parafalcine acute subdural
hematoma with a hematocrit level and local mass effect. Stable
small, acute left convexity and left tentorial subdural
hematomas.
NCHCT [**2188-2-28**]
IMPRESSION:
1. Slight decrease in the size of the left parieto-occipital
parenchymal hematoma with decreased associated mass effect on
the left lateral ventricle.
2. Interval decrease in the size of the left cerebral
hemispheric convexity SDH, left parafalcine SDH, and SDH
overlying the left leaflet of the tentorium cerebelli.
Brief Hospital Course:
Intracranial Hemorrhage
Read as subdural, but review of films reveals intraparenchymal
component at calcarine fissure. This presented a problem given
that she has a mechanical mitral valve (requiring Coumadin) and
recent PCI (requiring Plavix). Anticoagulation was reversed and
when bleeding was stable, intravenous heparin with low PTT goals
was started, followed by Coumadin, then finally Plavix and
aspirin. She was discharged when her INR was 2.6 (above 2.5).
This bleed was seen as traumatic. She will follow-up in [**Hospital 4038**]
clinic.
Groin Wound
Post-PCI, Mrs.[**Known lastname 94162**] groin wound had failed to heal. We
continued vancomycin at hemodialysis sessions and defer to her
nephrologist and PCP to determine the final course. Two doses of
vancomycin were missed prior to obtaining the OSH records.
Mood
Mrs. [**Known lastname 94161**] has previously been depressed. She was very
despondent given these new events, but these were thought to
constitute an understandable exacerbation in her depressed mood.
Celexa was continued.
Hypertension
This was well-controlled throughout the admission, with some
high numbers early in the course of her hospitalization.
Renal Failure
Hemodialysis was continued three times per week, Monday,
Wednesday and Friday.
UTI
Her course of Bactrim was completed.
Headache
Occurred in the context of her hemorrhage and was exacerbated by
dialysis - this had not previously been a problem at dialysis.
Dyslipidemia
Her statin was continued at her admission dose.
Medications on Admission:
- ASA 81 mg
- Plavix 75 mg
- Toprol XL 50 mg [**Hospital1 **]
- Imdur 30 mg TID
- Folic acid 1 mg
- Pepcid 20 mg
- Simvastatin 40 mg QHS
- Nephrocap PO QD
- PhosLo 1336 mg TID w/ meals
- Coumadin 5 mg QD
- Citalopram 10 mg
- Bactrim, for UTI
- ? Vancomycin (IV antibiotic at dialysis for inguinal open
wound, per daughter, [**Doctor Last Name 360**] unknown and not on home list, next
dose due at dialysis Wednesday)
- Recently on hydralazine PO 20 mg QID
Discharge Medications:
1. Vancomycin 750 mg IV HD PROTOCOL
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday): Prior to dialysis.
Disp:*15 Tablet(s)* Refills:*0*
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily): Nephrocaps.
4. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. isosorbide dinitrate 30 mg Tablet Sig: One (1) Tablet PO
three times a day.
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): PhosLo.
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
14. Outpatient Occupational Therapy
Loss of vision in right visual field - adapting to this and
safety given fall risk and anticoagulation (risk of bleeding
with a fall).
15. Outpatient Physical Therapy
Please perform home safety evaluation and help with mobility
given time in bed in hospital and wrist fracture.
16. Outpatient Lab Work
Please check PT/INR. Fax results to:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] E.
Location: THE MEDICAL GROUP
Address: [**Last Name (un) 15488**] [**Apartment Address(1) 31103**], [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**Telephone/Fax (1) 10508**]
Fax: [**Telephone/Fax (1) 31104**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary
Subarachnoid hemorrhage
Intraparenchymal hemorrhage
Secondary
End-stage renal disease, on hemodialysis
Hypertension
Coronary artery disease
Mitral valve replacement
Left groin soft-tissue infection
Left wrist fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). CAUTION WITH LEFT WRIST GIVEN RECENT FRACTURE THAT HAS
NOT YET BEEN CAST.
Discharge Instructions:
You came to the hospital after falling and hitting the back of
your head. You were found to have both subdural and
intraparenchymal hemorrhage. This was quite a conumdrum - you
needed strong antiplatelet therapy as well as anticoagulation
given your coronary artery stents and mechanical mitral valve.
We held these medications and watched you closely as we
gradually reintroduced them after your bleed stabilized. Now
that your INR is 2.6 you are safe to return home. It will be
important for you to be careful and avoid falls given your high
risk of bleeding after trauma.
We changed your dose of metoprolol succinate from Toprol XL 50
mg twice daily to metoprolol tartrate 50 mg three times daily.
Please see Dr. [**Last Name (STitle) **] in clinic. Please also see your primary
care doctor soon as possible to discuss this admission and your
mood. You also need to see your orthopedist to cast your wrist
and discuss vancomycin antibiotic therapy at dialysis.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
[**Hospital1 18**], [**Hospital Ward Name 23**] Building, [**Hospital Ward Name 516**], Level 8
Date/Time:[**2188-4-11**] 1:30
|
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icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
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14398, 14469
|
10560, 12084
|
380, 387
|
14739, 14739
|
7899, 10537
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4862, 5019
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242, 342
|
415, 3404
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6777, 7880
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|
14754, 14971
|
3426, 4665
|
4681, 4846
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,749
| 177,571
|
40822
|
Discharge summary
|
report
|
Admission Date: [**2195-8-28**] Discharge Date: [**2195-9-10**]
Date of Birth: [**2115-3-1**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 6736**]
Chief Complaint:
Robotic prostatectomy, cystectomy with ileal conduit, requiring
post-op monitoring
Major Surgical or Invasive Procedure:
[**2195-8-28**]: Robotic prostatectomy, cystectomy with ileal conduit
by Urology
[**2195-8-28**]: intubation and sedation for surgery by Anesthesia
[**2195-8-28**]: extubation by ICU team
History of Present Illness:
80 yo male with bladder cancer
Past Medical History:
Past Medical History (per urology and Cardiology notes):
- CAD, s/p myocardial infarction, CABG [**2173**]
- hypertension
- bladder and prostate cancer
- PVD s/p peripheral stent [**2191**], R Fem-[**Doctor Last Name **]
- GERD
- Hypothyroidism
- L1 compression Fx
- AAA, 3.1 cm on observation
Social History:
Retired from navy and managed in [**Doctor First Name 391**] in [**Location (un) 7188**], [**Doctor Last Name 40074**]for many years and [**State 108**]. He lives with his wife now in
[**Name (NI) 20338**] and enjoys golfing. Quit smoking tobacco many years ago
and drinks in moderation. He denies any illicit drug use.
Family History:
Unremarkable
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.1 BP: 107/57 P: 99 R: 12 SaO2: 100% on AC at
500/12 50/5
General: Intubated, sedated, but does move head to voice
HEENT: PERRL 2-1mm, NG tube in place
Neck: JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended - 2 JP drains with serosanguinous
drainage, abdominal urinary catheter draining bloody urine
GU: no foley
Ext: cool but well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moves head to voice, PERRL
ICU Discharge Physical Exam:
Vitals: T 36.4 ??????C HR 76 BP 98/43 RR 18 SaO2 96%
General Appearance: No acute distress
HEENT: PERRL, Normocephalic
Lungs: Few scattered rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdominal: Soft, Bowel sounds present, mildly tender around
drains
Extremities: No edema, warm and well-perfused
Neurologic: Attentive, follows simple commands
Pertinent Results:
[**2195-9-7**] 09:25AM BLOOD WBC-7.9 RBC-2.69* Hgb-9.0* Hct-25.6*
MCV-95 MCH-33.5* MCHC-35.1* RDW-12.8 Plt Ct-514*
[**2195-9-6**] 08:25AM BLOOD WBC-8.5 RBC-2.79* Hgb-9.1* Hct-26.4*
MCV-95 MCH-32.7* MCHC-34.5 RDW-12.9 Plt Ct-530*
[**2195-9-7**] 09:25AM BLOOD Glucose-101* UreaN-11 Creat-1.1 Na-139
K-4.3 Cl-108 HCO3-22 AnGap-13
[**2195-9-7**] 07:10AM BLOOD Glucose-104* UreaN-12 Creat-1.1 Na-138
K-4.1 Cl-106 HCO3-22 AnGap-14
[**2195-9-7**] 09:25AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.2 Mg-1.9
Brief Hospital Course:
80-year-old male with PMHx MI s/p CABG in [**2173**], HTN, PVD s/p
left PCI with stenting 4 years ago in [**State 108**] presents to the
ICU s/p urologic surgery for monitoring.
.
# s/p Urologic surgery. In the ICU the patient was able to be
extubated without difficulty, awake and alert afterwards with
complaints of abdominal pain responsive to dilaudid.
Hemodynamically stable. Pain was well-controlled on
toradol/dilaudid prn, and he was transitioned to dilaudid PCA on
POD1. He received maintenance IV fluid rehydration, and a
nasogastric tube was kept for continued post-operative bowel
decompression. Ampicillin & Flagyl + 1 dose Gentamycin were
given for post-op infection prophylaxis.
.
# CAD. Patient with no complaints of chest pain. Breathing is
stable.
Continued on metoprolol PO with IV metoprolol PRN. Aspirin,
plavix, and [**Last Name (un) **] were held per urology recommendation. Lasix and
spironolactone were also held pending creatinine stabilization.
Home zetia and lipitor were restarted on POD1.
.
# Hypertension. BPs in the ICU ranged 95/42(59)-187/87(129).
Acute hypertension was expected in the setting of holding home
diuretics and antihypertensives (as above). Elevated SBP >160
was managed with IV hydralazine PRN.
.
# Hypothyroidism. Continued home levothyroxine at 50mcg daily.
.
# GERD. Continued home nexium.
Mr. [**Known lastname 51305**] is an 80 year old male with PMHx MI s/p CABG in
[**2173**], HTN, PVD s/p left PCI with stenting 4 years ago in [**State 108**]
who is coming to the ICU for monitoring after a Robotic
prostatectomy and cystectomy with ileal conduit. The patient
usually lives in [**State 108**] and was initially diagnosed there, but
came to see Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] a 2nd opinion as one of his relatives
see's Dr. [**Last Name (STitle) **]. It was felt that he had high-grade bladder
cancer with diffuse carcinoma in situ throughout the bladder and
[**Doctor Last Name **] Sum 6 adenocarcinoma of the prostate in two areas of the
prostate and was referred for the above procedure. He did see
Dr. [**Last Name (STitle) **] for pre-operative cardiac clearance at which time he
was started on metoprolol succinate 25mg daily.
.
He underwent the 7 hour procedure [**2195-8-28**]. He was intubated
using a Glide scope. He was fairly hemodynamically stable,
although he did require temporary use of phenylephrine for
hypotension thought to be secondary to anesthesia. His EBL was
200cc, he received a total of 5L crystalloid (4L LR, 1L NS) as
well as 1L 5% albumin and 1 unit PRBC. The procedure was
completed without major complication and the patient was
admitted to the ICU intubated for monitoring.
From the PACU he was taken to the general surgical floor where
he had a [**Hospital 5610**] hospital course secondary to postoperative
ileus. He was eventually discharged on [**9-10**] tolerating a regular
diet but with services to further promote care of his ostomy and
strength. His staples were removed prior to discharge and [**Doctor Last Name **]
his drains had been removed as well. He did have ureteral stents
in place visible at the stoma.
Medications on Admission:
- ASA 81'
- Plavix
- NTG PRN
- Diovan 80'
- Toprol XL 25'
- Lasix 40'
- Aldactone 25'
- Synthroid 50'
- Lipitor 80'
- Zetia 10'
- Vicodin PRN
- Nexium 40'
- [**Doctor First Name **] 180'
- Rhinocort nasal
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever>101.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Macrobid 100 mg Capsule Sig: One (1) Capsule PO twice a day
for 1 days: Take the morning of your appointment with Dr. [**Last Name (STitle) **].
Take until finished.
Disp:*2 Capsule(s)* Refills:*0*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: [**2-8**] Tablet, Chewables PO QID (4 times a day) as needed for
heartburn.
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
14. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
Bladder 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:
It has been a pleasure participating in your care. You will be
discharged home with visiting nurse services that will further
assist you with management of your ongoing physical therapy and
postoperative rehabilitation and urostomy care.
-Resume your pre-admission medications unless otherwise noted.
-Also, ibuprofen has been held as well. Do NOT resume NSAID
therapy (ibuprofen/aleve/motrin/advil etc.) UNLESS specifically
advised to do so by your Urologist
-Please also refer to educational materials provided by the
nurse specialist in urostomy care and management
-The maximum dose of Tylenol (ACETAMINOPHEN) is 4 grams (from
ALL sources) PER DAY.
-The prescribed pain medication may also contain Tylenol
(acetaminophen) so this needs to be considered when monitoring
your daily dose and maximum.
-Please do NOT drive, operate dangerous machinery, or consume
alcohol while taking narcotic pain medications.
-Do not drive while urostomy bag is in place and until you are
cleared to resume such activities by your PCP or urologist
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener--it is NOT a laxative.
-You may shower but do not tub bathe, swim, soak, or scrub
incision
-If you have had Skin clips (staples) or drains removed from
your abdomen; Bandage strips called ??????steristrips?????? have been
applied to close the wound. Allow these bandage strips to fall
off on their own over time. You may get the steristrips wet.
-No heavy lifting for 4 weeks (no more than 10 pounds)
[**Hospital 16237**] medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
Followup Instructions:
Please contact Dr.[**Name (NI) 10529**] office upon discharge to arrange follow
up appointment for 7-10 days from discharge.
Please call your PCP to arrange [**Name Initial (PRE) **] follow-up and to discuss your
medications and postoperative course.
Please call and schedule an appointment to see the Ostomy nurse
at [**Hospital1 18**] for 2 - 4 weeks from discharge. The clinic number is
[**Telephone/Fax (1) 23664**].
Please call with any questions.
Completed by:[**2195-9-17**]
|
[
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
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7768, 7831
|
2900, 6051
|
385, 574
|
7890, 7890
|
2381, 2877
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9900, 10387
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1306, 1320
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7852, 7869
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602, 634
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656, 951
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967, 1290
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1982, 2362
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,255
| 110,231
|
43096+58585
|
Discharge summary
|
report+addendum
|
Admission Date: [**2157-12-2**] Discharge Date: [**2157-12-4**]
Date of Birth: [**2078-6-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline
Analogues / Benadryl Decongestant / Erythromycin Base /
Aztreonam / Diatrizoate Meglumine
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 41058**] is a 79 year old female with a complex past medical
history significant for ANCA vasculitis on chronic prednisone
15mg, essential thrombocytosis and hypertension who presents
with a 10 day history of congestion, 5-day history of throbbing
headache, cough, pleuritic chest pain and worsening dyspnea.
The patient was reportedly in her normal state of health until
approximately 10 days ago, when she began to experience nasal
congestion which is like her usual ANCA vasculitis flare. She
was told to increase her prednisone to 20mg daily and was
started on azithromycin by her PCP for her flare. She improved
over next few days but started worsening five days ago with
cough, pleuritic chest pain and worsening shortness of breath.
She started another course of azithromycin along with
continuation of her steroids. Last night at dinner, she had
acute worsening of her shortness of breath which prompted her to
call EMS. She required 100% NRB and thus was transferred to
[**Hospital1 18**] ED as she was thought too unstable to make it to [**Hospital1 336**].
Of note, she describes this episode of acute
SOB/cough/congestion as similar to past "flares" of her
vasculitis. These episodes usually occur every 3 months for
which her dose of prednisone is increased and she takes a
z-pack. Her symptoms were not responsive this time to this
regimen. She does not take Bactrim for regular PCP pneumonia
prophylaxis.
Additionally, she reports she took a long flight to [**State 108**] 2
weeks ago. No sick contacts or travel out of the country.
ROS: 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:
* right greater trochanteric bursitis
* Myeloproliferative disease - essential thrombocythemia;
Regimen of hydroxyurea x2 weeks alternating with cellcept x4
weeks
* p-ANCA associated vasculitis: disease in her kidneys, lungs,
sinuses, and blood. First dx 20yrs ago. Regimen of prednisone
15mg daily. Followed by Dr. [**First Name (STitle) 1557**].
* history of LGIB - diverticulosis ([**8-22**])
* Hypertension
* Hypothyroidism
* Chronic renal insufficiency, baseline 1.6
* CAD s/p angioplasty [**2150**] of D1
* Cataract bilaterally
* S/P open Cholecycstectomy in [**9-/2153**]
Social History:
School teacher; lives in [**Location **] with partner, [**Name (NI) 2048**] who is
very supportive. She has not had alcohol in years. Never smoked.
Family History:
HTN (brother, mother)
MI (mother)- died at 88
Physical Exam:
Physical Exam on Admission to the MICU:
VS: 99.3 129/89 103 99% 70%NRB
GEN: Female in moderate respiratory distress
HEENT: Anicteric. Moist mucous membrane. PERRLA. EOMI
NECK: Supple neck
PULM: Bibasilar crackles. L > R. No wheezing appreciated.
CARD: Regular rate and rhythm. No mumurs or gallops appreciated
ABD: Soft, nontender and nondistended. Splenomegaly. NABS
EXT: No edema
NEURO: Alert and oriented to person, place and time. CN 2-12
intact. Sensation intact. Moving all extremities
Physical Exam on Admission to the General Medicine Floor:
VS - Temp 99.3F, BP 127/51 , HR 88 , RR21 , O2-sat 97% 4L NC
GENERAL - well-appearing, NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no LAD
LUNGS - Bibasilar crackles, but otherwise clear. Breathing is
not labored.
HEART - RRR, nl S1/S2, no M/R/G
ABDOMEN - BS+, soft, NT/ND, no rebound, no guarding, spleen tip
palpable with inhalation
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, grossly in tact
Physical Exam on Discharge:
VS: T99.2, BP 131/56, HR 83, RR 18, O2Sat 97% 1L
GENERAL - well-appearing, NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no LAD
LUNGS - Bibasilar crackles, but otherwise clear. Breathing is
not labored.
HEART - RRR, nl S1/S2, no M/R/G
ABDOMEN - BS+, soft, NT/ND, no rebound, no guarding, spleen tip
palpable with inhalation
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, grossly in tact
Pertinent Results:
Blood on Admission:
[**2157-12-2**] 09:36PM BLOOD WBC-5.5# RBC-4.39 Hgb-12.5# Hct-37.6
MCV-86# MCH-28.4# MCHC-33.2 RDW-20.8* Plt Ct-1129*#
[**2157-12-2**] 09:36PM BLOOD Neuts-63 Bands-3 Lymphs-20 Monos-4 Eos-0
Baso-0 Atyps-8* Metas-1* Myelos-1*
[**2157-12-2**] 09:36PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-2+ Polychr-1+ Ovalocy-1+
Blood on Discharge:
[**2157-12-4**] 05:14AM BLOOD WBC-3.4* RBC-3.24*# Hgb-9.0*# Hct-27.6*#
MCV-85 MCH-27.7 MCHC-32.5 RDW-20.9* Plt Ct-584*
Electrolytes on Admission:
[**2157-12-2**] 09:36PM BLOOD Glucose-160* UreaN-60* Creat-1.4* Na-139
K-4.5 Cl-97 HCO3-27 AnGap-20
[**2157-12-2**] 09:36PM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
[**2157-12-2**] 09:46PM LACTATE-3.5*
Electrolytes on Discharge:
[**2157-12-4**] 05:14AM BLOOD Glucose-114* UreaN-51* Creat-1.7* Na-138
K-3.7 Cl-99 HCO3-30 AnGap-13
[**2157-12-4**] 05:14AM BLOOD Calcium-7.6* Phos-2.9 Mg-2.0
Heart through hospital course:
[**2157-12-2**] 09:36PM BLOOD proBNP-1899*
[**2157-12-2**] 09:36PM BLOOD cTropnT-<0.01
[**2157-12-3**] 11:20AM BLOOD CK-MB-2 cTropnT-0.06*
[**2157-12-3**] 10:45PM BLOOD CK-MB-2 cTropnT-0.04*
[**2157-12-3**] 11:20AM BLOOD CK(CPK)-37
[**2157-12-3**] 10:45PM BLOOD CK(CPK)-24*
ABG:
[**2157-12-3**] 01:36AM BLOOD Type-ART pO2-92 pCO2-35 pH-7.47*
calTCO2-26 Base XS-1
Urine:
[**2157-12-3**] 12:32AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014
[**2157-12-3**] 12:32AM URINE Blood-NEG Nitrite-NEG Protein-500
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2157-12-3**] 12:32AM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2157-12-3**] 12:32AM URINE AmorphX-MOD
Cultures:
Blood culture ([**2157-12-2**]) x2 pending
MRSA Swab ([**2157-12-3**]) x1 pending
.
STUDIES:
CXR ([**12-2**]): Fullness of the hila and prominence of the
interstitial markings, suggest mild pulmonary edema. Patchy
retrocardiac opacity may relate to edema, although underlying
consolidation cannot be excluded.
.
CXR ([**12-4**]): Mild pulmonary vascular congestion. Increased
density in the left lower lobe suspicious for underlying
pneumonia. Clinical correlation is recommended.
Brief Hospital Course:
79 year old female with ANCA vasculitis on chronic prednisone,
essential thrombocythemia and hypertension who presents with a
10 day history of congestion, 5-day history of cough, pleuritic
chest pain and worsening dyspnea admitted on [**2157-12-3**] and
discharged on [**2157-12-4**].
# Worsening dyspnea, multifactorial. Likely flare of vasculitis
in the setting of possible community acquired pneumonia. This
is also complicated by pulmonary edema seen on CXR, elevated
BNP, and plateaued troponin values. Her initial symptoms were
similar (rhinorrhea, post-nasal drip, ear pain) to prior
vasculitis flare. Because of her requirement of NRB, she was
transferred to the MICU for respiratory status management. She
was ruled out of MI given unchanged EKG and initial negative
troponin. Repeat troponins were mildly elevated, but likely in
the setting of her CKD and possible demand that she had
initially. PE was considered given her underlying ET and sudden
onset, but her symptoms improved with treatments of pneumonia,
pulmonary edema, and vasculitis. Patient's symptoms improved
with antibiotics (vancomycin and levofloxacin in the ED and then
levofloxacin for the rest of her stay), prednisone, as well as
diuresis with IV lasix. Her Norvasc was held briefly. Her O2
requirement improved to 1-2L NC at the time of discharge. On
the day of discharge, she received increased prednisone dose 25
mg and another lasix 40 mg IV bolus. She was discharged home
with 60 mg po lasix, renally dosed levofloxacin for a total of 7
day course for the possible CAP, as well as an increased dose of
her prednisone to 25 mg daily given vasculitis flare.
# ANCA vasculitis: Discussed above in worsening dyspnea.
Prednisone dose was increased to 25mg daily. Patient was urged
to follow up with Dr. [**First Name (STitle) 1557**] within one week of discharge.
# Essential thrombocytosis: She reports she usually gets
hydroxyurea 2x week for two weeks alternating with cellcept x4
weeks. She is currently scheduled to get hydroxyurea soon. Her
aspirin was increased to 325 mg po qdaily from 81 mg po qdaily
while in the hospital.
# Anemia. Likely result of dilution given patient was given IVF
initially and IV antibiotics. All cell lines decreased. Her
vitals were stable. There was no clear source of bleeding and
BUN was not elevated above baseline to suggest any underlying GI
bleeding. It could also be a part of her underlying
myelodysplatic syndrome and therapy. This should be followed up
closely by her hematologist, Dr. [**First Name (STitle) 1557**].
# Hypertension: Blood pressure was stable in the 130s throughout
her stay. She was continued on home Torpol XL 100 mg po BID but
her Norvasc was held (5 mg po qdaily). She was continued on
Catapres 3 qweekly on Sunday. She is discharged to continue
with all three medications since low blood pressure was no
longer an issue. This can be followed by her primary care
physician.
# Hypothyroidism: This issue was stable throughout
hospitalization. She was continued on home Levothyroxine 50 mcg
po qdaily
# Chronic kidney disease. Baseline Crt ~ 1.7. Stage 3.
Patient received fluid while in the ED. She received
antibiotics and lasix while in the hospital, likely to account
for the increase in creatinine to 1.8 from admission. She was
discharged on levofloxacin that is dosed renally. This should
continue to be followed.
Medications on Admission:
1. Toprol 100 mg [**Hospital1 **]
2. Prilosec 40 mg [**Hospital1 **]
3. Furosemide 60 mg daily
4. Levothyroxine 50 mcg daily
5. Prednisone 12.5 mg daily
6. Norvasc 5 mg daily
7. Bicitra IT [**Hospital1 **]
8. Vitamin D 1000 mg daily
9. Tylenol (2 extended release) daily
10. Allopurinol 200 mg qhs
11. MVI qhs
12. Metamucil qhs
13. Folic acid 1 mg qhs
14. Catapres 0.3 mg qweek (Sunday)
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. prednisone 2.5 mg Tablet Sig: Ten (10) Tablet PO DAILY
(Daily): Please have 25mg per day until directed otherwise by
your PCP.
6. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. sodium citrate-citric acid 500-300 mg/5 mL Solution Sig:
Fifteen (15) ML PO BID (2 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
9. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. acetaminophen 650 mg Tablet Sustained Release Sig: [**11-20**]
Tablet Sustained Releases PO once a day as needed for pain or
fever.
12. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QSUN (every Sunday).
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every
other day for 3 days: Please take one pill on [**2157-12-6**], one pill
on [**2157-12-8**].
Disp:*2 Tablet(s)* Refills:*0*
15. Oxygen Continue home O2 2L at night and as needed during the
day to maintain SpO2 great than 90%.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Pneumonia
- P-ANCA vasculitis flare
Secondary Diagnosis:
- Essential Thrombocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear. Ms. [**Known lastname 41058**],
It was a pleasure taking care of you at [**Hospital1 827**] in [**Location (un) 86**].
You came to the hospital by ambulance for worsening shortness of
breath after a 10 day history of congestion and a 5 day history
of cough and pleuritic chest pain not responsive to increased
steroids and z-pack use. On chest X-ray, you were found to have
fluid in your lungs and pneumonia. You were treated with oxygen
for your shortness of breath, a diuretic to clear the fluid in
your lungs and an antibiotic for your pneumonia.
Over the course of your stay, you also developed a post-nasal
drip and ear pain, thought to likely be due to a flare of your
vasculitis. Your prednisone dose was increased to 25mg daily.
Please note the following changes in your medication.
-Please START levofloxacin 750mg by mouth, once on [**2157-12-6**]
and another one on [**2157-12-8**].
-Please INCREASE your dose of predinsone to 25mg per day until
otherwise directed by your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1557**]
[**Name (STitle) 21421**] START using oxygen supplement at 1-2L for at least 16
hours a day until you see Dr. [**First Name (STitle) 1557**] who will help to assess
your oxygen level.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1557**]
([**Telephone/Fax (1) 6309**]) within one week of discharge for follow up care
of your vasculitis and high platelets.
Completed by:[**2157-12-6**] Name: [**Known lastname 14623**],[**Known firstname 14624**] J Unit No: [**Numeric Identifier 14625**]
Admission Date: [**2157-12-2**] Discharge Date: [**2157-12-4**]
Date of Birth: [**2078-6-1**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline
Analogues / Benadryl Decongestant / Erythromycin Base /
Aztreonam / Diatrizoate Meglumine
Attending:[**First Name3 (LF) 11279**]
Addendum:
[**2157-12-11**]
Through medicine clerkship, had home visit with this patient.
Please see OMR for letter.
Discussed code status with patient. She reports that going
forward she would want to be full code as long as her cognitive
function and current quality of life were not compromised.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 3344**] [**Last Name (NamePattern4) 11280**] MD [**MD Number(2) 11281**]
Completed by:[**2157-12-11**]
|
[
"414.01",
"482.9",
"403.90",
"244.9",
"238.79",
"428.0",
"238.71",
"428.31",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14976, 15146
|
6953, 10358
|
418, 424
|
12452, 12452
|
4796, 4802
|
13907, 14953
|
3071, 3118
|
10795, 12273
|
12323, 12323
|
10384, 10772
|
5731, 6930
|
12635, 13884
|
3133, 4223
|
4251, 4777
|
5540, 5714
|
371, 380
|
452, 2285
|
12402, 12431
|
12342, 12381
|
5315, 5526
|
12467, 12611
|
2307, 2888
|
2904, 3055
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,322
| 139,825
|
8558+55955
|
Discharge summary
|
report+addendum
|
Admission Date: [**2189-9-8**] Discharge Date: [**2189-9-25**]
Date of Birth: [**2154-12-25**] Sex: F
Service: GYN ONC
HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old
gravida 2, para 2, with a history of recurrent adenocarcinoma
of the cervix, Stage IB, who presents with severe left hip
pain that radiates to the thigh and buttocks.
PAST ONCOLOGICAL HISTORY: On [**2188-3-24**], the patient
underwent a radical hysterectomy, bilateral pelvic
lymphadenectomy, and bilateral ovarian transposition for
Stage IB adenocarcinoma of the cervix. In [**2189-1-29**],
the patient developed lower left pelvic pain radiating to the
left leg. Work-up with an MRI demonstrated soft tissue mass
near the left vaginal apex. The patient had multiple vaginal
biopsies under anesthesia which were not diagnostic. On
[**2189-4-24**], the patient had transvaginal ultrasound
needle aspiration which was positive for carcinoma. At this
time, she was diagnosed with recurrent Stage IB cervical
cancer. From [**Month (only) 116**] through [**2189-5-29**], the patient received
radiation with concurrent cisplatin chemotherapy. She had
good symptomatic relief of her pain after initiating the
therapy. On [**2189-6-29**], radiation implants were inserted
and an omentopexy was performed.
The patient began having recurrent pain approximately two
weeks later which has been progressively worsening. The pain
became debilitating the night before admission. The pain is
sharp, stabbing and continuous. It begins in the left hip
and radiates along the anterior aspect of the thigh and
lateral buttocks. The pain is now exacerbated with activity.
Her leg feels heavy when she walks. Prior to exacerbation of
this pain it had been fairly well controlled with Motrin and
Klonopin.
PAST OBSTETRICAL HISTORY: Spontaneous vaginal delivery x 2.
PAST MEDICAL HISTORY: Stage IB adenocarcinoma of the cervix.
PAST SURGICAL HISTORY: As above.
ALLERGIES: IV contrast.
PAST GYN HISTORY: As above.
SOCIAL HISTORY: The patient denies alcohol, drug or tobacco
use.
EXAM: The patient was afebrile at 98, blood pressure 122/80,
respiratory rate 18, pulse 84. In general, she was in no
acute distress. Her heart was regular rate and rhythm. The
lungs were clear to auscultation bilaterally. The abdomen
was soft, nondistended with a well healed scar. There was
some diffuse tenderness in the left lower quadrant and along
the left lateral hip. On pelvic exam, the cuff was intact.
There were no obvious masses or nodules. The patient was
somewhat uncomfortable during the exam. Extremities - there
was [**5-2**] motor strength bilaterally and slightly decreased
sensation on the left extremity.
Her CT scan from [**2189-8-18**] revealed soft tissue
stranding, but no evidence of recurrence.
In summary, the patient is a 34-year-old gravida 2, para 2,
with a history of recurrent Stage IB adenocarcinoma of the
cervix, now presenting with debilitating left hip and leg
pain.
BRIEF HOSPITAL COURSE - 1) LEG PAIN: As noted, the patient
was admitted for pain control. She was initially started on
intramuscular Demerol and Vistaril which provided adequate
pain relief. The pain service was consulted and recommended
a cocktail which included neurontin, oxycodone, doxepin and
methadone. They also suggested to taper the Klonopin. As
per their recommendations, the patient was started on these
medications and the doses were adjusted according to their
recommendations with increased methadone from 5 mg po tid to
10 mg po tid, as well as gradual increase of the neurontin.
On hospital day #3, the patient underwent an MRI which
demonstrated left side tissue mass, unchanged from CT scan of
[**2189-7-29**]. There was also noted to be a new left
hydronephrosis. Please see below for details regarding her
hydronephrosis. Additionally, a neuro consult was called.
They recommended fine cuts through the LS spine to see if
there was any nerve impingement. Repeat MRI again
demonstrated no evidence of disease along the nerves.
On hospital day #7, the patient was made NPO after midnight
and she was scheduled for ultrasound-guided biopsy. Around
11:00 am on hospital day 7, the gyn oncology team was called
to radiology, as the patient was found to be very heavily
sedated and even apneic at times. She was noted to have
oxygen desaturation to the 80s. She was also noted to be
hypotensive and tachycardic. An EKG was obtained that showed
sinus tachycardia. The patient was given two doses of Narcan
of 40 mcg each. The pain service and anesthesia were called
to immediately see the patient. The patient was then
transferred to the PACU for closer monitoring.
In the PACU, the patient received an additional 200 mcg of
Narcan, as well as 1 mg of flumazenil. The patient appeared
to respond well to the flumazenil with increase in alertness.
Review of the medications showed that the patient had
received her PO regimen which included neurontin, methadone
and Klonopin, as well as two doses of 50 mg of demerol
overnight. In the PACU, the patient was sating 99%, she was
still somewhat tachycardic in the 120s-130s and her blood
pressure was 140/80. Her respiratory rate ranged from 8-12
breaths per minute. Her exam otherwise was unremarkable.
Labs were sent which showed that her electrolytes were all
within normal limits. However, her creatinine was noted to
be 1.6. Her prior creatinine on [**9-9**] was 1.1.
Additionally, an arterial blood gas was obtained that
demonstrated a pH of 7.3, PCO2 43, PO2 158, bicarb 24. The
patient was transferred to the Medical ICU for overnight
monitoring.
On hospital day #8, the patient was neurologically improved.
She was alert and awake. Her vital signs were now within
normal limits. Repeat creatinine was 1.1 and the rest of the
laboratory studies were normal. At this point, the patient
was transferred back to the floor. Her medication regimen
was readjusted and she was placed on Motrin, Klonopin and
oxycodone. On [**9-16**], the patient underwent a
transvaginal ultrasound-guided biopsy in the area of the
previous biopsy. This biopsy was negative for malignancy.
On hospital day #10, [**9-17**], the patient was started on
a fentanyl patch. She was still continued on oxycodone for
breakthrough, as well as Klonopin whose dose had been
titrated down to 0.5 mg [**Hospital1 **]. Neurology strongly recommended
neurontin. However, the patient was somewhat resistant, as
she felt this medication made her feel woozy. Additionally,
on hospital day #17, the patient complained of myotonic jerks
upon falling asleep. This was likely attributed to
neurontin. However, this side-effect usually occurs at much
higher doses. Secondary to this finding, neuro agreed that
the neurontin could be discontinued. The patient's pain
medications continued to be adjusted with a final regimen
that appeared to work and consisted of: naprosyn 500 mg [**Hospital1 **],
fentanyl patch 75 mcg, oxycodone 10 mg q 6 h prn, Klonopin
0.5 mg q hs. The patient has plans to follow-up with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], beeper #[**Numeric Identifier 30069**], on [**10-30**].
Additionally, she is scheduled for an EMG study on [**10-12**]
at 10:30 am.
2) LEFT HYDRONEPHROSIS/LEFT URETERAL OBSTRUCTION: Secondary
to findings of left hydronephrosis on MRI, a urology consult
was obtained. They recommended intravenous pyelogram. IVP
done on [**2189-9-18**] demonstrated no contrast excretion into the
left collecting system, as well as delayed faint renogram.
The right kidney and ureter was normal. The decision was
then made to place a percutaneous nephroureterostomy tube.
This was placed on [**9-21**]. The tube drained well and
was capped on [**9-23**]. The patient's creatinine was
1.0. The perc neph tube was placed by interventional
radiology. She was followed by Dr. [**Last Name (STitle) **], beeper #[**Numeric Identifier 30070**]. I
should mention that it was unclear whether the hydronephrosis
was caused by tumor versus radiation fibrosis. The patient
will need to follow-up with interventional radiology in four
weeks to make sure the stent is functioning properly.
3) DISPOSITION: The patient was discharged home. Medication
regimen as outlined above which included fentanyl patch,
Naprosyn, oxycodone and Klonopin. She has plans to follow-up
with Dr. [**First Name (STitle) 1022**] next week. Additionally, she has an appointment
in neurology on [**10-30**], as well as an appointment in EMG
on [**10-12**] at 10:30 am. She will also be sent home with
VNA services in order to check the proper drainage and care
of the nephrostomy tube.
CONDITION ON DISCHARGE: Improved.
STATUS: To home.
DISCHARGE MEDICATIONS: Naprosyn 500 mg po bid, fentanyl
patch 75 mcg q 72 h, oxycodone 10 mg q 6 h, Klonopin 0.5 mg q
hs.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4871**]
Dictated By:[**Name8 (MD) 30071**]
MEDQUIST36
D: [**2189-9-29**] 11:04
T: [**2189-9-29**] 10:39
JOB#: [**Job Number 29545**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 5255**]
Admission Date: [**2189-9-8**] Discharge Date: [**2189-9-25**]
Date of Birth: [**2154-12-25**] Sex: F
Service: Gynecologic Oncology
ADDENDUM: 1. Left leg pain: Additionally, the patient was
also on Doxepin 10 mg daily per recommendation of the pain
service. This was discontinued after the patient had had her
narcotic overdose episode.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4784**]
Dictated By:[**Name8 (MD) 5256**]
MEDQUIST36
D: [**2189-9-29**] 11:33
T: [**2189-9-29**] 12:08
JOB#: [**Job Number 5257**]
|
[
"591",
"184.0",
"728.85",
"V10.41",
"E936.3",
"E850.2",
"724.4",
"965.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"70.24",
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
8773, 9897
|
1947, 2014
|
169, 1860
|
1883, 1923
|
2031, 8694
|
8719, 8749
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,740
| 134,969
|
35079
|
Discharge summary
|
report
|
Admission Date: [**2175-8-30**] Discharge Date: [**2175-9-10**]
Date of Birth: [**2129-5-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Bee Pollens
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Epilepsy
Major Surgical or Invasive Procedure:
Insertion of depth electrodes and subdural grids for seizure
monitoring
History of Present Illness:
Known history of seizure disorder
Past Medical History:
Epilepsy as described above
Family History:
No seizures.
Physical Exam:
Neurointact post grid and depths. Had recorded seizure activity
on telemetry. Will confirm location and semiology with neuromed.
Brief Hospital Course:
[**Hospital 68517**] hospital course. Seizures recorded on telemetry.
Grids and depth electrodes removed. No complications. The
seizure focus has been identified in the left hippocampus. The
patient is a surgical candidate with the option of either an
open hippocampectomy or a radiosurgical hippocampectomy. We
shall arrange accordingly.
Discharge Medications:
1. Dilantin Extended 100 mg Capsule Sig: Two (2) Capsule PO in
the AM.
Disp:*60 Capsule(s)* Refills:*2*
2. Dilantin Extended 100 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Well
Discharge Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 7 days. Please call Dr.[**Name (NI) 12757**]
office for appointment.
Followup Instructions:
As above
Completed by:[**2175-9-10**]
|
[
"E930.0",
"310.2",
"345.51",
"693.0",
"V58.69",
"780.62",
"E929.3",
"907.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.93",
"01.22"
] |
icd9pcs
|
[
[
[]
]
] |
1270, 1276
|
671, 1011
|
284, 358
|
1328, 1334
|
1499, 1539
|
489, 503
|
1034, 1247
|
1297, 1307
|
1358, 1476
|
518, 648
|
236, 246
|
386, 421
|
443, 473
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,619
| 175,374
|
14867
|
Discharge summary
|
report
|
Admission Date: [**2163-6-21**] Discharge Date: [**2163-6-28**]
Date of Birth: [**2083-10-2**] Sex: M
Service: SURGERY
Allergies:
Dilaudid / Iodine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Juxtarenal abdominal aortic
aneurysm.
Major Surgical or Invasive Procedure:
[**2163-6-21**] Resection and repair of abdominal aortic aneurysm with
20-mm Dacron tube graft.
History of Present Illness:
This 79-year-old gentleman has a 5.5-cm infrarenal abdominal
aortic aneurysm that has been enlarging. The aneurysm has no
neck and is unsuitable for endovascular repair and he is
undergoing open repair.
Past Medical History:
CAD MI in [**2155**] s/p right coronary stents, hypercholesterolemia
prostate cancer s/p TURP and radiation c/b radiation cystitis
with recurrent episodes of hematuria weekly
Social History:
Prior to admission was living with wife independently.
Family History:
Family history is notable for coronary artery disease in both
his mother and father who passed from myocardial infarctions.
There is no family history of any aneurysmal disease.
Physical Exam:
On Discharge:
AFVSS 98.8 HR: 87 BP: 123/63 RR: 16 Spo2: 94%
Gen: NAD, Alert and oriented x3
CVS: RRR
Pulm: CTA bilaterally no resp distress
Abd: S/AT/ND C/D/I
Extremities: Mild BLE edema
Pertinent Results:
[**2163-6-21**] 01:17PM BLOOD WBC-6.9 RBC-3.40* Hgb-10.0* Hct-30.0*#
MCV-88 MCH-29.5 MCHC-33.5 RDW-15.3 Plt Ct-85*
[**2163-6-22**] 03:10AM BLOOD WBC-8.9 RBC-3.24* Hgb-9.8* Hct-28.8*
MCV-89 MCH-30.2 MCHC-33.9 RDW-15.5 Plt Ct-71*
[**2163-6-23**] 02:33AM BLOOD WBC-14.0*# RBC-3.79* Hgb-11.1* Hct-32.9*
MCV-87 MCH-29.4 MCHC-33.8 RDW-16.9* Plt Ct-67*
[**2163-6-24**] 03:56AM BLOOD WBC-16.0* RBC-3.71* Hgb-10.8* Hct-31.6*
MCV-85 MCH-29.0 MCHC-34.1 RDW-16.8* Plt Ct-96*
[**2163-6-25**] 04:00AM BLOOD WBC-12.6* RBC-3.60* Hgb-10.7* Hct-31.9*
MCV-89 MCH-29.8 MCHC-33.7 RDW-16.7* Plt Ct-94*
[**2163-6-26**] 09:20AM BLOOD WBC-12.6* RBC-4.22* Hgb-12.0* Hct-37.1*
MCV-88 MCH-28.5 MCHC-32.5 RDW-16.3* Plt Ct-145*#
[**2163-6-27**] 06:25AM BLOOD WBC-8.4 RBC-3.93* Hgb-11.2* Hct-34.6*
MCV-88 MCH-28.6 MCHC-32.5 RDW-16.2* Plt Ct-145*
[**2163-6-21**] 08:06PM BLOOD Neuts-90.2* Lymphs-5.0* Monos-4.0 Eos-0.1
Baso-0.0
[**2163-6-21**] 01:17PM BLOOD Plt Smr-LOW Plt Ct-85*
[**2163-6-24**] 03:56AM BLOOD PTT-28.0
[**2163-6-21**] 01:17PM BLOOD Glucose-155* UreaN-17 Creat-0.9 Na-140
K-4.1 Cl-109* HCO3-25 AnGap-10
[**2163-6-27**] 06:25AM BLOOD Glucose-99 UreaN-34* Creat-1.5* Na-142
K-3.0* Cl-104 HCO3-29 AnGap-12
[**2163-6-21**] 08:06PM BLOOD Calcium-7.9* Phos-4.0 Mg-1.4*
[**2163-6-27**] 06:25AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.0
[**2163-6-21**] 11:23AM BLOOD Type-ART pO2-261* pCO2-38 pH-7.40
calTCO2-24 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2163-6-21**] 12:16PM BLOOD Type-ART pO2-258* pCO2-51* pH-7.29*
calTCO2-26 Base XS--2 Intubat-INTUBATED Vent-CONTROLLED
[**2163-6-21**] 01:47PM BLOOD Type-ART FiO2-50 pO2-136* pCO2-40 pH-7.41
calTCO2-26 Base XS-1 -ASSIST/CON Intubat-INTUBATED
[**2163-6-21**] 05:30PM BLOOD Type-ART Rates-/11 PEEP-5 FiO2-40 pO2-88
pCO2-51* pH-7.34* calTCO2-29 Base XS-0 Intubat-INTUBATED
[**2163-6-21**] 08:25PM BLOOD Type-MIX
[**2163-6-22**] 03:25AM BLOOD Type-ART pO2-78* pCO2-46* pH-7.33*
calTCO2-25 Base XS--1
[**2163-6-22**] 06:36PM BLOOD Type-ART pO2-56* pCO2-27* pH-7.45
calTCO2-19* Base XS--2 Intubat-INTUBATED
[**2163-6-23**] 02:48AM BLOOD Type-[**Last Name (un) **] pH-7.44
[**2163-6-21**] 11:23AM BLOOD freeCa-1.09*
[**2163-6-23**] 02:48AM BLOOD freeCa-1.14
Brief Hospital Course:
The patient was admitted to the surgery service after having
Resection and repair of abdominal aortic aneurysm with 20-mm
Dacron tube graft.
Neuro: The patient received and epidural with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications Tramadol.
CV: Post-operatively the patients blood pressure was managed
with IV labetolol drip and nitroprusside. On discharge the was
stable from a cardiovascular standpoint; vital signs were
routinely monitored. He is currently on Metoprolol for beta
blockage with good blood pressure management.
Pulmonary: On discharge patient was stable from a pulmonary
standpoint; vital signs were routinely monitored. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout this hospitalization. He did have a CXR
on [**6-23**] which revealed opacities and pneumonia could not be
excluded. He will be discharged with levo/flagyl for suspect
pneumonia for a 2 week course.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF.
The patient's diet was advanced when appropriate, which was
tolerated well.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. He will be discharged
with levo/flagyl for suspect pneumonia for a 2 week course.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly. Sliding
scale to be continued.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Accupril,Amoxicillin,Atenolol,ASA,Axid,Rosovastatin,
Fluticasone, Casodex, Eligard
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 2 weeks: PNA treatment.
2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks: PNA treatment.
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day): New medication
.
4. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per sheet.
6. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
14. Axid 150 mg Capsule Sig: One (1) Capsule PO once a day.
15. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**1-29**] Nasal
once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] skilled nursing center
Discharge Diagnosis:
Juxtarenal abdominal aortic aneurysm
PMH:
CAD
Hypercholesterolemia
Prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-5**]
weeks
?????? You should get up out of bed every day and gradually
increase your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do
too much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**3-2**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without
your legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high
fiber, lean meats, vegetables/fruits, low fat, low cholesterol)
to maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer
taking pain medications
?????? You should get up every day, get dressed and walk,
gradually increasing your activity
?????? You may up and down stairs, go outside and/or ride in a
car
?????? Increase your activities as you can tolerate- do not do
too much right away!
?????? No heavy lifting, pushing or pulling (greater than 5
pounds) until your post op visit
?????? You may shower (let the soapy water run over incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin
daily, unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or
the ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow
or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2163-7-11**] 12:30
Completed by:[**2163-6-28**]
|
[
"486",
"788.5",
"441.4",
"414.01",
"595.82",
"496",
"272.0",
"511.9",
"293.9",
"E878.2",
"285.9",
"997.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
7091, 7161
|
3544, 5578
|
316, 414
|
7289, 7289
|
1340, 3521
|
10298, 10486
|
933, 1112
|
5712, 7068
|
7182, 7268
|
5604, 5689
|
7454, 9815
|
9842, 10275
|
1127, 1127
|
1141, 1321
|
238, 278
|
442, 647
|
7304, 7430
|
669, 845
|
861, 917
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,339
| 164,879
|
41452
|
Discharge summary
|
report
|
Admission Date: [**2124-1-21**] Discharge Date: [**2124-1-29**]
Date of Birth: [**2061-12-28**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
dyspnea, chest pain, hypoxia
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Chest tube placement and removal
History of Present Illness:
62 yo F with no significant PMH, recently diagnosed with
cryptogenic organizing pneumonia, who was transferred from an
OSH to [**Hospital1 18**] for left heart catheterization, who is now being
called out to the floor following initial management of
hemothorax (due to chest tube placed at OSH for unclear
reasons).
.
Briefly, Mrs. [**Known lastname **] presented to [**Hospital3 **] on [**2124-1-10**] with
6 months of cough, 30 lb weight loss, DOE, orthopnea and
lethargy.
.
On the day of presentation at the OSH, she also developed
bilateral LE edema, as well as increased dyspnea. She underwent
a chest CT (w/contrast) that ruled out PE but demonstrated
"multifocal multinodular infiltrates with nodular
consolidation", mediastinal and hilar adenopathy, and
tree-in-[**Male First Name (un) 239**] opacities. She had a VATS and RUL wedge lung biopsy
on [**2124-1-14**] which revealed COP /BOOP, with negative flow
cytometry. ANCA, Anti CCP, and AFB were negative as well. She
had a post-op chest tube from [**2033-1-12**]. She was started on
Solumedrol 40mg IV TID, which had been started for empiric
treatment of her dyspnea and concomitant eosinophilia of 17% on
presentation, and was continued after the tissue diagnosis of
BOOP /COP.
.
She developed chest pain initially in her hospital stay, and
enzymes revealed a peak troponin I of 7.960. ECG did not reveal
ST elevations, but given her elevated tropnin she was started on
Plavix, metoprolol, aspirin and Ranexa. TTE revealed mild LV
systolic dysfunction and diastolic dysfunction with moderate MR
and TR. Nuclear stress test on [**2124-1-12**] showed anterolateral
myocardial infarct with moderate ischemia and mildly reduced LV
function with segmental wall abnormalities.
.
She was transferred to [**Hospital1 18**] for cardiac catheterization on
[**2124-1-21**] which revealed clean coronary arteries. She remained on
the Cardiology service therafter. She was felt to have possible
myocarditis, but could not rule out small embolus to the cornary
artery. Cardiology advised f/u MRI as an outpatient.
.
She then developed recurrent chest pain. Pain was pleuritic and
located at the site of her VATS procedure in her right axilla.
She desaturated from the low 90s on 3 L to high 80s. She
underwent a repeat chest CT w/ contrast that was negative for
PE. It did reveal persistent "bilateral nodular and
centrilobular opacification with peribronchial wall thickening
and mucoid impaction, indicative of aspiration or chronic
infection/inflammation." She received analgesia for the chest
pain and her symptoms improved.
.
Thoracic surgery was consulted to evaluate an oozing chest tube
site, and they advised close monitoring.. Pulmonary was
consulted and advised transitioning to prednisone and started
PCP [**Name Initial (PRE) 1102**].
.
The patient then noted escalating pain at biopsy site. Pain
improved with analegesic, but worsened to [**7-5**] with associated
dyspnea and substernal chest pressure, and saturation on routine
vitals showed 87% on 9L. Increased drainage from chest tube
site was noted. Repeat CXR showed worsening right sided pleural
effusion. A thoracentesis was done on [**2124-1-23**] and pleural fluid
was sent for analysis. ABG on NRB showed 7.44 / 40 / 94 /28.
Chest pain and dyspnea improved with morphine and patient
repositioning. She became hypotensive to 70's, and chest tube
was placed due to worsening right sided pleural effusion was
noted on CXR. Tube drained 2.5L blood after initial placement,
and she was transfused 3 units PRBCs and given fluids. Since
then tube drained an addition 1L (not including initial 2.5L),
most recently 100 mL serosanguinous from 12A-8A, but since 8AM
~60 mL dark blood.
.
Currently, the patient denies chest pain, dyspnea, fevers,
chills. She reports recent right-sided chest pain, similar in
quality to previous pain, although less severe, that resolved
spontaneously. No other complaints.
.
On transfer to floor her VS were stable: T 96.3 afebrile HR 81
BP 131/71 RR 20 99% on 3L NC.
Past Medical History:
# COP
# Nasal polyps
# Varicose veins
# Allergic rhinitis
Social History:
Married with 3 kids, youngest is 27. Works as home health aid.
Takes care of her husband with cancer. Denies tobacco, alcholol,
or illicits. Does have a cat, dog and rabbit at home.
Family History:
Mother has a heart valve that requires replacement. Father had
MI at age 67. No history of blood clots or cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 96.8 BP: 147/84 P: 110 R: 18 O2: 97% on 15 L NRB
General: Alert, oriented, Comfotable and speaking in full
sentences while wearing NRB
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Dressing right back C/D/I. Decreased BS right base with
associated dullness to percussion at base to 1/3 up. Otherwise
fine crackles throughout.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE EXAM:
afebrile 130s/80s HR 80s RR 20 95% RA
General: Alert, oriented, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Dressing right back C/D/I. bibasilar rales right greater
than left.
Chest: drssing in place, small amount of serosanguinous fluid
draining from prior chest tube site
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2124-1-22**] 08:05AM BLOOD WBC-16.2* RBC-4.44 Hgb-12.6 Hct-39.2
MCV-88 MCH-28.4 MCHC-32.2 RDW-16.0* Plt Ct-257
[**2124-1-22**] 08:05AM BLOOD PT-11.8 PTT-21.2* INR(PT)-1.0
[**2124-1-22**] 08:05AM BLOOD Glucose-105* UreaN-23* Creat-0.6 Na-135
K-3.8 Cl-100 HCO3-29 AnGap-10
[**2124-1-22**] 08:05AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.2
.
PERTINENT LABS:
[**2124-1-23**] 07:10AM BLOOD CK-MB-8 cTropnT-<0.01
[**2124-1-24**] 11:32PM BLOOD ALT-456* AST-269* LDH-576* AlkPhos-43
TBili-0.9
[**2124-1-25**] 07:54AM BLOOD ALT-2207* AST-1446* AlkPhos-48 TBili-1.1
[**2124-1-26**] 01:52AM BLOOD ALT-1614* AST-794* LDH-421* AlkPhos-37
TBili-0.6
.
DISCHARGE LABS:
................................................................
MICROBIOLOGY:
[**2124-1-23**] Pleural Fluid Cx: Coag+ Staph aureus
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2124-1-23**] Blood Cx: NGTD
[**2124-1-23**] Urine Cx: negative
[**2124-1-25**] Pleural Fluid Cx: rare Gram+ Cocci
................................................................
IMAGING:
[**2124-1-21**] CXR:
The cardiomediastinal silhouette is within normal limits. There
is elevation of the right hemidiaphragm. Chain sutures in the
right upper lobe denote prior wedge resection. Patchy opacities
at both bases may reflect atelectasis or infection. There is no
pneumothorax or pulmonary edema.
.
[**2124-1-22**] CTA Chest:
1. Suboptimal timing bolus for pulmonary embolism. No large
central or lobar pulmonary embolism. No acute aortic syndromes.
2. Bilateral nodular and centrilobular opacification with
peribronchial wall thickening and mucoid impaction, indicative
of aspiration or chronic infection/inflammation.
3. Subplueral right 4mm pulmonary nodule in the right upper lobe
for which correlation with prior imaging can be obtained to
ensure stability.
.
[**2124-1-23**] CXR:
There has been development of a right-sided pleural effusion
since the previous study, which is small in size. There is
persistent atelectasis at the lung bases in the right mid lung
field.
.
[**2124-1-24**] CXR:
There is further increase in the large right fluid collection in
the pleural space. No definite left effusion is identified. No
displacement of the mediastinal contours. The left lung is
essentially clear.
.
[**2124-1-25**] CXR:
Drainage of extensive pleural effusion with moderate
pneumothorax
despite the presence of a chest tube.
.
[**2124-1-25**] RUQ U/S:
1. Normal son[**Name (NI) 493**] appearance of the liver, without focal
lesions. Please note ultrasound does not demonstrate
abnormalities in the setting of shock liver.
2. Small right pleural effusion.
.
[**2124-1-26**] CXR:
In comparison with study of [**1-25**], there is progressive clearing
of the opacification at the right base. Residual mild effusion
with atelectasis is seen. No convincing evidence of
pneumothorax.
................................................................
PROCEDURES:
[**2124-1-21**] Cardiac Cath:
1. Patent coronary arteries.
2. Mild pulmonary arterial hypertension.
3. Mild systemic arterial hypertension
4. Left ventricular diastolic dysfunction.
5. Normal left ventricular systolic function.
Labs at discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
22.8* 3.33* 10.1* 29.3* 88 30.5 34.6 16.2* 144*
Glucose UreaN Creat Na K Cl HCO3 AnGap
70 24* 0.7 135 4.0 102 26 11
Calcium Phos Mg
8.3* 1.9* 1.9
vancomycin trough 17.5
.
.
Pleural fluid:
pH 7.3
WBC Hct Polys Lymphs Monos Other
[**Numeric Identifier 25638**]* 15.0 78* 6* 15* 1*
TotProt LD(LDH) Amylase Albumin Triglyc
2.7 2204 155 1.8 59
[**2124-1-23**] 10:12 am PLEURAL FLUID PLEURAL.
**FINAL REPORT [**2124-1-27**]**
GRAM STAIN (Final [**2124-1-23**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
REPORTED BY PHONE TO [**Doctor First Name 26**],[**Doctor Last Name 37311**] @ 13:55, [**2124-1-23**].
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2124-1-26**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
blood cultures pending
IMPRESSION: PA and lateral chest compared to [**1-26**] through 3:
Small bilateral pleural effusions have increased in volume since
[**1-27**].
Lungs are clear; hyperinflation indicates COPD. Heart size
normal. No
pneumothorax. Thoracic aorta is very tortuous, but not dilated.
Right PIC
line ends in the mid SVC.
Brief Hospital Course:
62 yo woman with a recent diagnosis of COP and questionable
NSTEMI, who was transferred to [**Hospital1 18**] for cardiac cath which
revealed clean coronaries, transferred to the ICU for hypoxia
and found to have worsening right-sided pleural effusion
requiring placement of chest tube for treatment of hemothorax.
.
# Pleural effusion: Thoracentesis on [**1-23**] revealed an exudative
fluid with elevated WBCs, RBCs, and triglycerides, suggestive of
chylothorax. She was weaned to nasal cannula, but was noted to
have worsening hypoxia and hypotension on the evening of [**1-24**]. A
CXR revealed worsening pleural effusion and she was noted to
have a 10-point HCT drop (from 34 to 24). Thoracic surgery was
consulted and placed a chest tube which returned grossly bloody
pleural fluid, consistent with a hemothorax. She was transfused
2 units of PRBCs and her Hct stabilized. Her hypoxia resolved
and she was again weaned from non-rebreather to nasal cannula.
Serial CXRs showed resolving effusion. She required a total of
four units of packed red cells, and her Hct remained stable.
Chest tube was removed, without recurrence of effusion. Pleural
fluid cultures from the thoracentesis on [**2124-1-23**] grew out MRSA,
and the patient was discharged with intent to complete 14 day
course of vancomycin.
.
# COP/BOOP: She was continued on methylprednisolone and started
on Bactrim for PCP [**Name Initial (PRE) 1102**]. Pulmonary was consulted and
suggesting weaning prednisone to 30 mg daily, and continuing
Bactrim for PCP [**Name Initial (PRE) 1102**]. CT chest confirmed BOOP. Patient
will have close outpatient pulmonary follow up, with intent to
wean steroids over the course of weeks.
.
# Chest pain: CTA was negative for PE. Cardiac catheterization
revealed clean coronaries. Her EKG changes were likely due to
demand ischemia in the setting of respiratory distress, and her
chest pain/elevated cardiac enzymes were likely due to pleuritis
and possibly myocarditis. Plavix was stopped.
.
# Diastolic CHF: Noted on cardiac echo at OSH, with nuclear
stress test with anterior lateral defect. Patient may have had
silent event in the past, and cardiac function may be somewhat
depressed in the setting of possible myocarditis.
.
# Hyponatremia- patient clinically euvolemic on exam. Most
likely due to siADH in setting of pumonary disease, Uosm
inappropriately high in 600s. Patient alert and oriented x 3,
no signs of seizure/altered mental status. Continue fluid
restriction < 1000 cc/day, resolved at time of discharge.
.
# Thrombocytopenia- likely explanation is consumptive loss [**12-29**]
hemothorax. Patient has initially been started on heparin, will
consider HIT. Plts increased since transfusion on [**1-27**], and
continued to increase after patient had stopped bleeding,
consistent with consumptive
.
#. [**Last Name (un) **]: Patient??????s Cr rose from 0.8 to 2.0 in CCU in setting of
hypotension and hemothorax. [**Month (only) 116**] be secondary to pre-renal
azotemia, though also concern for ATN given hypotensive episode.
Creatinine and urine output have been improving, and creatinine
was normal at discharge.
.
#. Transaminitis: AST/ALT trending downward, likely due to
hypoperfused liver [**12-29**] hemothorax. LFTs improving, non-tender
abdomen. Normal RUQ ultrasound.
.
# Prophylaxis: pneumoboots (holding SC heparin given hemothorax
and continued CT output of bloody fluid), OOB & walking.
.
# Access: PICC, PIVs.
.
# Communication: Patient, Daughter [**Name (NI) 402**] [**Telephone/Fax (1) 90168**], cell
[**0-0-**].
.
# Code: Full (discussed with patient)
Medications on Admission:
1. B complex daily
2. Fish oil daily
3. Advil prn
Discharge Medications:
1. 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*
2. guaifenesin 600 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO Q12h () as needed for BOOP.
Disp:*60 Tablet Extended Release(s)* Refills:*2*
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours.
Disp:*3 inhalers* Refills:*2*
7. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
[**11-28**] Inhalation every six (6) hours.
Disp:*30 inhalers* Refills:*0*
8. vancomycin 1,000 mg Recon Soln Sig: One (1) unit Intravenous
once a day for 9 days.
Disp:*9 unit* Refills:*0*
9. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for
3 weeks.
Disp:*42 Tablet(s)* Refills:*2*
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 2
weeks: 12 hours on, 12 hours off, as directed.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
11. K phos di & mono-sod phos mono 250 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary Diagnosis:
Bronchiolitis Obilterans organizing pneumonia
possible myocarditis, although no biopsy
MRSA infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] from [**Hospital3 3765**] because your
doctors there [**Name5 (PTitle) 2985**] [**Name5 (PTitle) **] might have coronary artery disease. You
underwent cardiac catheterization which showed healthy arteries.
While you were here you also had some pain and low oxygen
saturation that was secondary to you being unable to take deep
breaths from the pain. We controlled your pain and your oxygen
sats improved. You will need to be treated for an infection in
your lung for two weeks with an IV antibiotic. VNA will assist
you with this.
.
While you were here we made the following changes to your
medications
We STARTED you on Albuterol
We STARTED you on ipratropium
We STARTED you on calcium carbonate
We STARTED you on Mucinex
We STARTED you on a lidocaine patch for the pain
We STARTED you on pantoprazole
We STARTED you on Prednisone
We STARTED you on Bactrim
We STARTED you on Vitamin D
.
Please see below for your follow up appointments.
Followup Instructions:
You should call your PCP [**Name Initial (PRE) 176**] 3 days to schedule a follow up.
She can be reached at [**Telephone/Fax (1) 21640**].
.
You should also call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**], ([**Telephone/Fax (1) 514**], for follow up in the next 2 weeks.
.
Please call Dr.[**Doctor Last Name **] office at [**Hospital1 18**], ([**Telephone/Fax (1) 17398**] on
Monday to schedule a follow up appointmemt.
|
[
"428.0",
"790.4",
"516.8",
"511.89",
"276.1",
"041.12",
"429.0",
"584.9",
"285.1",
"287.5",
"428.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"38.97",
"34.04",
"88.56",
"34.91",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
17045, 17097
|
11735, 15346
|
333, 391
|
17262, 17262
|
6196, 6196
|
18429, 18901
|
4761, 4876
|
15447, 17022
|
17118, 17118
|
15372, 15424
|
17413, 18406
|
6860, 9564
|
4891, 5560
|
5576, 6177
|
265, 295
|
9584, 11712
|
419, 4463
|
6212, 6546
|
17137, 17241
|
17277, 17389
|
6562, 6844
|
4485, 4545
|
4561, 4745
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,586
| 167,243
|
51973
|
Discharge summary
|
report
|
Admission Date: [**2177-8-14**] Discharge Date: [**2177-8-22**]
Service: CARDIOTHORACIC
Allergies:
Indapamide / Atenolol
Attending:[**Known firstname 922**]
Chief Complaint:
84M s/p CABG/aortic endovascular stenting with recurrent R
pleural effusion.
Major Surgical or Invasive Procedure:
R thorocostomy and pleurodesis with Doxycycline.
History of Present Illness:
This 84M is s/p CABGx1(SVG-PDA)/aoroto-inominate bypass,
endovascular stents of the aortic arch and descending aorta
[**2177-6-24**]. He had a LUE DVT and was anticoagulated with heparin,
and eneded up with cardiac tamponade. He was reexplored and had
a prolonged hodpital course involving trach and open G-J tube.
He was transferred to rehab on [**8-4**] and was initially improving.
His R effusion was tapped and recurred. He required more vent
support and was transferred back to [**Hospital1 18**] for further treatment.
Past Medical History:
HTN
Depression
Syncope
Vocal hoarseness with L vocal cord paralysis
s/p sinus surgery
s/p CABGx1, aortic stenting
Social History:
Lives alone
Cigs: 20 pk yr hx, quit 35 yrs. ago.
ETOH: none
Family History:
unremarkable
Physical Exam:
Elderly [**Male First Name (un) 4746**] on vent.
AVSS
HEENT: NC/AT, EOMI, oropharynx benign
Neck: supple, FROM, no lymphadenopathy or thyromegaly, carotids
2+= bilat., trach in place
Lungs: coarse bilat., decreased on R
CV: RRR without R/G/M
Abd: +BS, soft, nontender without masses or hepatosplenomegaly,
G-J tube in place.
Ext: without C/C/E, LUE edematous
Neuro: nonfocal, A+O
Pertinent Results:
[**2177-8-20**] 03:20AM BLOOD WBC-10.5 RBC-3.50* Hgb-10.3* Hct-31.0*
MCV-89 MCH-29.5 MCHC-33.3 RDW-15.2 Plt Ct-324
[**2177-8-20**] 03:20AM BLOOD Glucose-169* UreaN-27* Creat-0.9 Na-132*
K-4.4 Cl-92* HCO3-37* AnGap-7*
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2177-8-17**] 7:38 AM
CHEST (PORTABLE AP)
Reason: interval change
[**Hospital 93**] MEDICAL CONDITION:
84yo M s/p pleurodesis R chest tube [**8-16**]
REASON FOR THIS EXAMINATION:
interval change
PORTABLE CHEST ON [**2177-8-17**] AT 08:43
INDICATION: Pleurodesis - check for interval change.
COMPARISON: [**2177-8-16**].
FINDINGS: All lines and tubes remain in place. Accounting for
rotational differences, I see no significant change. Small right
apical pneumothorax persists as does the retrocardiac density.
No new consolidations. Right CP angle cut off from view.
IMPRESSION: No change versus prior.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SUN [**2177-8-17**] 9:37 PM
Brief Hospital Course:
The pt. was admitted on [**8-14**] and underwent a chest CT which
revealed a large R effusion. Thoracic surgery was consulted and
placed a chest tube. 1500 cc was drained and he was sclerosed
with Doxycycline. He was immediately improved and was weaned to
a trach mask. He received 2 more Doxy pleurodeses and his
drainage eventually subsided. He was weaned to a trach mask.
He had another swallowing evaluation which was unsuccessful and
remained on his tube feeds. He completed his course of
Ceftazidime on [**8-21**]. His chest tube was d/c'd on [**8-21**] and he was
discharged to rehab on [**8-22**] in stable condition.
Medications on Admission:
Heparin 5000 u SQ TID
Pepcid 30'
Atrovent neb
Fe gluc 300'
ASA 500"
Cefapime 2 gms' until [**8-21**]
Roxicet 5cc q 4-6 hours PRN
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
2. Ferrous Sulfate 325 (65) mg Tablet [**Month/Year (2) **]: One (1) Tablet PO
DAILY (Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1)
Injection TID (3 times a day).
4. Levothyroxine 25 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
8. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Recurrent R pleural effusion, s/p CABGx1, endovascular stents to
descending aorta
Discharge Condition:
Good
Discharge Instructions:
Follow discharge medications.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 35888**] after d/c from rehab.
Make an appointment with Dr. [**Last Name (STitle) 914**] after d/c from rehab.
Completed by:[**2177-8-22**]
|
[
"V45.81",
"311",
"997.3",
"E878.2",
"401.9",
"V44.4",
"511.9",
"707.03",
"V44.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.71",
"34.92",
"34.04",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
4348, 4391
|
2626, 3258
|
310, 361
|
4517, 4524
|
1578, 1912
|
4603, 4796
|
1149, 1163
|
3438, 4325
|
1949, 1996
|
4412, 4496
|
3284, 3415
|
4548, 4580
|
1178, 1559
|
194, 272
|
2025, 2603
|
389, 919
|
941, 1056
|
1072, 1133
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,893
| 184,538
|
50435
|
Discharge summary
|
report
|
Admission Date: [**2169-10-30**] Discharge Date: [**2169-11-15**]
Service: MEDICINE
Allergies:
Motrin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
hypertensive emergency, respiratory distress
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
86 y/o F, transfer from [**Hospital1 **], with PMH of AAA, CAD, HTN,
complains of mid-scapular back pain x 2weeks and acute SOB, with
? expanding AAA, sent for vascular evaluation. Preliminary CTA
there
with AAA 6.5 x 5.8 cm, w/ thrombus-ulceration. No PE.
.
In ED here, arrived SOB with 'pain in back'. Hypertensive to
205/73, 94% on 4L->100% on NRB, with CHF clinically. Resident
intake note reports SBP 230/130 on L, 170/100 on R. Given nitro
gtt, lasix 80mg, morphine IV. SBP down to 120's-130's systolic.
Foley output 400cc. Refusing ETT and not tolerating BiPAP.
Vascular evaluated pt. No change in AAA from previous.
Past Medical History:
# s/p R carotid thromboendarterectomy
# CAD- s/p MI at 65, no stents or CABG
# AAA- measures 6.3 x 5.5 cm by abdominal CT scan of [**2169-8-10**].
She has seen Dr. [**Last Name (STitle) 3407**] who has advised endovascular repair,
the patient has refused
# Spinal Stenosis w/ L4 fracture
# Depression
# Hearing Loss
# cataract surgery
# HTN
# autoimmune hemolytic anemia
# urinary retention
# s/p R distal radius fx s/p reduction and external fixation
# diabetes
Social History:
Widowed w/ one daughter and son in law very active in care.
+tobacco for many years. quit after MI in [**2128**]. no ETOH, IVDU
Family History:
Mother died of MI. Father w/ DM.
Physical Exam:
Vitals- t 100.2, 140/54, 94% on NRB, RR 25
gen- sleepy but arousable to voice, alert and oriented x 1
heent- EOMI. surgical pupils
neck- difficult to visualize JVP, prominent EJ
pulm- lungs with dense rales 2/3 up b/l lung fields, using abd
muscles
cv- RRR. no m/r/g
abd- soft, NT/ND. well healed surgical scars
ext- 1+ LE edema. ulcer L 2nd toe, ant tibia R. Non palpable
distal pulses.
neuro- waxing/[**Doctor Last Name 688**] mental status, following simple commands,
moving all extremities, equal b/l; oriented to person, not place
or time.
Pertinent Results:
[**2169-10-30**] 08:01PM CK(CPK)-71
[**2169-10-30**] 08:01PM CK-MB-NotDone cTropnT-0.08*
[**2169-10-30**] 08:01PM HCT-26.9*
[**2169-10-30**] 04:13PM GLUCOSE-150* UREA N-25* CREAT-1.3* SODIUM-144
POTASSIUM-4.5 CHLORIDE-108 TOTAL CO2-27 ANION GAP-14
[**2169-10-30**] 04:13PM CALCIUM-7.3* PHOSPHATE-4.9* MAGNESIUM-1.8
[**2169-10-30**] 04:13PM HCT-24.7*
[**2169-10-30**] 03:09PM TYPE-ART PO2-271* PCO2-48* PH-7.36 TOTAL
CO2-28 BASE XS-1
[**2169-10-30**] 01:31PM TYPE-ART PO2-116* PCO2-44 PH-7.41 TOTAL
CO2-29 BASE XS-3
[**2169-10-30**] 01:31PM LACTATE-1.9
[**2169-10-30**] 11:25AM CK-MB-NotDone cTropnT-0.04*
[**2169-10-30**] 02:59AM cTropnT-0.03*
.
CXR: CHF
.
EKG: NSR. Nl axis. RBBB w/ secondary ST changes. TW flattening
V4-5. RBBB pattern seen on prior EKG dated [**2169-8-10**].
.
Head CT w/o contrast: No hemorrhage, mass, or shift of normally
midline structures. No major vascular territorial infarct is
apparent. A small right-sided subinsular white matter
hypodensity and periventricular hypodensities are noted and
correlates to findings from prior MRI scan from [**2169-10-2**],
and likely represent chronic changes secondary to small vessel
infarction. Calcifications are seen within the cavernous portion
of the internal carotid. The surrounding osseous and soft tissue
structures are unremarkable.
.
Renal U/S: Compared to CT of [**2169-8-10**]. Right kidney is somewhat
diminutive measuring 8.6 cm. The left kidney is 9.9 cm. There
is no
hydronephrosis nor focal renal lesions. Again demonstrated is
the large
abdominal aneurysm, with extensive mural thrombus, measuring 6.2
cm in AP
dimension on the sagittal view and 5.6 x 6.0 cm on the
transverse views,
apparently not significantly changed from the CT of [**2169-8-10**]. No
free fluid seen in the retroperitoneum.
.
Echo:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Lipomatous
hypertrophy of the
interatrial septum.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%). Suboptimal technical quality, a focal LV
wall motion
abnormality cannot be fully excluded.
RIGHT VENTRICLE: Dilated RV cavity. Focal apical hypokinesis of
RV free wall.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root.
Normal ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Minimally increased
gradient c/w minimal AS. Mild (1+) AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Indeterminate PA systolic pressure.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Based on [**2160**] AHA endocarditis prophylaxis
recommendations,
the echo findings indicate a moderate risk (prophylaxis
recommended). Clinical
decisions regarding the need for prophylaxis should be based on
clinical and
echocardiographic data. Echocardiographic results were reviewed
by telephone
with the houseofficer caring for the patient.
Conclusions:
The left atrium is normal in size. There is mild-moderate
symmetric left
ventricular hypertrophy with normal cavity size and systolic
function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. The right ventricular
cavity is dilated
with focal hypokinesis of the apical free wall. The aortic valve
leaflets (3) are mildly thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are structurally normal with tivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokinesis.
Mild aortic regurgitation.
Compared with the prior report (images unavailable for review)
of [**2164-11-6**]
right ventricular cavity dilation and free wall hypokinesis are
identified c/w
ischemia. Mild aortic stenosis and mild aortic regurgitation are
now
identified.
CXR [**11-15**]:
COMPARISONS: Comparison is made to [**2169-11-8**].
TECHNIQUE: AP upright and lateral views of the chest.
FINDINGS: There is a right PICC with tip in the upper SVC. The
cardiac silhouette is enlarged but stable since the prior study.
The aorta is calcified and tortuous. There is interval
development of upper zone redistribution of the pulmonary
vascularity and peribronchial coughing suggesting mild CHF. The
bilateral hila are enlarged suggesting pulmonary artery
hypertension. There are bilateral pleural effusions. No overt
pulmonary edema is noted.
IMPRESSION: Mild CHF.
.
[**11-6**]
SINGLE VIEW, RIGHT SHOULDER, [**2169-11-6**].
COMPARISON: None.
FINDINGS: Single projection of the right shoulder was ordered
and obtained.
Please note, dislocations, particularly posterior, are difficult
to exclude
given single projection.
There is significant deformity of the proximal diaphysis of the
humerus from
remote fracture. There is near complete obliteration of the
acromiohumeral
interval, which can be seen in chronic rotator cuff tear. There
is
degenerative disease of the acromioclavicular joint noted. The
regional soft
tissues are relatively unremarkable. The visualized adjacent
lung is clear.
IMPRESSION: Markedly limited study given single projection. No
gross
traumatic lesion identified. There is suggestion of chronic
rotator cuff tear and AC joint osteoarthritis. Healed deformed
old fracture of the humerus is also evident.
LABS:
[**2169-11-15**]
WBC/Hgb/Hct/Plt Ct : 7.4 10.5* 32.2* 316
Na 141 K 3.9 Cl 97 HCO3 36 BUN 29 Cr 0.8
Brief Hospital Course:
1. Hypertensive emergency- The patient had elevated SBP to 200s
with respiratory distress and altered sensorium on admission.
She was managed acutely with nitro and lasix infusions in the
ER, dropping her SBP to the 130s. CT obtained before transfer
demonstrated no pulmonary embolism and no rupture of the
patient's AAA. She had a workup to rule out acute ischemic, and
cardiac enzymes were negative. An echocardiogram was obtained
which showed RV free wall hypokinesis and RV dilation in
comparison to previous. A renal U/S showed no hydronephrosis but
large, 6.2 cm sized AAA. Head CT did not show any intracranial
lesions. The patient was transferred to the ICU for continued
management of her hypertension and respiratory distress. Her
blood pressure was difficult to control on multiple agents and
ranged from 140s to 180s while in the ICU. Attempts to improve
her respiratory status were complicated by low urine output and
the need for fluid boluses, which led to volume overload and
pulmonary edema. The patient was gently diuresed and her
respiratory status improved while in the ICU. She was
transferred from the ICU on [**11-7**] on oral agents for blood
pressure control. The patient was admitted on metoprolol 25 [**Hospital1 **]
and lisinopril 40 qd. Over the course of her stay, her regimen
was increased to metoprolol 75 mg TID, lisinopril 40 qd,
amlodipine 10 mg qd, and imdur 60 mg qd, which brought her SBP
to the 140s, with intermittent breakthrough htn to the 160s.
.
2. AAA- Vascular surgery reviewed and followed the patient.
Blood pressure was aggressively addressed but was difficult to
control. CTA on day prior to admission showed no expanding AAA,
and no rupture. No concern for rupture throughout stay.
.
3. Respiratory status: The patient was admitted with respiratory
distress, thought secondary to her hypertensive emergency. She
refused intubation in the ICU, and her oxygenation was improved
with non-invasive continuous positive pressure ventilation. Her
oxygen requirement decreased over the length of her stay.
.
4. Heart failure: At time of discharge, patient required 1-2L
nasal cannula oxygen in order to maintain oxygen saturation
greater than 90%. Her increased oxygen requirement above
baseline was thought likely secondary to diastolic heart
failure. The patient demonstrated cardiomegaly and small pleural
effusions on chest x-ray, but on echocardiogram she had normal
ejection fraction. Therefore, she was presumed to have diastolic
failure. Notably, the echocardiogram also demonstrated some
hypokinesis in the right ventricle and a previous
catheterization demonstrated right coronary disease (see results
section). The patient was admitted on an outpatient dose of 20
mg lasix QD and was discharged on the same dose with expectation
that her weight will be followed and lasix dose adjusted as
needed.
.
4. Intravascular depletion: The patient's BUN/Cr level was
elevated to >20 and her bicarb increased to >30, likely due to
contraction alkalosis. Lasix was held for several days during
her stay due to concern of over-diuresis. She was dischargeed on
lasix 20 mg QD, her home dose, with the expectation of close
monitoring of her electrolytes.
.
5. Diabetes: Patient's oral hypoglycemic blood sugars were well
controlled with her oral hypoglycemic medication and insulin
sliding scale.
.
6. Depression- Patient was continued on paroxetine during stay
and inpatient psychiatry followed the patient.
.
7. Autoimmune hemolytic anemia- The patient was maintained on
her outpatient dose of prednisone
.
8. Skin ulcers: The patient has easy skin abrasions and chronic
ulcers on her toes and lower legs due to vascular insufficiency.
These do not appear to pose infection risk. Have been managed by
covering with gauze and on the toes with bandaids. Caution with
foot coverings and skin care/moisturizing creams.
.
9. DVT prophylaxis: The patient received subq heparin to
prophylax against DVT. Due to her immobility, she was discharged
on continued prophylaxis.
.
10. Back pain: The patient had chronic midscapular pain which
limited her ability to cough and caused her discomfort. She has
tried and failed pain treatment with opiate derivatives,
reportedly because of problems with mental status changes. She
is very adverse to trying any narcotic/opiate drugs in the
future out of concern for repeat of mental status changes. In
the hospital she was given tramadol 50 mg q4 hours as needed for
pain and acetaminophen as needed for pain. NSAIDs would likely
not be a good choice of [**Doctor Last Name 360**] for her given her cardiac status.
.
11. Access: The patient had a PICC line placed in her right arm
on [**2169-11-6**]. She was not receiving any IV medications, however
she has difficult access and has been requiring frequent
labaratory draws, which the PICC line has expedited. During
rehabilitation, her PICC line should removed as soon as
possible, (as the patient's status improves and she no longer
requires daily lab values), and evaluated for infection.
.
12. Code status: The patient expressed a wish not to be
intubated, but would like to be resuscitated in the event of a
cardiac arrest.
Medications on Admission:
ultram 50 mg q4-6prn
aspirin 81 mg daily
maalox prn
senna qhs
prednisone 7.5mg/day
docusate 100mg [**Hospital1 **]
omeprazole 20mg/day
duloxetine 60mg daily
hydroxyzine 10mg q4-6
sl ntg prn
metoprolol 25mg [**Hospital1 **]
lisinopril 40 mg daily
zocor 10mg/day
glipizide 5mg/day
lasix 20mg/day
paxil 10mg/day
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary Diagnosis:
1. Hypertensive Emergency
2. AAA
3. Diastolic heart failure
Secondary Diagnosis:
Diabetes
CAD
Depression
Autoimmune hemolytic anemia
Spinal stenosis
Disk compression
Discharge Condition:
Afebrile. Hemodynamically stable. Tolerating PO.
Discharge Instructions:
The patient has been diagnosed with hypertension. The patient's
medications for hypertension have been adjusted and should be
taken as directed in the Discharge Medications section included.
.
The patient has an abdominal aortic aneurysm. For this condition
she should maintain good blood pressure control.
.
The patient has been discharged on Lasix 20 mg PO QD. Her
creatinine concentration should be closely followed after
discharge. If her creatinine level rises above her normal range
of 0.6 to 0.8, the lasix should be held.
.
The patient should have her blood pressure measured on at least
a daily basis throughout rehab.
.
The patient should have access to a mental health professional
for counseling and therapy regarding her current health state
and concerns.
.
The patient is being discharged with a PICC line in place. This
should be removed as soon as deemed possible, taking into
account the fact that she has difficult venous access. The PICC
line should be evaluated for infection while it is in.
.
The patient's primary care doctor, Dr. [**Last Name (STitle) 2539**] of the [**First Name9 (NamePattern2) **] [**Location (un) 620**]
group, should be informed of her condition regularly.
.
The patient should maintain a cardiac healthy diet.
.
The patient should undergo aggressive physical therapy to
reattain her baseline status.
.
The patient would not like intubation. However, if her heart
stops she would like attempts at resuscitation.
Followup Instructions:
Please keep the following appointments:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Location (un) 54638**] PRACTICE ([**Location (un) **])
Date/Time:[**2169-11-23**] 2:45
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2169-12-25**] 2:00
Provider: [**Name10 (NameIs) 475**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 474**], M.D. Phone:[**Telephone/Fax (1) 1989**]
Date/Time:[**2170-1-5**] 2:40
Completed by:[**2169-11-15**]
|
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"440.23",
"283.0",
"402.01",
"441.4",
"428.0",
"518.82",
"E944.4",
"311",
"584.9",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13433, 13505
|
7919, 13074
|
260, 282
|
13736, 13787
|
2203, 7896
|
15292, 15787
|
1587, 1622
|
13526, 13526
|
13100, 13410
|
13811, 15269
|
1637, 2184
|
176, 222
|
310, 937
|
13628, 13715
|
13546, 13607
|
959, 1425
|
1441, 1571
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,527
| 103,937
|
54818
|
Discharge summary
|
report
|
Admission Date: [**2110-8-17**] Discharge Date: [**2110-9-4**]
Date of Birth: [**2079-8-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Tracheostomy
PICC line placement
Bronchoscopy
History of Present Illness:
Patient is a 31 yo M with no significant PMHx who presented to
OSH with complaints of weakness developing acute respiratory
failure found to have a saddle PE started on heparin gtt
trasnferred to [**Hospital1 18**] for further management.
Patient initially presented to OSH ED with complaints of
weakness, that started 5 days prior to presentation. He was
initially seen in the ED, received 2L NS for hydration, and then
discharged. He represented with porfound weakness, requiring his
brother to help him to the [**Name (NI) **]. He had a headache and body aches.
He also noted fevers, chills, and sweats, along with n/v. Per
OSH H&P, the patient reported vomiting 10-15 times. The vomitus
was non-bloody. He denied abdominal pain or diarrhea at the time
of presentation. He denied recent travel or known sick contacts.
His friend reports that he had bowel and bladder incontinence.
He denied any sore throat.
At the OSH, the patient was initially able to provide history.
Upon presentation, his temperature was 99.3. He was thought to
have pulmoanry edema for which he received lasix. Because of his
weakness and observation that he had a sensory level at T8, he
was initially thought to have a transverse myelitis. However,
MRI of the head was negative; MRI of the cervical and thoracic
spine revealed no abnormalities. He underwent an LP at the OSH;
the LP showed WBC 550,00 with 15% polys, 19% lymphs, and 16%
monos. The patient was noted to be serologically positive for
Lyme disease as well as EBV virus. Lyme CSF was negative. He was
started on IV ceftriaxone for coverage of possible Lyme
meningitis. The patient also was given IV acyclovir prior to
presentation to [**Hospital1 18**] in case the patient's clinical picture
represented EBV encephalitis. The patient was noted to have an
acute hypoxic event on [**2110-8-11**], during this OSH
hospitalization. CTA at the OSH showed saddle PE wtih probably
lower lobe pulmoanry infarcts. LENI at OSH were negative fo DVT.
The patient was intubated and started on heparin gtt. TTE showed
dilated hypokinetic RV with flattened septum and well preserved
LV function. Cardiac surgery evaluated the patient for
thrombolectomy, who did not feel that thrombolectomy was acutely
indicated. CT abdomen/pelvis at the OSH showed normal kidney,
ureters, and bladder as well as hepatomegaly and trace ascites.
Bone windows were negative.
On arrival to the MICU, the patient is intubated and sedation.
Review of systems: Unable to obtain as patient is intubated and
sedated.
Past Medical History:
None per OSH records
Social History:
Unable to obtain as patient intuabted and sedated. [**Doctor Last Name **]. Former
Marine. Patient lives with his brother's family. He does not
drink EtOH. Smoker 1 pack cigarettes every 2 days.
Family History:
Per OSH recrods. Father died of stroke at age 69.
Physical Exam:
Admission Exam
Vitals: 98.6, 177/117, 112, 24, 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: mild bibasilar crackles
Abdomen: soft, exquisitely TTP, + guarding, + rebound
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact,
Discharge Exam
General: Awake and alert.
HEENT: Tracks to voice., answers to yes and no questions
Neck: Trach in place with no external blood
CV: RRR. No murmurs.
Lungs: Coarse breath sounds anteriorly. No crackles or wheezes.
Abd: BS+. Soft. NT/ND.
Ext: No clubbing, cyanosis, edema.
Neuro: Hand grip equal, [**4-14**] RUE flexion. Moving feet bilaterally
more vigorously as compared with yesterday. 1+ patellar reflexes
bilaterally. [**5-15**] plantarflexion b/l.
Pertinent Results:
[**2110-8-17**] 01:45PM BLOOD WBC-17.0* RBC-3.57* Hgb-10.5* Hct-33.4*
MCV-94 MCH-29.5 MCHC-31.6 RDW-12.8 Plt Ct-364
[**2110-8-23**] 03:44AM BLOOD WBC-11.5* RBC-3.80* Hgb-11.5* Hct-34.8*
MCV-92 MCH-30.3 MCHC-33.1 RDW-12.9 Plt Ct-571*
[**2110-8-29**] 04:38AM BLOOD WBC-11.7* RBC-3.42* Hgb-10.4* Hct-31.3*
MCV-92 MCH-30.4 MCHC-33.2 RDW-15.1 Plt Ct-435
[**2110-9-4**] 03:54AM BLOOD WBC-7.8# RBC-2.87* Hgb-9.1* Hct-24.7*
MCV-86 MCH-31.5 MCHC-36.7* RDW-15.7* Plt Ct-511*
[**2110-8-17**] 01:45PM BLOOD PT-14.0* PTT-66.0* INR(PT)-1.3*
[**2110-8-25**] 03:39AM BLOOD PT-13.1* PTT-27.3 INR(PT)-1.2*
[**2110-9-2**] 05:31AM BLOOD PT-17.6* PTT-36.6* INR(PT)-1.7*
[**2110-9-3**] 04:51AM BLOOD PT-19.2* PTT-39.0* INR(PT)-1.8*
[**2110-9-4**] 03:54AM BLOOD PT-18.6* PTT-41.0* INR(PT)-1.8*
[**2110-8-17**] 01:45PM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-142
K-4.2 Cl-101 HCO3-36* AnGap-9
[**2110-8-21**] 04:24AM BLOOD Glucose-186* UreaN-24* Creat-0.6 Na-145
K-4.7 Cl-103 HCO3-34* AnGap-13
[**2110-8-24**] 03:53AM BLOOD Glucose-126* UreaN-24* Creat-0.6 Na-139
K-4.4 Cl-100 HCO3-31 AnGap-12
[**2110-8-28**] 03:03AM BLOOD Glucose-86 UreaN-23* Creat-0.6 Na-139
K-4.6 Cl-101 HCO3-27 AnGap-16
[**2110-9-1**] 04:20AM BLOOD Glucose-124* UreaN-18 Creat-0.5 Na-134
K-4.3 Cl-96 HCO3-29 AnGap-13
[**2110-9-4**] 03:54AM BLOOD Glucose-87 UreaN-24* Creat-0.4* Na-139
K-4.4 Cl-100 HCO3-33* AnGap-10
[**2110-8-17**] 01:45PM BLOOD ALT-61* AST-40 LD(LDH)-319* AlkPhos-152*
TotBili-0.3
[**2110-8-22**] 02:58AM BLOOD ALT-150* AST-39 CK(CPK)-43* AlkPhos-110
TotBili-0.2
[**2110-8-27**] 04:01AM BLOOD ALT-93* AST-32 LD(LDH)-279* AlkPhos-92
TotBili-0.5
[**2110-9-1**] 04:20AM BLOOD ALT-92* AST-28
[**2110-9-4**] 03:54AM BLOOD ALT-82* AST-41* LD(LDH)-175 AlkPhos-88
TotBili-0.5
[**2110-8-28**] 03:03AM BLOOD Lipase-12
[**2110-9-4**] 03:54AM BLOOD Albumin-3.0* Calcium-9.5 Phos-4.5 Mg-2.0
[**2110-8-17**] 01:45PM BLOOD VitB12-1446*
[**2110-8-17**] 01:45PM BLOOD TSH-1.5
[**2110-8-20**] 04:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2110-8-17**] 07:50PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2110-8-28**] 03:03AM BLOOD IgG-1038 IgA-173 IgM-200
[**2110-8-17**] 01:45PM BLOOD PEP-NO SPECIFI
[**2110-8-20**] 04:15AM BLOOD HCV Ab-NEGATIVE
[**2110-8-18**] 02:53AM BLOOD LYME BY WESTERN BLOT-Test Name
[**2110-8-18**] 02:53AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG-Test
[**2110-8-18**] 02:53AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-Test
[**2110-8-18**] 02:53AM BLOOD BARTONELLA (ROCHALIMEA) HENSELAE
ANTIBODIES, IGG AND IGM-Test
[**2110-8-18**] 02:53AM BLOOD ARBOVIRUS ANTIBODY IGM AND IGG-Test Name
MRI Head ([**2110-8-17**])
Abnormal, multifocal, T2-signal hyperintensity throughout the
spinal cord, most severe in the cervical cord as above. Similar
abnormalities are present in the brain (that study is reported
separately). This appearance is not specific though would
favour viral infection, including that with West Nile virus.
Other infectious entities may have a similar appearance, such as
encephalomyelitis related to listeria, mycoplasma, or
campylobacter, amongst others (given the element of
rhomboencephalitis on the brain imaging).
Demyelinating processes such as MS, ADEM or neuromyelitis optica
and other
vatiants are also possibilities, as are other inflammatory
disorders such as [**Last Name (un) 39722**] encephalitis. Neoplastic or
vasculitic etiologies are less likely given the appearance,
short-interval change and extent of involvement.
MRI ([**2110-8-25**])
In comparison to [**2110-8-17**] exam, diffuse bilateral T2/FLAIR
hyperintensities have significantly progressed. Differential
considerations remain infectious or non-infectious
encephalitides, possibly a paraneoplastic process.
Demyelinating process such as ADEM is felt less likely given the
lack of
improvement despite reported treatment with steroids.
Neoplastic and
vasculitic etiologies are unlikely given appearance and
distribution.
Brief Hospital Course:
Patient is a 31 year old male with no significant PMHx who
presented to OSH with complaints of weakness developing acute
respiratory failure found to have a saddle PE started on heparin
gtt trasnferred to [**Hospital1 18**] for further management with MRI
findings suggestive of ADEM treated with IV steroids/IVIG, whose
mental status and neurological function improved.
# Respiratory failure: Multifactorial; etiologies include saddle
pulmonary embolism with infarction in combination with profound
weakness from ADEM. The patient was difficult to oxygenate at
times initially. Patient underwent trach and PEG placement in
light of prolonged intubation. Improving currently, he is
tolerating trach collar at times up to 30 minutes. Speech and
swallow are also working with him. Be sure to look for signs of
carbon dioxide retention if mental status worsens on PSV as
patient could tire out at times. He is usually arousable to
voice, alert and can nod to yes/no questions, oriented X3.
# ADEMS: Patient underwent head MRI as well as full spine MRI as
part of work-up of his clinical picture, and Neurology felt that
the findings were consistent with ADEM. He was treated with 5
days of IV steroids and five more days of IVIG. The patient's
exam improved along with repeat MRI imaging showed progression
of the lesions, but this was in the context of improved exam
clinically, and no further interventions were done. His
diaphgram has improved function with today's NIF of -43. He has
slowly regaining strength in his extremities with 3/5 UE and LE
strength (R > L). Please continue to ensure he has ongoing
physical therapy.
# Pulmonary embolism: Patient with saddle embolism at the OSH.
Patient was hemodynamically stable upon arrival to [**Hospital1 18**] with
SBP 130-140s. Patient was evaluated for thrombectomy at OSH and
it was felt that pulmonary embolectomy would be counter
productive. Patient was initially continued on heparin gtt, at
one point being transitioned Lovenox /coumadin which he
currently is on with INR of 1.8 on [**2110-9-4**], 1.8 [**9-3**], [**9-2**]
1.7. Coumadin was uptitrated to 12.5 mg from 10 mg daily on
[**9-2**]. If INR < 2.0 on [**2110-9-5**], please consider increasing
coumadin to 15 mg daily. Continue Lovenox bridge until
therapeutic INR.
# Pericarditis: He was noted to have diffuse ST elevations on
[**2110-9-3**]. He had not chest pain. They resolved with
ibuprofen 600 mg TID.
# Fevers of unknown etiology. Resolved for past few days.
Work-up at the OSH included: negative HIV; weakly positive Lyme
IgM, negative Lyme CSF, negative Monospot, Negative Babesia,
Negative anaplasma, positive EBV CSF serology. ID and neurology
were consulted upon patient's arrival. Repeat lumbar puncture
was done; culture data returned showing no growth and serologies
were negative. The patient was initially on broach spectrum
antibiotics upon ID recommendations, but with negative CSF
culture data, negative CSF data antiobiotics were then peeled
back. His fevers were attributed to ADEM and resolved week prior
to discharge
# Elevated LFTs: There was concern for viral hepatitis, though
viral serologies at [**Hospital1 18**] returned negative. RUQ ultrasound did
not show concerning findings. LFTs were trended through the
admission and remained stable.
Medications on Admission:
Medications HOME:
None
.
Medications on TRANSFER:
--Acyclovir 800mg ONCe
--Ceftriaxone 2grams IV daily
--Famotidine 20mg [**Hospital1 **]
--Heparin GTT
--Ipratropium/albuterol 6-8 puffs QID
--Propofol 1000mg GTT
--Acetaminophen 650mmh q4hours PRN PR
--Fentanyl 25mcg q1hours PRN pain
--Zofram 4mg IB q6hours PRN nausea
Discharge Medications:
1. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eyes
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation.
3. Docusate Sodium (Liquid) 100 mg PO BID
hold for loose stools
4. Enoxaparin Sodium 100 mg SC Q12H
5. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES TID
6. Pantoprazole 40 mg IV Q24H
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 1 TAB PO BID:PRN constipation
9. Warfarin 12.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
ADEM
Saddle Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure to care for you at the hospital.
.
You were admitted for altered mental status and weakness. You
were found to have a encephalitis and lung blood clot. You
needed to be intubated during the admission and were cared for
in the ICU. You were treated for the encephalitis with IVIG and
are currently improving from a neurologic perspective. Your
respiratory status is also stable and slowly imroving.
.
Your physcial therapy and rehab. will continue at a specialized
facility.
Followup Instructions:
Please follow up with your primary care physician after
discharge
|
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icd9cm
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311, 359
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,369
| 195,429
|
6099
|
Discharge summary
|
report
|
Admission Date: [**2125-6-19**] Discharge Date: [**2125-6-22**]
Date of Birth: [**2071-7-11**] Sex: F
Service: MEDICINE
Allergies:
Gemzar / Morphine / Hydromorphone
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Fever/Malaise
Major Surgical or Invasive Procedure:
[**2125-6-19**] -had paracentesis which removed 2L fluid in [**Hospital Unit Name 153**], final
Cx pending
History of Present Illness:
This is a 53 year-old female with a history of Stage III
peritoneal serous CA who presents to the ED 5 days s/p third
cycle of Alimta, with mild fever and malaise. A CT torso was
performed which showed a worsening pleural effusion, new
pericardial effusion, and no abdominal process seen. She
initially had stable vitals, was at her baseline SBP's in the
90's with a small O2 requirement and was to be sent to the
floor, but became hypotensive to the 70's this morning with hr's
to 120's. She was asymptomatic and was responsive to 1L fluid,
with BP's coming back up to 90/60. The concern was for tamponade
from the enlarging pericardial effusion and they did a bedside
echo which they thought might have shown ? chamber collapse.
Pulsus wnl. Cardiology was called, and their stat echo showed
small to moderate effusion with no evidence of tamponade per
cards fellow. She was given cefepime and vanco for her fevers.
She remains 97% 2L NC upon transfer to [**Hospital Unit Name 153**].
.
Upon arrival, the patient seems comfortable and says she feels
tired. Initial BP was 90/58, but she dropped subsequently to
83/50. She is satting 99%2L.
.
ROS: The patient denies any weight change, nausea, vomiting,
abdominal pain, diarrhea, constipation, melena, hematochezia,
chest pain, orthopnea, PND, lower extremity edema, cough,
urinary frequency, urgency, dysuria, lightheadedness, gait
unsteadiness, focal weakness, vision changes, headache, rash or
skin changes.
Past Medical History:
Stage III primary peritoneal carcinoma, status post
suboptimal debulking surgery. Six cycles of carboplatin and
Taxol with recurrence. Poor tolerance on gemcitabine. Completed
6 cycles of low-dose weekly Taxol with gradual response to
therapy complicated by severe colitis and C. difficile
infection.
She was started on Taxol in [**9-/2124**] and radiation on the right
ilium/hip sacral area in 01/[**2124**]. Restarted Doxil in [**12/2124**], 6
cycles.
Social History:
denies alcohol or tobacco. very supportive sisters
Family History:
mother with lung CA. CVD and DM2.
Physical Exam:
Physical Exam:
Vitals: T: 97.5 BP: 95/71 HR: 94 RR: 16 O2Sat: 98% 2L NC
GEN: Chronically ill-appearing, no acute distress
HEENT: EOMI, PERRL, sclerae anicteric, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, +rub no M/G, normal S1 S2, radial pulses +2
PULM: Decreased breath sounds half way up on left, basilar
crackles on the right.
ABD: Soft, NT, mild distention, +BS, no HSM, +fluid wave and
shifting dullness.
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. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2125-6-19**] 02:36PM ASCITES TOT PROT-3.9 ALBUMIN-2.5
[**2125-6-19**] 02:36PM ASCITES WBC-133* RBC-203* POLYS-0 LYMPHS-33*
MONOS-48* MESOTHELI-19*
[**2125-6-19**] 12:27PM HCT-29.9*
[**2125-6-19**] 07:11AM GLUCOSE-93 UREA N-7 CREAT-0.6 SODIUM-140
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-25 ANION GAP-11
[**2125-6-19**] 07:11AM GLUCOSE-93 UREA N-7 CREAT-0.6 SODIUM-140
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-25 ANION GAP-11
[**2125-6-19**] 07:11AM ALT(SGPT)-36 AST(SGOT)-29 LD(LDH)-254* ALK
PHOS-93 TOT BILI-0.3
[**2125-6-19**] 07:11AM ALBUMIN-2.8* CALCIUM-7.6* PHOSPHATE-3.9
MAGNESIUM-1.6
[**2125-6-19**] 07:11AM CA125-35
[**2125-6-19**] 07:11AM PT-14.3* PTT-26.2 INR(PT)-1.2*
[**2125-6-18**] 09:10PM LACTATE-0.8
[**2125-6-18**] 09:00PM URINE HOURS-RANDOM
[**2125-6-18**] 09:00PM URINE [**Known lastname 3143**]-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-TR
[**2125-6-18**] 08:25PM NEUTS-64 BANDS-0 LYMPHS-13* MONOS-23* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2125-6-18**] 08:25PM WBC-9.4 RBC-3.77* HGB-10.8* HCT-31.0* MCV-82
MCH-28.7 MCHC-34.9 RDW-17.3*
.
ECHOCARDIOGRAM: [**2125-6-19**]
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets appear structurally normal
with good leaflet excursion. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is high normal. There is a small circumferential pericardial
effusion without evidence for hemodynamic compromise.
.
IMPRESSION: Small circumferential pericardial effusion without
evidence for hemodynamic compromise. Preserved global
biventricular systolic function.
.
.
CT C/A/P [**2125-6-19**]
IMPRESSION:
1. New moderate pericardial effusions.
2. Worsening left pleural effusion.
3. No pulmonary embolism.
4. New right upper lobe 9-mm spiculated mass concerning for
metastasis.
5. Stable liver and peritoneal lesions.
6. Multiple new bony hyperdense foci concerning for spinal and
sternal
metastasis.
7. Large volume abdominal and pelvic ascites, which somewhat
limits
assessment. No evidence of an acute bowel process.
8. Large volume of dense colonic and rectal stool.
.
.
CT Cervical Spine [**2125-6-19**]
IMPRESSION: A tiny sclerotic focus in the medial aspect of the
left first
rib, but otherwise no evidence of osseous metastatic disease
within the
cervical spine.
Brief Hospital Course:
Assessment: 53 year-old female with a history of Stage III
peritoneal serous CA who presents to the ED 5 days s/p third
cycle of Alimta, with mild fever and malaise and transient
hypotension.
.
# Fevers/Hypotension: The patient was transferred to the unit
and fluid resuscitated. There was initial concern re: sepsis
physiology but the patient's BP stabilize with minimal IVF and
the fevers resolved after 24 hours. A pericardial effusion was
noted on CT scan. An echocardiogram showed that the effusion
was too small to drain and there was no evidence of tamponade
physiology. A paracentesis was done for therapeutic and
diagnostic reasons. There was concern regarding spontaneous
bacterial peritonitis, but the patient's peritoneal fluid
analysis was negative for such a process. Cultures remained
negative. No clear source of fevers was found.
.
# Hypoxia: Patient denied SOB but had low O2 sats (to 90%) and
an increased pleural effusion on the left with a new small RUL
mass on CT chest. The hypoxia was felt to be more consistent
with patient's effusion. The patient was weaned off oxygen and
thoracocentesis was deferred.
.
# Stage III peritoneal serous CA: patient just completed her 3rd
round of Alimta. She had a mild transaminitis which was being
attributed to the chemo. Initially seemed to be having good
response with reduction in CA-125 levels, but now has mets in
the spine which are new and a possible new met in the RUL of the
lung. The patient's primary oncologist preferred to further
evaluate these lesions as an outpatient. A CT of the cervical
spine was done to evaluate neck pain for bony mets and the
cervical spine was negative for mets.
# Recurrent DVT/PE: patient was to be on lifelong coumadin
therapy, which was stopped by patient's PCP for unclear reasons.
Heme/onc consulted and suggests pt. restarts Coumadin after
discharge given her high risk. CTA done was negative for new
PE. The patient was encourgaged to contact her PCP and have
coumadin restarted as she is at high risk for PE. Patient had
office visit scheduled with PCP for next day to discuss matter.
Medications on Admission:
Medications:
DEXAMETHASONE 2 mg Tablet - 1 Tablet(s) by mouth once a day take
twice a day the day before, day of and day after chemo
DOLASETRON [ANZEMET] - 50 mg Tablet - 1 Tablet(s) by mouth [**Hospital1 **]
GABAPENTIN [NEURONTIN] - 300 mg Capsule - 1 Capsule(s) by mouth
TID
LATANOPROST 0.005 % Drops - 1 drop at bedtime to both eyes
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1
Adhesive(s) DAILY (Daily) do not leave on longer than 12 hours
LORAZEPAM [ATIVAN] - 1 mg Tablet - 1 Tablet(s) by mouth q4-6hrs
prn
OLANZAPINE [ZYPREXA] 2.5 mg Tablet - 1 Tablet(s) by mouth prn
and hs
OXYCODONE - 5 mg Tablet - [**11-22**] Tablet(s) by mouth q4-6hrs as
needed for breakthrough pain
RANITIDINE HCL 150 mg Tablet - 1 Tablet(s) by mouth twice a day
TRAMADOL [ULTRAM] 50 mg Tablet - 2 Tablet by mouth four times a
day
WARFARIN [COUMADIN] ***NOT TAKING***- 6 mg Tablet - 1 Tablet(s)
by mouth every other day alternates with 7.5mg qd
Discharge Medications:
1. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO four times a day
as needed for pain. Tablet(s)
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: Do NOT leave on skin longer than 12 hrs. .
Adhesive Patch, Medicated(s)
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Olanzapine 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
7. Latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic at
bedtime as needed for pain.
8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day:
As instructed for chemotherapy .
9. Folic Acid 800 mcg Tablet Sig: One (1) Tablet PO once a day.
10. Zyprexa 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Pleural effusion
Ascites
Peritoneal Serous Cancer
Discharge Condition:
Good
Discharge Instructions:
You presented with Fevers of unclear cause. You were also found
to have worsening fluid collections around your lung and in your
belly. You had fluid removed from your abdomen. All of your
culture data was negative and your fever resolved prior to
discharge.
If you develop fevers, chills, cough, worsening shortness of
breath, or chest pain, abdominal pain or pain with urination or
other symptoms, please call your doctor immediately or go to the
emergency room.
There were no changes to your home medication regimen. Please
take all of your medications as you were prior to admission. We
recommend that you discuss restarting coumadin for recurrent
DVT/PE with your PCP. [**Name10 (NameIs) **] needs to be initiated in a setting
in which the INR can be monitored.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2125-6-27**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2125-6-27**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2125-6-27**] 3:00
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
Completed by:[**2125-6-26**]
|
[
"285.29",
"511.9",
"780.6",
"789.51",
"V15.3",
"295.90",
"276.51",
"197.0",
"197.7",
"423.9",
"158.8",
"V10.82",
"799.02",
"V10.43",
"458.9",
"V45.77",
"198.5",
"V12.51",
"V58.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10025, 10031
|
5982, 8093
|
309, 417
|
10131, 10138
|
3370, 5959
|
10962, 11623
|
2472, 2507
|
9085, 10002
|
10052, 10110
|
8119, 9062
|
10162, 10939
|
2537, 3351
|
256, 271
|
445, 1908
|
1930, 2387
|
2403, 2456
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,281
| 139,060
|
53700
|
Discharge summary
|
report
|
Admission Date: [**2135-7-18**] Discharge Date: [**2135-7-22**]
Service: SURGERY
Allergies:
Morphine / Penicillins / Clindamycin / Tricor / Ambien
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
Endovascular AAA repair.
History of Present Illness:
Ms [**Known lastname 12056**] is a 88 year old female recently discharge from [**Hospital1 18**]
after embolization coiling of R proximal hypogastric artery. She
is here with an
enlarging 5.6 cm aneurysm of the infrarenal aorta. She is now
undergoing endovascular repair.
Past Medical History:
1. History of Pulmonary embolus and deep vein thrombosis in
[**2126**], last pe in [**3-/2134**]
2. Recurrent cellulitis.
3. Hypertension.
4. Hypercholesterolemia.
5. Coronary artery disease, status post coronary artery
bypass graft in [**2126**].
6. Chronic obstructive pulmonary disease.
7. Chronic venous stasis.
8. Chronic renal insufficiency.
9. Severe osteoarthritis.
10. gout
Social History:
She is [**Name Initial (MD) **] former RN who lives with daughter and walks with
walker. no etoh or ivdu but 1 glass wine a day
Family History:
No history of nerve or muscle diseases.
Physical Exam:
PULSES: Fem [**Doctor Last Name **] DP PT
R 2+ - tri [**Hospital1 **]
L 2+ - tri [**Hospital1 **]
Brief Hospital Course:
Patient tolerated procedure well and was transported to Fa9
VICU. Post-operative course was unremarkable. Pain was well
controlled. She was anticoagulated post-op with Heparin gtt. On
POD#1, she was found to have Proteus in urine and was treated
accordingly with Bactrim. After a rehab facility was found, she
was deemed suitable and stable for discharge to rehab on POD#4.
Medications on Admission:
Coumadin 2.5 mg, Folic Acid 1 mg, Furosemide 20 mg, Atorvastatin
Calcium 40, Allopurinol 300', Atenolol 25', neurontin 300"'
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) 7658**]
Discharge Diagnosis:
AAA
Discharge Condition:
Good.
Discharge Instructions:
Go to an Emergency Room if you experience symptoms including,
but not necessarily limited to: new and continuing nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Proceed to the ER/EW/ED if your wound becomes red, swollen,
warm, or produces pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Leave the steri strips on until they begin to peel, then you may
remove them. Staples and stitches will remain until your
follow-up
appointment.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Continue taking your home medications unless otherwise
contraindicated and follow up with PCP.
Followup Instructions:
F/U in [**2-6**] weeks with [**Doctor Last Name **]. Call for appt.
Completed by:[**2135-7-22**]
|
[
"401.9",
"V45.81",
"496",
"599.0",
"414.00",
"278.01",
"441.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.71"
] |
icd9pcs
|
[
[
[]
]
] |
2194, 2271
|
1342, 1717
|
265, 292
|
2319, 2326
|
3533, 3632
|
1163, 1204
|
1892, 2171
|
2292, 2298
|
1743, 1869
|
2350, 3510
|
1219, 1319
|
222, 227
|
320, 594
|
616, 1000
|
1016, 1147
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,047
| 153,979
|
2688
|
Discharge summary
|
report
|
Admission Date: [**2103-8-3**] Discharge Date: [**2103-8-4**]
Date of Birth: [**2040-12-21**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Elective coronary angiography
Major Surgical or Invasive Procedure:
Small aortic dissection following failed percutaneous coronary
intervention
History of Present Illness:
This is a 62 y/o male with a history of hypertension and
hyperlipidemia, medically managed, who presented for an elective
catherization. A proximal RCA lesion was noted. Attempt at
crossing the lesion was difficult. Procedure was complicated by
small aortic dissection of the aorta, visible with injection on
contrast directly into the lesion. LVG revealed no wall motion
abnormalities.
.
Patient tolerated procedure well and was chest pain free.
[**5-16**] normal ETT EKG
[**7-16**] ETT MIBI: EF 53%, normal perfusion
Past Medical History:
Hypertension
Hyperlipidemia
Kidney stones
Basal cell carcinoma of the nose
Genital warts
Social History:
Sales representative at [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] alcohol or drug use
Family History:
Father died from sudden cardiac death following an myocardial
infarction.
Physical Exam:
VS: HR 47;BP 113/62; RR13
Gen: NAD
HEENT: neck supple, no JVD
Heart: nl rate, S1S2, no gallops/ murmurs/ rubs
Lungs: CTA- bilaterally
Abdomen: bengign
R groin: 2+ femoral, no ecchymosis, no bruit, +DP
Extremities: no c/c/e
Pertinent Results:
Cardiac Enzymes
[**2103-8-3**] 11:30AM BLOOD CK-MB-3 cTropnT-<0.01
[**2103-8-3**] 02:51PM BLOOD CK-MB-3
[**2103-8-3**] 11:07PM BLOOD CK-MB-3
[**2103-8-4**] 05:26AM BLOOD CK-MB-4
.
[**2103-8-3**] 11:30AM BLOOD CK(CPK)-140
[**2103-8-3**] 02:51PM BLOOD CK(CPK)-123
[**2103-8-3**] 11:07PM BLOOD CK(CPK)-114
[**2103-8-4**] 05:26AM BLOOD CK(CPK)-104
.
Chemistry
[**2103-8-3**] 11:30AM BLOOD Glucose-112* UreaN-19 Creat-1.0 Na-138
K-3.8 Cl-107 HCO3-23 AnGap-12
.
[**2103-8-3**]
Echo
Conclusions:
Technically difficult study. Limited views obtained.
1. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. There appears to be mild regional left
ventricular systolic
dysfunction with distal septal hypokinesis.
2.There is no pericardial effusion.
.
[**2103-8-3**]
Catherization
COMMENTS:
1. Selective coronary angiography of the RCA revealed a chronic
total
occlusion of the proximal RCA with the distal vessel filling via
prominent bridging collaterals.
2. Limited resting hemodynamics revealed normal systemic
arterial
pressures.
3. Failed PCI of the RCA resulting in a proximal RCA dissection
(see
PTCA comments).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Failed PCI of the RCA.
Echo [**8-4**]: Overall left ventricular systolic function is low
normal (LVEF 50-55%). There is no pericardial effusion.
Brief Hospital Course:
This is a 62 y/o male with a history of hypertension and
hyperlipidemia who presented for an elective catherization. Pt
had a proximal RCA occlusion. Attempt to cross the lesion was
complicated by dissection of the proximal RCA which involved the
aorta at the level of the right coronary sinus. Patient was
stable post cath but was admitted to the CCU for monitoring.
.
Overnight the patient did well. SBPs were stable in the 90s.
He was mentating well, denied any chest pain, or SOB. Pt had
good urine output. Echos showed no pericardial effusion.
Pulsus paradoxus done every 6 hours was negative. Patient was
discharged to home on [**2103-8-4**]. He is to follow-up with Dr.
[**Last Name (STitle) 911**] in [**1-14**] months and with his PCP [**Last Name (NamePattern4) **] [**1-14**] weeks.
Medications on Admission:
ASA 81
Atenolol 25
Zocor 20
Discharge Disposition:
Home
Discharge Diagnosis:
Limited aortic root dissection
Discharge Condition:
Good
Discharge Instructions:
You must call 911 immediately if you experience chest pain,
chest pressure, shortness of breath, numbness or tingling in
your jaw, or arms.
Followup Instructions:
You are to follow-up with Dr. [**Last Name (STitle) 911**] within 2 months.
You must follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 410**] within 1 week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"414.01",
"413.9",
"E879.0",
"272.4",
"997.1",
"458.29",
"401.9",
"441.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.22",
"36.01",
"88.56",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
3773, 3779
|
2892, 3695
|
297, 374
|
3854, 3860
|
1514, 2662
|
4049, 4366
|
1181, 1256
|
3800, 3833
|
3721, 3750
|
2679, 2869
|
3884, 4026
|
1271, 1495
|
228, 259
|
402, 926
|
948, 1038
|
1054, 1165
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,809
| 104,955
|
48878
|
Discharge summary
|
report
|
Admission Date: [**2131-9-16**] Discharge Date: [**2131-10-5**]
Date of Birth: [**2078-12-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation in the medical intensive care unit
History of Present Illness:
52 y/o woman with IDDM, diabetic polyneuropathy, HTN, [**Doctor Last Name 933**],
Hepatitis C who has been extremely depressed at home, stating
that "she wants to die" and refusing to take her medications per
her daughter who brought her to the [**Name (NI) **] for nausea, vomiting,
AMS. On arrival in the ED, she was found to be febrile to 101.6,
tachy to 131, hemodynamically stable, yet somnolent and oriented
only to person. Her initial labs were remarkable for a glucose
of 1300, a gap of 31, ketonuria, and a K of 6.3. Her ECG did not
show any ischemic changes, but did have diffuse peaked TW
changes. She was given IV insulin 5 U push, put on 5 U per hour
infusion, given 6 litres of NS bolus, calcium gluconate,
levaquin and flagyl emperically. Her UA was negative, CXR clear.
Blood cultres were sent times two.
Past Medical History:
1. IDDM diagnosed in [**2127**], followed at [**Last Name (un) **] by Dr. [**Last Name (STitle) **]. No
recent HbA1c on file.
2. Diabetic polyneuropathy
3. Hypertension
4. Grave's disease, on tapazole
5. Reactive airway disease
6. Seronegative arthritis, followed in rheumatology
7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
no on antiviral therapy
8. GERD
9. Migraines
10.Bilateral knee arthroscopy in [**5-24**]
11.s/p TAH and pelvic floor surgery with bladder lift
Social History:
She lives at home with her 2 daughters, aged 24 and 21. No sick
contacts. She is a life-long non-smoker. No EtOH.
Family History:
Positive for DM, mother died of colon cancer.
Physical Exam:
per Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
T 101.6 115 141/92 29 100% on RA
Gen - somnolent but arousable to voice
HEENT - non-icteric, EOMI, PERRLA, MM dry
CV - tachy, reg, no m/r/g
Lungs - CTA anteriorly, poor compliance with exam
Abd - diminished BS, Soft, NT, ND
Ext - no edema or rash, dry skin
Neuro - somnolent but arousable to voice, moves all four,
oriented to person only
Pertinent Results:
ED Labs:
Glucose 1356
BUN 31
Cr 1.5
Na 126
K 6.3
HCO3 13
anion gap of 31
ketonuria
EKG: no ischemic changes but positive peaked T waves
UA negative
CXR clear
.
Admission Labs:
149 I 120 I 11
--------------< 139
3.4 I 23 I 0.7
.
pH
7.32 pCO2
33 pO2
47 HCO3
18 BaseXS
-8
.
Trop-*T*: <0.01
CK: 28 MB: Notdone
Ca: 8.9 Mg: 2.1 P: 2.3 D
ALT: 16 AP: 133 Tbili: 0.4 Alb: 3.3
AST: 18 [**Doctor First Name **]: 15 Lip: 12
TSH:<0.02 Free-T4:2.5
.
12.1
18.8 >----< 343
36.2
PT: 12.5 PTT: 22.0 INR: 1.1
Lactate:5.5
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
.
Cultures:
blood cultures negative except [**2131-9-21**]: coag neg staph
CSF cultures negative
Urine cultures negative
Sputum: 2+ gm pos cocci, 1+ gm pos rods
.
CSF:
ANALYSIS WBC RBC Polys Lymphs Monos Macroph
4th 10 609* 67 12 0 21
1st 17 7650* 67 23 0 10
HSV Negative
.
Thyroid: FT4 2.5 to 0.9
HIV Negative
.
Imaging:
CXR Portable AP [**9-16**]: Portable semi-upright chest radiograph
reviewed. The lungs are grossly clear. The pleura are normal
without pneumothorax. The heart and mediastinal contours are
within normal limits. Pulmonary vasculature is normal. The
right subclavian central venous catheter overlies the lower SVC.
.
CT Spine: negative for fracture
Head CT: negative
.
MRI head:
Diffusion images demonstrate no evidence of acute infarct. The
ventricles and extraaxial spaces are normal in size. There are
no focal signal abnormalities or evidence of age inappropriate
brain or medial temporal atrophy. Following gadolinium, no
abnormal parenchymal, vascular, or meningeal enhancement seen.
Mild mucosal thickening is seen in both mastoid air cells.
Again noted is occipitalization of C1 with mild tonsillar
ectopia.
IMPRESSION: No significant change or evidence of acute infarct.
No enhancing lesions. No mass effect, hydrocephalus, or focal
signal abnormalities.
.
EEG:
This is an abnormal EEG in the waking and sleeping stages
due to the bursts of generalized slowing seen in drowsiness.
This is a
nonspecific finding which may be observed with deep midline
subcortical
dysfunction, or could represent a state of altered sleepiness.
.
Right upper ex ultrasound: no DVT
Brief Hospital Course:
52 year old woman with IDDM, HTN, [**Doctor Last Name 933**], Hep. C, depression
admitted with altered mental status thought likely due to DKA.
HOSPITAL COURSE BY PROBLEM
.
1) DM1- DKA on admission. In the ICU, pt was started on insulin
gtt and seen by the [**Last Name (un) **] consult team. Weaned off insulin gtt
within a few hours as her AG closed and started on NPH 70/30.
DKA thought secondary to medication non compliance. However, an
evaluation for occult infection was also performed as well (see
below). She was transferred to the floor and was stable.
Subsequently she had a hypoglycemic seizure. She was seen by
neuro and transferred back to the MICU. She was intubated
briefly for airway protection. Her blood glucose stabilized and
she was transferred back to the floor. We adjusted her insulin
regimen so that she now is getting glargine 33mg qhs and insulin
humalog sliding scale FOUR times a day. She has very close
followup with [**Last Name (un) **].
.
2) Infectious Diseases - The pt was febrile to 101.6 in ED with
occasional fevers while in the ICU and on the floor. The pt was
pan-cultured several times (see above). C.diff was also sent
given the pt's diarrhea, however was negative. Had leukocytosis
on admission which trended down. She had fevers after her
seizure so an LP was performed. It showed 10 WBCs which, in the
setting of a seizure and altered mental status - she was treated
for presumed meningitis with vanco and meropenem for 10d. Her
fevers stopped and she successfully completed her antibiotics.
.
3) Psych: The patient had a flat affect and even was catatonic
briefly during her stay. She was evaluated closely by the
neurologists and psychiatrists. We performed multiple imaging
modalities and lab studies. Her only metabolic abnormality was
thyroid disease (see below). We started remeron 30mg qhs and
then zoloft 25mg qd during her stay. She had significant
improvement in her mood. She had also experienced some
dementia/neurocognitive deficits associated with this
depression. The etiology was unclear. However, given the lack
of imaging abnormalities and her improvement, it was thought not
to be neurologic in origin. We scheduled her for neurocognitive
testing as an outpatient. We also scheduled her for a VNA and
also "best" program to help with her mood and deficits. Her
family was counseled substantially on the importance of
assisting the patient with her illnesses.
.
3) HTN - As the pt was hypotensive on admission, BP meds were
held while in the ICU, but were restarted once transferred to
the floor with good result.
.
4) [**Doctor Last Name 933**] disease - On admission, had an undetectable TSH and
elevated free T4, likely [**2-22**] medication non-compliance. Pt's
hyperthyroid state may have contributed to compliants of
diarrhea. Methimazole was restarted and [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs, the pt
will likely need RAI ablation of thyroid for more definitive
treatment in the future. Will recheck TFTs in four days to check
for response on methimazole treatment.
.
5) Reactive Airways disease - The pt was continued on outpatient
meds.
.
6) Hepatitis C - LFTs stable. The pt has never been on antiviral
therapy.
Medications on Admission:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Methimazole 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-22**]
Drops Ophthalmic PRN (as needed).
5. Zomig 2.5 mg Tablet Sig: One (1) Tablet PO qday prn.
6. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed.
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Serevent Diskus Inhalation
12. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO twice a
day.
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
14. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) Inhalation
twice a day.
15. HYZAAR 100-25 mg Tablet Sig: One (1) Tablet PO once a day.
16. Hyoscyamine Sulfate 0.375 mg Tablet Sustained Release 12HR
Sig: One (1) Tablet Sustained Release 12HR PO twice a day.
17. Insulin
Take 80 units qam and 90 units qpm, as directed by your PCP
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-22**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 unit* Refills:*2*
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Hyoscyamine Sulfate 0.375 mg Capsule, Sust. Release 12HR Sig:
One (1) Capsule, Sust. Release 12HR PO BID (2 times a day).
Disp:*60 Capsule, Sust. Release 12HR(s)* Refills:*2*
5. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Flovent 220 mcg/Actuation Aerosol Sig: Two (2) inh Inhalation
twice a day.
Disp:*1 unit* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
9. Remeron 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
10. Methimazole 10 mg Tablet Sig: Three (3) Tablet PO once a
day.
Disp:*90 Tablet(s)* Refills:*2*
11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
Disp:*15 Tablet(s)* Refills:*2*
15. Insulin Glargine 100 unit/mL Solution Sig: Thirty Three (33)
Units Subcutaneous at bedtime.
Disp:*1 Bottle* Refills:*2*
16. Humalog 100 unit/mL Solution Sig: variable units
Subcutaneous at breakfast, lunch, AND dinner: Take blood sugar
at each meals. Adjust insulin dose as follows:
if blood glucose=61-80 take 0 units, if 81-120 take 4u, if
121-160 take 6u, if 161-200 take 8u, if 201-240 take 10u, if
241-280 take 12u, if 281-320 take 14u, if 321-360 take 16u, if
361-400 take 18u.
Disp:*1 bottle* Refills:*2*
17. Humalog 100 unit/mL Solution Sig: variable units
Subcutaneous at bedtime: check blood sugar at nighttime. if
61-200, give 0 units. if 201-240 give 2u, if 241-280 give 3u,
if 281-320 give 4u, if 321-360 give 5u, if 361-400 give 6u.
Disp:*1 bottle* Refills:*2*
18. Insulin Syringes (Disposable) Syringe Sig: One (1)
syringe Miscell. four times a day: Please provide patient with
a syringe that goes up to 50 units. .
Disp:*120 syringes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
1. Insulin Dependent Diabetes Mellitus (type 1)
2. Diabetic polyneuropathy
3. Hypertension
4. Grave's disease, on tapazole
5. Reactive airway disease
6. Seronegative arthritis, followed in rheumatology
7. Hepatitis C, genotype 1A, biopsy with grade 1 inflammation,
no on antiviral therapy
8. GERD
9. Migraines
10.Bilateral knee arthroscopy in [**5-24**]
11.s/p TAH and pelvic floor surgery with bladder lift
12.Major Depression
13.hypoglycemic seizure
14.possible CNS infection
15. Anemia
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital with extremely high blood
sugar levels. You were treated in the ICU with insulin and
transferred to the floor. You then experienced a seizure and
were transferred back to the ICU. You were followed very
closely by the neurologists and the psychiatrists, and we think
your seizure was related to hypoglycemia. We also treated you
with IV antibiotics. You were showing symptoms of depression
which we treated medically. You improved during your stay.
.
It is extremely important for you to keep all of your followup
appointments. We have made some adjustments to your insulin
medications so you very much need to keep your appointments at
[**Last Name (un) **]. Your family has agreed to help you with your
medications and we also are sending a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **]
in your care.
.
Please check your blood sugars FOUR times a day and use the
appropriate amount of insulin to balance your blood sugar
levels. If you have an extremely high level (>400) please
contact your doctor immediately. If you have a low level (<60)
please eat some crackers and drink 4 oz of juice. Recheck your
blood sugar in 15 minutes and if it continues to be low, please
call your doctor or visit an emergency department.
.
If you experience chest pain, shortness of breath, severe
abdominal pain, nausea, vomiting, or fever please call your
doctor or visit an emergency department.
.
Please follow up with your primary care provider and your [**Name9 (PRE) **]
doctor within 1 week of discharge.
.
It is very important for you to have a colonoscopy in the next
three months.
Followup Instructions:
You need to call your physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7537**], to schedule an
appointment within the next week. He can be reached at
[**Telephone/Fax (1) **].
Please keep your appointment with Dr.[**Name (NI) 102660**] [**Name (STitle) **]
Practitioner, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2489**], on [**10-9**] at 1:00pm.
[**Telephone/Fax (1) **]
Please keep your appointment with Dr. [**Last Name (STitle) **] at [**Last Name (un) **] on
[**2131-11-28**] at 8:30am
Colonoscopy: Provider: [**Name10 (NameIs) **] WEST,ROOM FOUR GI ROOMS
Date/Time:[**2131-10-10**] 8:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2131-11-30**] 9:00
Please undergo neurocognitive testing with Provider: [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2131-10-16**] 8:30
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"V15.81",
"493.90",
"780.39",
"790.7",
"250.13",
"250.83",
"296.20",
"401.9",
"E932.3",
"242.00",
"787.91",
"250.63",
"V58.67",
"070.70",
"322.9",
"357.2",
"348.30",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11844, 11913
|
4614, 7846
|
293, 340
|
12446, 12456
|
2352, 2512
|
14147, 15257
|
1848, 1895
|
9232, 11821
|
11934, 12425
|
7872, 9209
|
12480, 14124
|
1910, 2333
|
232, 255
|
368, 1190
|
3677, 4591
|
2528, 3668
|
1212, 1700
|
1716, 1832
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,852
| 149,680
|
46093
|
Discharge summary
|
report
|
Admission Date: [**2187-8-3**] Discharge Date: [**2187-8-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
hyponatremia, decreased mental status
Major Surgical or Invasive Procedure:
Peripherally inserted central catheter
History of Present Illness:
[**Age over 90 **] yo F with H/o hypothyroid presents after fall. Recently
admitted for fall and pain control on [**9-6**], noted to have
low Na (129) at the time, she then returned with altered mental
status in setting of hyponatremia (112). Initially attempted
correction with normal saline, but she became volume overloaded
w/ pulmonary edema [**12-21**] diastolic dysfunction. Then, attempted
diuresis caused bradycardia and hypotension. She was
transferred to MICU for further stabilization, and did well
subsequently with minimal intervention - fluid restriction and
small amount of hypertonic saline, which was discontinued. She
was then transferred to the floor for further titration of pain
regimen and treatment of L1 fracture.
<BR>
On evaluation of her back, an MR of the L-Spine revealed acute
compression fracture of L1 vertebra with retropulsion and 50%
narrowing of central portion of the spinal canal, moderate
spinal stenosis at L4-5 level due to disc and facet degenerative
changes. Moderate-to-severe left foraminal stenosis at L5-S1
level secondary to disc degenerative changes and facet
degeneration.
<BR>
Pt was initially placed on a fentanyl patch (25mcg) in MICU for
pain control.
<BR>
On transfer, pt was denying any pain, chest discomfort or
shortness of breath
Past Medical History:
1. HTN
2. Hypothyroidism
3. h/o migraines
4. History of post-op MI
5. spinal stenosis
6. s/p TAH
7. urinary incontinence
8. h/p post-herpetic neuralgia [**2183**]
9. History of drop attacks
10. s/p right eye hemorrhage earlier this year
[**91**]. Echo [**1-21**]- Nl EF. 2+ MR, 2+ AR
12. peripheral neuropathy [**12-21**] spinal stenosis
Social History:
Lives independently. Was driving prior to hemorrhage in eye. No
tob, etoh or drugs.
Family History:
NC
Physical Exam:
VS 98.2 112/62 76 16 93%
GENERAL: NAD
HEENT: L pupil post-surgical, R 2mm. [**Last Name (LF) 3899**], [**First Name3 (LF) **] tacky.
NECK: JVP 7cm, supple, no LAD.
CARDIOVASCULAR: S1, S2, reg, II/VI systolic LUSB.
LUNGS: CTAB by anterior exam.
ABDOMEN: Active bowel sounds, soft, NT, ND.
EXTREMITIES: Warm, no CCE.
NEURO: A/OX self, place, situation, time.
Pertinent Results:
[**2187-8-2**] 02:00PM PLT COUNT-317
[**2187-8-2**] 02:00PM NEUTS-83.7* BANDS-0 LYMPHS-10.9* MONOS-4.9
EOS-0.4 BASOS-0.1
[**2187-8-2**] 02:00PM WBC-12.2* RBC-3.20* HGB-10.2* HCT-28.1*
MCV-88 MCH-31.7 MCHC-36.2* RDW-14.3
[**2187-8-2**] 02:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-30.8*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-8-2**] 02:00PM OSMOLAL-252*
[**2187-8-2**] 02:00PM CALCIUM-8.7 PHOSPHATE-4.7*# MAGNESIUM-2.1
[**2187-8-2**] 02:00PM CK-MB-5 cTropnT-<0.01
[**2187-8-2**] 02:00PM CK(CPK)-156*
[**2187-8-2**] 02:00PM GLUCOSE-120* UREA N-26* CREAT-1.2*
SODIUM-112* POTASSIUM-6.7* CHLORIDE-78* TOTAL CO2-25 ANION
GAP-16
[**2187-8-2**] 03:00PM URINE HYALINE-0-2
[**2187-8-2**] 03:00PM URINE RBC-[**1-21**]* WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2187-8-2**] 03:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2187-8-2**] 03:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2187-8-2**] 03:00PM URINE OSMOLAL-447
[**2187-8-2**] 03:00PM URINE HOURS-RANDOM CREAT-81 SODIUM-LESS THAN
POTASSIUM-49
[**2187-8-2**] 03:04PM NA+-116*
[**2187-8-2**] 05:20PM GLUCOSE-115* UREA N-24* CREAT-1.1 SODIUM-114*
POTASSIUM-5.2* CHLORIDE-83* TOTAL CO2-23 ANION GAP-13
MR L SPINE W/O CONTRAST [**2187-8-4**] 12:11 PM
Acute compression fracture of L1 vertebra with retropulsion and
50% narrowing of central portion of the spinal canal. Moderate
spinal stenosis at L4-5 level due to disc and facet degenerative
changes. Moderate- to-severe left foraminal stenosis at L5-S1
level secondary to disc degenerative changes and facet
degeneration.
ECHO Study Date of [**2187-8-4**]
1. The left atrium is mildly dilated. The left atrium is
markedly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Tissue velocity imaging
E/e' is elevated (>15) suggesting increased left ventricular
filling pressure (PCWP>18mmHg).
3.While difficult to assess, the right ventricular cavity is
probably mildly dilated. Right ventricular systolic function
appears depressed.
4.The aortic valve leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. Mild to
moderate ([**11-20**]+) aortic regurgitation is seen.
5. The mitral valve leaflets are structurally normal. Moderate
(2+) mitral regurgitation is seen.
6. Moderate [2+] tricuspid regurgitation is seen.
7.There is moderate pulmonary artery systolic hypertension.
8. Significant pulmonic regurgitation is seen.
9.There is no pericardial effusion.
Brief Hospital Course:
[**Age over 90 **]F Mitral regurg, probable diastolic dysfunction intially
admitted with delirium probably secondary to hyponatremia, poor
PO intake, and severe pain [**12-21**] L1 compression fracture. In
detail:
1. Hyponatremia: Pt. initially presented with Na of 112. She
was given NS which precipitated volume overload and pulmonary
edema secondary to diastolic dysfunction and mitral
regurgitation. She subsequently had an episode of hypotension
[**12-21**] overdiuresis and was transferred to the ICU. Volume was
allowed to reequilibrate, and the patient's sodium improved with
fluid restriction and a small amount of hypertonic saline. This
was therefore thought to be as a result of combination SIADH as
well as hypovolemic hyponatremia.
2. Compression fracture: An MRI showed a compression fracture of
the L1 vertebra with retropulsion and 50% narrowing of central
portion of the spinal canal, moderate spinal stenosis at L4-5
level due to disc and facet degenerative changes. She may be a
candidate for future kyphoplasty. For the time being she has
been fitted with a TLSO brace. Her pain regimen was tailored
during her stay. Pt. was able to ambulate with PT.
3. Falls: We reduced the patients narcotics dose and she was
evaluated by PT. She continued her rehabilitation at the [**Hospital1 100**]
House.
4. Heart failure: The patient's pulmonary edema is resolving.
Her ECHO reveals a EF55% 2+TR, 2+MR, RV depressed, Pulm
Regurg, mod PA HTN. <BR>. She was started on Lisinopril and
continued on her metoprolol and ASA.
5. Pain Control: for the patient's compression fracture, Mrs. [**Known lastname 98082**] pain was controlled with a Lidocaine patch, oxycodone
sustained release 10mg q12, OxycodONE liquid 2.5 mg PO Q4H:PRN
pain. We stopped her fentanyl patch (25mcg) as it caused the
patient to become confused. Narcotics should be used very
carefully in this patient as she tends to become confused and is
susceptible to falls.
6. ? Pneumonia: As pt became hypoxic in the setting of mental
status changes shortly after admission, she was treated
empirically with a course of levofloxacin. However, she was
never febrile and did not produce sputum, so antibiotics were
discontinued at the time of discharge.
* Code status: DNR/DNI
* Comm: [**Name (NI) **] - healthcare proxy ([**Name (NI) **] [**Name (NI) **])
Medications on Admission:
ASA 81
Levothyroxine 25
Colace 100 [**Hospital1 **]
Pantoprazole 40
Levofloxacin 250
SQH
Tobramycin eye drops
Lidocaine 5% patch
Fentanyl Patch 25mcg
Metoprolol 50 [**Hospital1 **]
Morphine IV PRN
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on then 12 hours off.
6. Tobramycin Sulfate 0.3 % Drops Sig: Two (2) Drop Ophthalmic
QID (4 times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours): hold for
sedation an/or rr<12.
9. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO Q4-6H (every 4 to
6 hours) as needed for pain.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: asdir
ML Intravenous DAILY (Daily) as needed: flush PICC per
protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
1. Delirium secondary to hyponatremia probable secondary to
dehydration
2. L1 vertebral compression fracture
3. spinal stenosis
4. hypertension
5. hypothyroidism
6. urinary incontinence
7. history of drop attacks
8. peripheral neuropathy
9. Congestive heart failure
10. Mitral valve regurgitation
11. Hypotension secondary to overdiuresis
Discharge Condition:
stable. can ambulate with brace, sodium 130
Discharge Instructions:
1. please continue to take your medications as prescribed.
2. please wear your brace when ambulating.
3. if you experience chest pain, shortness of breath, worsening
back pain or other worrisome symptoms please seek medical
attention.
4. At your rehabilitation facility: Please have sodium level
checked on [**2187-8-13**], then weekly thereafter.
Followup Instructions:
1. Please call and make an appointment with your primary care
physician [**Last Name (NamePattern4) **] [**11-20**] weeks. [**Last Name (LF) **],[**First Name3 (LF) 251**] D. [**Telephone/Fax (1) 250**] Recommend
serial X ray while in brace over next three months.
Recommend reevaluation of thyroid function tests one month
following discharge.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2187-12-26**] 11:00
|
[
"285.29",
"293.0",
"486",
"428.0",
"244.9",
"427.89",
"E888.9",
"401.9",
"458.29",
"276.1",
"805.4",
"428.30",
"253.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9171, 9256
|
5350, 7696
|
298, 338
|
9639, 9684
|
2541, 5327
|
10081, 10543
|
2143, 2147
|
7944, 9148
|
9277, 9618
|
7722, 7921
|
9708, 10058
|
2162, 2522
|
221, 260
|
366, 1662
|
1684, 2024
|
2041, 2127
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,878
| 195,676
|
50383
|
Discharge summary
|
report
|
Admission Date: [**2163-4-10**] Discharge Date: [**2163-4-27**]
Date of Birth: [**2113-11-22**] Sex: F
Service: MEDICINE
Allergies:
Flagyl / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Dilaudid
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Endotracheal intubation
Tracheostomy placement
PICC line placement
History of Present Illness:
49 yo F with morbid obesity, DM2, HTN, and asthma on home 02 [**2-18**]
liters, who was brought in by EMS for respiratory distress.
Per EMS, the patient had a fever x2 days and short of breath
since 5pm the evening prior to admission. She was talking to
EMS upon arrival.
.
In the ED, initial vs were: T 97.9 P 102 BP 154/64 R 40 O2 sat
84% on NRB. She appeared diaphoretic and cyanotic. Patient was
given Combivent, Solumedrol, and 2 grams of Mag. She did not
receive antibiotics in the ED. She was intubated, after 4
attempts, and was a very difficult intubation, and subsequently
difficult to ventilate. She was intubated wtih DL 4-0 MAC + 7.0
ETT. Vitals prior to transfer were HR 91 BP 116/82 RR 14 100%
on FiO2 100% Vt 500 RR 14 Peep 5.
.
On the floor, the patient is intubated and sedated.
.
Review of systems:
(+) Per HPI
(-) Unable to complete
Past Medical History:
-Morbid obesity
-DM
-Hypertension
-Hyperlipidemia
-Hypothyroidism
-Gastroesophageal reflux disease (GERD)
-Asthma
-Depression/Anxiety
-Possible sleep apnea (has declined sleep studies)
-chronic low back pain
Social History:
Lives alone, with home health aide. She endorses only rare
social alcohol intake and she smokes [**12-19**] cigarettes daily. At
baseline, she is wheelchair bound. Home health aide helps her
with her errands and ADLs. Patient has a long psychiatric
history including counselling since childhood, learning
disabilities, she has left the hospital AMA on multiple
occasions, she has had Code Purples called for aggressive
behavior, she has been accused of calling EMS inappropriately
(several times per month at one point) for factitious
complaints, and she has reported history of sexual assault.
There have been SW involved to try to have this patient live in
rehab or another situation to better care for herself but these
attempts have all failed.
Family History:
father w/CA of "belly", Mother alive & healthy, 2 grandparents
w/DM. Brother died of illicit drug related causes
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T: 97.5 BP:139/90 P: 83 R: 14 O2: 100% on FiO2 of 100%
General: Intubated, sedated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse rhonchi bilaterally on anterior exam.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese. soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE PHYSICAL:
GENERAL: obese female, trach in place, awake, speaking in brief
sentences, in no distress
HEENT: NCAT, MMM
CVS: RRR, nl S1 S2, no m/r/g
RESP: anterior lung fields clear, no wheezes or crackles,
transmitted sounds from vent
ABD: very obese, +BS, soft, distended, non-tender
EXT: warm, well pefused, erythema on right inner thigh and left
anterior thigh appears stable, no skin breaks or oozing
SKIN: Linear skin breakdown at panus with mild erythema, but no
oozing, right lower leg panus improving
GU: Rectal tube in place
Pertinent Results:
ADMISSION LABS:
[**2163-4-10**] 03:08AM BLOOD WBC-12.2* RBC-4.52 Hgb-13.2 Hct-44.1
MCV-98 MCH-29.3 MCHC-30.0* RDW-14.7 Plt Ct-348
[**2163-4-10**] 03:08AM BLOOD Neuts-76* Bands-2 Lymphs-13* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2163-4-10**] 03:08AM BLOOD PT-13.1 PTT-30.0 INR(PT)-1.1
[**2163-4-10**] 03:08AM BLOOD Glucose-305* UreaN-16 Creat-0.7 Na-141
K-5.5* Cl-91* HCO3-44* AnGap-12
[**2163-4-10**] 05:53AM BLOOD ALT-88* AST-64* LD(LDH)-246 AlkPhos-59
TotBili-0.9
[**2163-4-13**] 06:45AM BLOOD Lipase-34
[**2163-4-10**] 03:32PM BLOOD CK-MB-2 cTropnT-<0.01
[**2163-4-10**] 03:08AM BLOOD cTropnT-<0.01
[**2163-4-11**] 03:00AM BLOOD Calcium-9.5 Phos-2.9# Mg-2.4
[**2163-4-10**] 06:44AM BLOOD Type-ART pO2-246* pCO2-85* pH-7.30*
calTCO2-44* Base XS-12
.
DISCHARGE LABS:
[**2163-4-26**] 03:53AM BLOOD WBC-16.9* RBC-3.32* Hgb-10.1* Hct-30.7*
MCV-93 MCH-30.3 MCHC-32.8 RDW-17.4* Plt Ct-239
[**2163-4-26**] 03:53AM BLOOD Neuts-69 Bands-0 Lymphs-17* Monos-9 Eos-2
Baso-0 Atyps-0 Metas-1* Myelos-0 Other-2*
[**2163-4-26**] 03:53AM BLOOD PT-14.5* PTT-80.7* INR(PT)-1.3*
[**2163-4-26**] 03:53AM BLOOD Glucose-146* UreaN-32* Creat-0.8 Na-137
K-3.7 Cl-93* HCO3-33* AnGap-15
[**2163-4-26**] 03:53AM BLOOD Calcium-10.7* Phos-3.2 Mg-2.3
.
MICRO:
[**2163-4-21**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL [**2163-4-21**] SPUTUM GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL [**2163-4-19**] BLOOD CULTURE
Blood Culture, Routine-FINAL INPATIENT
[**2163-4-19**] BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
[**2163-4-19**] URINE URINE CULTURE-FINAL
[**2163-4-16**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS
SP.} - Resistant to vancomycin
[**2163-4-15**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram
Stain-FINAL INPATIENT
[**2163-4-15**] URINE URINE CULTURE-FINAL {ENTEROCOCCUS
SP.} Resistant to vancomycin
[**2163-4-10**] Influenza A/B by DFA DIRECT INFLUENZA A
ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL
INPATIENT
[**2163-4-10**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL [**2163-4-10**] URINE Legionella Urinary
Antigen -FINAL INPATIENT
[**2163-4-10**] URINE URINE CULTURE-FINAL INPATIENT
[**2163-4-10**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2163-4-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2163-4-10**] BLOOD CULTURE Blood Culture, Routine-FINAL
.
STUDIES:
CXR [**2163-4-10**]:
IMPRESSION:
1. Asymmetric pulmonary opacities, right greater than left,
likely asymmetric pulmonary edema. A superimposed aspiration/
infection is not excluded in the right base.
2. ET tube in optimal position.
ECHO:
The left atrium is mildly dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Probably preserved left ventricular ejection fraction.
Right ventricle not well visualized. The ascending aorta is
mildly dilated. The aortic valve is not well seen. The mitral
valve leaflets are not well seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: VERY Suboptimal image quality. Preserved globall
left ventricular systolic function. Valvular structures not well
visualized. Right ventricle not well visuarlized. Cannot assess
diastolic function or pulmonary artery pressures.
[**2163-4-24**] Portable Chest X-Ray:
FINDINGS: Tracheostomy tube tip terminates about 4 cm above the
carina.
Other indwelling devices are unchanged in position. Widening of
cardiomediastinal contours is similar allowing for patient
rotation.
Pulmonary vascular congestion is accompanied by mild
interstitial edema and a small right pleural effusion tracking
into the minor fissure.
Brief Hospital Course:
HOSPITAL COURSE:
This is a 49 yo F with a presumed history of asthma, morbid
obesity who presents with acute hypoxic respiratory failure. Pt
was intubated in the ED, and was a difficult intubation
requiring 4 attempts. Pt was admitted to the MICU and initially
started on broad spectrum abx, but this was tailored to
CTX/Azithromycin for CAP. Pt was continued on standing albuterol
& atrovent MDI's while intubated. Cultures were sent and there
was no growth. Respiratory viral screen was negative. Pt was
diuresed. TTE was a poor quality study. MICU course was
complicated by agitation, requiring propofol. However, given
elevated TG's, this was discontiued. She was started on Seroquel
for agitation in addition to home Zoloft. MICU course was also
complicated by acute renal failure of pre-renal etiology likely
[**1-19**] to aggressive diuresis.
.
# Acute hypoxic respiratory failure: Unclear etiology.
Differential includes severe asthma exacerbation given history
of asthma. Likely also CAP on top of exacerbation. PE thought to
be high probability, since pt unable to get any imaging
procedures given her obesity, empiric heparin was started. Per
report, pt had a recent fever, and CXR showed opacities on the
right. Respiratory viral screen sent, and showed no viral
infection, MI unlikely, and CE's negative. Pt was initially
started on broad spectrum abx; however, given that last
hospitalization 2 months prior, tailored to CTX/Azithromycin for
CAP. She was placed on solumedrol 125mg IV q6hrs, which was
switched to prednisone 60mg po daily and tapered prior to
discharge.
Sputum culture was unrevealing. Continued on Albuterol and
Ipratropium MDIs while intubated. Thought that diastolic heart
failure could be contributing, and she was placed on lasix gtt
for diuresis. She initially diuresed well while in the MICU.
She was started on a lasix gtt with metolazone; however, she
developed acute renal failure and her creatinine increased to
1.9. Diuresis was stopped and patient received IV fluids to
treat renal failure, which improved (see below).
Following treatment of pneumonia and diuresis, patient could not
be weaned off ETT. Patient had trach placed in OR by thoracic
surgery. Patient remains on vent. Please wean off as
tolerated.
.
# Leukocytosis: Patient's WBC count increased on [**4-16**]. She was
pan cultured and only infectious etiology identified was VRE
UTI. Patient received 7 day course of linezolid for VRE UTI.
She continued to have leukocytosis, but all other culture data:
sputum, c.diff, urine, blood was unrevealing. Her WBC remained
elevated, but stable. Her blood smear on [**4-26**] showed 1 blast.
It was reviewed by hematology/oncology and showed blasts that
were "reactive." No further work-up for blasts necessary at
this time. Please check CBC every other day.
.
# ? Thromboembolic Disease: Concern that patietn may have PE
causing hypoxia. Patient was started on heparin gtt to treat
empirically. She is too large to have CTA or VQ scan. Coumadin
was started. Please plan on 3 month course of treatment for
coumadin. Continue heparin gtt until INR in therapeutic range
(2 - 3). Continue coumadin for three month course.
.
# Acute renal failure: Patient received lasix gtt and lasix
boluses in addition to metolazone. Bicarb increased with
diuresis and patient received diamox. With aggressive diuresis
patient was -16 L net fluid balance, however, her creatinine
increased from 0.6 on admission to a peak of 1.9. Diuresis was
held. Felt to be pre-renal etiology as patient had FE urea
calculated at 5. Patient received IVF boluses and her
creatinine improved to 0.7 at discharge. Avoid nephrotoxins,
trend creatinine.
.
# VRE UTI: Patient with VRE UTI during hospitalization. Foley
catheter was changed and repeat culture grew VRE. Patient was
treated on seven day course of linezolid. Repeat urine culture
showed no growth.
.
# DM 2: Placed on home regimen of Lantus and ISS with qid
fingersticks.
Home glyburide held while in house. During admisssion patient
had very elevated fingersticks into 400s despite aggressive home
lantus dose and sliding scale. Patient was started on an
insulin drip and required as much as 47 units of regular insulin
per hour. [**Last Name (un) **] consulted and recommended starting patient on
U500 with humalog sliding scale. Patient stared U500 0.3 mL
(150 units) three times a day prior to tube feeding. Patient
also on humalog insulin sliding scale. Please titrate up
sliding scale as needed. Patient should follow-up at [**Last Name (un) **].
.
# Psych: Pt with baseline psych/agitation issues. Pt on
Sertraline per last discharge, though her family was unfamiliar
with her home regimen. She was treated with Zyprexa in the MICU
for agitation. Baseline QTc normal. Continued on Zoloft per
home dosing (clarified with PCP). She continued to have
agitation and required propofol for sedation as she was agitated
with Fentanyl/Versed. TG's were checked and were elevated so
propofol was stopped. Seroquel was used for sedation, and
Zyprexa was discontinued.
.
Psychiatry ultimately consulted and recommended stopping
psychiatric medications while taking linezolid because of
increased risk of serotonin syndrome. Patient was weaned off
all sedation and all psychiatric medications, including
seroquel, were stopped except haldol PRN for agitation. Zoloft
was restarted at discharge. Please use haldol PRN for
agitation.
.
# Capacity: Concern for whether patient has capacity to make
decisions. Psych consulted and family will pursue legal
guardianship for mother to be legal guardianship. Please
continue guardianship process as her mother wants to pursue
this.
.
# Hypothyroidism: Continued on home dose of levothyroxine.
Please continue 100 mg daily.
.
# Code Status: Full Code
Medications on Admission:
Medications:
1. acetaminophen 1000 mg po q8h
2. albuterol sulfate [**12-19**] Inh Q4H PRN shortness of breath,
wheeze.
3. aspirin 81 mg po daily
4. fluticasone-salmeterol 250-50 mcg/dose inh [**Hospital1 **]
5. glyburide 5 mg po daily
6. insulin glargine 30u sc bid
7. insulin lispro SSI
8. levothyroxine 100 mcg po daily
9. lidocaine 5 %Adhesive Patch daily
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for yeast infection.
11. omeprazole 20 mg po daily
12. sertraline 50 mg po daily
13. oxycodone 5 mg po q6h PRN
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours).
3. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation QID (4 times a day).
5. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever: Do not exceed more than 4
grams per day.
6. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash: For rash on abdomen, skin
folds.
11. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
12. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
13. heparin (porcine) in NS 10,000 unit/1,000 mL Parenteral
Solution Sig: Sliding Scale Units Intravenous As per sliding
scale: Please see sliding scale. Currently at 2700 units/hour.
.
14. insulin regular hum U-500 conc (Injection) 500 unit/mL
Solution
150 units (0.3 mL) SUBCUTANEOUS TID - please give before tube
feed boluses.
15. haloperidol lactate 5 mg/mL Solution Sig: 2.5 mg Injection
Q6H (every 6 hours) as needed for agitation.
16. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
17. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
18. insulin aspart 100 unit/mL Cartridge Sig: Sliding Scale
units Subcutaneous four times a day: Please see humalog sliding
scale. .
19. furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
PRN: Give as needed to keep Is&Os even to -500 cc daily. .
20. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY: Hypoxic Respiratory failure, community acquired
pneumonia, asthma, acute renal failure, acute on chronic
diastolic congestive heart failure exacerbation
SECONDARY: Obesity, hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
It was a pleasure to participate in your care Ms. [**Known lastname 105003**]. You
were admitted to the Intensive Care Unit for respiratory failure
and you required a breathing tube to breathe. We could not
remove the breathing tube and we had a tracheostomy palced as it
will take time for your breathing to become strong without the
breathing machine. We also treated you for a urinary tract
infection. We gave you medication to remove fluid from your
body to help you breathe more easily. You will go to a long
term acute care facility for further treatment.
Please make the following changes to your medications:
1. Stop glyburide 5 mg po daily
2. Stop insulin glargine 30u sc bid
3. Start ipratropium bromide MDI 17 mcg 4 - 6 puffs QID
4. Add warfarin 7.5 mg daily
5. Start heparin gtt
6. Start insulin U500
7. Start haldol
Followup Instructions:
You will follow-up with the doctors at your [**Name5 (PTitle) **] term care
facility.
Please follow up with Dr. [**First Name (STitle) 4375**] [**Name (STitle) 3617**] at [**Last Name (un) **]. Please ([**Telephone/Fax (1) 17256**] to make this appointment in the next 1 - 2 weeks.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
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4,445
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Discharge summary
|
report
|
Admission Date: [**2146-4-12**] Discharge Date: [**2146-4-22**]
Date of Birth: [**2080-11-19**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Cephalosporins
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
transfered here for epicardial abscess management
Major Surgical or Invasive Procedure:
Intubated, R-SCV placed, A-line, Pacer Wire placed, PICC line
History of Present Illness:
65 y.o. M with steroid dependent COPD/asthma, recurrent
pulmonary infections due to MRSA/pseudomonas, s/p [**Hospital 39700**]
transferred from [**Hospital3 **] on [**2146-4-12**] with endocarditis
and complete heart black with temporary pacer with no escape
rhythm.
.
Patient was admitted to [**Hospital1 **] on [**4-9**] with presumed COPD
exacerbation and CHF. Overnight he became more tachypnic with
hypercarbic respiratory failure and was intubated in the morning
of [**4-10**]. He was also found to have [**3-23**] second paused and
responded to atropine. Patient was also hypotensive to 80s
during the episode and then recovered to SBP of 100s. Patient
was also found with with 3:4 Wenckebach rhythm varying with
Mobitz pattern rhythm, then PAF with tachyarrhythmia 1-teens,
with 4-5 second pauses. TEE was performed on [**4-10**]. He went into
patient was found to be in in complete heart block. Luckily, by
that point he had a single temporary V wire inserted through R
IJ on [**4-10**]. Since then patient with no escape rhythm.
.
Patient has severe undelrying COPD (FEV1 0.79) requiring chronic
high dose steroids. He was started on high dose solumedrol at
[**Hospital1 **]. Patient was also found to be bacteremic with MRSA [**3-22**]
BCx upon initial admission with less than 24 hours, started on
Vanco and Levo. Gentamycin was added the next day for synnergy.
Patient also with 4/23 GNR in his sputum. Patient was recently
treated for MRSA bacteremia and sepsis back in [**10-23**]. Presumed
source was IV thrombophlebitis. Patient was also found to have
lung septic embolic. Patient underwent 6 week course of Vanco IV
and 4 week of Linezolid (for presumed improved pulmonary
penetration). Repeat CT on [**1-/2146**] showed improvement of
pulmonary cavitations on chest CT.
.
Patient was transfered to [**Hospital1 18**] for further management. On the
morning of transfer patient with Hct from 33 to 27 with minimal
coffee ground emesis and guiac positive stools. Hct appears to
be stable @ 27 upon repeat.
ROS: upon arrival to CCU, patient is intubated, he stays he is
in mil pain. He denies any cp, sob. No fevers/chills.
Communication is limited due to intubation but he appears lucid.
Past Medical History:
# NO known CAD
# HTN
# COPD - FEV1 .79 ~ 29%, requiring persistent high dose steroids
and mulitiple admission to [**Hospital3 **]/[**Hospital1 1872**] Rehab. CO2
33 on [**4-9**] with pH of 7.39, CO2 63, pO2 74, HCO3 38, Sats 94%.
# Multiple cavitary lession- NOS - in lungs after MRSA skin
infection in [**2145-10-19**], appears to be improved [**1-/2146**]
# MRSA septicemia - [**10-23**] from IV line Tx with Vanco 6 weeks,
then Linezolid x 4 weeks with septic emboli to the lungs.
# Pseudomonas in sputum
# Cervical disk disease - C4-5 discectomy [**2142-9-18**]
- chornic management with moderate narcotics
# ? epidrual abscess or a large disk herniation - due to
complain of increased neck pain detected on MRI on [**12/2145**]
---- repeat CT on [**4-11**] showed no evidence of epidural mass
although a small epidural abscess may not be excluded if very
small and unable to be picked up by CT resolution
---- C3-C4 small posterior protrusion, also milD dorSal bulging
consistent with degenerative narrowing of C5-C6 narrowing of
left C6 foramen, same @ C6-C7.
# Chronic Hepatitis C -s/p succesful IFN therapy 8 years ago
# Chronic Anemia -
# Multiple surgeries including ventral hernia repair s/p bullet
wound in 20s.
# Chronic Anxiety and depression
# Nl renal function - Cr 0.7 upon admission to [**Hospital1 **] [**4-9**]
# Recurrent epistaxis - s/p septal repair - thus no
anticoagulation
Social History:
SHx: h/o tobacco, no etoh. No IVDU. Chronic narcotic use. Lives
alone. single.
.
Family History:
FHx: emphysema in mother, no other known CAD
Physical Exam:
Vitals: wt 61.5 97.1 HR 60 BP 102/60 RR 15 100%
Gen: awake, frail, elder gentleman, ETT, NAD
HEENT: anicteric, left inferio-medial conjuctival hemorrhage, MM
dry, R IJ cordis with pacer wire, no JVD appreciated on L side,
NECK: no adenopathy
CV: RRR, nl S1, S2, unable to appreciate murmur given increased
AP diameter of chest.
Chest: diffuse rales, no wheezes, no crackles, mechanical breath
sounds, barrel chested.
Abd: + BS - faint, snt/nd, no masses
Ext: no edema, no cyanosis, no clubbing
Skin: both hand (palms) and feet(soles) with Osler nodes and
[**Last Name (un) **] lesions.
Vasc: + 1 DP b/l
Pertinent Results:
Labs:
from OSH:
[**4-9**] BCx x 2 - total 6 cultures, each day + for MRSA
[**4-10**] Sputum: GNR, staph
[**4-12**]
146/4.4 109/32 45/0.8 Ca7.7 Alb 1.5 tProt 5.5 tBili 1.8 Dbili
0.8 AlkPhos 117 ALT 67 AST 85
WBC 16K 22% B [**4-9**] -> 22.2 -> 16.3 -> 13.7 @ [**Hospital1 18**]
Hct 33 -> 27.2 Plt 112
Trop [**4-9**] 0.52 -> 0.49 -> 0.71
BNP 756 [**4-9**]
.
Labs:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2146-4-21**] 05:04AM 17.1* 3.84* 10.8* 32.4* 84 28.1 33.4
19.1* 91
[**2146-4-12**] 12:30PM 13.7* 3.29* 8.6* 28.9* 88 26.2* 29.8*
16.3* 90
Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos
[**2146-4-12**] 12:30PM 95* 3 0 2 0 0 0 0 0
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2146-4-21**] 05:04AM 120* 23* 0.4* 136 3.7 100 32 8
.
HEMOLYSIS LABS:
Fibrino FDP D-Dimer
[**2146-4-20**] 03:17PM 40-80
[**2146-4-18**] 06:02AM 40-80
[**2146-4-18**] 06:02AM 132* 2753
.
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili IndBili
[**2146-4-20**] 03:17PM 438* 2.2
Hapto
[**2146-4-20**] 03:17PM 25
.
HEPATITIS:
HCV Ab
[**2146-4-19**] 05:09PM POSITIVE
[**2146-4-19**] 5:09 pm IMMUNOLOGY Source: Line-aline.
HCV VIRAL LOAD
>700,000 IU/ml.
.
MICRO:
[**4-20**] SPUTUM: *FINAL REPORT [**2146-4-22**]**
GRAM STAIN (Final [**2146-4-20**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2146-4-22**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
.
[**4-19**] SPUTUM: 5:09 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2146-4-19**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
STAPH AUREUS COAG +. MODERATE GROWTH.
.
[**4-12**] BCX:
[**2146-4-12**] 12:10 pm BLOOD CULTURE Random.
**FINAL REPORT [**2146-4-18**]**
AEROBIC BOTTLE (Final [**2146-4-17**]):
[**2146-4-15**] REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13478**] AT 7:00 AM.
PSEUDOMONAS AERUGINOSA.
.
[**Date range (1) 11757**] BCX: NO GROWTH
.
[**4-16**] BCX:[**2146-4-16**] 6:34 pm BLOOD CULTURE
**FINAL REPORT [**2146-4-22**]**
AEROBIC BOTTLE (Final [**2146-4-22**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2146-4-20**]):
STAPH AUREUS COAG +.
.
5/2BCX:
[**2146-4-19**] 5:22 pm BLOOD CULTURE
AEROBIC BOTTLE (Preliminary):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci
5/3BCX: Pending
.
[**4-13**]: TEE: Large mobile anterior leaflet mitral valve vegetation
with leaflet perforation and moderate-severe mitral
regurgitation. Echolucent space consistent with an abscess in
the interatrial septum posterior to the aortic root and color
flow consistent with fistulous connection into the right atrium.
Smaller mobile vegetation on the tricuspid valve.
.
[**4-13**]: CT head: Two small foci of increased density within the
right frontal lobe. The study is limited by the lack of a
non-contrast acquisition, however, these findings could
represent enhancing vessels versus small foci of extra-axial
hemorrhage or cortical enhancement.
.
[**4-13**]: CT neck: Multiple cavitating and noncavitating pulmonary
nodules at the right and left lung apices, and bilateral pleural
effusions. The findings are consistent with septic emboli. No
definite evidence of epidural abscess.
.
[**4-17**]: Chest CT:
IMPRESSION:
1. Numerous nodular opacities throughout the lungs, many of
which are cavitary consistent with septic emboli. The largest is
within the right middle lobe measuring 3.6 x 3.0 cm with an
air-fluid level.
2. Small bilateral pleural effusions.
3. Striated, hyperdense nephrograms bilaterally concerning for
renal failure.
.
[**4-17**] RUQ US:
FINDINGS: Multiple small 3-5 mm likely polyps are present within
the gallbladder. No stones are identified. The gallbladder wall
is mildly thickened measuring 5 mm. There is moderate ascites in
the right upper quadrant. No shadowing gallstones are
identified. The common bile duct is not clearly identified, and
thus is likely not dilated. The proximal pancreas is normal.
IMPRESSION: Edematous gallbladder wall likely secondary to third
spacing. No gallstones identified. Right upper quadrant ascites.
.
[**4-18**] CXR:
PORTABLE SEMI-UPRIGHT CHEST RADIOGRAPH:
The endotracheal tube is seen at the thoracic inlet. The carina
is not well visualized. There is no significant change in
positioning compared to prior study. Pacer wire is again noted
and unchanged. Right-sided PICC line tip is seen within the
distal SVC.
Again noted are multiple bilateral cavitary opacities (better
seen on recent CT), consistent with multifocal infection and
possible septic emboli that are unchanged compared to prior.
Brief Hospital Course:
A/P: 65 y.o. M with severe steroid dependent COPD, recent MRSA
cellulitis in [**10-23**] with pulmonary septal emboli/cavitations,
myocardial abscess, MV vegetation, [**Last Name (un) 1003**] lessions and MRSA
bacteremia, intubated for increasing tachypnea and hypoxia.
.
# Valves/Mitral Valve: MRSA bacterial endocarditis
w/paravalvular abscess, vegetations - seen on TEE with
myocardial abscess. Pt had evidence of septal emboli in
conjuctivae, fingertip, lungs, spleen, spine, and 2 foci in
brain. Pt did not have any neurological deficits and no signs of
hemorrhage in brain. He was closely followed by ID. He was
started on Vanc and completed 5 days of Gentamycin for Abx
synergy. His blood cultures cleared from [**4-13**] as well as
remained afebrile. His blood cultures were followed daily, his
WBC fluctuated without any specific pattern but remained
elevated. CT [**Doctor First Name **] was following pt for possible surgery but the
following concerns for sugery included; 1. inability to suspend
new valve, 2. persistent bacteremia 3. lack of CHF or urgency
for surgery 4. septic emboli 5. poor PFTs 6. GIB. Per the
Brother, if surgery was a possibility then to proceed with
surgery. However, per the pt he did not want any heroic
measures. There was a tentative plan for OR on [**5-2**], awaiting
for Brain foci to mature, improve his nutrition as his albumin
was 1.5. Multiple discussions were had with CT surgery, Dr.
[**Last Name (STitle) **], Dr. [**Last Name (STitle) 66985**] regarding surgical intervention. On [**4-21**]
there was a discussion with the pt whom did not want to proceed
with surgery, and did not want to be intubated. The pt
understood completely that without the surgery he would die. The
pt was adamant that he did not want to proceed with the surgery
nor remain intubated. The pt was lucid and it was agreed upon
with the brother and medical team to proceed with extubation.
The pt expired the following morning on [**4-22**] at 6am.
.
.
# Rhythm/Complete Heart Block - Patient with complete heart
block; initial presentation was with tachy/brady arrythmias,
pacer wire placed for severe bradycardia w/ intermittent
block-->eventual CHB. Wire place [**4-10**]. Transition from EMS pacer
to CCU pacer showed evidence of CHB w/o escape rhythm.
- paced @ 60, no issues, per ID will leave temporary wire in
- EP: s/p screwed in R V - VVI wire with external RSCL pacer -
[**4-13**]. On day of extubation the pt had many episodes of pacer
not capturing in setting of respiratory distress.
.
# Pump - patient with no h/o CHF, per prelim echo appears to
have nl EF with +1MR, echo here showed + 3 MR. Pt did not have
any evidence of fluid overload. Captopril 6.25 TID to help with
MR, however it was held on several occasions for hypotension.
.
# CAD - patient with + troponins, flat CKs and no ischemic EKG
changes@ OSH, peak CK 24, peak Trop .71, most likely due to
myocardial abscess and associated myocardial necrosis. No ASA
was given in the setting of GIB and possible surgery. He was not
on Lipitor, BB, and Ace as no prior known disease.
.
# Respiratory failure - most likely due to severe underlying
COPD, ?flair. Currently intubated due to respiratory distress
(tachypneic to 40, shallow breathing, tiring out): hypercarbic
respiratory failure (per ABG). Pt was kept intubated for
>10days. Pulmonary was consulted in setting of possible
extubation. He was maintained on steroids and weaned to 10mg
Prednisone daily. He was also found to have pseudomonas in his
sputum and treated w/10days of Aztreonam. He continued to show
psuedomonas in his sputum cultures following Aztreonam
treatment. However, pt requested to be extubated. On [**4-21**] post
extubation, pt eventually had respiratory distress, his O2 sats
dropped to 70s and expired early morning on [**2146-4-22**].
.
# MRSA bacteremia - primary bacteremia vs secondary bacteremia
from pulmonary cavitation vs ? epidural abscess. Pt was
continued on Vanco with 6 days of Gent synergy. Daily
surveillance cultures were followed, as well as fever curve and
WBC. Endocarditis as mentioned above. On [**4-19**] started to have
fevers, his A line was resited, his PICC was kept in place as
difficulty with access and possible interference with pacer
wires. Plan for PICC line removal when BCX returned as started
to have new + blood cultures from [**4-19**]. However, pt shortly
expired post extubation on [**2146-4-22**] in am.
.
# ? epidural abscess - patient evaluated by IR @ [**Hospital1 **], it may
be one of the sources for recurrent septicemia. Percutaneous C&S
of pre-vertebral Abnormality @ C5 was enteretained. However,
patient is very high risk and there is no neurological
involvement. Also, previous MRI w/o evidence of abscess, CT of
cervical vertebrae could not exclude a small epidural abscess.
repeat CT [**4-13**] showed no clear evidence in C3-4, but ? of
abscess in L4 region. As there was no neurological deficits and
given his more pressing MV endocarditis no further w/u for spine
done. Continued IV Vanco.
.
# Anemia - patient with admission Hct of 33, this AM with a drop
to 27.2 of almost 6 points. Hct here of 28.9. NGT with minimal
coffee grounds initially that resolved. He had a few episodes of
BRBPR as well as ~200cc blood from ETT. He received 2 UPRBC as
well as a bag of platelets. Stool were grossly positive for
ocult blood. GI was consulted and advised to stop ASA, protonix
IV BID. He was ruled out for a retroperitoneal bleed with CT on
[**4-14**]. His HCT was followed closely. Hemolysis labs were checked
and showed a mild DIC picture, but no schistocytes, stable PLTs.
Heme was consulted for persisten Thrombocytopenia. Most likely
etiology was poor synthetic function rather than DIC picture or
loss. Heme recommended supportive care as needed with clotting
factors in setting of bleeding. Pt remained HD stable and did
not require further transfusions beyond [**4-15**].
.
# Hypernatremia - patient appears dehydrated with free water
deficit of 2.4L
- give 1/2 NS x 2L over next 24 hours
- high BUN with high bicarb suggest contraction alkalosis as
well vs. baseline given severe COPD. His hypernatremia
resolved.
.
# Elevated INR - [**1-20**] to old HepC, vs malnutrition (alb 1.2) vs.
current levo, vs infiltrative/embolic liver disease, vs recently
started statin
- d/c statin, continue to follow, reverse if needed for
procedures with FFP, IVF
- vitamin k 10mg x1 on [**4-12**] - improving INR
- nutrition consult
.
# HCP - [**Name (NI) **] [**Name (NI) 66986**]: [**Telephone/Fax (1) 66987**]
.
# DNR
Medications on Admission:
Prednisone 10 mg QD
Albuterol nebs [**Hospital1 **]
Spririva 18 mcg QD
Fentanyl 50 mcg q72
Ativan 0.5 mg PO BID
KCl 20 mg QD
Advair 500/50 1 puff [**Hospital1 **]
Ranitidine 150 mg QD
Percocet 3/325 1 tab po TID
Vitamin D 50,000 po Qwk
.
from [**Hospital1 **]:
Methylpred 40 mg IV q8
Vanco 1 gm q12
Levquin 500 mg IV qd
Gentamicin 60 mg IV q8
Lipitor 80 QD
Fentanyl patch 50 mcg every 72 hrs
Protonix 40 IV QD
ECASA 325
NTP 0.5
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2146-4-23**]
|
[
"286.7",
"518.81",
"491.21",
"722.4",
"995.92",
"V58.65",
"070.54",
"421.0",
"482.1",
"038.11",
"707.03",
"401.9",
"513.0",
"V09.0",
"426.0",
"578.1",
"434.10",
"567.31",
"785.52",
"707.14",
"444.89",
"287.5",
"038.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.78",
"99.05",
"38.91",
"96.6",
"38.93",
"88.72",
"96.72",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
17106, 17115
|
10045, 16599
|
349, 412
|
17166, 17175
|
4870, 6780
|
17227, 17261
|
4184, 4230
|
17077, 17083
|
17136, 17145
|
16625, 17054
|
17199, 17204
|
4245, 4851
|
6821, 8140
|
260, 311
|
440, 2647
|
8149, 10022
|
2669, 4069
|
4085, 4168
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,835
| 171,801
|
6800
|
Discharge summary
|
report
|
Admission Date: [**2159-2-6**] Discharge Date: [**2159-2-24**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
diarrhea and BRBPR x2days.
Major Surgical or Invasive Procedure:
colonoscopy, EGD
rectal tube decompression
History of Present Illness:
The patient is a 90 with pmhx of hypertension and 1 month of
diarrhea who presents with 2 days of bright red blood per
rectum. She reports large volume bowel incontinence this am and
her family member reports seeing bright red blood on bathroom
floor.
On ROS she notes anorexia, feeling unsteady on her feet,
fatigue, Denies cp/cob.
In ED she received 1L NS, and vomitted x 1 for which received
Anzamet. On exam she was noted to have external hemmorhoids.
Labs noteworthy for arf (crea 2.2), and leukocytosis with left
shift (81%) and bands of 9.
Past Medical History:
Hypertension
Hemorrhoids
Mild Dementia
Family History:
non-contributory
Physical Exam:
T-98.1 HR 90 Bp 130/98 98% RA
Gen: Well appearing elderly female
Heent: PERRL.
Neck: No cervical/sm/sc [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: Regular, s1,s2. IV/VI SEM @ LUSB.
Chest: LCA b/l
Abd: +bs. soft. nt. nd. no organomegaly.
Ext: no le edema.
Pertinent Results:
[**2159-2-6**] 05:00PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2159-2-6**] 04:05PM GLUCOSE-216* UREA N-85* CREAT-2.2* SODIUM-143
POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-24 ANION GAP-19
[**2159-2-6**] 04:05PM CALCIUM-10.1 PHOSPHATE-3.7 MAGNESIUM-4.5*
[**2159-2-6**] 04:05PM WBC-15.3*# RBC-4.17* HGB-12.3 HCT-39.1 MCV-94
MCH-29.6 MCHC-31.5 RDW-14.1
[**2159-2-6**] 04:05PM NEUTS-81* BANDS-9* LYMPHS-2* MONOS-7 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2159-2-6**] 04:05PM PLT COUNT-394
[**2159-2-6**] 04:05PM PT-13.3 PTT-22.8 INR(PT)-1.1
CXR [**2-1**]: Unchanged appearance of the chest with eventration of
the
diaphragm and hiatal hernia. Compression fracture of the
thoracic spine
Brief Hospital Course:
This [**Age over 90 **]yo F was admitted to the medical service for work-up
and treatment of her diarrhea and BRBPR. The ARF was considered
secondary to dehydration and treated with IVF resuscitation and
electrolyte repletion. A GI consult was obtained. Stool was
sent for culture and tested for CDiff, which came back positive.
She was placed on Flagyl PO but continued to have significant
diarrhea. The HCT drifted from 31 to 28 and she was transfused
1U of PRBCs, with response to 31. She was taken for colonoscopy
and EGD on HD 4 with the finding of pseudomembranes consistent
with CDiff, duodenal erythema (biopsied), and small hiatal
hernia.
She continued to have diarrhea and increasing abdominal
distension. PO Vanco was added to the IV Flagyl. A rectal tube
was placed, with serial abdominal exams showing no evidence of
peritonitis. A KUB on HD 5 showed dilated loops < 7cm and
air-fluid levels, a CT scan confirmed no obstruction or toxic
megacolon.
On HD 8, stool output ceased and abdominal distension
developed, as well as low urine output. A repeat KUB showed a
9.5cm cecum and ? pneumotosis. A surgical consult was obtained,
and she was transferred to the SICU for further management. She
was continued with NGT and rectal tube, begun on TPN, and
continued on Vanco/Flagyl. A CVL was placed and echo for murmur
revealed 2+ MR, nl LVEF. The WBC rose slightly, no fever, and
rpt KUB showed no evidence of obstruction.
She gradually improved and was transferred to the floor on HD
12. The rectal tube was removed on HD 13, clear liquid diet
begun and tolerated. She developed swelling on her LLE, U/S was
negative for DVT. She initially had poor PO intake, calorie
counts were initiated, and TPN was gradually weaned. She then
developed siginificant constipation, which responded only to a
complete regimen of colace, dulcolax, and mineral oil. She
failed to independently void after Foley [**Last Name (un) **] was removed; the
catheter was re-placed for 450cc. Physical therapy consult was
obtained.
Medications on Admission:
Aspirin
HCTZ
Diovan
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] - [**Location (un) **]
Discharge Diagnosis:
Clostridium Dificile colitis
hypertension
constipation
acute renal failure secondary to hypovolemia
dementia
Discharge Condition:
stable
Discharge Instructions:
Continue antibiotics for one week further.
Usual home medications.
Foley catheter may be removed for a voiding trial.
Continue with bowel regimen as prescribed, but hold if diarrhea
develops.
[**Name8 (MD) **] MD for significant diarrhea or constipation, fever or
chills.
Encourage PO liquids to prevent dehydration.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 141**] in 1 week. Call [**Telephone/Fax (1) 142**] for an
appointment.
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
|
[
"553.3",
"455.3",
"008.45",
"276.5",
"564.00",
"401.9",
"280.9",
"569.89",
"729.81",
"535.60",
"584.9",
"428.0",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.24",
"38.93",
"45.16",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
4190, 4263
|
2072, 4120
|
288, 332
|
4416, 4424
|
1321, 2045
|
4789, 5002
|
988, 1006
|
4284, 4395
|
4146, 4167
|
4448, 4766
|
1021, 1302
|
222, 250
|
360, 910
|
932, 972
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,099
| 175,213
|
52094
|
Discharge summary
|
report
|
Admission Date: [**2137-4-1**] Discharge Date: [**2137-4-5**]
Date of Birth: [**2055-8-13**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 year old man with a history of prostate cancer metastatic to
bone, evidence of RV failure on echo in [**5-26**], CAD s/p CABG who
was brought in by his family for increasing somnolence. Admitted
to the MICU for hypotension. Was breifly on levophed for
hypotension and started on vanc cefepime empirically for
?sepsis. Now being transferred to medicine floor for further mx.
The pt was discharged from rehab two days ago, was at rehab
since discharge from [**Hospital1 18**] on [**2137-3-1**] for somnolence where he
was found to have a UTI and C.diff infection, per his family at
the time of his discharge from rehab he was at his baseline
mental status (AAOx3, able to recall the days events). Last
night his family notes that he was increasingly somnolent, and
this morning he was sleeping more often but arousable and
complained of fatigue. His family also noted that he had
worsening erythema and edema of his left lower extremity. His
family also noted that he had been having significant amounts of
diarrhea (7 BM's per day) while at rehab, most recently treated
with loperamide and since returning home has improved, with no
bowel movements today.
In the ED, initial VS were: 100.1, 100, 117/49, 16, on 100% 10L.
He initially was somnolent, only responding to deny pain, cough,
dyspena and dysuria. In the ER was noted to be somnolent
initially, his mental status improved with IV fluids however
when he spiked a temp to 100.9 his blood pressure dropped to
77/48, mentating well at that time. He was given 1LNS and his
SBP improved to the 90's, however his blood pressure dropped
again to 82/40, so he was given a second liter and started on
levophed. He had a LLE ultrasound that was negative for DVT, RUQ
US which showed a 6mm CBD, no cholecystitis, a CT head with no
acute process and a CXR with no evidence of pneumonia. He was
given vancomycin for presumed cellulitis and empiric cefepime
for the hypotension. His labs were notable for a lactate of 1.4,
troponin of 0.02, CK of 367, MB of 2, AST of 41, AP of 206. VS
on transfer: 99.6 ??????F (37.6 ??????C), 91, 16, 108/49, 96% on RA.
On arrival to the MICU, VS were 98.5, 90, 101/63, 18, 94% on RA.
He currently is awake, alert and oriented x 3, denies any pain,
chest pain, shortness of breath, n/v/d, abdominal pain, he also
says that the swelling in his left leg is significantly improved
from prior. His only current complaint is that he is thirsty.
Currently
Review of systems:
(+) Per HPI and for chronic diarrhea
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
- Metastatic Prostate Cancer
- CABG x 4 vessels [**2120**].
- Hypertension.
- Hyperlipidemia.
- E. coli urosepsis in [**2135-5-17**].
- One fall with subsequent wrist fracture.
- Right heart failure (EF 65%).
- [**2135-9-21**] underwent T9 to L1 fusion with vertebrectomy T11.
Past Oncologic History:
Prostate cancer diagnosed in [**2117**]. S/p radical prostatectomy.
XRT to pelvis approx one and a half years after prostatectomy
for rising PSA. In [**2123**], started hormones for metastatic
prostate cancer. In [**2130-11-16**], started on KHAD trial of
Ketoconozole, Hydrocortisone, and Dutasteride as he became
hormone refractory. Was on Sutent Trial temporarily from
[**Date range (1) 31896**]. Was on diethylstilbesterol from approx [**2131**] to
[**2134-1-5**]. Has also been maintained on Lupron/Pamidronate. Last
dose of Lupron was [**2134-1-5**] at dose of 22.5 mg. He is status
post Clinical Trial #08-359 taxotere every 3 weeks plus
atrasentan vs placebo and prednisone daily. He was unable to
tolerate this regimen secondary to toxicity. He received
Taxotere every
3-4wks & lupron every 3mos. He finished cycle 15 of Taxotere on
[**2135-7-25**]. He was then on leupropride every 12 weeks, which began
on [**2135-7-5**].
He is s/p Clinical Trial #08-359 taxotere every 3 weeks plus
atrasentan vs placebo and prednisone daily. He was unable to
tolerate this regimine secondary to toxicity. He was changed to
taxotere alone, off protocol he recieved 16cycles.
He was followed and started on DES/coumadin after his insurance
denied coverage for another therapy
- [**2136-10-9**] taxotere/lupron C1
- [**2136-11-6**] C2 taxotere
- [**2136-11-27**] C3 taxotere
- [**2136-12-18**] C4 taxotere
- [**2137-1-8**] C5 Taxotere, briefly discontinued secondary to
declining PSA and LE edema
- [**2137-2-12**] C6 Taxotere followed by Neulasta [**2137-2-13**]
Social History:
- Retired construction worker. Lives at home with his son.
- Tobacco: None.
- etOH: Former social drinker, last use 35 yo ago.
- Illicits: None.
Family History:
Brother with prostate cancer.
Physical Exam:
ADMISSION
VS: 98.5, 90, 101/63, 18, 94% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
DISCHARGE:
VS: TC 97.9 BP 146/70 HR 98 RR 18 98% RA
General: Alert, oriented X 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Mild stasis changes.
Neuro: CNII-XII intact
Pertinent Results:
ADMISSION LABS
[**2137-3-31**] 08:10PM BLOOD WBC-8.2 RBC-3.08* Hgb-8.7* Hct-28.4*
MCV-92 MCH-28.2 MCHC-30.6* RDW-18.2* Plt Ct-206
[**2137-3-31**] 08:10PM BLOOD Neuts-73.2* Lymphs-19.5 Monos-6.7 Eos-0.4
Baso-0.2
[**2137-3-31**] 09:07PM BLOOD PT-13.8* PTT-28.9 INR(PT)-1.3*
[**2137-3-31**] 08:10PM BLOOD Glucose-128* UreaN-23* Creat-1.1 Na-136
K-4.3 Cl-102 HCO3-26 AnGap-12
[**2137-3-31**] 08:10PM BLOOD CK-MB-2
[**2137-3-31**] 08:10PM BLOOD cTropnT-0.02*
[**2137-4-1**] 02:51AM BLOOD CK-MB-2 cTropnT-0.01
[**2137-4-1**] 07:52PM BLOOD CK-MB-1 cTropnT-<0.01
[**2137-4-1**] 02:51AM BLOOD Albumin-2.6* Calcium-7.7* Phos-3.2 Mg-1.7
[**2137-3-31**] 08:26PM BLOOD Lactate-1.4
[**2137-4-1**] 11:53AM BLOOD Lactate-1.3
[**2137-4-1**] 02:51AM URINE Mucous-RARE
[**2137-4-1**] 02:51AM URINE RBC-<1 WBC-<1 Bacteri-MOD Yeast-NONE
Epi-<1
[**2137-4-1**] 02:51AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2137-4-1**] 02:51AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
DISCHARGE LABS
[**2137-4-5**] 05:20AM BLOOD WBC-5.0 RBC-2.76* Hgb-7.8* Hct-25.4*
MCV-92 MCH-28.2 MCHC-30.6* RDW-18.0* Plt Ct-211
[**2137-4-5**] 05:20AM BLOOD Glucose-100 UreaN-14 Creat-0.7 Na-136
K-3.8 Cl-104 HCO3-23 AnGap-13
[**2137-4-5**] 05:20AM BLOOD Calcium-8.0* Phos-2.6* Mg-2.1
STUDIES:
CT HEAD [**2137-3-31**]:
CT OF THE BRAIN: There is no evidence of acute intracranial
hemorrhage,
discrete masses, mass effect or shift of normally midline
structures. The
ventricles and sulci appear slightly prominent, consistent with
age-related involutional changes. Minimal periventricular and
subcortical white matter changes appear consistent with sequelae
of chronic small vessel ischemic disease. [**Doctor Last Name **]-white matter
differentiation is preserved.
There is atherosclerotic calcification of the bilateral
vertebral arteries, left greater than right. Bilateral mastoid
air cells are clear. Visualized paranasal sinuses are
unremarkable. Rounded metallic density seen in the soft tissue
infraorbitally on the right.
IMPRESSION: No acute intracranial process.
ABD U/S [**2137-3-31**]:
IMPRESSION:
1. No evidence of acute cholecystitis.
2. Right lobe hepatic cyst unchanged from CT of [**2136-8-23**].
LENIS [**2137-3-31**]:
IMPRESSION: No evidence of DVT in left lower extremity
ECHO [**2137-4-1**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 5-10 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
right ventricular cavity is mildly dilated with borderline
normal free wall function. There is abnormal septal
motion/position. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Dilated right ventricle with borderline normal free
wall function. Moderate tricuspid regurgitation with
moderate-severe pulmonary artery systolic hypertension.
Preserved left ventricular regional and global systolic
function. Mild mitral and aortic regurgitation.
Compared with the prior study dated [**2135-5-27**] (images reviewed),
pulmonary artery systolic pressure is worse. The right ventricle
is better seen on the current study and is similarly dilated
with borderline systolic function. Other findings are similar.
CXR [**2137-4-2**]:
Recent mild pulmonary edema has improved, and nearly resolved in
the left
lung. Greater opacification at the base of both lungs
particularly the right is an indication of decreasing aeration
either by virtue of atelectasis or Pneumonia. Small right
pleural effusion is probably unchanged since [**3-31**], and
noncontributory. Heart size and mediastinal contours are normal.
Right subclavian infusion port ends in the right atrium. No
pneumothorax.
MICRO:
C.DIFF: TEST NOT PERFORMED AS STOOL FORMED
URINE CULTUREL NO GROWTH
BLOOD CULTURES x 2: NO GROWTH TO DATE
Brief Hospital Course:
HOSPITAL COURSE: Mr. [**Known lastname **] is an 81 y/o M with a history of
metastatic prostate cancer, recent hospitalization for a UTI and
C.diff infection who presented from home with increasing
somnolence and improved with empiric broad spectrum antibiotics.
Was found to have a pneumonia and possible recurrence of his c
diff colitis. Discharged back to rehab in a safe condition.
#) Hypotension: The patient's hypotension resolved in the
context of fluid resuscitation, antibiotics, and time. He has
not had any localizing symptoms other than perhaps some
tachypnea and a subjective sense of dyspnea in concert with
increasing perihilar consolidation. We initially started him on
IV Vancomycin and cefepime for presumed cellulitis because of
the eryhtema in his legs but that was later judged to be venous
insufficincy. He was noted to have an opacity in his RLL which
was read as pneumonia vs atelectasis. However, at time of
discharge, given that he had been on room air for his stay on
the floor, and had no other sign of recurrent infection, was
transitioned to PO levofloxacin and will complete an 8 day
course at rehab. He was also noted to have some watery diarrhea
on and off and therefore was started on PO vancomycin for a
total 14 day course for possible recurrence of his c. diff. He
was dc-ed to rehab in a stable condition.
#) Metastatic Prostate Cancer: Pt has completed cycle 6 of
docetaxel on [**2137-3-4**] and radiation therapy for a spinal met as
well. We increased his home dose of oxycodone prn. Per his
oncologist, dr [**Last Name (STitle) **], unlikely to get any furhter chemo for his
cancer.
#) CAD s/p CABG: stable. We held atenolol but restarted it on
dc. Aspirin and simvastatin were continued.
#) GERD: we continued home omeprazole
TRANSITIONAL ISSUES: PT WILL NEED 4 MORE DAYS OF LEVO AND 10 OF
PO VANCOMYCIN. HOSPICE OPTION WAS DISCUSSED BY PCP AND MEDICAL
TEAM AND THE PT [**Name (NI) **] BE AMENABLE TO IT. THIS MUST BE CONTINUED AT
REHAB.
Medications on Admission:
1. atenolol 50 mg DAILY
2. folic acid 1 mg DAILY
3. furosemide 20 mg DAILY
4. gabapentin 300 mg Q12H
5. nitroglycerin 0.4 mg as needed for chest pain
6. omeprazole 20 mg DAILY
7. oxycodone 5 mg Q6H as needed for pain.
8. prednisone 5 mg DAILY
9. simvastatin 40 mg 0.5 Tablet QHS
10. aspirin 81 mg DAILY
11. ferrous sulfate One Tablet DAILY
12. ondansetron 4 mg every eight hours as needed for nausea.
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every
twelve (12) hours.
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: as directed
Sublingual every 3 minutes upto 3 times as needed for chest
pain.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended
Release Sig: One (1) Capsule, Extended Release PO at bedtime.
11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
12. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
13. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days.
14. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 3075**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for Living
Discharge Diagnosis:
PRIMARY DIAGNOSES:
1. Pneumonia
2. Recurrent C. Diff Colitis
SECONDARY DIAGNOSES:
1. Metastatic Prostate Cancer
2. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr [**Known lastname **],
It was a pleasure taking care of you at the [**Hospital1 18**]. You were
admitted with confusion and low blood pressures which was likely
thought to be due to an infection in your lungs. You improved
with antibiotics and are now being discharged with antibiotics
to treat your lung infection as well as your belly infection.
You were discharged to your nursing home for continued care.
MEDICATIONS STARTED:
1. Levofloxacin: please take this for 4 more days (until
[**2137-4-9**]), once a day by mouth in the morning for your pneumonia.
2. Vancomycin: please take for 10 more (until [**2137-4-15**]) days via
mouth four times a day for your diarrheal illness
Followup Instructions:
Department: ADULT MEDICINE
When: WEDNESDAY [**2137-5-1**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8471**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
We are working on a follow up appointment with your primary care
provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for your hospitalization. You need to
be seen within 1 week of discharge. The office will contact you
at home with an appointment. If you have not heard within 2
business days or have any questions please call the office at
[**Telephone/Fax (1) 1144**].
We are working on a follow up appointment for your
hospitalization with in Hematology/Oncology with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. You need to be seen within 1 week of discharge. The
office will contact you at home with an appointment. If you have
not heard within 2 business days or have any questions please
call the office at [**Telephone/Fax (1) 10784**].
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,443
| 152,312
|
34018
|
Discharge summary
|
report
|
Admission Date: [**2153-6-2**] Discharge Date: [**2153-6-23**]
Date of Birth: [**2129-9-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
[**2153-6-2**]
1. Intramedullary nail, left femur.
2. Debridement open fracture to bone.
3. Intramedullary nail, left tibia.
4. Measurement interstitial compartment pressures.
5. Four-compartment fasciotomy.
6. Application of medial and lateral wound V.A.C. sponges.
[**2153-6-5**]
1. Closure, fasciotomy wounds medial and lateral.
History of Present Illness:
23 yo male s/p motor vehicle crash vs. barrier on [**2153-6-2**] where
he was a passenger ejected by report ~100 feet. He was taken to
an area hospital with a GCS [**6-2**] and then transferred to [**Hospital1 18**] ED
for further
care.
Past Medical History:
ADHD
Social History:
Singe, lives with family
Family History:
Noncontributory
Pertinent Results:
[**2153-6-2**] 08:44PM TYPE-ART TEMP-37.8 RATES-20/ TIDAL VOL-550
PEEP-5 O2-50 PO2-203* PCO2-38 PH-7.41 TOTAL CO2-25 BASE XS-0
-ASSIST/CON INTUBATED-INTUBATED
[**2153-6-2**] 08:44PM GLUCOSE-124* LACTATE-3.0* K+-4.2
[**2153-6-2**] 08:26PM CK(CPK)-5722*
[**2153-6-2**] 08:26PM CK-MB-56* MB INDX-1.0
[**2153-6-2**] 04:44PM WBC-10.0 RBC-4.13* HGB-12.6* HCT-35.4* MCV-86
MCH-30.4 MCHC-35.5* RDW-14.8
[**2153-6-2**] 04:44PM PLT SMR-LOW PLT COUNT-140*
[**2153-6-2**] 04:44PM PT-14.5* PTT-31.4 INR(PT)-1.3*
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2153-6-2**]
9:48 AM
FINDINGS: There is a nondisplaced left occipital bone fracture,
extending to
the level of the foramen magnum and superiorly to near the
vertex of the
skull. There is associated high-density material layering along
the
tentorium, likely representing a subdural hematoma. No other
foci of
hemorrhage is clearly identified. There is no edema, mass
effect, shift of
normally midline structures, or acute major vascular territorial
infarction.
Ventricles and sulci are normal in caliber and configuration.
There is fluid/blood filling a few right mastoid air cells, with
fluid/blood
within the middle ear on the right. No discrete temporal bone
fracture is
identified. There are air- fluid levels within the sphenoid
sinuses, with
areas of ossific densities within it, which may represent
osteomas. There is
also a patchy mucosal thickening of ethmoidal sinuses. There is
extensive
soft tissue swelling with air in the soft tissues overlying the
vertex of the
skull.
IMPRESSION:
1. Nondisplaced left occipital bone fracture, extending
inferiorly to the
level of foramen magnum and superiorly adjacent to the skull
vertex.
Associated layering hemorrhage within the cerebellar tentorium,
compatible
with subdural hematoma.
2. Fluid and blood within the right mastoid air cells and within
the right
middle ear. Temporal bone CT can help for further ivaluation, if
indicated.
3. Extensive soft tissue hematoma and lacerations particularly
in the region
of the vertex of the skull.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2153-6-2**]
9:52 AM
FINDINGS: There is no prevertebral soft tissue abnormality.
Cervical
lordosis is preserved. No acute fracture or malalignment of the
cervical
spine is identified. There is a fracture involving the left
occipital bone,
that is nondisplaced, extending to almost the level of the left
occipital
condyle, however, appears to largely spare the occipital
condyle. This is
better assessed on the concurrent head CT. The central canal
appears largely
patent, without evidence of an epidural hematoma. Of note, CT is
not as
sensitive as MRI for evaluation of the thecal sac. The patient
is intubated,
within an endotracheal tube visualized. Slight irregularity of
the right
styloid process is likely artifactual due to patient motion.
IMPRESSION:
1. No acute fracture or malalignment of the cervical spine.
2. Left occipital bone fracture, better assessed on concurrent
head CT.
Radiology Report CT CHEST W/CONTRAST Study Date of [**2153-6-2**] 9:49
AM
CT OF THE CHEST WITH IV CONTRAST: The heart, pericardium, and
great vessels
are unremarkable, without evidence of an acute injury. There is
no
mediastinal, hilar, or axillary lymphadenopathy.
There are linear opacities within the superior segment of the
right lower
lobe, which may represent areas of pulmonary contusion. The
lungs are
otherwise clear. There is no pneumothorax. There is no pleural
effusion. An
endotracheal tube is present.
CT OF THE ABDOMEN WITH IV CONTRAST: Tiny rounded hypodensity
within the right
lobe of the liver (2:65) is too small to characterize.
Otherwise, the liver
is unremarkable. The spleen, kidneys, adrenal glands,
gallbladder, and
pancreas are within normal limits. The stomach and small bowel
are normal.
There are a few scattered diverticula within the colon, without
evidence of
diverticulitis. There is no free air, free fluid, or adenopathy.
CT OF THE PELVIS WITH IV CONTRAST: There is air within the
bladder, which is
likely related to Foley catheter placement. The rectum and
prostate are
unremarkable. There is no pelvic free fluid or free air.
OSSEOUS STRUCTURES: No fracture is identified.
There is subcutaneous stranding of both gluteal regions, likely
reflecting
areas of injury.
IMPRESSION:
1. Possible areas of pulmonary contusion in the superior segment
of the right
lower lobe.
2. No other evidence for an acute injury.
Radiology Report for Repeat CT HEAD W/O CONTRAST Study Date of
[**2153-6-4**] 11:27 AM
FINDINGS: There has been no change in a small subdural hematoma
layering
along the left tentorium. No other sites of intracranial
hemorrhage are seen.
There has been evolution of the left frontal scalp hematoma.
Fluid levels are
noted within the sphenoid sinus. There is no mass effect, shift
of normally
midline structures, hydrocephalus, or evidence of acute vascular
territorial
infarction. Again noted is the nondisplaced left occipital
fracture which
traverses the transverse sinus.
IMPRESSION: Overall, no appreciable change compared to [**2153-6-2**].
Small
subdural hematoma layering along the left tentorium.
Nondisplaced left
occipital fracture. Fluid levels in the sphenoid sinus air
cells. Left
frontal scalp hematoma.
Radiology Report CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
Study Date of [**2153-6-15**] 10:09 AM
FINDINGS:
There is a right orbital floor fracture with herniation of fat
into the
maxillary sinus. There is no imaging evidence for muscle
entrapment although
the inferior rectus muscle does approach the fracture. No muscle
hematoma is
seen. There is no extraconal hematoma. No radiopaque foreign
bodies are
identified.
There is hyperdensity along the left tentorial reflection
compatible with
resolving subdural hematoma.
There is a fibro-osseous lesion in the right sphenoid sinus.
There is a fluid
level in the left sphenoid sinus.
A non-displaced fracture of the right nasal bone is also
suspected.
IMPRESSION:
Right orbital floor fracture without evidence for extraconal
hematoma or
imaging evidence for entrapment.
Radiology Report FEMUR (AP & LAT) LEFT Study Date of [**2153-6-16**]
10:39 AM
FINDINGS: Eight images of the femur and tibia and fibula are
compared to
prior study dated [**2153-6-2**]. Intramedullary rods seen transfixing
comminuted
fractures of the tibia and femur. Fracture of the mid fibular
shaft is also
seen. There is no evidence of hardware complication or fracture.
There is an
area of calcification seen in the suprapatellar region about the
knee.
Question whether this may represent early myositis ossificans.
Recommend
clinical correlation as to the exact location of the patient's
pain.
IMPRESSION:
No hardware complication or fracture. Area of calcification seen
in the
suprapatellar region about the left knee as noted above.
Radiology Report UNILAT LOWER EXT VEINS LEFT Study Date of
[**2153-6-18**] 7:21 PM
FINDINGS: Grayscale and color Doppler son[**Name (NI) **] of the left
common femoral,
superficial femoral, and popliteal veins were obtained. There is
normal flow,
compressibility, and augmentation. A view of the right common
femoral vein
was not obtained, at the patient's request, which is typically
obtained per
protocol.
IMPRESSION: No evidence of DVT of the left lower extremity.
Brief Hospital Course:
He was admitted to the Trauma Service. Orthopedics was consulted
urgently due to his injuries. He was taken to the operating room
on [**2153-6-2**] for IM nail and four compartment fasciotomy with
application of VAC dressing. There were no intraoperative
complications. He was again taken back to the operating room on
[**2153-6-5**] for closure of fasciotomy wounds medial and lateral.
Postoperatively he was taken to the Trauma ICU where he remained
for several days.
He was eventually weaned and extubated and was transferred to
the regular nursing unit on the following day. He was noted to
have some cognitive issues related to the traumatic brain
injury; he was started on standing Zyprexa and Trazodone was
added to help regulate his sleep wake cycle. His mental status
improved significantly. He was followed closely by Occupational
therapy for cognitive training as well as Physical therapy for
gait training and transfers.
He was noted to complain of right orbital pain and diplopia, a
facial CT scan was done which revealed a right orbital fracture
and nasal bone fracture. Ophthalmology was consulted to
determine if there was any entrapment and none was identified.
Plastics was then consulted; operative intervention was not
warranted at the time. He will need to follow up with Plastics
and Ophthalmology as an outpatient.
Urology was consulted given that he failed voiding trials x3;
Flomax had been initiated. It was recommended to trial
intermittent catheterization and if unsuccessful to replace
indwelling Foley and have patient follow up for urodynamics as
an outpatient. Patient failed intermittent catheterization and
so the Foley was replaced.
A family/team meting took place to discuss disposition as
patient was uninsured at time of crash. An application was
subsequently filed with NH Medicaid and is pending at time of
this dictation. Plans were discussed whether to discharge to a
rehab facility or to home. It was felt that if rehab was not an
option that he could be managed at home with supervision. His
mother has agreed to care for him at home. Plan for discharge to
home on [**6-23**] with his family.
He will continue on Lovenox for another 2 weeks; free care
application for this was completed. Patient and his family have
expressed an interest in getting his follow up care in NH,
closer to home. A copy of this summary will be sent to Dr. [**Name (NI) 78534**] (new PCP) office. A DVD with all of patient's radiology
imaging studies has been given to patient's mother for the
providers who will be seeing patient in NH.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constiaption.
4. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*168 Tablet Sustained Release(s)* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3
hours) as needed for breakthrough pain.
Disp:*100 Tablet(s)* Refills:*0*
6. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-27**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*1*
9. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours): take with food.
Disp:*90 Tablet(s)* Refills:*2*
10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Lovenox 40 mg/0.4 mL Syringe Sig: 0.4 ML's Subcutaneous once
a day for 2 weeks.
Disp:*14 * Refills:*0*
13. Outpatient Occupational Therapy
s/p Motor vehicle crash
Dx: Traumatic brain injury; right femur fracture
Cognitive evaluation & treatment
14. Outpatient Physical Therapy
s/p Motor vehicle crash
Dx: Traumatic brain injury, right femur fracture
WBAT
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Traumatic Brain Injury - Occipital fracture w/ ?supratentorial
SDH
Right orbital floor fracture without entrapment
Nasal bone fracture
Right pulmonary contusion
Left mid femur fracture
Left mid tibia/fubula fracture
Left thigh & calf compartment syndrome
Urinary retention
Discharge Condition:
Good
Discharge Instructions:
Because of the motor vehicle crash you sustained many injuries,
including a traumatic injury to your brain. It is not uncommon
to experience short term memory loss, periods of
irritability/changes in mood. You have been given a booklet on
brain injuries that you may refer to at anytime.
Return to the Emergency room if you develop any fevers, chills,
headache, dizziness, shortness of breath, chest pain, abdominal
pain, nausea, vomiting, diarrhea, increased redness/drainage
from your incisions and/or any other symptoms that are
concerning to you.
Followup Instructions:
Your family has indicated that you have an appointment with a
new primary care doctor for this coming [**Last Name (LF) 766**], [**6-25**]. It
has been recommended that you be referred to an Orthopedic
surgeon for your femur fracture, Urologist for your urinary
retention, Plastic surgeon for your orbital fracture,
Opthamologist for a follow up eye exam for your recent double
vision and Neurosurgeon for your brain injury.
You may if you choose follow up in [**Location (un) 86**] with the following:
Follow up in 2 weeks with Dr. [**Last Name (STitle) **] in [**Hospital 5498**] clinic,
call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks with Opthamology, call [**Telephone/Fax (1) 253**] for an
appointment.
Follow up as needed in [**Hospital 3595**] Clinic for any concerns related
to your facial fractures; call [**Telephone/Fax (1) 5343**] if an apppintment is
needed.
For any general questions or concerns related to your recent
hospital stay you may call [**First Name8 (NamePattern2) 17148**] [**Last Name (NamePattern1) 2819**], NP [**Telephone/Fax (1) 67547**] or Dr.
[**Last Name (STitle) **], Trauma Surgery at [**Telephone/Fax (1) 6429**].
Completed by:[**2153-6-25**]
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22,384
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20061
|
Discharge summary
|
report
|
Admission Date: [**2185-3-16**] Discharge Date: [**2185-4-6**]
Date of Birth: [**2112-5-1**] Sex: F
Service: MEDICINE
Allergies:
All drug allergies previously recorded have been deleted
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Tracheostomy
PICC line
History of Present Illness:
72 F with insulin dependent diabetes having refused fingersticks
lately and her daughter reportedly refusing to administer
insulin went to OSH with altered mental status. She was
intubated and found to have glucose > 1000 and hyperkalemia
without an anion gap. She was transferred to the [**Hospital1 18**] for
further management. In our ED, she was noted to have HR 83,
124/68, 14, 100%, cvp 11 and possible pancreatitis. A left IJ
was placed, an insulin drip was begun at 6 units per hours, and
750 mg of levaquin with IVF was administered. Blood and urine
cultures were obtained and she was sent to the [**Hospital Unit Name 153**]. Of note, no
paperwork was delivered with patient so initial history was per
OMR notes from [**2181**]. Later, in the [**Hospital Unit Name 153**], her daughter would
expand on the presentation and would state that the patient had
become agressive, scratching her caregivers (family) and
throwing diapers at them.
Past Medical History:
1. Coronary artery disease, status post myocardial infarction in
[**2177**].
2. Chronic atrial fibrillation.
3. History of CVA in [**2181-3-6**] with left arm paralysis
4. Insulin dependent diabetes with neuropathy and retinopathy.
5. Patient is legally blind.
6. Hypertension.
7. History of gastrointestinal bleed secondary to ulcers.
8. History of a scull fracture as a child.
9. History of chronic anemia.
10. History of urinary tract infection.
11. History of depression anxiety.
12. superficial femoral perineal artery bypass with
nonreversible saphenous vein graft [**2181**].
13. s/p left BKA [**2180**] for nonhealing heel ulcer and
14. Dyslipidemia.
PAST SURGICAL HISTORY: Significant for:
1. Coronary artery bypass graft at [**Hospital6 54007**] in the year [**2177**].
2. Cataract surgery with loss of vision.
3. Right below the knee amputation in [**2181-11-5**].
Social History:
The patient is a married female. She usually lives with her
daughter. She does not smoke. She does not drink. She has had
blood transfusions in the past.
Family History:
unknown
Physical Exam:
T 97.4 BP 87/65 with HR 65 O2 100% on AC PEEP 5 TV 400 RR 14
overbreathing by 4 FIO2 0.6
Gen: obtunded, moaning, intubated
HEENT: dry mm, eyes deviated up and to left, minimally reactive
pupils
Neck: supple, no bruits, left IJ in place without erythema
Cor: irreg irreg, no murmurs
Chest: CTAB no crackles, right nipple inverted
Abd: soft NT ND decreased bowel sounds
Ext: s/p bilateral BKAs, moving arms, right brachial reflex 2+
left diminished.
Skin: multiple escars, 3x4 cm over right hip, 4x6 under left
pannus,
2x3 on back, 6x8 cm erosions under left breast
Pertinent Results:
EKG: low voltage a.fib at 80, left axis, poor R wave
progression, TWI V3-v6, no ST changes.
.
CHEST (PORTABLE AP) [**2185-3-16**] 4:02 AM
Portable AP chest dated [**2185-3-16**] is compared to the prior from
[**2181-12-25**]. The patient is intubated. The endotracheal tube
terminates 3.9 cm above the carina. The heart size is normal.
There is no pulmonary vascular congestion. There is stable
elevation of the left hemidiaphragm. There is patchy opacity in
the left retrocardiac region, which could represent atelectasis
and/or aspiration. There is no pleural effusion or pneumothorax.
IMPRESSION: Endotracheal tube is appropriately positioned. Left
lower lung lobe patchy airspace opacity likely represents
atelectasis and/or aspiration.
CT HEAD WITHOUT CONTRAST [**3-16**]
CONCLUSION: Extensive areas of diminished density within the
cerebral hemispheres suggesting prior infarcts. If a new infarct
is suspected, MR is a more sensitive imaging modality to detect
acute brain ischemia.
CT SCAN ABDOMEN/PELVIS [**3-22**]
IMPRESSION:
1. Left parapelvic cyst, with no evidence of renal abscess or
hydronephrosis.
2. Bilateral moderate pleural effusions with adjacent
compressive atelectasis.
3. Large ascites, generalized anasarca.
4. Fluid and stranding surrounding the pancreatic head, with
heterogeneous enhancement, consistent with pancreatitis; there
is no evidence of complication.
5. Abnormal appearance of the sigmoid and distal descending
colon with hausrtral edema, a non-specific finding in a setting
of ascites; however, this may be seen in pseudomembranous and
other colitis, and should be correlated clinically.
6. Mildly distended gallbladder with enhancing borderline wall
thickening. This, too, is non-specific, and follow-up son[**Name (NI) 867**]
should be considered, if there is clinical concern for
cholecystitis.
7. Multiple splenic infarcts
[**2185-3-16**] ECHO
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure is
11-15mmHg. There is moderate regional left ventricular systolic
dysfunction
with hypokinesis of the anterior septum, anterior wall, and apex
(EF ~ 35%).
The remaining segments contract well. Right ventricular chamber
size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Regional left ventricular dysfunction consistent
with coronary
artery disease. Mild mitral regurgitation.
[**2185-3-16**] 05:46PM TYPE-MIX TEMP-36.2 RATES-/25 TIDAL VOL-330
PEEP-12 O2-40 PO2-42* PCO2-41 PH-7.33* TOTAL CO2-23 BASE XS--4
INTUBATED-INTUBATED
[**2185-3-16**] 05:24PM GLUCOSE-34* UREA N-65* CREAT-1.0 SODIUM-137
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-20* ANION GAP-13
[**2185-3-16**] 05:24PM ALBUMIN-1.7* CALCIUM-6.8* PHOSPHATE-1.6*
MAGNESIUM-1.5*
[**2185-3-16**] 05:24PM WBC-14.7* RBC-3.91* HGB-10.9* HCT-32.3*
MCV-83 MCH-27.9 MCHC-33.8 RDW-14.0
[**2185-3-16**] 05:24PM PLT COUNT-217
[**2185-3-16**] 08:10AM TYPE-MIX TEMP-36.3 RATES-18/4 TIDAL VOL-360
PEEP-5 PO2-40* PCO2-46* PH-7.34* TOTAL CO2-26 BASE XS--1
INTUBATED-INTUBATED
[**2185-3-16**] 08:10AM LACTATE-4.2*
[**2185-3-16**] 07:55AM GLUCOSE-363* UREA N-71* CREAT-1.3*
SODIUM-148* POTASSIUM-3.5 CHLORIDE-113* TOTAL CO2-22 ANION
GAP-17
[**2185-3-16**] 07:55AM LD(LDH)-243 AMYLASE-606*
[**2185-3-16**] 07:55AM LIPASE-864*
[**2185-3-16**] 07:55AM CALCIUM-7.5* PHOSPHATE-2.1* MAGNESIUM-1.9
IRON-20*
[**2185-3-16**] 07:55AM calTIBC-120 FERRITIN-GREATER TH TRF-92*
[**2185-3-16**] 07:55AM TRIGLYCER-170*
[**2185-3-16**] 07:55AM TSH-5.7*
[**2185-3-16**] 07:55AM T4-3.7* FREE T4-0.89*
[**2185-3-16**] 07:55AM URINE HOURS-RANDOM UREA N-531 CREAT-47
SODIUM-43
[**2185-3-16**] 07:55AM WBC-13.8* RBC-4.07* HGB-11.5* HCT-34.2*
MCV-84 MCH-28.2 MCHC-33.6 RDW-13.9
[**2185-3-16**] 07:55AM PLT COUNT-257
[**2185-3-16**] 07:55AM RET AUT-1.5
[**2185-3-16**] 05:20AM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.024
[**2185-3-16**] 05:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2185-3-16**] 05:20AM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-MANY
EPI-0-2
[**2185-3-16**] 04:47AM GLUCOSE-572* UREA N-75* CREAT-1.4* SODIUM-145
POTASSIUM-3.4 CHLORIDE-110* TOTAL CO2-22 ANION GAP-16
[**2185-3-16**] 04:47AM ALT(SGPT)-12 AST(SGOT)-24 LD(LDH)-235
CK(CPK)-342* ALK PHOS-108 AMYLASE-590* TOT BILI-0.4
[**2185-3-16**] 04:47AM LIPASE-1096*
[**2185-3-16**] 04:47AM CK-MB-8
[**2185-3-16**] 04:47AM ALBUMIN-1.9* CALCIUM-7.2* PHOSPHATE-2.7
MAGNESIUM-1.9
[**2185-3-16**] 04:47AM OSMOLAL-352*
[**2185-3-16**] 04:47AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-3-16**] 04:47AM WBC-15.2*# RBC-3.86* HGB-10.9* HCT-33.2*
MCV-86 MCH-28.1 MCHC-32.7 RDW-14.4
[**2185-3-16**] 04:47AM NEUTS-92.8* BANDS-0 LYMPHS-4.2* MONOS-2.7
EOS-0.1 BASOS-0.3
[**2185-3-16**] 04:47AM PLT SMR-NORMAL PLT COUNT-226# LPLT-1+
[**2185-3-16**] 04:47AM PT-13.9* PTT-32.5 INR(PT)-1.2*
[**2185-3-16**] 04:45AM LACTATE-5.4* K+-3.5
Brief Hospital Course:
Ms. [**Known lastname 634**] is a 72 year old woman with with HHNK and
pancreatitis with a hospital course complicated by respiratory
failure requiring intubation now s/p tracheostomy.
MICU events:
[**3-21**]: Respiratory arrest, bradycardic, hypotensive, with desat
to 15%. Intubated at 9:30am. Atropine given. Started on
dopamine. Bronchoscopy showed secretions, no evidence of tube
feed aspiration or plugs.
[**3-18**]: Asystolic arrest. recovered after one dose of epinephrine
and atropine. Was intubated. No EKG changes.
.
# Hypoxic respiratory failure: The etiology was thought to be
multifactorial, with an infectious component, possibly
aspiration pneumonia, as well as mucous plugging. A tracheostomy
was performed at the bedside on [**3-28**]. The patient remained
ventilator dependent, transitioning from A/C to Pressure
Support, until [**3-30**], when she had a successful trach collar
trial. She was put back on CPAP during the night and again on
trach collar [**3-31**]. She had abundant secretions during her course
which were treated with suction and mucomyst. She completed a 10
day course of meropenem for aspiration pneumonia. However,
because fever and hypotension persisted transiently on abx, as
well as diarrhea, she has also to complete a course of Flagyl
(last day [**4-5**]), Ceftriaxone (last day [**4-5**]) and Fluconazole (last
day [**4-4**]). At the time of discharge the patient was saturating
well on 12L/min trach collar with FiO2 40%. She was successfully
fitted for Passy-Muir valve.
.
# Altered mental status: Initially thought to be from HHNK but
she had persistently deviated eyes to left concerning for new
CVA, and she has h/o CVA. Head CT showed old stroke. She also
had evidence of proteus UTI. TSH was normal. Her urine grew
yeast, besides proteus, and a beta glucan was positive. Her AMS
was multifactorial, due to hyperglycemia, sepsis, and uremia.
MS resolved and returned at baseline with aggressive antibiotic
and antifungal treatment, and resolution of metabolic imbalance
and ARF.
.
# AG metabolic acidosis resolved gradually as her sugars were
brought under control. Successive urine analysis showed no
ketones.
.
# HHNK: Now resolved. Initially with serum glucose >1000 at OSH
with osms > 350 in setting of no insulin administration. Her
sugars remained between 100 and 200 and the sliding scale was
tightened and [**Last Name (un) **] consult obtained. [**Last Name (un) **] started her on
lantus 8 units daily, then increased to 12 units daily on [**3-31**].
At the time of discharge she showed good blood sugar control,
ranging from 80-170 on the 24 hours prior to discharge.
.
# Pancreatitis: Pancreatic enzymes trended down and normalized
paralleling resolution of renal failure, so this might not have
been a true pancreatitis. The patient did not have epigastric
pain.
.
# UTI: She grew proteus in blood and urine, sensitive to
meropenem and ceftriaxone. She completed a ten day course of
meropenem and a 14 day course of ceftriaxone, last dose on [**4-5**].
Later she grew yeast. She also had a positive beta glucan. She
was started on caspofungin and then switched to fluconazole,
last dose 4/30.
.
# Renal failure. ARF of pre-renal etiology, low urinary output.
The patient was severely dehydrated on presentation, and the
renal failure resolved with fluids. All medications were renally
dosed, and nephrotoxins were avoided. Her creatinine is at
baseline now.
.
# Skin breakdown/eschars over dermatomal distribution:
concerning for osteomyelitis and also for zoster. She was put on
zoster precautions, and briefly on vancomycin. Most of these
lesions were consistent with pressure sores. Wound consult and
plastics consult was obtained and, with accuzyme, air mattress,
frequent position changes, optimization of nutrition, and
zinc/vitamin C x 14 days (ongoing, last dose [**2185-4-12**]), the
wounds began to heal. However, on [**3-28**] her edema became worse
and she had true anasarca, as a result of which new skin lesions
started to develop. Lasix was started and her extremities were
apropriately dressed to avoid moisture. The patient was negative
>1L in the 24 hours prior to discharge. She requires more
diuresis. This must be followed further at her rehab facility.
.
# History of CAD: The patient had Atrial Fibrillation but no
RVR. Plavix and aspirin were held initially. Aspirin was
restarted early in the course and plavix was restarted on [**3-29**].
She was felt not to be a candidate for systemic anticoagulation
as this would exacerbate her poor wound healing. The question of
systemic anticoagulation can be readdressed as an outpatient at
a later date. The patient was initially on lopressor but this
was d/ced due to bradycardia and hypotension.
.
# Anemia: appears to be at baseline, likely anemia of chronic
disease. Iron studies were not consistent with iron deficiency
and hemolysis labs were not consistent with lysis.
.
# Pain: The patient has significant pain. She became oversedated
on a fentanyl patch. She was treated with morphine and tylenol
PRN. She stil endorsed pain on questioning and may require
uptitration of her pain medications.
.
# Hemiparesis: the patient has L hemiparesis and bilateral BKA.
A PT consult was obtained.
.
# Thrombocytopenia: HIT negative. The most likely etiology was
vancomycin as thrombocytopenia resolved once Vancomycin was
stopped.
.
# Social issues: per signout, patient has been refusing
fingersticks and daughter has been refusing to administer
insulin. Currently being investigated for possible neglect. This
issue needs to be clarified before the patient can be made
DNR/DNI. The patient stated that her health care proxy is her
daughter.
.
# Nutrition: The patient was severely malnourished at
presentation. Nutrition consult was obtained early on and
followed the patient until discharge. Tube feeds were aimed at
maximizing protein intake, and the patient tolerated well. A
Dubhoff feeding tube was placed under bronchoscopy on [**3-28**]. Zinc
and vitamin supplements were started for a course of 14 days
(last dose 5/8). The patient was thought not to be a PEG
candidate due to poor wound healing.
.
# Prophylaxis: hep SQ, PPI.
.
# Access: left IJ d/c on [**3-29**], PICC line placed [**3-29**].
.
# FULL CODE.
Medications on Admission:
Unknown
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Year (2) **]: One (1)
Injection TID (3 times a day).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Miconazole Nitrate 2 % Powder [**Month/Year (2) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
4. Lactulose 10 g/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H (every
8 hours) as needed.
5. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Atorvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Citalopram 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. Nystatin 100,000 unit/g Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
11. Acetylcysteine 10 % (100 mg/mL) Solution [**Hospital1 **]: 1-2 MLs
Miscellaneous Q4-6H (every 4 to 6 hours) as needed.
12. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day) for 14 days: Last dose [**2185-4-12**].
13. Zinc Sulfate 220 (50) mg Capsule [**Month/Day/Year **]: One (1) Capsule PO
DAILY (Daily) for 14 days: Last dose [**2185-4-12**].
14. Clopidogrel 75 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
15. Insulin Glargine 100 unit/mL Cartridge [**Month/Day/Year **]: One (1) 12
Subcutaneous at bedtime.
16. Morphine 10 mg/5 mL Solution [**Month/Day/Year **]: 1-2 mg PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
18. Aspirin 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily).
19. Albuterol Sulfate 0.083 % Solution [**Month/Day/Year **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
20. Furosemide 10 mg/mL Solution [**Month/Day/Year **]: Sixty (60) mg Injection
once a day as needed for For fluid overload for 2 days: As
needed for fluid overload. Patient still requires several liters
diuresis at goal negative 1L/day. To be reassessed by a
physician [**Name Initial (PRE) **] 2 days.
21. Papain-Urea 830,000-10 unit/g-% Spray, Non-Aerosol [**Name Initial (PRE) **]: One
(1) Appl Topical [**Hospital1 **] (2 times a day).
22. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
23. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every [**3-11**]
hours as needed for Pain or fever.
24. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (3) **]: Two (2) PO twice a
day.
25. Insulin sliding scale
Four times daily fingerstick glucose with humalog insulin
correction sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
hyperosmolar nonketotic coma
hypoxic respiratory failure
s/p trach
proteus UTI
sepsis
bradycardia
pancreatitis
anemia
thrombocytopenia
multiple pressure ulcers
hypoxic cardiac arrest following intubation, twice
Discharge Condition:
Stable, breathing comfortably on trach collar.
Discharge Instructions:
Please administer all medications and do trach care as
indicated.
.
Continue trach collar: 12L/min, FiO2 40%
.
Continue 4 times daily blood sugar monitoring with standing
insulin (glargine 12U at bedtime) and humalog sliding scale.
Followup Instructions:
Please have the patient follow up with her PCP 1-2 weeks after
discharge from rehab: [**Last Name (LF) 54008**],[**First Name3 (LF) 247**] O. [**Telephone/Fax (1) 54009**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
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"584.9",
"599.0",
"276.2",
"357.2",
"933.1",
"707.01",
"250.62",
"V49.75",
"427.5",
"428.0",
"276.51",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"33.22",
"96.71",
"31.1",
"93.90",
"96.72",
"96.04",
"38.93",
"99.60",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
17722, 17805
|
8364, 9897
|
337, 362
|
18060, 18109
|
3038, 8341
|
18389, 18693
|
2429, 2438
|
14678, 17699
|
17826, 18039
|
14646, 14655
|
18133, 18366
|
2045, 2241
|
2453, 3019
|
276, 299
|
390, 1340
|
9912, 14620
|
1362, 2022
|
2257, 2412
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,603
| 124,117
|
40663
|
Discharge summary
|
report
|
Admission Date: [**2166-5-31**] Discharge Date: [**2166-6-4**]
Date of Birth: [**2095-4-28**] Sex: F
Service: MEDICINE
Allergies:
amlodipine / Cephalosporins / Codeine / lisinopril /
pioglitazone
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
syncope, [**Last Name (un) **], GNR bacteremia
Major Surgical or Invasive Procedure:
ERCP with replacement of CBD stent
History of Present Illness:
71 yo female with new diagnosis pancreatic cancer due to get
whipple on [**6-17**], presented with sudden onset abdominal pain and
gas at 2:30 yesterday morning. She presented 1 month prior with
painless jaundice, found to have a pancreatic mass with ERCP
brushing confirming the diagnosis of pancreatic adenocarcinoma
on [**2166-5-19**]. After she felt this sudden onset abdominal gas pain
yesterday morning, she got up to go to the bathroom and vomited
multiple times. She went upstairs and became lightheaded and
weak, and subsequently fell to the ground. She hit her face and
left knee on the carpet. She noted neck pain thereafter. She
denies CP, SOB, fevers, chills, nausea, diarrhea, cough,
dysuria, visual changes. Her last BM was today with no prior
abdominal surgeries. She was seen by her PCP this afternoon,
and found to have a UTI and acute renal failure. UA revealed
mod leuk est with WBC. At PCP 2 hours ago, glucose was 171, WBC
19, crit 31, creat 1.8 (last 1.2), +UA. Per PCP note jaundice
looks worse. Her PCP did not prescribe antibiotics but rather
sent her to the ED.
.
In the ED, initial vs were: 98.1 85 108/50 16 98% on RA. Exam
jaundice, abd exam benign, no LE edema or rashes. Cspine
cleared clinically, neuro exam normal. WBC 23, lactate 3.2, 4L
IVF, vanco/zosyn. Pressures in 80's - CVL on levophed. RUQ u/s
normal with CBD stent in place, not dilated. CXR in place. V/S
prior to transfer: 98.1 76 88/50 (prior to levo) 19 97% on RA.
Access: CVL with 18G PIV.
.
On the floor, she is resting comfortably, without complaints.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Pancreatic AdenoCA- presented with painless jaundice on [**2166-5-13**]
DM neuropathy with neurologic complications
Glaucoma
Obese BMI = 31.5
Screening for colon CA: moderate diverticulosis four adenomas,
F/u 3y Murmur- echo [**9-/2161**]- Mild LVF, EF = 60% Mild LAE,
Thickening of
the AV w/o stenosis, MAC with mild MR
[**Year (4 digits) **], with history of Myxedema
[**Year (4 digits) 88948**] Hernia
Hypercholesterolemia
HTN
Anemia
Bipolar
Clostridium Perfrigens Infections
History of PUD/Gastritis/Duodenitis
Renal Mass: [**2162-5-1**]
Limb cramps
Leiomyoma of uterus
Social History:
Lives with her partner of 31 years. She has 2 [**Last Name (LF) 88949**], [**First Name3 (LF) **] and
daughter. [**Name (NI) **] - [**Name (NI) **] [**Name (NI) **] - [**Telephone/Fax (1) 88950**]. [**First Name8 (NamePattern2) 8771**] [**Last Name (NamePattern1) 13512**]
[**Telephone/Fax (1) 88951**]. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **]- partner. She previously smoked for
13 pack years and quit in [**2143**]. Denies EtOH or illicits. She
is a teacher's aide for grades [**12-4**].
Family History:
Mother: brain cancer at age [**Age over 90 **].
Father: metothelioma - 75 first in his testes.
Brother in good health.
Sister with superficial melanoma on his breast. Sister with
stomach tumor which was removed 40 years ago and now in good
health. Tumor assumed to be benign.
No h/o GI disorders of GI cancers.
2 maternal aunts with [**Name (NI) 2481**] disease.
Physical Exam:
Admission PE:
Vitals: afebrile 78 137/64 14 97% on RA
General: Alert, oriented, no acute distress, fatigued
HEENT: Sclera anicteric, MMdry, oropharynx clear, no sinus
tenderness
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: +BS, soft, non-tender, non-distended, no rebound
tenderness or guarding, no organomegaly
GU: +foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&OX3
Discharge VS:
Afebrile 152/73 p72 R20 98RA
Pertinent Results:
Admission labs:
[**2166-6-1**] 05:09AM BLOOD WBC-14.0* RBC-2.54* Hgb-7.8* Hct-24.2*
MCV-95 MCH-30.8 MCHC-32.3 RDW-16.0* Plt Ct-226
[**2166-5-31**] 06:40PM BLOOD WBC-22.9*# RBC-3.09* Hgb-9.4* Hct-28.7*
MCV-93 MCH-30.4 MCHC-32.7 RDW-16.7* Plt Ct-264
[**2166-5-31**] 06:40PM BLOOD Neuts-73* Bands-23* Lymphs-2* Monos-1*
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2166-6-1**] 05:09AM BLOOD Glucose-152* UreaN-40* Creat-1.5* Na-141
K-4.0 Cl-107 HCO3-24 AnGap-14
[**2166-5-31**] 06:40PM BLOOD Glucose-258* UreaN-43* Creat-2.1* Na-137
K-5.2* Cl-99 HCO3-23 AnGap-20
[**2166-6-1**] 05:09AM BLOOD ALT-303* AST-243* LD(LDH)-215
AlkPhos-248* TotBili-3.7*
[**2166-5-31**] 06:40PM BLOOD ALT-375* AST-391* AlkPhos-315*
TotBili-4.8*
[**2166-6-1**] 06:11AM BLOOD Lactate-1.2
[**2166-5-31**] 06:46PM BLOOD Lactate-3.2*
[**2166-6-1**] 06:07AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2166-6-1**] 06:07AM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2166-6-1**] 06:07AM URINE RBC-0 WBC-180* Bacteri-FEW Yeast-NONE
Epi-<1
Discharge labs:
[**2166-6-4**] 05:00AM BLOOD WBC-10.6 RBC-3.06* Hgb-9.5* Hct-28.6*
MCV-93 MCH-31.1 MCHC-33.3 RDW-15.8* Plt Ct-281
[**2166-6-4**] 05:00AM BLOOD Glucose-68* UreaN-18 Creat-1.0 Na-142
K-4.2 Cl-105 HCO3-25 AnGap-16
[**2166-6-4**] 05:00AM BLOOD Calcium-9.4 Phos-2.9 Mg-1.9
[**2166-6-4**] 05:00AM BLOOD ALT-122* AST-33 AlkPhos-221* TotBili-2.0*
MICRO:
[**2166-6-1**] URINE URINE CULTURE-Negative
[**2166-6-1**] URINE URINE CULTURE-Negative
[**2166-6-1**] Blood Culture, Routine-PENDING INPATIENT
[**2166-6-1**] Blood Culture, Routine-PENDING INPATIENT
[**2166-6-1**] MRSA SCREEN MRSA SCREEN-No MRSA isolated
[**2166-5-31**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {KLEBSIELLA PNEUMONIAE}; Anaerobic Bottle
Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
Blood Culture, Routine (Final [**2166-6-3**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12176**],7/03/11,8:35AM.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of [**2166-5-31**]
IMPRESSION:
1. Pneumobilia with no intrahepatic or extrahepatic biliary
ductal dilataion.
2. No evidence of acute cholecystitis.
3. Hypoechoic mass involving head of the pancreas is better
characterized on CTA torso of [**2166-5-20**].
.
[**2166-6-1**] - ercp report
Impression: Stent in the major papilla - this had migrated
proxiamlly into the bile duct. This was removed.
Biliary stricture in the lower third of the bile duct.
A double pig-tail stent was placed.
(stent placement)
Otherwise normal ercp to third part of the duodenum
Recommendations: Return to ICU. Continue antobiotics and
supportive care.
Repeat ERCP with Dr. [**Last Name (STitle) **] in 8 weeks if patient does not
undergo surgery.
Brief Hospital Course:
71 yo female with new diagnosis of pancreatic adenocarcinoma
with recent cbd stent and decompression presented with fever and
septic shock.
# Sepsis
# Klebsiella bacteremia
# Probable Cholangitis
# Biliary obstruction
# Cholestatic hepatitis
# Urinary tract infection
Patient presented wtih abdominal pain, found to have fever,
leukocytosis, renal failure, and hypotension that was refractory
to IVF. She was on levophed in the ED, but was quickly weaned
off levophed in the ICU and required no further support after
proper fluid resuscitation. Differential for source included
UTI given mild urinalysis however, patient did not have any
symptoms of a UTI. Cholangitis was also a possibility as CBD
stent migrated proximally and LFTs were elevated. Tbili was 5
at admission when it was initially 15 prior to decompression.
[**1-1**] BCx positive for GNRs, which later found to be klebsiella.
Placed on vanc/zosyn prior to cultures with good resolution of
symptoms, ERCP was consulted. ERCP found the CBD stent had
migrated; the stent was replaced and her LFT's subsequently
downtrended. Her blood cultures grew pan-senstitive klebsiella,
and her antibiotics were changed to Cipro, with plans for a 2
week course (from date of ERCP).
# Pancreatic cancer
Dr.[**Name (NI) 9886**] surgical service followed throughout the
hospitalization. She is scheduled for Whipple with Dr. [**Last Name (STitle) 468**]
[**2166-6-17**]. She has been scheduled for pre-op testing.
# Acute on chronic kidney disease
Suspect patient's acute renal failure was likely due to acute
infection/sepsis, with pre-renal failure. Her renal function
gradually improved, and her Cr was 1.0 at the time of discharge.
# Hypertension
It was noted that her home Diovan had previously been
discontinued in the setting of acute renal failure, which
appears to have been in the setting of acute infection. Blood
pressure medications were initially held in the setting of
sepsis, however, with improvement in infection, she became
hypertensive. She was resumed on Valsartan 80 mg po q day, but
the HCTZ was continued to be held on discharge.
# T2 diabetes
Associated with neuropathy. Continued on her home insulin
regimen.
# Bipolar disorder
Her lithium dose was initially decreased given acute renal
failure, but she was resumed on her home dosing prior to
discharge, as her renal function had returned to baseline.
Medications on Admission:
1. levothyroxine 125 mcg Tablet PO DAILY
2. lithium carbonate 300 mg PO QHS - not taking for one week
3. humulin 24 u qAM, 32 qPM
4. dorzol/timolol 2-0.05%OP [**Hospital1 **]
5. lumigan 2.5mg daily
Discharge Medications:
1. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO QHS
(once a day (at bedtime)).
3. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): R eye.
4. bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic qhs ()
as needed for glucoma: R eye.
5. valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. NPH insulin human recomb 100 unit/mL Suspension Sig: as
directed units Subcutaneous twice a day: 24 units q am; 32 units
q pm.
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
8. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day as needed for constipation: may purchase over the counter.
Discharge Disposition:
Home
Discharge Diagnosis:
# Sepsis
# Klebsiella bacteremia
# Probable Cholangitis
# Biliary obstruction
# Cholestatic hepatitis
# Urinary tract infection
# Acute renal failure
# Pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with nausea, vomiting, chills and found to
have bacteria in your blood. Due to low blood pressure, you
required admission to the intensive care unit as well as
medications to keep your blood pressure up. You improved rapidly
with antibiotics and it was unclear whether or not this was due
to an infection starting in your urinary tract, biliary tree or
elsewhere. You underwent an ERCP and your old stent was replaced
with a new one.
You should continue to take oral antibiotics to complete a 2
week course
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2166-6-9**] at 10:45 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PAT PREADMISSION TESTING
When: MONDAY [**2166-6-9**] at 12:30 PM
With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Last Name (LF) 7356**], [**Name8 (MD) **], NP
Location: [**Hospital3 **] MEDICAL CENTER-[**Location (un) **]
Address: 75 [**State **], [**Location (un) **],[**Numeric Identifier 85712**]
Phone: [**Telephone/Fax (1) 17663**]
When: Monday, [**6-16**], 1:45PM
|
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icd9cm
|
[
[
[]
]
] |
[
"51.10",
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icd9pcs
|
[
[
[]
]
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11717, 11723
|
8209, 10607
|
372, 408
|
11937, 11937
|
4589, 4589
|
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|
3613, 3978
|
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10633, 10833
|
12088, 12614
|
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|
3993, 4570
|
2027, 2458
|
286, 334
|
436, 2008
|
4606, 5675
|
11952, 12064
|
2480, 3056
|
3072, 3597
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,164
| 108,132
|
54650
|
Discharge summary
|
report
|
Admission Date: [**2118-7-4**] Discharge Date: [**2118-7-8**]
Date of Birth: [**2065-6-12**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hematemasis
Major Surgical or Invasive Procedure:
EGD ([**7-6**])
Intubation ([**7-5**])
Dialysis (started on [**7-6**])
Central line in left IJ (started on [**7-5**])
History of Present Illness:
This is a 53 yo male with a history of alcoholic cirrhosis and
type 2 DM presenting with vomiting dark brown material for 1
week. The patient reports that 7 days prior to admission that
he vomiting dark coffee colored emesis, followed by diarrhea of
with dark red stool the following day. He also develop
epigastric/RUQ abdominal 6 days prior to admission. He was
admitted to an OSH at that time, but left AMA (unclear what
day). After arriving home he continued to have intermittent
abdominal pain, dark brown emesis, but denies having stools for
the past 2-3 days. He continued to vomit so he returned to
[**Location 111781**] General, who gave him protonix 80mg, 25grams of
25%albuin, vancomycin 1 gram, ctx 1gram, 2mg of PO lorazepam,
1mg of IV ativan vitamin K 10mg IV x 1 dose. Basic labs were
also obtained (see records for details) and transferred him to
[**Hospital1 18**] for further management.
In the ED, initial VS were: 106 129/55 20 100% The patient was
started on an octreotide gtt. A CBC reveal a Hct of 29 (down
from 32 at OSH) and the patient was admitted to the MICU for
further management.
After arrival to MICU, the patient vomited coffee ground emesis.
Past Medical History:
Alcohol abuse
Cirrhosis
Type 2 DM
Social History:
- Tobacco: 1 [**11-29**] pack x 20-30 years
- Alcohol: heavy drinker, told to stop > 1 year ago, last drink
2 weeks ago
- Illicits: mj, denies IVDA:
Family History:
Non-contributory
Physical Exam:
Vitals: T 97.2 BP 121/36 HR 101 RR 30 SpO2 97% RA
General: Alert, oriented, jauncided
HEENT: Sclera icteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Tense, distended, non-tender, bowel sounds present, no
organomegaly
Skin: Jaundice, spider angiomas
Ext: warm, well perfused, palmar eythema, 2+ pulses, no
clubbing, cyanosis or edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred,
Discharge Exam:
Deceased
Pertinent Results:
IMAGING:
EGD ([**2118-7-6**]):
No esophageal varices. Diffuse portal hypertensive gastropathy.
Coffee ground material seen in the stomach, no ulcers or
erosions, no gastric varices. No signs of active bleeding.
Otherwise normal EGD to second part of the duodenum.
EKG ([**2118-7-5**]):
Sinus tachycardia. Compared to the previous tracing of [**2118-7-4**]
there is now
marked ST segment depression in leads I, II, III and aVF and
V3-V6,
downsloping in appearance. These findings are consistent with
global ischemic process. Rule out myocardial infarction.
Followup and clinical correlation are suggested.
Rate PR QRS QT/QTc P QRS T
108 130 104 376/460 71 60 -26
Abdominal x-ray ([**2118-7-5**])
CLINICAL HISTORY: 53-year-old man with concern for ischemic
bowel. Evaluate for acute intra-abdominal process.
COMPARISON: None.
FINDINGS: Single portable supine view of the abdomen is
provided. There are gas filled loops of small and large bowel
throughout the abdomen ,NG tube tip within the stomach.
Underlying bony structures are unremarkable.
Imp: non-specific pattern, no definite ileus or obstruction.
Abdominal ultrasound ([**2118-7-5**])
1. Findings of cirrhosis with some variation in size of liver
nodularity.
Liver MRI or multi-phasic CT is recommended for further
evaluation.
2. Gallbladder sludge without evidence of cholelithiasis or
cholecystitis.
3. Small amount of intraperitoneal ascites and splenomegaly.
4. Normal Doppler evaluation of the hepatic vasculature.
ADMISSION LABS:
[**2118-7-4**] 06:13PM BLOOD WBC-26.7* RBC-2.68* Hgb-9.2* Hct-29.0*
MCV-108* MCH-34.4* MCHC-31.7 RDW-15.3 Plt Ct-213
[**2118-7-4**] 06:13PM BLOOD Neuts-80* Bands-6* Lymphs-7* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2118-7-4**] 06:13PM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-3+ Microcy-1+ Polychr-1+ Burr-1+
[**2118-7-4**] 06:13PM BLOOD PT-38.0* PTT-50.5* INR(PT)-3.7*
[**2118-7-4**] 09:53PM BLOOD
[**2118-7-4**] 06:13PM BLOOD Glucose-98 UreaN-55* Creat-4.5* Na-130*
K-5.7* Cl-87* HCO3-13* AnGap-36*
[**2118-7-4**] 09:53PM BLOOD ALT-75* AST-162* LD(LDH)-353* AlkPhos-104
TotBili-4.2*
[**2118-7-4**] 09:53PM BLOOD Albumin-2.7* Calcium-7.1* Phos-9.4*
Mg-2.1
[**2118-7-4**] 11:07PM URINE Color-GREEN Appear-Cloudy Sp [**Last Name (un) **]-1.019
[**2118-7-4**] 11:07PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-TR Ketone-10 Bilirub-LG Urobiln-NEG pH-5.0 Leuks-MOD
[**2118-7-4**] 11:07PM URINE RBC-2 WBC-7* Bacteri-FEW Yeast-NONE Epi-1
[**2118-7-4**] 11:07PM URINE CastHy-3*
[**2118-7-4**] 11:07PM URINE Mucous-RARE
[**2118-7-4**] 11:07PM URINE
[**2118-7-4**] 10:30PM ASCITES WBC-161* RBC-112* Polys-4* Lymphs-3*
Monos-0 Eos-3* Mesothe-16* Macroph-74*
[**2118-7-4**] 10:30PM ASCITES TotPro-0.5 Albumin-LESS THAN
RELEVENT LABS:
[**2118-7-5**] 02:26AM BLOOD CK-MB-4 cTropnT-0.03*
[**2118-7-5**] 10:21AM BLOOD CK-MB-8 cTropnT-0.16*
[**2118-7-4**] 09:53PM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE
[**2118-7-4**] 09:53PM BLOOD HCV Ab-NEGATIVE
[**2118-7-4**] 09:53PM BLOOD AFP-3.6
[**2118-7-5**] 05:07AM BLOOD Type-[**Last Name (un) **] Temp-36.4 O2 Flow-2 pO2-55*
pCO2-22* pH-7.21* calTCO2-9* Base XS--17 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2118-7-5**] 05:07AM BLOOD Lactate-14.1*
Brief Hospital Course:
Mr. [**Known lastname **] is a 53 yo male with h/o alcoholic cirrhosis who
presented to [**Hospital1 18**] with coffee ground emesis and a hematocrit
drop to 25. On admission he was talking but subequently went
into acute liver failure, acute tubular necrosis renal failure
and respiratory failure. He was intubated and was started on
CVVH to correct his worsening electrolytes. EGD was performed
during the first 24 hour which showed no ulcers, erosions or
varices. He was coagulopathic and was transfused 5 units of prBC
and 5 units of FFP with slight increase of his hematocrit. He
was stablized over a couple of days. On [**7-7**] he developed melena,
increased Fio2 requirement and his CVVH stopped functioning. He
developed a lactic acidosis. During this time his liver
function worsened and his Bilirubin increased to 35, and he was
not a transplant candidate. Given his grave prognosis, goals of
care were discussed with his HCP in light of his worsening
clinical status and it was decided to make the patient CMO. He
was terminally extubated and time of death owas 1650 on [**2118-7-8**].
Medications on Admission:
None
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Alcohol cirrhosis
Discharge Condition:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"276.4",
"V49.86",
"780.97",
"275.3",
"571.1",
"571.2",
"789.59",
"572.4",
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"453.86",
"250.00",
"578.0",
"570",
"537.89",
"572.2",
"303.91",
"305.1",
"578.1",
"V66.7",
"275.41",
"288.60",
"411.89",
"291.81",
"518.81",
"276.52",
"572.3",
"285.1",
"458.9",
"996.1",
"286.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"39.95",
"94.62",
"45.13",
"54.91",
"38.95",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7054, 7063
|
5868, 6970
|
321, 440
|
7125, 7271
|
2623, 4114
|
1897, 1915
|
7025, 7031
|
7084, 7104
|
6996, 7002
|
1930, 2578
|
2594, 2604
|
270, 283
|
468, 1656
|
4130, 5845
|
1678, 1714
|
1730, 1881
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,926
| 142,332
|
40245
|
Discharge summary
|
report
|
Admission Date: [**2156-12-19**] Discharge Date: [**2157-1-3**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
found down, transfer from OSH with concern for Right MCA
infarct
Major Surgical or Invasive Procedure:
Endotracheal intubation
Bronchoscopy
History of Present Illness:
88 year old right handed woman with a large posterior scalp
mass but no other significant medical history who was brought to
an OSH after having been found down and head CT was concerning
for a right parietal infarct.
Per patient, several nights ago she slid out of her bed and has
been unable to move. She didn't initially note weakness or
difficulty with speech although her mental status limits the
history she provides. She reports she was able to call her
neighbors to do her shopping, and they apparently found her down
and called EMS and brought her to an OSH this evening. At the
OSH, BP 177/81, she was lethargic, dry appearing, and mucuous
plugs were suctioned. She was noted to be in afib with RVR. CT
head revealed small wedge shaped srea of low density in the
right
parietal lobe, atrophy, small vessel disease, and a posterior
scalp mass. She was given 5mg lopressor x 2, CTX x 1, zithromax
x 1, 3L NS. LFTS increased, troponin 0.15, CK 611. CXRAY showed
left sided opacification. CT neck done without obvious fracture
and pelvic films also negative. Transferred to [**Hospital1 18**] for further
managment.
In the ED, she is sfebrile, requiring 3L O2. Labs, CTA head and
neck requested, remains in afib and cardiology consulted with
initiation of a heparin gtt. Also given lopressor 5 mg x 1.
Troponin trended downwards. Given vancomycin and admitted to ICU
for further care.
Past Medical History:
large posterior scalp massl patient says surgery postponed
because PCP recently retired
per patient scalp sugery in the [**2105**], broken ankle in [**2114**]
anemia
Social History:
lives alone, retired English school teacher, nonsmoker,
denies alcohol, has a cousin in [**State 5887**], uses a cane
Family History:
unknown
Physical Exam:
T-97.9 BP-124/85 HR- 128RR- 20 O2Sat 100%3L
Gen: Lying in bed, noisy breathing
HEENT: large poterior scalp mass, moist oral mucosa
Neck: supple
CV: tachy
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
Skin: erythematous areas over LE
ext: no edema
Neurologic examination:
Mental status:
General: alert, awake, normal affect
Orientation: oriented to person, [**Hospital1 756**], [**2156-12-18**] but says
incorrect day -asks if it is tues, wed, thursday?.
Executivefunction:
*Follows simple axial and appendicular commands: closes and
opens
his eyes, shows tongue. releases a grip at command.
Speech/Language: dysarthria pronounced, repetition intact
Praxis/ agnosia: Able to demonstrate how to brush teeth and comb
hair
No field cuts: to red pin in different quadrants.
Able to tell how many people there are in the room .
Calculations: incorrect: says 7 quarters in 2.75
Cranial Nerves:
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V1-3: Sensation intact V1-V3.
VII: left facial droop
VIII: Hearing intact to finger rub bilaterally.
IX & X: Palate elevation symmetric. Uvula is midline.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength bilaterally.
XII: Good bulk. No fasciculations. Tongue midline, movements
intact.
Motor:
Normal bulk bilaterally.
Delt; C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7
Left 1 0 1 0 0
Right 5 5 5 5 5
.
IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex
Left 4+ 5 5 5 5 5
Right 4+ 5 5 5 5 5
.
Deep tendon Reflexes:
.
Biceps: Tric: Brachial: Patellar: Achilles Toes:
Right 1 1 1 1 1 mute
Left 1 1 1 1 1 up
.
Sensation: Intact to light touch, vibration
Coordination: finger-nose-finger normal on right only
Gait: untested
Romberg: untested
ON DISCHARGE
T 96.6 P 90s-110s BP 142/56 RR 21 SpO2 98% (40% facemask)
HEENT: large posterior scalp [**Hospital3 **]: eyes open lynig in bed w/ tachypnea
Pulm: crackles b/l at bases
CV: irregular, nS1S2
Abd: soft, NT
Ext: no edema
Neuro: MS: alert w/ eyes open - unresponsive to sternal rub, not
following simple commands
CN: II - XII intact, pupils react, EOMI
Motor: R side withdraws to noxious stim; L side minimal movement
Pertinent Results:
WBCs 17.5
CXR ([**1-2**])
One view. Comparison with the previous study done [**2156-12-30**]. There
is motion
artifact. Retrocardiac consolidation appears stable. There is
streaky
density in the lower right lung likely representing subsegmental
atelectasis and evidence of a small right effusion as before.
The heart and mediastinal structures are unchanged in
appearance. A feeding tube and PICC line remain in place.
EEG ([**12-29**])
This is an abnormal routine EEG due to slowing and
disorganization of the low voltage background, indicative of a
moderate
to severe encephalopathy. Toxic, metabolic and infectious
disturbances
are common causes. No evidence of epileptiform discharges,
electrographic seizures or nonconvulsive status epilepticus was
seen
during this recording. There were no prominent focal
abnormalities, but
encephalopathies may obscure focal findings.
CT (head)[**2156-12-22**]
1. Acute infarction, predominantly in the right MCA territory,
but also
involving left corona radiata, redemonstrated. No evidence of
extension, new infarction, or hemorrhagic conversion.
2. Large posterior scalp soft tissue mass redemonstrated, again
possibly
representing extensive venolymphatic malformation or hemangioma,
or other
non-aggressive process, with other differential diagnostic
considerations as outlined in the report of very recent MRI.
TTE [**2156-12-20**]
The left atrium is moderately dilated. No thrombus/mass is seen
in the body of the left atrium. No atrial septal defect is seen
by 2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
mild to moderate global left ventricular hypokinesis (LVEF =
40%). No masses or thrombi are seen in the left ventricle. There
is no ventricular septal defect. Right ventricular chamber size
is normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a very small
pericardial effusion. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
Stroke
Patient was admitted after being found down. She was found to
have a right parietal infarct. Her exam worsened during the
hospitalization and she required intubation for pulmonary
distress. Stroke was thought secondary to cardioembolic source
and patient was found to be intermittently in Atrial
Fibrillation. Vessel imaging and cardiac echo revealed no
dissections and no vegetations. She was on heparin therapy and
bridged to coumadin while she had a NGT in place. She pulled out
the tube on [**2157-1-2**] and decision was made not to replace it.
Pneumonia
Patient was in respiratory distress and required intubation. She
had two bronchoscopies which did not reveal any culture positive
organisms. She was extubated after discussions with her HCP, but
continued to be in respiratory distress requiring 40% facemask
with sats in the 80s-90s. Decision on [**2157-1-3**] to make CMO after
discussion with her HCP.
Comfort Measures
Discussion was had with her HCP [**First Name8 (NamePattern2) **] [**Name (NI) 916**], [**Telephone/Fax (1) 88347**]) and
decision was made to withdraw care and make CMO after she pulled
out her NGT, and failed to improve clinically. She was
transferred to hospice care.
Medications on Admission:
None
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain.
2. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal ONCE (Once) for 1 doses.
3. morphine concentrate 20 mg/mL Solution Sig: 0.25 - 1.0 ml PO
Q2H (every 2 hours) as needed for discomfort.
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 11729**] Home - [**Location (un) 686**]
Discharge Diagnosis:
Left parietal stroke
Pneumonia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic and minimally responsive
Activity Status: Bedbound.
Discharge Instructions:
Patient was admitted to the hospital after being found down.
Initially the patient was in respiratory distress and intubated
in the ICU. Bronchoscopy was negative for infection, and
endotracheal tube was taken out after discussion with health
care proxy. After being minimally responsive for one week
outside of the ICU, thre decision was made to make comfort
measures only.
- administer SL morphine for distress
- administer SL Ativan for agitation
- scopolamine patch for secretions
Followup Instructions:
Patient made CMO
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2157-1-3**]
|
[
"427.31",
"707.21",
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"V66.7",
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"276.3",
"707.07",
"790.5",
"112.2",
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"E884.4",
"729.90",
"342.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8904, 8987
|
7207, 8420
|
318, 357
|
9062, 9062
|
4723, 7184
|
9718, 9876
|
2126, 2135
|
8475, 8881
|
9008, 9041
|
8446, 8452
|
9208, 9695
|
2150, 2417
|
213, 280
|
385, 1783
|
3065, 4704
|
9077, 9184
|
2441, 2441
|
1805, 1973
|
1989, 2110
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,937
| 141,549
|
29782
|
Discharge summary
|
report
|
Admission Date: [**2133-2-16**] Discharge Date: [**2133-2-26**]
Date of Birth: [**2092-7-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Chest Tube Placement
Central Line Placement
PICC Line placement
History of Present Illness:
40 yo M with IPF, s/p double lung tx [**2128**], h/o recurrent
pneumonia, chronic rejection and obliterative bronchiolitis,
polymiositis presents with acute on chronic respiratory failure.
Was sent from [**Hospital3 672**] Rehab for hypoxia (O2 sat 78%) and
lethargy, also some report of migratory chest pain/pleuritic CP.
Vent settings prior to event AC 400/15/0.40/5, started to be
ambu bagged with improvement to 96%, then placed on FiO2 100%
but decreased again to 80%. At baseline can write and interact
with staff but was not doing so today. Was satting 78% on vent
there with difficulty suctioning.
.
In the ED, VS T 101.4 HR 98, BP 132/64, O2 sat 88%, suctioned
here without improvement. ABG 7.05/190/111-->6.98/204/119.
Patient was bronched by pulm in ED, airways were found to be
patent. Considered replacing trach vs intubation and removal of
trach, but ultimately, was started on heliox and thought to be
doing better. Also given Zosyn and flagyl for likely aspiration
PNA on CXR. CT performed in ED given report of pleuritic CP.
Patient was also transiently hypotensive from 110s to 90s,
received fluid bolus total 4L and started on stress dose
steroids.
Past Medical History:
- IPF dx in [**2122**], s/p b/l lung transplant in [**2128**] c/b chronic
resp failure vent dependent since [**2-7**] s/p tracheostomy/PEG
- h/o trach dislodgement s/p revision with dilation and
placement of [**Last Name (un) 295**] #8 trach
- PFTs [**1-6**]: FEV1 0.38, FVC 0.81, FEV1/FVC 47%
- h/o multiple PNAs, aspiration - h/o pseudomonas, algaliceus
species, aspergillus
- h/o Polymyositis, anti-[**Doctor First Name **] negative, [**Doctor First Name **] +, ?cause for IPF
- h/o esophageal dysmotility, GERd
- Hypertension
- h/o A.fib
- Hyperlipidemia
- DM, h/o DKA in past
- h/o sacral decubiti
- h/o ESBL Proteus UTI
- h/o VRE/MRSA
- CRI (?baseline Cr)
- ?h/o seizure disorder (documented in one note, not in [**Hospital1 2025**]/[**Hospital1 112**]
notes)
Social History:
Lives at [**Hospital 671**] Rehab, wife is supportive. Has two sons. [**Name (NI) **]
drinking, smoking, drug use.
Family History:
NC
Physical Exam:
VS: T 97.0 BP 117/71 HR 93 Vent: AC 280/20/0.4/8 O2 sat 82->100%
GEN: intubated, NAD
HEENT: Op moist, PERRL, EOMI, aniceric
LUNGS: diminished air movement, no wheezing/rales
CVS: nl S1 S2, tachy, regular, no m/r/g appreciated
ABD: soft, NT/ND, BS+, no HSM appreciated
EXT: warm, wasted, no edema, 2+ dp pulses
NEURO: opening eyes, following commands, normal muscle tone
Pertinent Results:
[**2133-2-16**] 08:23AM BLOOD WBC-21.7* RBC-3.08* Hgb-8.7* Hct-30.0*
MCV-97 MCH-28.3 MCHC-29.1* RDW-14.9 Plt Ct-340
[**2133-2-18**] 07:43AM BLOOD WBC-14.3* RBC-2.68* Hgb-7.7* Hct-25.4*
MCV-95 MCH-28.6 MCHC-30.2* RDW-14.9 Plt Ct-273
[**2133-2-19**] 04:23AM BLOOD WBC-7.9 RBC-2.33* Hgb-6.8* Hct-21.6*
MCV-93 MCH-29.0 MCHC-31.2 RDW-14.8 Plt Ct-176
[**2133-2-24**] 03:50AM BLOOD WBC-10.3 RBC-3.16* Hgb-8.9* Hct-28.6*
MCV-91 MCH-28.1 MCHC-31.0 RDW-15.5 Plt Ct-240
[**2133-2-16**] 08:23AM BLOOD Neuts-77* Bands-3 Lymphs-7* Monos-8 Eos-2
Baso-1 Atyps-0 Metas-2* Myelos-0
[**2133-2-22**] 03:50AM BLOOD Neuts-91.2* Lymphs-3.8* Monos-4.3 Eos-0.5
Baso-0.2
[**2133-2-16**] 08:23AM BLOOD Hypochr-2+ Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-NORMAL
Polychr-NORMAL Ovalocy-OCCASIONAL
[**2133-2-16**] 08:23AM BLOOD PT-11.1 PTT-24.8 INR(PT)-0.9
[**2133-2-19**] 04:23AM BLOOD PT-11.1 PTT-38.4* INR(PT)-0.9
[**2133-2-22**] 06:40AM BLOOD PT-11.4 PTT-35.4* INR(PT)-1.0
[**2133-2-24**] 03:50AM BLOOD Plt Ct-240
[**2133-2-18**] 07:43AM BLOOD Ret Aut-1.1*
[**2133-2-19**] 04:23AM BLOOD Fibrino-444*
[**2133-2-16**] 08:23AM BLOOD Glucose-181* UreaN-33* Creat-1.2 Na-142
K-5.8* Cl-97 HCO3-41* AnGap-10
[**2133-2-20**] 02:48AM BLOOD Glucose-124* UreaN-50* Creat-1.6* Na-139
K-4.9 Cl-100 HCO3-35* AnGap-9
[**2133-2-23**] 03:52AM BLOOD Glucose-93 UreaN-41* Creat-1.4* Na-142
K-6.3* Cl-108 HCO3-30 AnGap-10
[**2133-2-24**] 03:50AM BLOOD Glucose-91 UreaN-35* Creat-1.3* Na-145
K-4.7 Cl-108 HCO3-32 AnGap-10
[**2133-2-16**] 08:23AM BLOOD CK(CPK)-62
[**2133-2-16**] 04:09PM BLOOD CK(CPK)-26*
[**2133-2-19**] 04:23AM BLOOD TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2133-2-21**] 03:58AM BLOOD ALT-12 AST-19 LD(LDH)-207 AlkPhos-61
Amylase-637* TotBili-0.1
[**2133-2-22**] 03:50AM BLOOD Amylase-321*
[**2133-2-23**] 09:15AM BLOOD ALT-11 AST-20 LD(LDH)-222 AlkPhos-57
Amylase-132* TotBili-0.2
[**2133-2-24**] 03:50AM BLOOD ALT-10 AST-19 AlkPhos-56 Amylase-109*
[**2133-2-21**] 03:58AM BLOOD Lipase-514*
[**2133-2-22**] 03:50AM BLOOD Lipase-87*
[**2133-2-24**] 03:50AM BLOOD Lipase-35
[**2133-2-16**] 08:23AM BLOOD CK-MB-3 cTropnT-0.02*
[**2133-2-16**] 04:09PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2133-2-16**] 08:23AM BLOOD Calcium-8.9 Phos-5.0* Mg-1.7
[**2133-2-22**] 03:50AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.1
[**2133-2-24**] 03:50AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.8
[**2133-2-21**] 03:58AM BLOOD Vanco-55.4*
[**2133-2-23**] 09:15AM BLOOD Vanco-28.1*
[**2133-2-18**] 04:35AM BLOOD Hapto-222*
[**2133-2-17**] 08:30AM BLOOD FK506-8.0
[**2133-2-18**] 04:35AM BLOOD FK506-7.1
[**2133-2-20**] 02:48AM BLOOD FK506-11.0
[**2133-2-23**] 09:30AM BLOOD FK506-6.3
[**2133-2-24**] 03:50AM BLOOD FK506-6.5
[**2133-2-16**] 08:24AM BLOOD Type-ART Tidal V-350 FiO2-60 pO2-111*
pCO2-190* pH-7.05* calTCO2-56* Base XS-14 -ASSIST/CON
Intubat-NOT INTUBA
[**2133-2-16**] 10:07AM BLOOD Type-ART PEEP-5 pO2-119* pCO2-204*
pH-6.98* calTCO2-52* Base XS-9 -ASSIST/CON Intubat-INTUBATED
[**2133-2-16**] 12:13PM BLOOD Type-ART Temp-36.1 Rates-20/ Tidal V-300
PEEP-5 FiO2-40 pO2-41* pCO2-93* pH-7.26* calTCO2-44* Base XS-10
Intubat-INTUBATED Vent-CONTROLLED
[**2133-2-16**] 08:01PM BLOOD Type-ART pO2-62* pCO2-101* pH-7.21*
calTCO2-43* Base XS-8 -ASSIST/CON Intubat-INTUBATED
[**2133-2-18**] 07:55AM BLOOD Type-ART pO2-96 pCO2-92* pH-7.25*
calTCO2-42* Base XS-9
[**2133-2-18**] 02:19PM BLOOD Type-ART Temp-37.7 Rates-20/26 Tidal
V-280 PEEP-8 FiO2-50 pO2-66* pCO2-106* pH-7.16* calTCO2-40* Base
XS-4 -ASSIST/CON Intubat-INTUBATED
[**2133-2-18**] 03:28PM BLOOD Type-ART pO2-426* pCO2-107* pH-7.19*
calTCO2-43* Base XS-8
[**2133-2-18**] 06:58PM BLOOD Type-ART pO2-102 pCO2-80* pH-7.28*
calTCO2-39* Base XS-6
[**2133-2-22**] 09:11AM BLOOD Type-ART Temp-37.3 pO2-74* pCO2-71*
pH-7.26* calTCO2-33* Base XS-1
[**2133-2-16**] 08:24AM BLOOD Glucose-189* Lactate-0.6 Na-143 K-5.4*
Cl-90*
[**2133-2-16**] 12:13PM BLOOD Glucose-154* Lactate-0.6
[**2133-2-16**] 08:24AM BLOOD freeCa-1.29
[**2133-2-19**] 04:23AM BLOOD B-GLUCAN-PND
[**2133-2-20**] 02:48AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
.
Other: Pleural Fluid
WBC 133 RBC [**Numeric Identifier 71271**] Poly 61 Lymph 31 Mono 6 Meso 1 Macro 1
LDH 336 TP 2.5 Gluc 108 pH 7.44
Mycoplasma Pneumonia pending
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2133-2-16**] 10:34 AM
.
CTA CHEST WITHOUT AND WITH IV CONTRAST: The pulmonary arteries
are patent without evidence of filling defects to suggest
pulmonary embolism. The heart, pericardium, and great vessels
are within normal limits. Small mediastinal lymph nodes do not
meet CT criteria for pathologic enlargement. There are diffuse
hazy opacities and right lower lobe consolidation consistent
with pneumonia. Bronchiectasis is noted with a lower lobe
predominance and most prominently involving the right lower
lobe. There is a 6 mm right upper lobe pulmonary nodule.
Moderate right and small left pleural effusions are identified.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions. Patient is status post median sternotomy.
IMPRESSION:
1. No PE.
2. Diffuse pulmonary opacities and right lower lobe
consolidation consistent with multifocal pneumonia.
3. Bronchiectasis, most prominently involving the right lower
lobe.
4. 6 mm right upper lobe pulmonary nodule. Comparison with prior
examinations is recommended. If not available followup exam in
three to six month is recommended.
.
CHEST (PORTABLE AP) [**2133-2-16**] 8:19 AM
SINGLE PORTABLE VIEW OF THE CHEST: Tracheostomy tube seen with
tip at the level of the clavicles. Sternotomy wire seen
overlying the chest. Cardiac and mediastinal contours appear
within normal limits. There is increased opacity in the right
lower lobe. Small right upper lobe nodule also noted. Moderate
right sided and small left- sided pleural effusions also
identified. Gastrostomy tube seen overlying the stomach.
IMPRESSION:
1. Increased opacity in the right lower lobe consistent with
pneumonia. Moderate right and small left pleural effusions.
2. Small right upper lobe nodule. Followup imaging recommended
to document stability.
.
ECG
Probable ectopic atrial rhythm
Diffuse ST-T wave changes - could be in part early
repolarization pattern/
normal variant but consider also pericarditis
No previous tracing available for comparison
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2133-2-18**] 4:01 PM
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST. Study is limited
by streak artifact from patient's arm. There is no evidence of
central pulmonary embolism. No definite pulmonary emboli
identified, although evaluation of the more distal vessels is
severely limited.
There has been interval increase in visualized bronchiectasis
within the upper segment of the right lower lobe, compared to
study from two days prior. Extensive bronchiectasis again noted
within the lower segment of the right lower lobe.
There has been interval increase in the size of the right
pleural effusion. Again seen are diffuse hazy opacities, as well
as focal consolidations within the lungs consistent with
infection.
Pulmonary nodules also again noted, not significantly changed in
appearance from the study performed two days prior.
BONE WINDOWS: No suspicious lytic or blastic lesions are
identified.
IMPRESSION:
1. No evidence of central pulmonary embolism. Evaluation of more
distal vessels severely limited by streak artifact.
2. Interval increase in visualized bronchiectasis at the upper
segments of the right lower lobe. While this appearance might
partially be secondary to differences in respiratory phase,
these findings raise concern for worsening infection. Extensive
bronchiectasis again noted in the lower segments of the right
lower lobe.
3. Worsened interval increase in right pleural effusion, focal
consolidations again seen within both lungs consistent with
infection.
4. Again seen are pulmonary nodules not significantly changed in
appearance from study performed two days prior.
Findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**] immediately
following completion of the study.
.
[**Numeric Identifier **] PICC W/O PORT [**2133-2-20**] 7:47 AM
PROCEDURE AND FINDINGS: As no suitable superficial veins were
visible, ultrasound was used to localize a suitable vein. The
right brachial vein was patent and compressible. The right upper
extremity was prepped and draped in sterile fashion.
Approximately 5 cc 1% lidocaine was used for local anesthesia.
Under direct ultrasonographic guidance, a 21-gauge needle was
advanced into the right brachial vein and a 0.018 inch guidewire
was advanced into the SVC under fluoroscopic guidance. Hard copy
ultrasound images were obtained before and after venous access
documenting vessel patency. The needle was exchanged for a 5
French micropuncture sheath. Next it was determined that a
length of 34 cm would be suitable. The 5 French double- lumen
PICC was trimmed to length and advanced over the wire into the
SVC under fluoroscopic guidance. The wire and peel-away sheath
were removed. A final fluoroscopic spot image of the chest
demonstrates the PICC line tip in the SVC. The line was flushed,
heplocked and statlocked. The patient tolerated the procedure
well and there were no complications. IMPRESSION: Successful
placement of right brachial PICC with the tip in the SVC. The
line is ready for views.
.
CT ABDOMEN W/O CONTRAST [**2133-2-21**] 2:29 PM
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST
CT OF THE CHEST WITH IV CONTRAST: The patient has a tracheostomy
tube, not well evaluated here. A right subclavian central venous
catheter terminates in the superior vena cava. There is a small
pericardial effusion. Contrast is visualized in a somewhat
dilated distal esophagus, although there is no wall thickening.
There is a small 11-mm right hilar lymph node that is unchanged,
or perhaps a vascular structure such as a pulmonary venous
branch.
There is a 6-mm pulmonary nodule in the right upper lobe that is
unchanged. Continued followup as suggested previously is
recommended. There has been interval improvement in patchy
consolidation in the right lower lobe. Bronchiectasis is again
noted in the right middle lobe and lingula.
A right-sided chest tube is present. There is a tiny
pneumothorax tracking anteriorly.
Several lungs cysts are unchanged. Although less severe, there
are similar changes of bronchovascular thickening, patchy
consolidation and bronchiectasis in the left lower lobe that is
little changed since the prior study. There is a similar small
left pleural effusion, and a tiny right residual pleural
effusion.
CT OF THE ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Within the
limitations of a non-contrast study, the liver, gallbladder,
pancreas, spleen are unremarkable.
The left adrenal gland is unremarkable. The right adrenal gland
is poorly visualized.
There is persistent contrast opacification of the renal cortices
bilaterally, presumably related to recent contrast bolus. This
could be reflective of renal insufficiency. There is focal soft
tissue stranding about the right pararenal fascia. A gastrostomy
tube is positioned within the stomach. The proximal small bowel
is decompressed. Distally, the bowel is partly opacified and
appears normal.
There is fluid throughout the colon, but no wall thickening.
There is no evidence of lymphadenopathy or free air. There is a
small amount of ascites.
CT OF THE PELVIS WITHOUT IV CONTRAST: There is a Foley catheter
within the collapsed bladder. A few sigmoid diverticuli are
present. The rectum is unremarkable. There is a small amount of
ascites. The seminal vesicles are within normal limits. There is
no lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. Persistent bibasilar predominantly peribronchial opacities
with residual, but improved, consolidations.
2. Status post placement of right chest tube into right
effusion, which is considerably smaller. There is a miniscule
pneumothorax, but this appearance is not surprising in the
setting of recent chest tube placement
3. Fluid within the colon, but no wall thickening.
.
CHEST (PORTABLE AP) [**2133-2-23**] 3:20 PM
Portable AP view of the chest dated [**2133-2-23**] is compared to the
prior from [**2133-2-20**]. Small bilateral pleural effusions are
stable. Right chest tube is again seen with its tip terminating
in the medial aspect of the right upper lobe. The patient is
status post lung transplant and bilateral median sutures are
again noted. Tracheostomy tube is in place, with the tip
approximately 5 cm above the carina, unchanged. The heart size
is stable. The lungs are unchanged showing patchy bilateral
lower lung zone airspace opacities, right greater than left.
IMPRESSION: Stable appearance of the chest including stable
small bilateral pleural effusions and bilateral lower lobe
patchy opacities.
.
Microbiology
[**2133-2-16**] 8:58 am BLOOD CULTURE #2 LH.
**FINAL REPORT [**2133-2-22**]**
AEROBIC BOTTLE (Final [**2133-2-22**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2133-2-22**]): NO GROWTH.
[**2133-2-16**] 8:23 am BLOOD CULTURE
**FINAL REPORT [**2133-2-22**]**
AEROBIC BOTTLE (Final [**2133-2-22**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2133-2-19**]):
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] @ 12:30 [**2133-2-17**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
.
[**2133-2-16**] 8:23 am BLOOD CULTURE
**FINAL REPORT [**2133-2-22**]**
AEROBIC BOTTLE (Final [**2133-2-22**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2133-2-19**]):
REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] @ 12:30 [**2133-2-17**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
.
[**2133-2-16**] 12:52 pm Influenza A/B by DFA
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2133-2-16**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2133-2-16**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2133-2-16**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
.
[**2133-2-16**] 4:09 pm URINE
**FINAL REPORT [**2133-2-18**]**
URINE CULTURE (Final [**2133-2-18**]): NO GROWTH.
.
[**2133-2-18**] 11:46 am BRONCHOALVEOLAR LAVAGE R/O CMV.
GRAM STAIN (Final [**2133-2-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2133-2-21**]):
OROPHARYNGEAL FLORA ABSENT.
PROTEUS MIRABILIS. ~6OOO/ML. PRESUMPTIVE
IDENTIFICATION.
Trimethoprim/Sulfa sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2133-2-19**]):
PNEUMOCYSTIS CARINII NOT SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2133-2-19**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
Rapid Respiratory Viral Antigen Test (Final [**2133-2-21**]):
Respiratory viral antigens not detected.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for direct detection of
parainfluenza
virus in specimens; interpret parainfluenza results with
caution.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Final [**2133-2-23**]):
TEST CANCELLED, PATIENT CREDITED.
DUPLICATE SPECIMEN.
REFER TO VIRAL CULTURE FOR RESULTS.
.
[**2133-2-19**] 12:52 pm STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2133-2-21**]**
FECAL CULTURE (Final [**2133-2-21**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2133-2-21**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2133-2-20**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
.
[**2133-2-19**] 4:25 pm PLEURAL FLUID
GRAM STAIN (Final [**2133-2-19**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2133-2-22**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
CMV IgG ANTIBODY (Pending):
CMV IgM ANTIBODY (Pending):
.
[**2133-2-21**] 11:35 am CATHETER TIP-IV Source: R Femerol.
**FINAL REPORT [**2133-2-23**]**
WOUND CULTURE (Final [**2133-2-23**]): No significant growth.
.
01/20-21/07 11:42 am BLOOD CULTURE LINE/SPEC: A-LINE.
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
Brief Hospital Course:
Mr. [**Known lastname **] is a 40 yo M with chronic respiratory failure [**3-6**] IPF
s/p b/l lung transplant c/b chronic rejection, recurrent
pneumonias presenting with acute on chronic respiratory failure
secondary to multifocal pneumonia with underlying poor pulmonary
reserve. His hospital course is summarized below by problem.
.
# RESP FAILURE. Long standing lung disease, IPF dx in 96 s/p b/l
lung tx in [**2128**] c/b chronic rejection, requires chronic
ventilatory support. Acute decompensation likely multifactorial
mainly secondary to pneumonia and mucous plugging. Aspiration is
also likely. Patient was initially very difficult to ventilate
with ABG showing 6.98/204/119 in the ED at which time he was
unresponsive. Upon arrival to the ICU he was placed on AC 280 x
22, FiO2 .70, Peep of 8. His arterial blood gases continued to
improve over the course of his hospitalization. Our goals were
to keep his O2 sats >88%, PCO2 ~ 100. With these parameters he
was mentating and following commands. His ventilation continued
to improve gradually with PCO2 ranging 70-80s.
.
Patient was iniated on broad coverage given h/o multiple drug
resitant organisms in the past. He as treated with Meropenem and
Vancomycin. Vancomycin was discontinued on [**2-24**] per ID
recommendations. He continues on Meropenem for a 14 week course
(started on [**2133-2-16**]). Influenza was negative. Patient had two
bronchoscopies performed during this admission, BAL from [**2-18**]
grew Proteus Mirabilis resistant to quinolones. A Chest Tube was
placed on [**2-19**] due to persistent pleural effusions and concern
for loculation. It drained serosanguinous fluid, making criteria
for exudate with LDH 336. It continued to drain fluid <200 cc
per day mainly serous. The chest tube was pulled on ... Patient
was also continued on Prednisone 20 mg daily (trasiently on
stress dose steroids on admission) and his other
immunosuppressant medications (see below). ID evaluated the
patient and recommened contiuing the same antibiotic coverage
and discontinuing vanco if he remained afebrile. C.diff was
checked given loose stool which was negative. CMV viral load was
pending at the time of discharge. Prior to discharge he was also
diuresed with IV lasix to improve minimize drainage from his
chest tube and since he was markedly fuid overloaded since
admission (positive 8.5 L since admission).
.
B-Glucan was positive; galactomannan was negative. It is
unknown whether beta-glucan was due to fungal infection vs blood
transfusion, antibiotic, or other. Antifungal agents were not
given; however, ID consult recommended that he continue to be
monitored with repeat beta-glucan assays drawn at Radius.
.
# Leukocytosis and Fever - SIRS, transiently hypotensive on
admission which rapidly resolved. Likely secondary to pneumonia.
Blood cultures in the ED grew 1/4 bottles coag negative staph.
Urine cultures showed no growth. Patient remained hypertensive
throughout the remained of his admission and restarted on a beta
blocker at high dose. He remained afebrile.
.
# Cardiovascular. Patient reportedly had pleuritic chest pain
the day of admission prior to his acute respiratory decline. EKG
showed early repolarization no acute ST-T changes. There was no
old EKG for comparison. Two sets cardiac enzymes are negative.
Telemetry subsequently showing frequent PVCs and few episodes of
NSVT. His beta blockade was increased to Metoprolol 100 mg q 8
hrs. His electrolytes were agressively replete to keep K >4 Mg
>2. He was continued on a statin. After this his telemetry was
normal without further events.
.
# Pancreatitis. Patient complained of abdominal pain
intermittently. His abdomen was distended however he was making
stool and he was non tender on exam. CT of the abdomen showed a
normal pancrease, gallbladder and spleen, fluid throughout the
colon was noted but no bowel wall thickening. His PEG tube was
in good position. Amylase and lipase were elevated on [**2-21**] to
636 and 514 respectively. His tube feeds were stopped. There
enzymes trended down subsequently (see results). C.diff was
negative. Tube feeds were restarted slowly and his amylase and
lipase started to increase. GI was consulted and they
recommended repositioning his feeding tube more distally.
Patient's feeding tube was successfully repositioned by
interventional radiology on day of discharge.
.
# Anemia. Unclear etiology, initially 30-->21 today s/p two
units pRBCs on [**2-19**], Hct 29 today and stable. Stool trace guaiac
positive. No evidence of hemolysis.
- active type and screen
- transfuse if <21
.
# s/p Lung Tx: Continue Prograf/Cellcept/Prednisone
- follow Tacrolimus level 6.3 [**2-23**]--check level in AM
- check level in AM
.
# DM - Humalog SS
.
# Polymyositis - stress dose steroids
.
# HTN. Borderline hypotensive on admission, now BP on high side
- titrated up BP, consider adding other [**Doctor Last Name 360**] if not adequately
controlled
.
# H/o A.fib not on anticoagulation.
- monitor on tele
.
# Hyperlipidemia - continue Lipitor
.
# FEN - monitor K, TFs on hold, maintenance fluids.
.
# Dispo - stable, likely back to Radius this week, possibly
wednesday, discuss with case management.
.
# full code per wife
.
# Comm: [**Hospital3 672**] and Rehab Center [**Telephone/Fax (1) 71272**]
Next of [**Doctor First Name **]: [**First Name4 (NamePattern1) **] [**Known lastname **] [**Telephone/Fax (1) 71273**]
Medications on Admission:
- seroquel 50 mg qAM, 100 mg qHS, 25 mg prn
- Motrin 600 mg tid (recently d/ced after renal consult for ARF)
- Lidoderm daily
- Maalox
- Humalog SS
- Feosol 300 mg [**Hospital1 **]
- Klonopin 0.25 mg QHS
- Neutra phos 2 pkts [**Hospital1 **]
- nexium 40 mg daily
- Lovenox 40 mg sc daily
- combivent 4 puffs qid prn
- Dulcolax 10 mg daily
- tylenol elixir 650 mg q 4 hrs prn
- oxycodone 5 mg q6 hrs
- senna liquid 10 ml qHS
- Bactrim susp 20 ml daily
- Prograf 9 mg [**Hospital1 **]
- Cellcept [**Pager number **] mg [**Hospital1 **]
- prednisone 10 mg daily
- Lipitor 10 mg daily
- Celexa 40 mg daily
- Aranesp 40 mcg weekly
- lopressor 50 mg q8hrs
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation QID (4 times a day).
4. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension [**Last Name (STitle) **]:
Twenty (20) ML PO DAILY (Daily).
5. Mycophenolate Mofetil 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO
BID (2 times a day).
6. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
7. Citalopram 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
8. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 2-4 Puffs Inhalation
Q6H (every 6 hours) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed.
11. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day) as needed.
12. Prednisone 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
14. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a
day).
15. Zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime)
as needed.
16. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID
(3 times a day).
17. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
18. Hydrochlorothiazide 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
DAILY (Daily).
19. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
20. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: 500 mg Recon Solns
Intravenous Q6H (every 6 hours) for 4 days.
21. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
22. Dolasetron Mesylate 25 mg IV Q8H:PRN nausea/vomiting
23. Morphine Sulfate 2-6 mg IV Q3-4H:PRN abdominal pain
24. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
25. Insulin Lispro (Human) 100 unit/mL Solution [**Last Name (STitle) **]: per sliding
scale Subcutaneous ASDIR (AS DIRECTED).
26. Tacrolimus 5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2 times
a day): In total should receive tacrolmius 9 mg [**Hospital1 **].
27. Tacrolimus 1 mg Capsule [**Hospital1 **]: Four (4) Capsule PO twice a
day: In total should receive Tarolimus 9 mg [**Hospital1 **] .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary diagnoses
- Pneumonia - complicated by loculated effusions requiring
placement if chest tube
- pancreatitis
Secondary diagnoses
- idiopathic pulmonary fibrosis
- s/p lung transplant
- anemia
- DM
- polymyositis
- HTN
- hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
You were admitted with a pneumonia which required agreesive
treatment with antibiotics and a chest tube. You will need to be
on antibiotics for a total of 14 days (you have 4 days left).
Your chest tube was removed on [**2133-2-25**] and you have been doing
well since then. Please follow up with your pulmonologist Dr.
[**First Name (STitle) 2405**] at Radius. He will need to continue to follow your
Tacrolimus levels.
.
You also developed abdominal pain and pancreatitis, which we
believe was secondary to your tube feeds. Your labs (amylase,
lipase) should continue to be followed by your doctors [**First Name (Titles) **] [**Name5 (PTitle) 71274**].
.
Please call your doctor or return to the emergency room if you
develop fevers, increased shortness of breath, abdominal pain,
nuasea/vomiting, or any other symptoms that are concerning to
you.
Followup Instructions:
Please follow-up with your PCP/pulmonologist upon your return to
Radius.
|
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icd9cm
|
[
[
[]
]
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[
"33.21",
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icd9pcs
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[
[
[]
]
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29825, 29880
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|
333, 399
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|
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|
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2535, 2539
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|
274, 295
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20625, 20625
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427, 1597
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20176, 20191
|
1619, 2387
|
2403, 2519
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,605
| 120,175
|
20136
|
Discharge summary
|
report
|
Admission Date: [**2179-4-21**] Discharge Date: [**2179-4-27**]
Date of Birth: [**2112-11-5**] Sex: M
Service: MEDICINE
Allergies:
Diphenhydramine
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
transfer for monitoring, intubated
Major Surgical or Invasive Procedure:
intubation and extubation
failed transjugular intrahepatic protal shunt X 2
paracentesis
History of Present Illness:
66 year-old M with mantle cell lymphoma with pancytopenia,
cryptogenic cirrhosis, and DM who presents s/p failed TIPS
procedure for monitoring. He was scheduled for an elective TIPS
today for diuretic-resistant ascites and hyponatremia. TIPS
failed due to inability to cannulate the portal vein (last
Doppler US in [**9-11**] showed patent vasculature). He underwent
310 ml paracentesis. He received 2 units of platelets during
the procedure. Due to hypotension to SBP 70s, he was transfused
2 units of blood and given 10 mcg neosynephrine. He became
bradycardic post-procedure and received 0.4 mg atropine and 15
ephedrine . His sheath was removed in the PACU, but the patient
was left intubated due to concern for hematoma formation with
extubation. He is admitted to the MICU for monitoring.
Of note, pre-procedure he received cefazolin 2 g. He also took
Mucomyst pre-procedure.
ROS: History obtained per chart; wife unable to be reached.
Past Medical History:
1. Mantle cell lymphoma: diagnosed in [**Month (only) **]/[**2175-11-6**] following
colon biopsy. Followed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1557**]. Receiving thalidomide
daily and monthly rituxan (last on [**2179-4-7**]).
2. Cryptogenic cirrhosis: complicated by portal hypertension,
esophageal varices, and diuretic-resistant ascites. followed by
Dr. [**Last Name (STitle) 497**].
3. DM type 2: on metformin and glyburide at home. No documented
nephropathy, neuropathy or retinopathy. No known CAD, no h/o
CVA, no PVD.
4. CRI: baseline Cr of 1.3. possibly related to the
chemotherapy
5. Unspecified colitis: x years with intermittent diarrhea
Social History:
The patient is married and lives with his wife in [**Name (NI) 3597**], [**Name (NI) **]. He
has 2 adult children. He worked as a manager of a call support
center for real state agency but is presently on disability. No
tobacco or EtOH use.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97.7 BP: 88/47 P: 68 RR: 14 SaO2: 100% on
SIMV 600/14/5/5/0.60
General: intubated, NAD.
HEENT: PERRL, sclera icteric.
Neck: supple, RIJ site with dry dressing, no hematoma
appreciated.
Pulm: clear anteriorly, faint crackles to b/t bases
Cardiac: RRR, nl S1/S2, 2/6 systolic murmur
Chest: L port-o-cath site without erythema or fluctuance.
Abdomen: firm, NT, distended with ascites. + BS. paracentesis
site to RLQ with dry dressing
Ext: 2+ LE edema b/t, warm
Skin: no rashes or lesions noted.
Neurologic: intubated, sedated. withdraws to painful stimuli.
does not open eyes to voice. moves all extremities
spontaneously.
Pertinent Results:
[**2179-4-20**] 12:50PM WBC-1.2* RBC-2.13* HGB-8.9* HCT-25.9*
MCV-121* MCH-41.8* MCHC-34.4 RDW-17.4*
[**2179-4-20**] 12:50PM PLT COUNT-28*
[**2179-4-20**] 12:50PM PT-14.6* PTT-27.8 INR(PT)-1.3*
[**2179-4-21**] 02:47PM GLUCOSE-54* LACTATE-1.9 NA+-129* K+-4.0
CL--101
[**2179-4-21**] 02:47PM TYPE-[**Last Name (un) **] O2-50 PO2-70* PCO2-38 PH-7.43 TOTAL
CO2-26 BASE XS-0
[**2179-4-21**] 03:46PM freeCa-1.34*
[**2179-4-21**] 03:46PM GLUCOSE-124* LACTATE-2.2* NA+-129* K+-3.9
CL--101
.
US with Dopplers [**4-22**]:
Interval development of a hematoma within the left lobe of the
liver. No evidence for portal venous thrombosis. Appropriate
Doppler waveforms visualized within the liver.
.
TIPS [**4-23**]:
Unsuccessful percutaneous transhepatic portogram. We will re-
attempt in 1 week when coagulation factors will be corrected.
.
LUE US [**4-24**]:
No DVT. Thrombus is identified within the superficial left
cephalic vein.
Brief Hospital Course:
66 year-old M with mantle cell lymphoma with pancytopenia,
cryptogenic cirrhosis, and DM who presents s/p failed TIPS
procedure admitted for monitoring. Hospital course by problem
below:
# Cryptogenic Cirrhosis with failed TIPS: Doppler US showed
patent vasculature. IR repeated TIPS via percutaneous approach
on [**4-23**] and failed. His diuretics and nadolol were initially
held, but were restarted on [**4-24**]. Patient had a therapeutic
paracentesis on day of discharge performed by attd after marked
with ultrasound. Two bags of platelets were administered prior
to tap.
# Post TIPS Hct Monitoring: Patient was monitored closely for
blood loss following two failed percutaneous TIPS with multiple
passes through liver. He had a Hct drop of 6 points after
procedure, which then stabilized. He was then transferred out of
the MICU and monitored where Hct remained stable to 2 days post
procedure. He then developed a large echymosis covering most of
his right flank as well as a 3 point Hct drop. Subsequent Hct
remained stable in the 25 range. He was not transfused and
remained hempdynamically stable.
# Hypotension: baseline SBPs 85-95. Post procedure, he had mild
hypotension attributed to general anesthesia. His diuretics and
nadolol were initially held given low BP, but then restarted on
[**4-24**]. His blood pressure remained stable for remainder of
hospital course.
# Bradycardia: Patient had bradycardia in the post procedure
period which was felt to be vagal etiology post-procedure or [**1-8**]
to neosynephrine. He was monitored on telemetry with no further
events on the floor.
# Hyponatremia: His Na was 129 on admission, but quickly
resolved. All subsequent Na values were within normal range.
# Thrombocytopenia: Patient has history of known splenomegaly
and his thrombycytopenia was felt likely from myelosupression as
well as splenic sequestration. He received 2 bags of platelets
in OR for procedure and then on day of dicharge received another
two bags in anticipation of paracentesis.
# Mantle Cell Lymphoma: ANC was 380. He was maintained on
neutropenic precautions, and was contined on his outpatient
prophylaxis of acyclovir and levofloxacin. he continued his
outpatient thalidomide.
# DM2: He was hypoglycemic post-procedure, thought to be due to
effects of glyburide in setting of renal dysfunction. He was
given a 10% dextrose drip to maintain blood sugars >60. He had
a normal cortisol stimulation test. Once he became
normoglycemic, he was restarted on insulin sliding scale and a
diabetic diet. He was restarted on his home oral medications at
discharge.
# CRI: His Creatinine on admission was lower than his baseline
over the last month. He was given 2 additional doses of
mucomyst for prophyllaxis.
# LE swelling: US with SVT, no DVT
*Prophylaxis: PPI, pneumoboots, neutropenic precautions
*Comm: with wife, [**Name (NI) **] (HCP) at [**Telephone/Fax (1) 54146**] (h), [**Telephone/Fax (1) 54147**]
*Access: L port-o-cath and 2 18g PIVs
*Code Status: Full
Medications on Admission:
Lasix 40 mg [**Hospital1 **]
Aldactone 100 mg [**Hospital1 **]
acyclovir 400 mg TID
Nadolol 20 mg QDay
levofloxacin 500 mg QHS
thalidomide 100 mg QHS
Rituxan once a month (last on [**2179-4-7**])
Metformin 1500 mg QAM / 1000 mg QHS
glyburide 10 mg [**Hospital1 **]
Zofran p.r.n.
Neulasta
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Thalidomide 100 mg Capsule Sig: One (1) Capsule PO qhs ().
7. Metformin 1,000 mg Tablet Sig: 1.5 Tablets PO QAM.
8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ascites
cryptogenic cirrhosis
Secondary:
mantle cell lymphoma
anemia
Discharge Condition:
stable
Discharge Instructions:
You have ascities from your cryptogenic cirrhosis and had two
failed TIPS procedures. You had a paracentesis to remove some of
your ascites.
Please call your doctor or go to the emergency room if you have
lightheadedness, dizzyness, fever, chills, shakes, abdominal
pain, bloody stools, black stools, shortness of breath,
palpitations, chest pain, or any other concerning symptoms.
We have made no changes in your outpatient medications.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] office to schedule an
appointment to follow-up with him within the next few weeks.
([**Telephone/Fax (1) 1582**]
Please attend the following appointments:
Primary care: Provider: [**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 9816**], RN
Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2179-5-7**] 9:00
Oncology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11755**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2179-5-7**] 9:00 Provider: [**Name10 (NameIs) 3242**] [**Apartment Address(1) 9575**]
Date/Time:[**2179-5-7**] 9:00
|
[
"276.1",
"202.80",
"276.6",
"585.9",
"458.29",
"571.5",
"998.12",
"789.5",
"284.1",
"250.80",
"V64.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"54.91",
"88.64",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8001, 8007
|
4018, 7037
|
310, 401
|
8130, 8139
|
3059, 3995
|
8628, 9310
|
2362, 2380
|
7376, 7978
|
8028, 8109
|
7063, 7353
|
8163, 8605
|
2395, 3040
|
236, 272
|
429, 1383
|
1405, 2085
|
2101, 2346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,239
| 120,068
|
46872
|
Discharge summary
|
report
|
Admission Date: [**2134-12-15**] Discharge Date: [**2134-12-21**]
Date of Birth: [**2058-4-4**] Sex: F
Service: MEDICINE
Allergies:
Zolpidem Tartrate / Heparin Agents
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
Tunnelled catheter placement
History of Present Illness:
Ms. [**Known lastname **] is a 76 year-old woman with history of ESRD (started
on HD ~ 1 month ago) who presented to an OSH on [**2134-12-15**] with
non-specific complaints including lethargy, malaise. She was
found to have R IJ hemodialysis cathether infection and new
onset atrial fibrillation. At OSH was given vancomycin 1g,
Narcan 0.2mg IV, hydralazine 25mg po x1, labetalol 20mg IV x1,
and ASA 162mg x1.
She was then transferred to [**Hospital1 18**] for further management. In our
ED, patient was satting 90% RA. She was given metoprolol 100mg
po x1, ASA 325mg x1, plavix 75mg x1, lasix 20mg IVx1, lasix 80mg
IVx1, lopressor 5mg IV x1, lasix 40mg IV x1, nitro gtt,
clonazepam 2mg po x1, and labetalol 10mg IV x1. Renal was
consulted and recommended HD, but pt had troponin leak and
therefore requested HD in ICU setting. Cards was contact[**Name (NI) **] re:
elevated troponins (2.13, 2.18) - [**Hospital 24816**] medical management
until infection cleared.
.
In the MICU, patient was continued on Vancomycin and Gentamicin
was initiated. Patient ruled in for NSTEMI by enzymes, and was
started on heparin drip. Blood cultures eventually grew out
Nafcillin-sensitive Staph Aureus, and patient was transitioned
to IV Nafcillin on [**12-16**]. Atrial fibrillation resolved with fluid
removal, and fluid overload from renal failure was presumed to
be the etiology. Patient received an ECHO in the MICU which
revealed ef 70-80% no hypokinesis. With regards to HD access, a
Left IJ tunneled catheter was placed on [**12-17**], and was used for
dialysis on the same day without issue.
.
At time of transfer, patient was satting 99% on 3L O2. She was
without symptoms of chest discomfort, shortness of breath,
nausea, or vomiting, and per MICU resident, was feeling
significantly better compared to admission. She was first taken
to HD, and thereafter brought to the floor. On arrival to the
floor, patient reported some feelings of gas pressure in her
abdomen and some constipation, [**Last Name (un) **] no sob, cp, n, v,
palpitations, f or chills. She denies any current pain.
.
Past Medical History:
- Adult onset DM x 26 years
- HTN
- Hypercholesterolemia
- CAD - s/p 2V CABG [**2118**], CEA [**2123**]
- Chronic kidney disease [**2130**], now ESRD on HD - R IJ tunneled
catheter placed in [**11-28**], HD initiated [**11-28**]
- retinal surgery [**2130**]
- depression
Social History:
Smoked 60 pack years, no alcohol. No other illicit drugs. Lives
in [**Location (un) 26671**] in an apartment for the elderly by herself. Has a
housekeeper that helps her to do laundry, shopping and drives
around. Son in law stays with her recently since her daughter
died.
Family History:
- heart disease - brother, mother (died age 68), father (died
age 87)
- DM - mother
Physical Exam:
Gen: appears somewhat fatigued, NAD
HEENT: PERRL, EOMI, MM dry, OP clear
Chest: R IJ tunneled line - area of breakdown and purulence
superior to entrance of catheter, mild erythema around this
area, no tenderness to palpation
CV: irregularly irregular, nl S1/S2, no murmurs
Pulm: decreased breath sounds R > L, crackles at L base
Abd: soft, NT/ND, +BS, no masses
Ext: no c/c/e, cool to touch, good pulses
Neuro: remembers [**11-24**] words, can spell world backwards,
appropriate, cannot recall much of timeline of her medical
problems
Pertinent Results:
results:
[**2134-12-14**] 07:43PM LACTATE-1.3 K+-3.6
[**2134-12-14**] 07:30PM GLUCOSE-197* UREA N-44* CREAT-3.9*
SODIUM-130* POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-21* ANION
GAP-18
[**2134-12-14**] 07:30PM ALT(SGPT)-39 AST(SGOT)-39 CK(CPK)-11* ALK
PHOS-157* AMYLASE-17 TOT BILI-0.6
[**2134-12-14**] 07:30PM LIPASE-17
[**2134-12-14**] 07:30PM CK-MB-NotDone cTropnT-2.13* proBNP-GREATER TH
[**2134-12-14**] 07:30PM ALBUMIN-2.4* CALCIUM-8.4 PHOSPHATE-3.7#
MAGNESIUM-1.7
[**2134-12-14**] 07:30PM WBC-21.7*# RBC-3.06* HGB-8.9* HCT-27.0*
MCV-88 MCH-29.0 MCHC-32.9 RDW-18.0*
[**2134-12-14**] 07:30PM NEUTS-85.9* BANDS-0 LYMPHS-10.2* MONOS-3.5
EOS-0 BASOS-0.4
[**2134-12-14**] 07:30PM PLT COUNT-356
.
results:
ct head: IMPRESSION:
1. No evidence of acute intracranial hemorrhage or mass effect.
2. Stable changes associated with small vessel angiopathy.
.
echo: Conclusions:
The left atrium is moderately dilated. The estimated right
atrial pressure is 16-20 mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is no ventricular septal defect. The right
ventricular cavity is dilated. Right ventricular systolic
function is borderline normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No masses
or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There
is no mitral valve prolapse. No mass or vegetation is seen on
the mitral
valve. Mild to moderate ([**11-23**]+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
.
76 bpm, atrial fibrillation, Q waves in III, T wave inversions
in I, aVL, V4-V6 (old) with ST depressions of 1mm (old)
Brief Hospital Course:
76F ESRD on HD, CAD s/p CABG, HTN, HL p/w line infection, line
replaced, now doing better
.
1. HD catheter infection/bacteremia: As above, given the
patient's need for HD and a current NStemi she was in the Micu
and was treated for her infection with vancomycin and
gentamicin. Her R IJ tunneled cath was removed on admission and
new line was placed. Blood culture growing MSSA from [**2133-12-14**],
so based on this the patient was started on IV nafcillin. Her
surveillance cultures were continually monitored and remained
negative. Her TTE on admission lacked any vegetations and
therefore her infection was attributed to her catheter
infection. Upon discharge, she will be converted to cefazolin to
be given following dialysis sessions for the next 3 weeks.
.
2. Irregular rhythm: In the micu the patient was thought to be
in afib and was treated with heparin. The ECG interpreted to be
afib initially, however, read by cardiology attending reveals
sinus tachy with frequent APBs. Based on this it does not seem
the patient has afib, and her EKG on the floor did not reveal
atrial fibrillation. So this issue was resolved prior to the
patient coming to the floor. By time of discharge, she was in
sinus rhythm with frequent atrial ectopy.
.
3. NSTEMI: The patient was found to have elevated troponins
(2.13, 2.18), and cardiology [**Hospital 24816**] medical management until
her infection cleared. The patient's enzymes were followed and
continued to trend down. She was on a heparin drip, asa,
statin, ace and BB. Her BB was uptitrated for optimization. She
experienced no subsequent chest pain. She was admitted on high
dose statin however her LDL was 131 (higher than her goal of
<70). As it was unclear whether she was taking this medication
at home, no additional lipid lowering medications were added.
Her LDL should be repeated in the next 2-3 months with goal <70.
.
3. HYPOXIA: The patient required oxygen in the MICU and was
attributed to fluid overload in the setting of missed HD and
clinical exam. The patient was closely followed and as her
volume status improved. As her volume status was corrected to
euvolemic with HD/UF sessions, her hypoxia resolved to her
baseline.
.
4. ESRD on HD: The patient was continued on HD as an inpatient
and had no active issues. She was followed closely by the renal
team. New hemodialysis access was established as above.
.
5. Diabetes Mellitus: The patient was well-controlled on her
home regimen and was checked frequently.
.
6. Hypertension: In the ICU the patient was poorly controlled
and was on metoprolol, lisinopril, and nitroglycerin gtt.
Hydralizine and amlodopine were added and nitro stopped. On the
floor she was well controlled with Metoprolol, ACE, Hydralazine,
and Amlodipine.
.
7. Dispo: following stabilization of the above, she was
discharged to a nursing facility prior to being evaluated for
return to home.
Medications on Admission:
MEDICATIONS AT HOME:
atorvastatin 80mg daily
folate 1mg daily
pantoprazole 40mg daily
metoprolol 50mg tid
celexa 20mg daily
Epo 3000 units qHD
NTG patch 0.6mg/hr
insulin NPH 10 units qAM
clonazepam 2mg tid prn
senna 1 tab [**Hospital1 **]
dulcolax 10mg daily prn
aspirin 81mg daily
lisinopril 5mg qMWF, 10mg qSuTuThSa
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
celexa.
6. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO TID:PRN.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
Disp:*240 Tablet(s)* Refills:*2*
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:*2*
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten
(10) units Subcutaneous qAM.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
16. Hemodialysis
Hemodialysis: Monday Wednesday Friday at [**Location (un) **] Hemodialysis
Center
Next session on [**2134-12-22**] at 2:30pm
17. Cefazolin 1 g Recon Soln Sig: One (1) gram Intravenous
qMoWedFri for 3 weeks: to be given after HD sessions at [**Location (un) **]
Dialysis center.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Primary:
1. Line infection.
2. NSTEMI
3 Diastolic Heart Failure.
Secondary:
1. Peripheral Vascular Disease.
2. CAD s/p 2-Vessel CABG [**2118**].
3. Multiple Embolic Strokes.
4. Diabetes Mellitus Type II.
5. Hypertension.
6. Chronic Kidney Disease Stage V on HD.
7. Atrial Premature Beats (no known AF)
Discharge Condition:
stable, tolerating po. stable oxygenation.
Discharge Instructions:
1. You were admitted with a catheter/blood stream infection as
well as a heart attack. You were treated with antibiotics for
your infection and medications to protect your heart. You will
complete 4 total weeks of antibiotics for the infection.
2. You were discharged to a Nursing facility to improve your
strength prior to returning home.
3. please make all follow-up appoinments as listed below.
Followup Instructions:
1. Make a follow-up in 1 week. Call your primary care Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] C. [**Telephone/Fax (1) 11144**] for an appointment
.
2. Dialysis: your next dialysis session is on Wednesday at 2:30
at the [**Location (un) **] Dialysis Center.
.
Previously scheduled:
Neurology: Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2135-2-8**] at 1pm. Please call
[**Telephone/Fax (1) 2574**] with questions.
|
[
"403.91",
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"V45.81",
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"397.0",
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"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
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|
5678, 8576
|
303, 334
|
11210, 11255
|
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255, 265
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362, 2446
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|
2757, 3032
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,375
| 172,733
|
10303
|
Discharge summary
|
report
|
Admission Date: [**2149-6-13**] Discharge Date: [**2149-6-17**]
Date of Birth: [**2091-6-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 14802**]
Chief Complaint:
new brain lesion
Major Surgical or Invasive Procedure:
[**2149-6-14**] R craniotomy for resection of brain lesion
History of Present Illness:
58 y/o F with history of NSCLC presents with abnormal head
MRI. Patient states that she has been feeling unwell for 2 days
with nausea and loss of appetite. She contact[**Name (NI) **] her oncologist
which became concerned for a brain lesion and ordered MRI of
head. MRI head was completed and showed a R frontal lesion with
edema and minimal midline shift. Neurosurgery was consulted for
further evaluation. She denies any headache, n/v, dizziness, or
change in vision.
Past Medical History:
Ulcerative colitis
Raynaud's
CREST syndrome
Toxic Megacolon 20 years ago
Social History:
>40 pack year smoking history with ongoing 1/2ppd use. Rare
EtOH. Lives alone since her husband left her recently. Describes
a great deal of stress in her life related to this.
Family History:
Mother alive at >[**Age over 90 **] years.
Maternal aunt deceased in her 20's of UC.
No other known diagnosed colitis or bowel disease.
Physical Exam:
O: T:98.6 BP:92/54 HR:62 R:16 O2Sats:97%
Gen: WD/WN, comfortable, NAD.
HEENT: telangiectasia
Pupils: 4-3mm bilaterally EOMs: intact
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-22**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-24**] throughout. No pronator drift
Sensation: Intact to light touch
On Discharge:
nonfocal
incision c/d/i with staples
Pertinent Results:
MR HEAD W & W/O CONTRAST [**2149-6-12**]
1. Large enhancing mass with hemorrhage in the right frontal
lobe with
associated significant perilesional edema causing mass effect on
the frontal [**Doctor Last Name 534**] of right lateral ventricle and shift of midline
structures to the left. This is concerning for metastasis.
2. Small enhancing lesions in the right and left parietal bones
which may represent hemangiomas or bone metastases.
3. Diffuse T1 hypointensity noted of the marrow of the skull,
which may
represent marrow reconversion. However, possibility of marrow
infiltration cannot be ruled out.
4. No evidence of acute infarct.
CT head [**2149-6-14**] POST OPERATIVE:
1. Post-right frontal tumor resection, with no evidence of
hemorrhage or
acute mass effect at the surgical bed.
2. Expected mild pneumocephalus and subcutaneous emphysema at
the right
craniectomy site.
MR HEAD W & W/O CONTRAST [**2149-6-15**]
1. Post-surgical changes, along with fluid-filled cavity at the
surgical
resection site in the right frontal lobe, with blood products
and fluid level within. Minimal peripheral enhancement can
relate to the reactive changes. No obvious nodular enhancement
to suggest obvious tumor. However, consider followup for better
assessment of the tumor after resolution of the reactive
changes.
No new lesions.
Persistent moderate vasogenic edema and leftward shift of
midline structures, with leftward displacement of the anterior
cerebral arteries. Follow up closely.
Brief Hospital Course:
58 y/o F with known NSCLC presents with nausea and loss of
appetite. Patient's oncologist recommended an MRI of head which
revealed a new R frontal lesion. She was admitted to the
neurosurgery service for further evaluation and monitoring. On
[**6-14**], she was taken to the OR with no complications. Post
operatively, she was extubated and transferred to the ICU. Post
op head CT shows post operative changes with stable vasogenic
edema. On [**6-15**], MRI head was completed which showed vasogenic
edema with post surgical changes, no residual tumor was seen. On
[**6-17**], patient remained stable on exam, PT has cleared her safe
to discharge home.
Medications on Admission:
Amlodipine, Celebrex, citalopram,
dexamethasone,enoxaparin, lorazepam, Lialda, ondansetron,
OxyContin, oxycodone, acetaminophen, prochlorperazine maleate,
Aciphex, spironolactone, and magnesium oxide
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
6. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. oxycodone 10 mg Tablet Sig: Three (3) Tablet PO Q12H (every
12 hours).
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO refer to
other instructions: Please take 3mg (1.5 tabs) Q6H x 1 day, then
2mg (1tab) Q6H x1 day, then 2mg (1 tab) [**Hospital1 **] ongoing.
Disp:*QS Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
R frontal metastatic lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-29**] days(from your date of
surgery) for removal of your staples and a follow up with Dr.
[**Last Name (STitle) **] for a wound check. Please make this appointment by
calling [**Telephone/Fax (1) 1669**].
?????? A Brain tumor clinic appointment has been scheduled for you.
You are scheduled to see Dr. [**Last Name (STitle) 724**] on [**2149-6-30**] at 3pm. His office
is located on the [**Hospital Ward Name **] in the [**Hospital Ward Name 23**] Bulding. Please
call [**Telephone/Fax (1) 1844**] with any further questions
Completed by:[**2149-6-17**]
|
[
"V87.41",
"556.9",
"V16.52",
"V10.11",
"492.8",
"443.0",
"300.00",
"311",
"V12.51",
"348.5",
"V15.82",
"V15.3",
"710.1",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
6179, 6185
|
4022, 4677
|
338, 399
|
6257, 6257
|
2495, 3999
|
8316, 8953
|
1207, 1344
|
4927, 6156
|
6206, 6236
|
4703, 4904
|
6408, 8293
|
1359, 1508
|
2438, 2476
|
281, 300
|
427, 900
|
1801, 2424
|
6272, 6384
|
922, 996
|
1012, 1191
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,298
| 179,822
|
48206+59070
|
Discharge summary
|
report+addendum
|
Admission Date: [**2101-1-31**] Discharge Date: [**2101-2-14**]
Date of Birth: [**2036-12-16**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Aspirin / Niacin
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Posterior Lumbar decompression L2-L5 with Fusion L4-5
History of Present Illness:
Progressive back pain with neurogenic claudication
Past Medical History:
HTN
DM
Obesity
Arthritis
Social History:
Lives alone
Daughter assists
Family History:
non-contributory
Physical Exam:
Wound healing primarily
motor and sensory exam intact lower extremities
Pertinent Results:
[**2101-1-31**] 09:00PM HCT-30.9*
Brief Hospital Course:
Uncomplicated Surgery
Hypotensive and tachycardic episode POD #1, responded to fluid
and blood replacement therapy. Observed overnight in ICU wihtout
sequelae. Cardiac enzymes negative. Hemodynamically stable
after replacement.
Ambulatory
Medications on Admission:
see below
Discharge Medications:
1. Cyclobenzaprine HCl 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) as needed for spasm.
Disp:*60 Tablet(s)* Refills:*0*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*0*
3. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Raloxifene HCl 60 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*60 Tablet(s)* Refills:*2*
5. Imipramine HCl 50 mg Tablet Sig: Two (2) Tablet PO PM ().
Disp:*60 Tablet(s)* Refills:*2*
6. Imipramine HCl 10 mg Tablet Sig: Three (3) Tablet PO AM ().
Disp:*60 Tablet(s)* Refills:*2*
7. Pramipexole Dihydrochloride 0.25 mg Tablet Sig: One (1)
Tablet PO daily ().
Disp:*60 Tablet(s)* Refills:*2*
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
10. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
sheryle House
Discharge Diagnosis:
Spinal stenosis
Spondylosis
Degenerative spondylosisthesis
Discharge Condition:
Stable, neuro intact, wound healing primarily
Discharge Instructions:
Keep sound clean and dry
Regular diet
leave steri strips on
[**Month (only) 116**] shower, no immersion
Followup Instructions:
as planned Dr. [**Last Name (STitle) 363**] [**Telephone/Fax (1) 3573**]
Name: [**Known lastname 10750**],[**Known firstname 3485**] Unit No: [**Numeric Identifier 16355**]
Admission Date: [**2101-1-31**] Discharge Date: [**2101-2-14**]
Date of Birth: [**2036-12-16**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Niacin
Attending:[**First Name3 (LF) 1513**]
Addendum:
Transferred to Medicine Service
Chief Complaint:
Hyponatremia, SOB
Major Surgical or Invasive Procedure:
Posterior Lumbar decompression L2-L5 with Fusion L4-5
History of Present Illness:
Pt is a 64 yo female w/ h/o HTN, OSA, DM who initially presented
to hospital for elective fusion-laminectomy of L3-L5. Surgey
went well however post op was complicated by hypotension,
tachycardia, and hypoxia. She had lost apporximately 1300 cc of
vblood duriing the procedure and received 2 untis of PRBC post
op. She was transferred to the TSICU for observation overnight.
She stayed one night in the TSICU then was transferred back to
the floor. Subsequently her Na began to drop, she had some
mental status changes and continued to have SOB. She was then
transferred to medicine for management of her hypoxia, SOB, and
hyponatremia. On transfer patient complained of SOB at rest.
She had + orthopnea and was unable to lay flat. Denied any
fevers, chills, N/V, chest pain.
Past Medical History:
HTN
DM
Obesity
Arthritis
OSA- on Bipap
GERD
Neuropathy
Social History:
lives alone, pet hamster, no tob/etoh/ivdu
Family History:
No history of early cardiac death, HF. + CAD There are family
members with HF but developed later in life.
Physical Exam:
p115 bp 120/80 RR44 Pox 98%/4L O2 NC
Gen-Dyspneic at rest
HEENT- MMM, no JVD
Neck-no appreciable JVD but neck obese
CV- nl S1 S2 RRR no m/r/g
Pulm- [**Month (only) **] BS at bilat bases [**1-31**] way up w/ rales, exp wheezes
throughout
Abd- +bs, soft obese, NT, ND, and tympanitic
Ext- no edema, warm; mild tenderness in R calf, non-tender L
calf
Pertinent Results:
Na 133->137->120->135
Hct 30.9 dropped to 26.2. Recieved blood responded to 34 then
remained around 30.
Trop <0.01 times three then increased to 0.03 then 0.02
TSH 3.8
CPK peaked to 2500 after surgery around POD 5 was 253
CT Abd/Pelvis [**2101-2-2**]:
1. No intraperitoneal, retroperitoneal or operative site
hematoma detected.
2. Small bilateral pleural effusions. Airspace opacity in the
left lung base may represent pneumonia.
CT Chest [**2101-2-7**]: Non-contrast study shows bilateral pleural
effusions, cardiomegaly and septal lines consistent with left
ventricular heart failure.
ECHO [**2101-2-8**]
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is severe global left ventricular
hypokinesis. The basal inferolateral wall contracts best. No
masses or thrombi are seen in the left ventricle. Right
ventricular chamber size is normal. There is focal hypokinesis
of the apical free wall of the right ventricle. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe biventricular systolic dysfunction c/w
diffuse process.
Brief Hospital Course:
Please see surgical d/c summary for input on info prior to
transfer.
# [**Name (NI) 16356**] Pt was transferred from the ortho service to the medicine
for concerns of SOB and hyponatremia. On transfer the patient
was extremely tachypneic and requiring 4L of oxygen. Prior to
her admission she had no SOB at baseline or exertion and did not
require oxygen. Her post op course was complicated by
hypotension, hypoxia, tachycardia, tachypnea. During the
surgery she lost 1300 cc of blood per the TSICU admit note. She
was given two untis of blood and fluids as well post
operatively. Her BP responded to the blood and however she
continued to be tachycardic and hypoxic. She was then
transferred back to the floor. She continued to be tachypneic
with hypoxia requiring oxygen via nasa canula. Her HR remained
in the 120' and became hyponatremic so medicaine was consulted.
CXR demonstrated bilateral pleural effusions. On transfer we
were concerned about PE (pt was no on heparin, recent surgery,
obese, and on evista) versus CHF. Plan was for CTA however
unfortunately patient lost IV access and therefore was only able
to get nonconstrast chest CT. We then got a D-dimer which was
elevated as expected, but decided to go ahead and start the
patient on heparin IV for possible PE. A central line was
placed by the procedure service. The CT chest ended showing
moderate sized bilateral pleural effusion and pulm edema. Thus
we also gave patient some lasix which she responded to well.
The following LENI's were performed which showed no evidence of
DVT. Thus our suspicion at this point was CHF and we felt
comfortbale stopping the heaprin. ECHO was ordered and
demonstrated severe biventricular dysfunction with EF of 20%.
The finding of newly diagnosed was concerning given the fact
that the patient had a stress MIBI from [**6-1**] which showed EF of
67%. It was unclear as to how the patient could have developed
such severe HF over 1 year. We checked a TSH which was normal.
Also thought about ischemia in the setting of the surgery.
However her troponin only increased to 0.03. Her CPK's were
elavated initially but this was in the setting of the surgery
and MB's were not done. Another possibilty was either
tachycardic induced cardiomyopathy or idiopathic. It was noted
that when reviewing the patient's old ECG's normally she had
sinus tachycardia with prolonged PR interval. ECG during
hospital showed no ST changes but there was noted poor R wave
progession. Pt was lasix naive when getting her first dose and
responded extremely well. After single dose of lasix her
respiratory status improved. She was continued on ACEI which
was subsequently titrated up. Lasix IV was continued with goal
of -1 liter per day. On IV lasix she diuresed several liters.
HEr lung exam improved and required less oxygen. After
diuresing her several liters the lasix was switched to PO. When
she was felt to be compensated BB was added for rate control and
CHF management. On discharge patient was compensated requiring
no oxygen and able to ambulate without dyspnea. She will need
follow up ECHO to evaluate her EF and will also need to be
followed up by the heart failure clinic for medical management,
with follow-up PMIBI to assess for ischemic cause of CHF.
# [**Name (NI) 16357**] Pt had no history of CAD prior to admission. P-MIBI from
[**6-1**] showed no perfusion defects and normal EF. She had no
chest pain during her hospital stay. CPK was elevated after
surgery but this was likely secondary to the surgery itself, no
MB or troponin was done. On transfer to medicine her enzymes
were cycle with peak troponin to 0.03 due to CHF. Thus there
was no indication the patient had an MI. After discharge
patient should have a follow up P-MIBI to evaluate for coronary
artery disease.
# [**Name (NI) 16358**] Pt had initial Na of 137. After surgery this
trended down to 122. She had some mental status changes which
were likely effected by the electrolyte disturbance and
narcotics. The hyponatremia was associated with her CHF and
increased ADH in the setting of pain associated with surgery. We
restricted her fluid intake to 1L per day and treated the
underlying cause of CHF. With restriction and resolution of CHF
her Na returned to [**Location 1867**] levels of 135. Fluid restriction was
liberalized to 1500cc per day by d/c. She will need f/u to
assess for need for continued fluid restriction.
# [**Name (NI) 16359**] Pt was started on RISS and continued on her home regimen
of metformin. On transfer to medicine metformin was stopped
secondary for concern of development of side effects ie lactic
acidosis. For added control pt was started on glargine qhs.
When she had become more stable she was switched back to her
home regimen of metformin; metformin was held for 2 days prior
to d/c in the setting of CT dye load, but should be restarted on
[**2101-2-15**].
# Anemia- On admission Hct was 30.9. After the surgery Hct
dropped to 26 and she was subsequently transfused two units.
Her Hct increased to 36. This then trended down back to her
baseline of 30. She was guaiac negative. Fe studies revealed
anemia of chronic disease with low Fe and elevated ferritin.
# Back [**Name (NI) 16360**] Pt underwent successful fusion and laminectomy
of L3-L5. Her pain after the surgery was controlled by PCApump
but this lead to mental status changes. Narcotics were then
intially avoided. As her other medical problems resolved we
restarted percocet for pain control along with lidoderm patch to
facilitate ambulation. She was able to tolerate PT and
ambulation with good pain control. Pt was ambulating with
walker without difficulty.
Medications on Admission:
Cyclobenzaprine 10 mg qday, Tolterodine 2 mg qday, Raloxifene
60mg qday, Imipramine 30 am/100pm Pramipexole 0.25 mg qday,
Lisinopril 10 mg qday, Gabapentin 300 mg tid, Metformin 850mg
tid
Discharge Medications:
1. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Metformin HCl 850 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12 ().
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
5. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. 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*
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*300 ML(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Imipramine HCl 10 mg Tablet Sig: Three (3) Tablet PO QAM.
12. Imipramine HCl 50 mg Tablet Sig: Two (2) Tablet PO QPM.
13. Neurontin 400 mg Capsule Sig: One (1) Capsule PO three times
a day.
14. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO QAM.
15. Mirapex 0.25 mg Tablet Sig: One (1) Tablet PO once a day.
16. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
sheryle House
Discharge Diagnosis:
Spinal stenosis
CHF
DM
Anemia
Hyponatremia
Discharge Condition:
Stable, neuro intact, wound healing primarily. Able to ambulate
without SOB or need of oxygen
Discharge Instructions:
Keep wound clean and dry. [**Month (only) 412**] shower, no immersion
Please call [**Telephone/Fax (1) 16361**] to make follow up appointment with Dr.
[**First Name (STitle) 1313**] (Cardiologist) within 2-3wks. You also need to arrange
with Dr. [**Last Name (STitle) 16362**] for ECHO and stress test.
Please take all the medications as directed.
If you experience any shortness of breath, chest pain, weight
gain, lower extremity edema you should seek medical attention.
Followup Instructions:
Follow-up as planned with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1742**]
Follow-up with Dr. [**First Name (STitle) 1313**] (Cardiologist [**Telephone/Fax (1) 16361**]) in [**3-3**]
weeks for stress test.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 189**] [**Hospital 16363**] Phone:[**Telephone/Fax (1) 23**] Date/Time:[**2101-3-8**] 12:00
Provider: [**Name10 (NameIs) **] INJECTIONS Where: [**Hospital6 189**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 16364**] Date/Time:[**2101-3-9**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 856**], RD Where: [**Hospital6 189**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 16365**] Date/Time:[**2101-3-15**] 4:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1514**] MD [**MD Number(2) 1515**]
Completed by:[**2101-2-14**]
|
[
"276.1",
"738.4",
"276.5",
"250.00",
"285.1",
"722.10",
"401.9",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"38.93",
"99.04",
"81.08"
] |
icd9pcs
|
[
[
[]
]
] |
13632, 13672
|
6064, 11761
|
3024, 3080
|
13759, 13855
|
4540, 6041
|
14380, 15341
|
4047, 4156
|
11999, 13609
|
13693, 13738
|
11787, 11976
|
13879, 14357
|
4171, 4521
|
2967, 2986
|
3108, 3893
|
3915, 3971
|
3987, 4031
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,106
| 123,298
|
26540
|
Discharge summary
|
report
|
Admission Date: [**2130-8-2**] Discharge Date: [**2130-8-8**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
ERCP, management of a complicated patient
Major Surgical or Invasive Procedure:
1. ERCP with stent placement
2. Bone marrow biopsy
History of Present Illness:
Mr. [**Known lastname **] is an 86-year-old man with history of CAD s/p MI, a
fib, AAA, who is transferred from [**Hospital **] hospital for ERCP.
He initially presented to [**Hospital **] hospital on [**7-30**] for
shortness of breath and drop in hematocrit. The patient notes
that he developed progressive SOB and DOE over the past few
weeks prior to admission, to the point that he would have to
rest after walking 20 feet. Denies fevers, chills, cough, chest
pain. Of note, he was seen by an outside dermatologist recently
for chronic urticaria and pruritis, felt to be related to his
anemia. On admission to [**Location (un) **], he was noted to have a hct
of 19.6 from a baseline of 30. MCV was 111. He received a
total of 4 packed red blood cell transfusions with an
appropriate hematocrit bump to 30. Upper endoscopy and
colonoscopy were performed at the outside hospital showing mild
gastritis, duodenitis, sigmoid-predominant diverticulosis, and
internal hemorrhoids, but no evidence of active or recent
bleeding. CT abdomen/pelvis yesterday revealed a 1.4cm gall
stone obstructing the distal common bile duct with 1.4 cm
dilation of the common bile duct as well as mild intrahepatic
ductal dilatation, cirrhotic appearing liver with a ~1cm
hypodense lesion, extensive abdominal aortic aneurysm, and
sigmoid diverticulosis. He was reportedly seen by hematology
with plan for possible bone marrow biopsy as an outpatient. The
morning of transfer, the patient became hypotensive to the
70-80s systolic. Reportedly asymptomatic. His heart rate was
55-65. He was given a 250cc NS bolus followed by maintenance
fluids and his systolic blood pressure improved to 90. Blood
and urine cultures were sent and he received one dose of
levofloxacin 250mg IV. He was transferred to [**Hospital1 18**] for further
management.
Past Medical History:
Hypertension
Coronary artery disease s/p Inferior Myocardial Infarction in
[**2114**]
Stage II chronic kidney disease, baseline 1.4 as of [**9-2**]
Atrial fibrillation-- off of anticoagulation s/p Upper
Gastrointestinal bleed 1.5 yrs ago
History of duodenal ulcer with bleed 1.5 yrs ago
Chronic anemia (baseline hct 30)
pending heme w/u MDS
Atrial Septal Defect
Pulmonary hypertension
Mitral Regurgitation
Tricuspid valve disease
Carotid stenosis- totally occluded R ICA
Abdominal Aortic Aneurysm
History of Transient Ischemic Attack
Seizure disorder
Diverticulosis
Hearing loss
Choledocholithisis/cholelithisis diagnosed this admission
Social History:
Lives with his 82-year-old wife in [**Name (NI) 65536**]. married x 45
years. Independent of ADLs, does his own yard work. Formerly
worked as an advertising salesman for the [**Location (un) **] Gazette for
35 years. Smoked up to 3 ppd since age 13, quit 4 years ago.
Drinks 2 vodka martinis daily. Has one son who lives in [**Name (NI) **]
[**Doctor Last Name **], AK, and one daughter who lives in [**Name (NI) 108**].
Family History:
noncontributory
Physical Exam:
Vitals: T: 96.3, BP: 111/60, P: 77, R: 18, O2: 100% RA
General: Alert, oriented, pleasant elderly male in no acute
distress
HEENT: mildly icteric sclera, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, no ascites
Ext: Warm, well perfused, 1+ distal pulses, no clubbing,
cyanosis or edema
Skin: no spider angiomata, no palmar erythema
Pertinent Results:
Outside Hospital Labs:
Hct trend: 19.6 ([**7-30**]) --> 21.4 ([**7-31**])--> 30.5 ([**8-1**])
WBC: 11.7 ([**7-30**]) --> 6.6 ([**8-1**]), 79% PMN, 8 bands, 9 lymphs
MCV: 111 (prior to RBC transfusion)
INR: 1.3 ([**7-30**])
[**7-30**] TIBC 211, iron 90, ferritin >1500, B12 1205, folate 14.2,
transferrin 151
[**8-1**] Na 132, K 4.2, Cl 102, CO2 20, GUN 57, Cr 3.0, gluc 145
T bili 2.6, D bili 1.7, AST 111, ALT 213, Alk phos 455
[**8-2**] Cr 3.6, T bili 1.7, direct bili 1.0, AST 70, ALT 152, Alk
phos 350, LDH 129, dilantin 4.6
.
Images:
[**8-2**] CT abd/pelvis:
1. Findings are consistent with choledocholithiasis and
associated biliary obstruction. Suggestion of mild intrahepatic
biliary ductal dilatation. There is dilation of the
extrahepatic portion of the CBD which measures 1.4 cm. Within
the distal CBD right at the level of the ampulla there is an
obstructing gall stone measuring 1.3 x 1.4 x 1.4 cm.
2. Cirrhotic appearance to the liver with the presence of a
subtle hypodense focus within the left lobe (0.8 x 1.1 x 1.3cm).
The possibility of a neoplastic focus needs to be excluded.
3. Bilateral atrophic kidneys.
4. Extensive abdominal aortic vascular disease involving the
mesenteric vessels, renal arteries, and iliac arteries which are
aneurysmally dilated. Evaluation limited by non-contrast scan.
5. Coronary artery disease.
6. Mitral valve calcifications.
7. Cholelithiasis.
8. Sigmoid diverticulosis without evidence for diverticulitis.
9. Degenerative changes in the lumbar spine.
.
[**7-30**] CXR: There is calcified granuloma in the right lower chest
peripherally unchanged. Minimal atelectasis is seen at the left
lateral sulcus, this may reflect an element of scarring as it is
similar to that seen previously. The left hemidiaphragm is
slightly elevated. The right lung is otherwise clear. The
heart is upper normal in size. There is no CHF.
Labs at [**Hospital1 18**]:
[**2130-8-8**] 01:30PM BLOOD WBC-4.5 RBC-3.08* Hgb-10.2* Hct-30.1*
MCV-98 MCH-33.0* MCHC-33.8 RDW-20.5* Plt Ct-230
[**2130-8-8**] 01:30PM BLOOD Plt Ct-230
[**2130-8-5**] 07:00AM BLOOD Fibrino-471*
[**2130-8-3**] 01:32PM BLOOD Ret Aut-0.8*
[**2130-8-8**] 01:30PM BLOOD Glucose-143* UreaN-27* Creat-1.8* Na-136
K-4.5 Cl-104 HCO3-22 AnGap-15
[**2130-8-8**] 01:30PM BLOOD ALT-41* AST-25 CK(CPK)-26* AlkPhos-314*
TotBili-1.8*
[**2130-8-3**] 04:00AM BLOOD ALT-111* AST-45* LD(LDH)-138 AlkPhos-303*
TotBili-1.2 DirBili-0.9* IndBili-0.3
[**2130-8-7**] 04:48PM BLOOD CK-MB-4 cTropnT-0.10*
[**2130-8-8**] 12:30AM BLOOD CK-MB-4 cTropnT-0.10*
[**2130-8-8**] 01:30PM BLOOD CK-MB-4 cTropnT-0.07*
[**2130-8-8**] 01:30PM BLOOD Calcium-8.7 Phos-2.1* Mg-1.8
[**2130-8-3**] 04:00AM BLOOD calTIBC-124* VitB12-820 Folate-13.6
Ferritn-GREATER TH TRF-95*
[**2130-8-2**] 08:02PM BLOOD TSH-1.5
[**2130-8-5**] 07:00AM BLOOD PTH-49
[**2130-8-2**] 08:02PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2130-8-2**] 08:02PM BLOOD AFP-<1.0
[**2130-8-3**] 04:00AM BLOOD Phenyto-3.9*
[**2130-8-2**] 08:02PM BLOOD HCV Ab-NEGATIVE
[**2130-8-3**] 04:00AM BLOOD PEP-NO SPECIFIC ABNORMALITY
Echo [**2130-8-8**]: The left atrium is mildly dilated. The estimated
right atrial pressure is 10-20mmHg. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. LV systolic function appears globally depressed
(ejection fraction approximately 30 percent), with regional
variation (the posterior and lateral walls contract better than
the rest of the ventricle). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. The aortic root
is mildly dilated at the sinus level. The ascending aorta is
mildly dilated. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. There is severe mitral annular calcification. At least
moderate (2+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation is likely
significantly UNDERestimated.] The left ventricular inflow
pattern suggests a restrictive filling abnormality, with
elevated left atrial pressure. The tricuspid valve leaflets are
mildly thickened. The supporting structures of the tricuspid
valve are thickened/fibrotic. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. The main pulmonary artery is dilated. The
branch pulmonary arteries are dilated. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2127-3-11**], the left ventricular ejection fraction is
further decreased, and the mitral and tricuspid regurgitation
are significantly increased
ERCP [**2130-8-7**]:
Cannulation of the biliary duct was successful and deep with a
Clever Cut sphincterotome using a free-hand technique.
A single 15mm filling defect consistent with a calcified round
stone that was causing partial obstruction was seen at the lower
[**1-28**] of the common bile duct. There was post-obstructive
dilation.
A biliary sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
A 10FR by 7cm Cotton [**Doctor Last Name **] biliary stent was placed
successfully.
Diverticulum in the distal duodenal bulb
[**2130-8-7**] ECG:
Atrial fibrillation. Leftward axis. Intraventricular conduction
delay.
Inferior myocardial infarction, age undetermined. T wave
inversions in
leads I, aVL, as well as leads V2-V6 may be due to left
ventricular
hypertrophy, although the contour also is consistent with
coronary ischemia and should be considered strongly. Clinical
correlation is suggested. Compared to the previous tracing of
[**2127-3-10**] repolarization abnormalities are new and the rate has
increased.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 0 128 472/486 0 -26 173
Brief Hospital Course:
Mr. [**Known lastname **] is an 86 year old gentleman with coronary artery
disease, atrial fibrillation, congested heart failure, and
multiple other problems transferred from [**Name (NI) 65537**]Hospital for choledocholithiasis, hypotension and acute renal
failure, had a brief stay at the ICU before transferred to the
general medicine unit.
While at the ICU, Mr. [**Known lastname **] was started on Flagyl 500 mg IV Q8H
and Ciprofloxacin 500 mg PO Q24H for 24 hours. He was given a
total of 4500cc IV fluid during his ED and ICU stay. The ICU
team decided to postpone on Mr. [**Known lastname 65538**] ERCP until Monday ([**8-7**])
because he was afebrile and hemodynamically stable without
leukocytosis.
On [**8-4**], patient was seen by hematology/oncology consultants who
performed bone marrow biopsy to work up his acute on chronic
anemia. Given chronic elevated MCV in the setting of normal
folate and B12, differentials then include alcohol,
myelodysplastic syndrome, liver disease, reticulocytosis, or
medications such as anti-metabolites. In Mr. [**Known lastname 65538**] case, the
first two causes were highest on the differential. Over the
course of his stay, Mr. [**Known lastname 65538**] hematocrit stayed around 25
(from a baseline of 31). He subsequently received two units of
red blood cell transfusion, one in the evening of [**8-7**], and one
in the early morning of [**8-8**], with subsequent hematocrit at 31.
On Monday [**8-7**], Mr. [**Known lastname **] [**Last Name (Titles) 1834**] ERCP for extraction of his
common bile duct stone. The procedure had no complication.
Sphinterotomy was performed, and a single 15mm filling defect
consistent with a calcified round stone that was causing partial
obstruction was seen at the lower [**1-28**] of the common bile duct.
There was post-obstructive dilation. The stone was not able to
be extrated at the time because of its size and calcification. A
10 French 7cm stent was placed to enable drainage of the bile.
Patient was told to return for a repeat ERCP in six weeks
([**9-21**]) for re-evaluation. A routine EKG done after ERCP
showed diffuse T wave inversion with asymmetrical T waves. CK
levels over the next 24 hours remained around 25, and Troponin T
was 0.1->0.1->0.07. Patient was asymptomatic throughout the
episode. No pre-ERCP EKG was available for comparison, and
cardiology consult felt that these changes were unlikely
ischemic because the non-territorial nature of T wave inversion,
and that similar inversions were noted in selected lead II in
telemetry from [**Hospital **]Hospital. It is possible that
the patient had a demand ischemic event in recent past, but in
the setting of recent acute kidney injury and anemia, had a mild
elevation of cardiac enzymes that persisted. He was started on
aspirin, metoprolol, and statin. Heparin was not initiated
because of the lack of symptoms, unclear timing and onset for
the elevated troponin, and the past history of upper GI bleed.
Echocardiography on [**8-8**] (one day after the EKG change) showed
ejection fraction of 30%, a reduction from 40% in [**2127**]. It also
showed diffusely depressed left ventricular wall motion. His
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33474**], was informed of
these findings, and a stress test had been scheduled within a
week of discharge at [**Hospital 65539**]Hospital with his
cardiologist, Dr. [**Last Name (STitle) 1683**]. He will continue to take aspirin,
statin, lisinopril and beta blocker (his heart rate was 75 with
metoprolol). Given that he had not previously been on statin,
his liver function test should be checked on an outpatient
basis, and this had been communicated to his primary care
physician.
Mr. [**Known lastname **] also had acute kidney injury when he initially
presented to us.
FeNA was borderline (1.9%) but of uncertain value because
patient was receiving IV bolus of lasix prior to transfer at
OSH. This acute on chronic renal failure was likely secondary to
hypoperfusion of the kidney, as the patient's blood pressure was
in the 70s/40s prior to transfer. His creatinine gradually
improved throughout his stay here, coming down from 3.1 to 1.8
(with his baseline at 1.4). His urine output was adequate, and
renal ultrasound was unremarkable. He was also hyponatremic on
presentation, but the level improved after fluid restriction.
Mr. [**Known lastname **] also had a history of alcohol abuse, and throughout
this hospitalization he was given daily thiamine, multivitamin,
and folate. His CT at [**Hospital 65540**]Hospital showed a
cirrhotic liver with a hypodense lesion in the left liver lobe,
and the team recommended that this be followed up on an
outpatient basis, along with education on alcohol cessation.
This had also been communicated to the primary care physician.
Medications on Admission:
Medications at home:
Iron sulfate 325mg PO BID
HCTZ 25mg PO daily
KCl 20 mEq PO daily
Lisinopril 10mg PO daily
Prilosec 20mg PO daily
Dilantin 300mg PO qHS
Spectrovite 1 tab PO daily
.
Medications on transfer:
Levofloxacin 250mg IV x 1
Protonix 40mg PO daily
Dilantin 300mg PO qHS
K Clor Con 20 mEq PO QOD
Ferrous sulfate 325mg PO BID
Lisinopril 10mg PO daily
HCTZ 25mg PO daily
Spectrovite 1 tab PO daily
Procrit 10,000 units SQ x 1 today
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO HS (at bedtime).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day.
5. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
7. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Please measure Na, K, Cl, HCO3, BUN, Cr on [**8-11**] and have the
results faxed to your primary care doctor's office.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
Choledocholithiasis,
hypotension,
acute kidney injury
Anemia
Coronary Artery Disease
Discharge Condition:
Stable
Discharge Instructions:
You originally presented to [**Hospital **]Hospital on [**7-30**]
with low blood pressure, acute kidney injury, and were found to
have a stone in your common bile duct. You were treated with
fluid and antibiotics for presumed abdominal infection, and you
were transferred to the [**Hospital1 69**],
first in the intensive care unit, and then here on the general
medicine floor. Your kidney function appears to be recovering
now, but your anemia is still being worked up. The hematology
oncology team here performed a bone marrow biopsy, and the
result will be communicated to your primary care physician, [**Name10 (NameIs) **]
this can be followed up on an outpatient basis. You also
[**Name10 (NameIs) 1834**] esophageal retrograde cholangiopancreatography (ERCP)
to evaluate your common bile duct stone. The stone was
calcified, and its large size and integration into the common
bile duct wall prevented a safe and swift removal with the ERCP.
Consequently, a metal stent of 10 French diameter was placed to
allow normal bile flow.
After ERCP, your routine electrocardiogram showed new changes
that were concerning for cardiac ischemia. We therefore
[**Name10 (NameIs) 1834**] a series of blood test to assess whether your heart
was sufferring from an acute injury. Over the next 24 hours,
your cardiac enzymes, although slightly elevated, did not
increase, and we concluded that the elevated level might be
secondary to your suboptimal kidney function, rather than as a
result of cardiac injury. You also [**Name10 (NameIs) 1834**] echocardiography as
part of this evaluation, and it did not show any new cardiac
wall motion abnormality suggesting heart muscle injury from
ischemia; nor was there evidence of any acute cardiac event.
Lastly, during your stay at the [**Location 65541**], a CT
scan of your abdomen showed a cirrhotic appearing liver with a
~1cm hypodense lesion. This needs to be followed up with your
primary care physician as an outpatient issue. You will have a
repeat ERCP here at [**Hospital1 18**] in one month to re-evaluate your
common bile duct stone and the newly placed stent.
Given the change in your cardiac status, we decided to add
several medications. You should continue to take metoprolol,
aspirin, and atorvastatin. Please speak with your primary care
physician as to whether you should continue these medications.
If you remain on atorvastatin you will need to have your liver
enzymes monitored.
In addition, you will need to have a stress test within one week
of discharge from the hospital. This may be arranged by your
primary care doctor.
Your lisinopril and hydrochlorothiazide were being held because
of the decreased kidney function. Your lisinopril was restarted
at half your normal dose on the day of discharge. You will need
to meet with your primary care doctor to decide whether you can
restart the hydrochlorothiazide, and whether he wants to
increase the lisinopril to your normal dose.
Please contact your physician or return to the emergency room if
you experience severe abdominal pain, chest pain, acute
shortness of breath, fever, sudden dizziness or weakness, or any
worsening signs and symptoms.
Followup Instructions:
1. Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 33474**] ([**Telephone/Fax (1) 65542**]) within one week regarding your anemia
(bone marrow biopsy) workup, your liver cirrhosis (based on the
recent CT finding), your kidney function, and management of your
coronary artery disease.
2. Repeat ERCP appointment: ERCP 2 (ST-4) GI ROOMS
Date/Time:[**2130-9-21**] 9:00
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2130-9-21**] 9:00
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Discharge summary
|
report
|
Admission Date: [**2141-7-3**] Discharge Date: [**2141-7-9**]
Date of Birth: [**2061-11-9**] Sex: F
Service: MEDICINE
Allergies:
Calcium Channel Blocking Agents-Benzothiazepines /
Statins-Hmg-Coa Reductase Inhibitors / Nexium / Amiodarone
Attending:[**Doctor First Name 1402**]
Chief Complaint:
Increasing palpitations
Major Surgical or Invasive Procedure:
Pulmonary vein isolation
History of Present Illness:
79-year-old female with a longstanding history of paroxysmal
atrial fibrillation, HTN, and hyperlipidemia who was admitted
for afib ablation. Has had atrial fibrillation x39 years but
recently episodes have increased in frequency, requiring four
hospitalizations since [**2140-12-22**]. She is symptomatic with
these episodes, with rates in the 140s to 160s. She describes
palpitations with her atrial fibrillation, as well as having
severe chest pain and burning that makes her feel like she is
having a heart attack, severe fatigue and lightheadedness. She
states that these episodes are incapacitating. She was referred
for pulmonary vein isolation and ablation of afib on day of
admission.
.
Atrial fibrillation history is as follows: She has had
paroxysmal atrial fibrillation since the age of 40 and has been
managed on beta-blockers, calcium channel blockers, digoxin,
amiodarone and more recently sotalol, on escalating doses.
Currently on 160mg PO BID and continues having breakthrough
episodes on that dose. She was intolerant to amiodarone with
extreme tremors and was unable to tolerate calcium channel
blockers as well. She has had two prior DC cardioversions and
multiple hospital admissions for chemical conversions.
.
Patient had pulmonary vein isolated with all veins isolated.
Found to have atrial tachycardia, pt shocked out of AT. Sheath
pulled in lab after protamine was given. Case complicated by
large pelvic hematoma (12x 5 cm) without retroperitoneal bleed,
so patient transfused 2units pRBCs, transferred to CCU for
further observation.
.
On arrival to CCU, pt in sinus rhythm, stable hemodynamics.
denied chest pain, dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope. Pt arrived on Neosynephrine drip, which was
subsequently weaned due to stable SBPs in the 130s--> 100s after
weaned. Finished her ordered 2 units of PRBC, rechecked Hct
q6hrs. Hct bumped appropriately from 29.4-->36.0. INR was
therapeutic at 2.8, coumadin held overnight. Controlled pain
with Tylenol #3.
.
Cardiac review of systems significant for no lower extremity
edema, orthopnea, syncope or presyncope. She has had no symptoms
consistent with stroke and/or TIA.
Past Medical History:
PAST MEDICAL HISTORY:
1.CARDIAC RISK FACTORS:(-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-atrial fibrillation x 39yrs
-PERCUTANEOUS CORONARY INTERVENTIONS:
-cardiac catheterization in [**2138**], complicated by femoral artery
either perforation or dissection.
-CABG: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Hyperlipidemia, not on statin due to intolerance/severe muscle
cramps
-Hypertension
-s/p 2 total right hip replacements and two additional right hip
surgeries
-GERD,
-[**2-26**]: emergent exploratory laparotomy after bowel perforation
from
swallowing part of a tooth pick
-s/p resection of skin cancers
-s/p appendectomy
-s/p resection of ovarian cyst
-s/p hemorrhoid surgery
Social History:
She is married and lives with her husband in [**Name (NI) 67742**],
[**State 2748**]. She has one 59 year old son.
[**Name (NI) 1139**]: She is a former smoker, quit 17 years ago
-ETOH: was a formal drinker but does not drink anymore due to
her
atrial fibrillation.
-Illicit drugs: Denies
Family History:
NC
Physical Exam:
VS: T=99.5 BP=131/64 HR=85 RR=12 O2 sat=99% on 2L NC
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of <10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VI systolic murmur throughout
precordium, no rubs/gallops. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft but tender to palpation over Left lower abdomen to
midline, 3-4cm below umbilicus. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Femoral sites oozing.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Pertinent Results:
ECGs
Post-Intervention ECG, [**2141-7-3**]: Sinus rhythm, rate 74bpm, L
axis, atrial bigeminy, old LBBB.
ECG on arrival to CCU [**2141-7-3**]: Sinus rhythm, rate 81bpm, left
axis, old LBBB.
[**2141-6-9**]: sinus rhythm at a rate of 57 beats per minute with a PR
interval of 180 ms, a QRS interval of 142, and QTC of 477. She
notably has a left bundle-branch block.
CARDIAC CATH: [**2141-7-3**] - PVI procedure - wet read per EP fellow
note
s/p PVI. all veins isolated. AT (lower loop around IVC; ablated:
then reentry around CS os (confirmed by pacing R and l side);
burns around CS and within CS. Cs sheath got pulled back during
case: case terminated; pt shocked out of AT. sheath pulled in
lab after protamine was given. L hemipelvic hematoma
CT abd/pelvis [**7-3**]:
There is a large complex fluid collection in the left
hemipelvis, with several fluid levels, suggestive of acute
bleeding. The collection displaces urinary bladder, which
contains a Foley catheter. The collection extends along the left
iliac vessels and into the left inguinal region. The overall
measurements are approximate due to complex shape. The largest
dimensions are 12.5 x 5.5 cm in the axial plane. The rectum is
unremarkable, and the sigmoid colon is displaced by a
collection.
CT abd/pelvis [**7-4**]:
- Large extraperitoneal left pelvic hematoma has slightly
increased in size, measuring overall 14.7 x 6.8 cm in largest
axial dimensions, compared to 12.5 x 6.0 previously. There is
slightly greater superior extent of the hematoma which now
slightly expands the left psoas muscle. The hematoma continues
to displace and compress the urinary bladder as well as the
sigmoid colon.
ADMISSION LABS
[**2141-7-3**] 09:01PM HCT-36.0
[**2141-7-3**] 02:29PM HCT-29.4*#
[**2141-7-3**] 02:03PM PO2-72* PCO2-37 PH-7.37 TOTAL CO2-22 BASE
XS--3
[**2141-7-3**] 02:03PM HGB-11.2* calcHCT-34 O2 SAT-94
[**2141-7-3**] 08:53AM WBC-9.0# RBC-4.61 HGB-13.4 HCT-39.8 MCV-86
MCH-29.1 MCHC-33.7 RDW-13.0
[**2141-7-3**] 08:53AM PLT COUNT-284
[**2141-7-3**] 06:45AM GLUCOSE-112* UREA N-17 CREAT-0.8 SODIUM-140
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-22 ANION GAP-16
[**2141-7-3**] 06:45AM PT-28.3* PTT-35.4* INR(PT)-2.8*
DISCHARGE LABS
INR=2.9
Hct=30.9
[**2141-7-9**] 05:18AM BLOOD Hct-30.9*
[**2141-7-8**] 07:39AM BLOOD WBC-8.2 RBC-3.72* Hgb-11.4* Hct-32.4*
MCV-87 MCH-30.5 MCHC-35.0 RDW-14.1 Plt Ct-210
[**2141-7-9**] 05:18AM BLOOD PT-29.0* PTT-32.9 INR(PT)-2.9*
[**2141-7-7**] 05:11AM BLOOD Glucose-114* UreaN-16 Creat-0.6 Na-136
K-4.0 Cl-101 HCO3-26 AnGap-13
Brief Hospital Course:
79-year-old female with a longstanding history of paroxysmal
atrial fibrillation, HTN, and hyperlipidemia with increasing
symptomatic afib presented for PVI which led to successful
conversion to normal sinus rhythm and was c/b large pelvic
hematoma.
RECURRENT AFIB s/p PVI: Patient s/p PVI for atrial fibrillation
on [**2141-7-3**]. All pulmonary veins were isolated, patient converted
to NSR post procedure. Patient asymptomatic post procedure.
Procedure complicated by large pelvic hematoma as below. Patient
continued on lower dose of sotalol 120 [**Hospital1 **] (home dose was 160mg
PO BID) and discharged on this lower dose. Initial INR was 2.8,
coumadin held in setting of bleed, and coumadin restarted
slowing as bleeding resolved. On discharge, patient was in sinus
rhythm, with INR of 2.9 on 5mg coumadin daily. She was
discharged back on her home dose of coumadin which 5mg PO daily
except for 2.5mg Tu, Fri. She should have INR and Hct rechecked
on Tuesday [**7-11**]. She was scheduled with f/u with Dr. [**Last Name (STitle) **]
as an outpatient.
PELVIC HEMATOMA: Had large pelvic hematoma as complication of
PVI procedure. Measured at 12x 6cm on initial CT, and repeat CT
was slightly increased at 14.7 x 6.8cm. Patient received total
of 7 units of pRBCs during her stay, coumadin was temporarily
held in setting of acute bleed, and by discharge, her Hct was
stable at 30.9 with decreased abdominal distension. Patient
should have Hct rechecked on [**7-11**] and faxed to PCP for followup.
She was discharged with instructions to limit activity to
moderate activity.
PUMP: Pt has preserved EF>60%. In setting of large blood volume
resuscitation, patient started having some symptoms of volume
overload on AM of [**7-6**], given 10mg IV lasix x 2 for diuresis.
After that, patient had autodiuresis and equilibration. She did
not need any ongoing lasix on discharge. Euvolemic at discharge.
CORONARIES: Status of coronaries not documented, no known h/o
CAD; had cath in past, but results unknown, no mention of CAD or
PCI. Risk factors include HTN and hyperlipidemia.
TRANSIENT HYPOTENSION: During PVI procedure had transient
hypotension requiring intra procedural neosynephrine, which was
weaned off within hours of arrival to CCU. No other issues with
BP, patient restarted on home doses of metoprolol and valsartan
and discharged on home BP medications.
GERD: Continued on ranitidine 150mg PO BID.
Hyperlipidemia: stable; not currently treated with statins.
COMM: [**Name (NI) **] [**Name (NI) 30864**] (husband): [**Telephone/Fax (1) 82167**]
Medications on Admission:
Folic acid 1 mg Tablet 1 Tablet(s) by mouth qpm
Losartan [Cozaar] 50 mg Tablet 1 Tablet(s) by mouth qpm
Metoprolol Tartrate 25 mg Tablet [**12-23**] Tablet(s) by mouth twice a
day
Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal 1
Tab(s) by mouth qpm
Ranitidine HCl 150 mg Tablet 1 Tablet(s) by mouth twice a day
Sotalol 160 mg Tablet 1 Tablet(s) by mouth twice a day
Warfarin 5 mg Tablet [**12-23**] Tablet(s) by mouth on Tuesdays and
Fridays, one tablet all other days
Magnesium Oxide 400 mg Tablet 1 Tablet(s) by mouth qpm
Multivitamin daily
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO at bedtime.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
Please have your INR and Hematocrit checked on Tuesday [**7-11**] and
fax to your primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1124**] for adjustment of
your coumadin at ([**Telephone/Fax (1) 82168**]
9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Recurrent atrial fibrillation
Secondary diagnosis
Pelvic hematoma
Hypertension
Hyperlipidemia
Gastroesophageal reflux
Discharge Condition:
Stable, walking around, abdominal pain and distension improved
Discharge Instructions:
You were admitted to the hospital for a procedure for your
recurrent abnormal heart rhythm called atrial fibrillation. You
developed a bleed in your pelvic area that we watched carefully
and gave you blood transfusions. While you were actively
bleeding, we temporarily held off on giving you your blood
thinner medication called coumadin but this was restarted and
you should continue taking coumadin daily on discharge.
Please continue taking all your home medications except for the
following additions and changes.
- Decrease your sotalol dosing from 160mg twice a day to 120mg
twice a day
- continue taking your 5mg coumadin pills - half tablet on
Tuesdays and Fridays, one tablet all other days. You will need
to check your INR at your appointment on [**7-20**] with Dr.
[**First Name (STitle) 1124**]
Please call your primary care physician or cardiologist if you
experience any dizziness, lightheadedness, palpitations,
shortness of breath, chest pain slurred speech, weakness, facial
droop, increased abdominal pain or distension, or any new or
worrisome symptoms.
Followup Instructions:
You have a follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] on
Friday [**2141-8-18**] at 3:40pm. ([**Telephone/Fax (1) 2037**]
You have a follow up appointment with your primary care doctor,
[**Last Name (LF) **],[**First Name3 (LF) 13704**] P. on [**2141-7-20**] at 11:00am. ([**Telephone/Fax (1) 82169**]
|
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icd9cm
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[
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11466, 11472
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4,185
| 161,720
|
24393
|
Discharge summary
|
report
|
Admission Date: [**2177-5-20**] Discharge Date: [**2177-6-6**]
Date of Birth: [**2099-12-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Nsaids
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Unstable angina
Major Surgical or Invasive Procedure:
[**2177-5-21**] - Two vessel coronary artery bypass grafting(SVG to LAD,
SVG to OM1) and aortic valve replacement(25mm [**Last Name (un) 3843**] [**Doctor Last Name **]
pericardial bioprosthesis)
History of Present Illness:
This is a 77 year old female who presented to [**Hospital3 4107**]
with right sided neck pain. Her symptoms were relieved with
sublingual Nitroglycerin. She ruled out for myocardial
infarction. She has known coronary artery disease and has been
on medical therapy. Cardiac catheterization in [**2176-11-20**] was
significant for severe three vessel coronary disease and normal
left ventricular function. The left main had a 60% lesion, the
LAD had a 50% stenosis, the circumflex had an ostial 70% lesion
while both the PLV and PDA had 50% stenoses. She was
subsequently transferred to [**Hospital1 18**] for coronary
revascularization.
Past Medical History:
paroxsymal atrial fibrillation, chronic renal insufficiency,
hypertension, cerebrovascular disease(h/o TIA and known left
carotid stenosis), breast cancer - s/p mastectomy, s/p
hysterectomy,
Social History:
Married, lives with husband. Denies tobacco and ETOH.
Family History:
No premature coronary disease
Physical Exam:
Vitals: Afebrile, Pulse 58, BP 166/45, RR 22, SAT 99% room air
General: No acute distress
HEENT: oropharynx benign, moist mucous membranes
Chest: wheezing noted, decreased sounds at bases
Heart: regular rate and rhythm, no murmur or rub
Abdomen: benign
Extremities: warm, 2+ edema
Wounds: clean, dry and intact
Pertinent Results:
[**2177-5-20**] 04:45PM PT-12.9 PTT-23.4 INR(PT)-1.1
[**2177-5-20**] 04:45PM PLT COUNT-185
[**2177-5-20**] 04:45PM WBC-9.1 RBC-4.22 HGB-12.7 HCT-36.9 MCV-87
MCH-30.1 MCHC-34.4 RDW-13.9
[**2177-5-20**] 04:45PM GLUCOSE-111* UREA N-19 CREAT-1.0 SODIUM-142
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-28 ANION GAP-14
[**2177-6-3**] 05:08AM BLOOD WBC-12.8* RBC-3.30* Hgb-9.4* Hct-29.4*
MCV-89 MCH-28.6 MCHC-32.1 RDW-15.3 Plt Ct-319
[**2177-6-3**] 05:08AM BLOOD Glucose-101 UreaN-23* Creat-0.9 Na-137
K-4.1 Cl-103 HCO3-26 AnGap-12
[**2177-6-5**] 02:47AM BLOOD PT-15.5* PTT-52.0* INR(PT)-1.6
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted on [**5-20**]. She underwent routine
preoperative evaluation which included a carotid ultrasound
which showed moderate plaque in the left internal carotid
artery(40-59%) and mild plaquing in the right internal carotid
artery(less than 40%). In addition, there was disease in the
right vertebral artery. An transthoracic echocardiogram was also
notable for mild aortic valve stenosis, mild aortic
regurgitation, mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
The rest of her workup was unremarkable and she was cleared for
surgery.
On [**5-21**], two vessel coronary artery bypass grafting was
performed in addition to an aortic valve replacement utilizing a
25 millimeter [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial bioprosthesis. Her
operative course was notable for small coronary vessels along
with severe and diffuse coronary calcifications. Therefore the
LIMA was not utilized and the PDA was not graftable. The
operation was otherwise uneventful and she was brought to the
cardiac SICU for further monitoring.
She was slow to wean from inotropic support. Amiodarone was
resumed for atrial fibrillation with rapid ventricular rate. She
was eventually extubated on postoperative day three. Over
several days, her hemodynamics stablized. She went on to
experience right upper extremity weakness and left facial
weakness for which a head CT scan was obtained on [**5-25**]. The
CT scan was notable for a large well-circumscribed hypodense
area of encephalomalacia in the left frontal lobe, chronic in
nature. It was difficult to exclude an acute extension of
infarction in this area. She was subseuqently kept hypertensive
to maintain cerebral perfustion. Warfarin therapy was also
resumed in addition to Aspirin. Swallow evaluation on [**5-26**]
showed no signs of aspiration. She initially had difficulty with
regular solids. Due to persistent atrial fibrillation, she
underwent cardioversion on [**5-27**]. She remained on oral
Amiodarone and remained mostly in a normal sinus rhythm. K and
Mg levels were monitored closely and repleted per protocol. Due
to a subtherapeutic INR, she was temporarily maintained on
intravenous Heparin. Her clinical status gradually improved and
she transferred to the SDU on postoperative day nine.
Amiodarone and beta blockade were continued for intermittent
episodes of paroxsymal atrial fibrillation. Beta blockade was
titrated accordingly for bradycardia. Given her cerebrovascular
disease, she was kept somewhat hypertensive. She remained volume
overloaded and continued to require diuresis. She responded well
to Lasix and by discharge, she was tolerating room air with
oxygen saturations of 99%. At discharge, she remained volume
overloaded and will continue to require diuresis. Warfarin was
dosed daily for a goal INR between 2.0 - 2.5. Haldol was
intermittently required for mild paranoia, agitation and mild
confusion. For the remainder of her hospital stay, her mental
status slowly improved as did her motor function. She made
steady progress with physical therapy. Repeat speech evaluation
on [**6-3**] revealed much improvement. She was eventually
cleared for discharge to rehab on postoperative day ******.
Due to her incomplete revascularization, she will need to follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] in approximately 8 weeks for repeat
stress test with potential for percutaneous coronary
intervention and stenting.
Medications on Admission:
Atenolol 100 mg Qd
Imdur 60 mg Qd
Lasix 20 mg Qd
Lexapro 10 mg Qd
Lipitor 10 mg Qd
Lisinopril 40 mg Qd
Aspirin
Warfarin 2.5 mg Qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed
Release (E.C.)(s)
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
7. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO QPM:
Daily dose may vary. Adjust for goal INR between 2.0 - 2.5.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours).
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: Last dose [**2177-6-8**].
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: Continue two tablets (400mg) for 7 days then drop to
one tablet(200mg) for indefinite amount of time.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days: then titrate according to weight and
respiratory status.
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days: Then adjust according to Lasix dose. Maintain K greater
than 4.0.
15. Albuterol Sulfate 0.083 % Solution Sig: [**12-22**] Inhalation Q6H
(every 6 hours) as needed.
16. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Discharge Disposition:
Extended Care
Facility:
tt
Discharge Diagnosis:
s/p AVR/CABG, HTN, elevated cholesterol, cerebrovascular disease
- h/o TIA, PAF, chronic renal insufficiency, Breast CA - s/p
mastectomy
Discharge Condition:
Stable
Discharge Instructions:
Patient may shower over incision - pat dry. No lotions or cream.
No driving for one month.
No lifting greater than 10 lbs for at least 10 weeks.
Followup Instructions:
Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in 4 weeks.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18323**] in [**12-22**] weeks.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] in 8 weeks for stress test.
Dr. [**Last Name (STitle) 911**] if indicated.
Completed by:[**2177-6-6**]
|
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icd9cm
|
[
[
[]
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] |
[
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[
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8070, 8099
|
2454, 6009
|
303, 501
|
8280, 8288
|
1844, 2431
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,744
| 165,769
|
29918
|
Discharge summary
|
report
|
Admission Date: [**2105-2-28**] Discharge Date: [**2105-3-4**]
Date of Birth: [**2066-6-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
upper GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
38yoM with h/o EtOH abuse, likely cirrhosis with grade I
varices, and s/p gastric bypass c/b prior GI bleed, who
presented to [**Hospital 8641**] Hospital ED today with complaint of 3days of
progressive bloody emesis associated with rectal bleeding, RUQ
abdominal pain, and dizziness. On presentation to OSH ED he was
hypotensive with SBP 90, HR 140. BP normalized after 3LNS.
Initial Hct was 18. EGD prior to this had showed 1+ varices and
gastritis. EGD at OSH showed grade I varices, oozing cratered
gastric ulcer with adherent clot at the anastomosis (30x30mm).
This was injected with epinephrine for hemostasis. Diffuse
moderately hemorrhagic mucosa without active bleeding but with
stigmata of bleeding. He received octreotide infusion, iv
pantoprazole, and sucralfate. He was transfused 5units PRBC
prior to transfer.
.
Patient normally drinks 6beers/day, but will binge for Patriot's
games. His last drink was two days ago. He denies having a
history of withdrawals. On presentation now he complains of
persistant RUQ pain.
Past Medical History:
EtOH abuse
h/o GI bleed after gastic bypass surgery
?cirrhosis, h/o alcoholic hepatitis
s/p gastric bypass surgery [**2099**]
polyneuropathy
obstructive sleep apnea s/p septoplasty
chronic pain syndrome
hypertension
s/p MVC [**9-/2103**]
h/o C.diff colitis ([**2104-12-21**])
tobacco use
legally blind following MCV [**2103**]
Social History:
lives alone, going through divorce with one seven year old son
Disabled
EtOH: 4-6beers/day, no h/o withdrawals
Tob: 1/2ppd x 20yrs
Illicits: denies
Family History:
mother w/ hypertension, COPD
son has a heart condition
Physical Exam:
Wt 86.7kg T 96.7 HR 114 BP 124/100 RR 15 97%RA
GEN: comfortable, cooperative, NAD
HEENT: PERRL, anicteric, MMM, OP clear
Neck: supple, JVP nondistended, no LAD
CV: tachy, regular, no mrg, PMI nondisplaced
Resp: CTAB
Abd: +BS, soft, ttp RUQ (non tender with distraction), no
rebounding/guarding, liver edge palpable
Ext: no edema, 2+ DPs
Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout,
sensation intact to touch
Skin: tattoos on chest and arms, no rashes
Pertinent Results:
[**2105-2-28**] 09:53PM GLUCOSE-81 UREA N-11 CREAT-0.5 SODIUM-135
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-8
[**2105-2-28**] 09:53PM estGFR-Using this
[**2105-2-28**] 09:53PM ALT(SGPT)-16 AST(SGOT)-30 LD(LDH)-109 ALK
PHOS-108 AMYLASE-24 TOT BILI-0.8
[**2105-2-28**] 09:53PM LIPASE-14
[**2105-2-28**] 09:53PM ALBUMIN-2.4* CALCIUM-8.0* PHOSPHATE-3.4
MAGNESIUM-1.9
[**2105-2-28**] 09:53PM WBC-4.4 RBC-3.14* HGB-9.5* HCT-26.9* MCV-86
MCH-30.4 MCHC-35.5* RDW-16.8*
[**2105-2-28**] 09:53PM NEUTS-55.6 LYMPHS-39.2 MONOS-3.3 EOS-0.7
BASOS-1.1
[**2105-2-28**] 09:53PM ANISOCYT-1+ POIKILOCY-1+ MICROCYT-1+
[**2105-2-28**] 09:53PM PLT COUNT-144*
[**2105-2-28**] 09:53PM PT-12.0 PTT-30.0 INR(PT)-1.0
Brief Hospital Course:
38yo man with h/o EtOH abuse c/b polyneuropathy, grade I
varices, and s/p gastric bypass p/w UGIB, gastric ulcer seen on
EGD at outside hospital. During his hospitalization the
following issues were addressed:
# UGIB: UGIB due to gastric ulcer seen at anastamosis site on
EGD. It was injected with epinephrine at the outside hospital
prior to transfer. He remained hemodynamically stable with
stable Hct. He did not require transfusion. Hct ranged 26-29.
He was continued on [**Hospital1 **] iv pantoprazole. He underwent repeat
EGD which showed nonbleeding ulcer. He was also evaluated by
surgical service who found no need for surgical intervention.
He should have a repeat endoscopy in four weeks. He should also
follow-up with his surgeon to further evaluate the anastamoses.
H.pylori serology was negative. He was having some intermittent
abdominal pain secondary to his ulcer. He will be discharged
with a small amount of pain medication for management of his
abdmoinal pain.
.
# EtOH abuse: He has no history of withdrawal. He was
monitored on a CIWA scale but did not require any
benzodiazepine. He was kept on thiamine, folate, and
multivitamin. Smoking and alcohol cessation were discussed with
the patient. He is interested in alcohol cessation but not
smoking cessation at this time. He does not have plans to go to
AA meetings.
.
# Cirrhosis: No documented history of cirrhosis but with h/o
varices and ascites. No varices were seen EGD here. No ascites
on exam. He is on lasix and spironolactone as an outpatient;
these were not restarted during his admission. He will discuss
restarting them with his PCP.
.
# HTN: Diltiazem was initially held and then restarted prior
to discharge.
.
# Polyneuropathy: thought to be d/t alcohol abuse; gabapentin
was initially held and then restarted prior ot discharge. He
also has a history of chronic pain syndrome and is on a Fentanyl
patch 25mcg at home.
.
# Dispo: He was discharged to home. His a full code.
Medications on Admission:
Meds on Admission to OSH:
KCl 20mEq po daily
Diltiazem XR 240mg daily
Fentanyl patch 25mcg Q72hr
Flagyl 250mg po QID
Gabapentin 300mg [**Hospital1 **]
Lasix 40mg daily
Spironolactone 50mg daily
MVI daily
FeSO4 325mg TID
Omeprazole 20mg daily
.
Meds on Transfer:
Sucralfate 1g QID
Nicotine TP
morphine 2mg prn pain
Zofran prn pain
Ativan per CIWA
Thiamine 100mg daily
MVI daily
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours as needed for pain for 5 days.
Disp:*12 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
bleeding gastric ulcer
.
Secondary:
alcohol abuse
tobacco abuse
cirrhosis
Discharge Condition:
good
Discharge Instructions:
1. Please plan to follow-up with a gastroenterologist to have a
repeat endoscopy in 4weeks
2. Please follow-up with your surgeon
.
Remember: if you stop drinking alcohol and smoking, you will
heal your ulcers more quickly
.
If you develop recurrent severe abdominal pain, bloody vomiting,
black vomit, or any bloody or black colored stool, please
contact your primary care doctor and/or return to the emergency
room
Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) **],
to discuss your hospitalization and have your blood levels (HCT)
checked to ensure you are not having ongoing bleeding. You have
an appointment scheduled for Monday [**3-23**] at 1:30 pm.
.
If you would like to see a new PCP at [**Hospital1 18**], please follow-up
with Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 1:30 pm on [**3-16**] at [**Hospital **], [**Hospital Ward Name 23**] building [**Location (un) 436**] - ([**Telephone/Fax (1) 1921**].
.
Please follow-up with gastroenterologist to have a repeat EGD in
four weeks. If you would like to follow-up here at [**Hospital1 18**], you
should call ([**Telephone/Fax (1) 2306**] to schedule an appointment.
.
Please follow-up with your surgeon as well to discuss the ulcer
that has developed on the suture site of your surgery
Completed by:[**2105-3-4**]
|
[
"357.5",
"531.40",
"571.2",
"305.01",
"305.1",
"496",
"V45.86",
"456.21",
"997.4",
"401.9",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6466, 6472
|
3247, 5244
|
328, 333
|
6599, 6606
|
2506, 3224
|
7072, 7992
|
1938, 1994
|
5672, 6443
|
6493, 6578
|
5270, 5514
|
6630, 7049
|
2009, 2487
|
274, 290
|
361, 1404
|
1426, 1754
|
1770, 1922
|
5532, 5649
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,112
| 108,620
|
29976
|
Discharge summary
|
report
|
Admission Date: [**2107-3-29**] Discharge Date: [**2107-4-6**]
Date of Birth: [**2037-4-4**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Called by ED to evaluate patient for brain hemorrhage
Major Surgical or Invasive Procedure:
Left arm fasciotomy
Left arm thrombectomy
Left arm debridement
History of Present Illness:
Pt is a 69 yo male w/ PMHx sig for HTN, Afib reportedly on
Coumadin seen healthy by VNA four days ago at his rural [**State 1727**]
cabin and then found down today with blue LUE. Pt medflighted
to [**Hospital1 18**].
Past Medical History:
morbid obesity, HTN, AFib
Social History:
unknown
Family History:
unknown
Physical Exam:
T: 36.9C 152 143/131 26 100/2L
General: lying in bed
HEENT: dry mucous membranes
Neck: supple, no carotid bruit
Pulmonary: CTA b/l
Cardiac: irreg irreg, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: LUE - Blue hand diffusely with marked edema. Cool
extremity distal to elbow.
Neurological Exam:
Mental status: Eyes open, states name, does not respond to other
questions.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: L facial droop
XII: Tongue midline without fasciculations.
Motor/[**Last Name (un) **]: L sided flaccid hemiplegia, does not withdraw to
pain. Antigravity strength in RUE and RLE with withdrawal to
painful stimuli
Reflexes: trace, left toe up, right toe down.
Pertinent Results:
141 109 68
- - - - - - gluc 217
4.2 20 1.5
CK: 5979
Ca: 7.8 Mg: 2.5 P: 4.9
ALT: 66 AP: 58 Tbili: 0.9 Alb: 2.3
AST: 148 LDH: 320
[**Doctor First Name **]: 14 Lip: 17
WBC 19.3 HCT 38.6 PLT 238
PT: 15.5 PTT: 76.8 INR: 1.4
Radiology:
CT head - 1. Moderate to large amount of edema, likely
cytotoxic, involving right frontal and temporal lobes with
areas of high attenuation within the right frontal sulci
representing either subarachnoid hemorrhage or cortical laminar
necrosis in the setting of ischemic disease. The overall
appearance is more suggestive of an MCA distribution infarct
rather than acute trauma. Amyloid angiopathy may also be
considered. Recommend MRI with diffusion- weighted sequences
for better evaluation. 2. Moderate mass effect with compression
of right lateral
ventricle and 7 mm of left [**Hospital1 **] sub falcine herniation.
ELBOW (AP, LAT & OBLIQUE) LEFT [**2107-3-29**] 2:15 PM
HUMERUS (AP & LAT) LEFT; ELBOW (AP, LAT & OBLIQUE) LEFT
1. No definite acute fracture or dislocation in the left arm.
Soft tissue swelling, most prominent in the distal forearm,
wrist, and left hand.
2. Fracture at the IP joint, extending into the joint space, of
uncertain age. Clinical correlation recommended to determine
acuity of this finding.
CT C-spine: 1. No acute fracture or abnormal alignment of
cervical vertebral bodies identified. 2. Multilevel degenerative
changes with areas of foraminal narrowing as described above. 3.
Apical paraseptal emphysema.
Head CT [**2107-3-29**]: 1. Moderately large region of cytotoxic edema,
involving right frontal and temporal lobes with gyriform
high-attenuation foci along the right frontal sulci, likely
representing early cortical laminar necrosis in a subacute right
MCA territorial infarction. The overall appearance is more
suggestive of an ischemic rather than an acute traumatic event.
Amyloid angiopathy with subarachnoid hemorrhage is a more remote
consideration. Recommend MRI with diffusion- weighted and GRE
sequences for more definitive characterization. 2. Moderate
mass effect with compression of right lateral ventricle and 7 mm
of leftward subfalcine, but no uncal or transtentorial,
herniation.
PCXR: No definite congestive heart failure or pneumonia.
Follow-up PA and lateral chest radiographs are recommended if
clinically warranted.
Head CT [**2107-3-30**]: No change in the appearance of the brain with
no change in the amount of mass effect nor change in the area of
possible intraparenchymal hemorrhage. There is no change in the
amount of mass effect or subfalcine herniation. There is no
uncal herniation.
Path [**2107-3-31**]: Muscle, left arm: Necrotic skin and skeletal
muscle.
Unremarkable tendon.
ECHO [**2107-3-31**]: Echocardiographic windows very suboptimal. The left
atrium is moderately dilated. The right atrium is moderately
dilated. Lef 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 grossly
normal (LVEF>70%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Head CT [**2107-4-1**]: No significant interval change in right middle
cerebral artery hemorrhagic infarct as described above as well
as mass effect and leftward midline shift.
PCXR [**2107-4-2**]: New right effusion.
EKG [**2107-4-2**]: Atrial fibrillation with a rapid ventricular
response. Diffuse non-specific ST-T wave changes. No previous
tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
108 0 88 [**Telephone/Fax (2) 71558**]5 -7
PCXR [**2107-4-4**]: No evidence of pneumonia. Bilateral effusions,
increasing on the left, and mild CHF.
CXR [**2107-4-4**]: Right IJ replacement.
Single AP view of the chest is obtained [**2107-4-4**] at 14:10 hours
and is compared with the prior examination performed
approximately two hours previously. No acute change is
demonstrated. The ET tube is approximately 5 cm above the
carina. The right-sided IJ line has its tip projecting over the
distal SVC. Increased opacity is seen in the right hemithorax
consistent with layering right pleural effusion. No large
pneumothorax is seen in this projection.
Brief Hospital Course:
Pt is a 69 yo male w/ PMHx sig for afib and HTN who presents
after being found down at cabin in [**State 1727**]. General exam shows
compartment syndrome of LUE. Neurological exam significant for
minimal verbal output and left sided hemiplegia without sensory
response. INR sub therapeutic. The patient likely had large
cardiac embolus secondary to afib occlude his proximal R MCA.
This resulted in his collapse and subsequent rhabdomyolysis and
ischemia of LUE. Pt to be taken to OR for fasciotomy and then
will transferred to the NeuroICU.
Post-operatively clot found in L brachial artery s/p
thrombectomy. After discussion w/ vascular surgery, likelihood
of additional clot in palmar arch likely. Heparin gtt initiated
with understanding that any change in neuro status heparin
should be shut off and immediate CT head should be obtained.
goal PTT 50.
[**Doctor First Name **]: Patient went to OR for fasciotomy and thrombectomy [**3-29**]
then again on [**3-31**] and [**4-2**] for debridement. Plan was made on [**4-5**]
to proceed with amputation of the left arm. However, family
declined further care.
Neuro: Patient admitted to Neuro ICU. Head of bed was kept at
less than 30 degrees. HOB < 30 degrees
- q 1hr neuro checks, cardiac telemetry
- SBP < 185 and DBP < 105 and keep MAP > 65
- normothermia, normoglycemia
- if change in exam, get stat head CT and consult Nsurg given
possible ICH
- wean sedation when possible
- pain control
Cardiac:
- rate control
- Dc'd heparin IV [**3-31**] and started on coumadin [**3-30**]
- ruled out MI
- 2D ECHO poor study ~70% EF and does not comment on wall motion
abnormality or possible clot
Pulm:
- will discuss w/family ?trach/peg
Renal:
- IVF for Rhabdomyolysis
- follow Cr downtrending
PPX:
- colace/IV PPI
Code: full -> had converstaion with HCP [**Name (NI) **] [**Name (NI) **] on [**2107-4-5**]
where she made patient comfort measures only. Patient was
subsequently extubated and passed away on [**2107-4-6**]. Family
declined autopsy.
Comm: [**Name (NI) 501**] [**Last Name (NamePattern1) 1637**], SW involved. Discussed goals of care with
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 71559**] (HCP)
Medications on Admission:
Coumadin, diltiazem
Discharge Disposition:
Expired
Discharge Diagnosis:
Right middle cerebral artery stroke
Anterior compartment syndrome of the left forearm
Discharge Condition:
Deceased
Completed by:[**2107-4-7**]
|
[
"729.71",
"518.5",
"584.9",
"E888.9",
"729.81",
"401.9",
"492.8",
"299.80",
"428.0",
"728.88",
"276.0",
"354.0",
"707.8",
"444.21",
"438.20",
"707.09",
"785.4",
"434.11",
"278.01",
"V15.81",
"427.31",
"348.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"82.22",
"96.72",
"82.09",
"83.32",
"38.91",
"99.07",
"99.04",
"96.6",
"38.03",
"96.04",
"04.43"
] |
icd9pcs
|
[
[
[]
]
] |
8540, 8549
|
6250, 8469
|
368, 432
|
8678, 8716
|
1630, 6227
|
770, 779
|
8570, 8657
|
8495, 8517
|
794, 1149
|
1168, 1168
|
275, 330
|
460, 680
|
1261, 1611
|
1183, 1245
|
702, 729
|
745, 754
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,917
| 154,530
|
8201
|
Discharge summary
|
report
|
Admission Date: [**2110-5-11**] Discharge Date: [**2110-6-7**]
Date of Birth: [**2047-5-25**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Thransthoracic echocardiogram
Transesophageal echocardiogram
tunnelled Dialysis catheter placed
PICC line placed
Renal biopsy
Right heart catheterization
History of Present Illness:
Ms. [**Known lastname **] is a 62 yo f w/ h/o DM2, living unrelated kidney
transplant [**2106**], pvd s/p several toe amputations, CAD s/p CABG,
dCHF, HTN, hyperlipidemia, obesity, OSA, current tobacco abuse,
presumed COPD with home O2 requirement, a fib s/p ablation, h/o
DVT on coumadin who was admitted [**2110-5-1**] to OSH with SOB. O2 sat
in ED 89% unclear if this was on any O2. She also had leg
swelling, no CP or cough. CXR on admission showed moderate CHF,
BNP 8500.
.
Review of OSH records show that she was admitted there from
[**Date range (1) 29151**] for SOB, CHF treated with Lasix gtt. During this
admission, she also had a flutter and an ablation. Admission
[**Date range (1) 29152**] for AMS thought [**1-7**] proteus UTI treated with
ertapenem and ARF to high 1's from baseline 1.2. Admission
[**Date range (1) 29153**] for AMS [**1-7**] E coli UTI treated with bactrim, ARF,
hyponatremia, CHF diuresed on lasix gtt, noted R pleural
effusion.
.
Of note the records of this 10 day hospitalization at the OSH
are remarkable for lack of completeness. Cr there trended
nadired at 1.7 on [**5-6**]-2 and then slowly rose to 2.3 on [**5-11**] when
pt was transferred. Of note, admission wt there [**5-2**] was 130.3
kg and weights there seem to have varied wildly but trended to
124.6 on [**5-11**]. She was also treated with a 10 day course of
ceftriaxone and bactrim ending [**5-10**] for presumably UTI. Pt was on
Bumex for 1 day ending [**2110-5-2**]. Was also on lasix gtt from
admission until [**2110-5-9**]. Pt recieved 1 dose metolazone [**5-4**]. Of
note, the pt states she has had 5 admissions this year with 1 at
[**Hospital3 5365**] where a stent was placed about 1 mo ago. States
most admissions for fluid overload and 4 with UTI.
.
Pulm c/s at [**Hospital6 33**] [**2110-5-6**] states pt was on ativan
for agitation; pt confirms high anxiety treated with this
medication. Pt had been afebrile for entire hospital course up
to that time, O2 sats were 94% on 5L O2, WBC 6, hct 27.9, plt
168K. She was noted to be excessively sleepy that day while
talking to the consultant. They recommended continued diuresis
and stated she had lost significant weight on lasix gtt. Inpt
sleep study was ordered at that time (records could not be
located at this time at OSH) and she was placed on empiric bipap
with O2. CT chest was also recommended (although records of this
could not be found o/n).
Renal was consulted on admission as was cardiology. She was
ruled out for an MI. Of note, in cards consultation, she stated
she had a stent 1 mo ago but cards could not find records of
this (likely b/c per pt this was at [**Hospital3 5365**]).
.
On arrival to the floor, pt states she is depressed, scared and
afraid to go to sleep. States she often needs ativan for her
anxiety in house. She denies any pain. She states she was put on
bipap at OSH but woke up in a panic with a sore throat from
this. Also c/o epistaxis at OSH. Does c/o SOB. Pt states she
does not recall all events from the OSH as she is often delerius
in the hospital. c/o morning nausea and headache at OSH. C/o
constipation.
.
ROS: Denies fever, chills, cough, chest pain, abdominal pain,
vomiting, diarrhea, BRBPR, melena, dysuria, hematuria.
Past Medical History:
ESRD s/p living unrelated renal transplant [**3-/2107**]
DM c/b retinopathy and neuropathy
HTN
CAD s/p CABG [**10/2103**]
diastolic heart failure w/ nl EF per OSH records
A fib s/p ablation
hyperlipidemia
PVD
h/o chronic LE ulcerations s/p several toe amputations and
debridements - h/o pseudomonas and VRE.
s/p BL LE revascularization [**2098**]
OSA- scheduled to start BIPAP as an outpt
hypothyroidism
current smoker
presumed COPD on home O2 (pt apparently unable to complete outpt
PFTs at OSH)
Obesity
h/o DVT on coumadin
anxiety
depression
TIA [**2105**]
urinary incontinence
.
Social History:
Smokes 10 cigarettes per day, denies heavy alcohol use, denies
other drug use. Lives with husband, does not work
Family History:
Father died of bulbar palsy, mother died of MI but per chart had
ALS. Brothers with DM
Physical Exam:
Vitals - T:98.4 BP:116/53 HR:66 RR:20 02 sat: 99% on 3L NC
GENERAL: obese, anxious F in NAD
HEENT: PERRL, ncat, sclera anicteric.
CARDIAC: regular, 3/6 systolic murmur heard best at RUSB
LUNG: Decr BS on left base with bronchial BS in whole of left
lung. R side with crackles [**12-7**] way up lung field
ABDOMEN: obese, + BS, soft, non-tender incl over renal
transplant site at RLQ.
EXT: stage 1 decub L heel, stage 1 sacral decub. 1+ PE bilat, 1+
DP bilat
NEURO: pt not oriented to date. knows month and year as well as
hospital. Oriented to person. CN 2-12 grossly intact.
Appropriate throughout conversation.
Pertinent Results:
[**2110-5-11**] 09:40PM PT-29.3* PTT-38.1* INR(PT)-2.9*
[**2110-5-11**] 09:40PM PLT COUNT-207
[**2110-5-11**] 09:40PM WBC-6.0 RBC-3.13* HGB-9.2* HCT-29.2* MCV-93
MCH-29.4 MCHC-31.5 RDW-17.1*
[**2110-5-11**] 09:40PM CALCIUM-8.8 PHOSPHATE-4.4 MAGNESIUM-2.9*
[**2110-5-11**] 09:40PM estGFR-Using this
[**2110-5-11**] 09:40PM GLUCOSE-213* UREA N-64* CREAT-2.6*#
SODIUM-138 POTASSIUM-3.8 CHLORIDE-92* TOTAL CO2-35* ANION GAP-15
[**2110-5-11**] 09:58PM URINE RBC-0 WBC->50 BACTERIA-FEW YEAST-NONE
EPI-[**10-25**] TRANS EPI-[**5-15**]
[**2110-5-11**] 09:58PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2110-5-11**] 09:58PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
[**2110-5-11**] 09:58PM URINE OSMOLAL-352
[**2110-5-11**] 09:58PM URINE HOURS-RANDOM UREA N-404 CREAT-96
SODIUM-12 POTASSIUM-66 TOT PROT-40 PROT/CREA-0.4
creatinine 2.6 -> 4.4
URINE CULTURE (Final [**2110-5-13**]):
YEAST. ~3000/ML.
URINE CULTURE (Final [**2110-5-15**]):
YEAST. 10,000-100,000 ORGANISMS/ML..
URINE CULTURE (Final [**2110-5-17**]): NO GROWTH.
[**2110-5-15**] 4:56 pm PLEURAL FLUID
GRAM STAIN (Final [**2110-5-16**]):
2+ (1-5 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 (Final [**2110-5-19**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2110-5-16**] 9:18 am PLEURAL FLUID
GRAM STAIN (Final [**2110-5-16**]):
1+ (<1 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 (Final [**2110-5-19**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Baso Meso
Macro Other
[**2110-5-16**] 09:18 45* [**Numeric Identifier 29154**]* 7* 67* 21* 4* 1* 1
[**2110-5-15**] 16:56 83* [**Numeric Identifier 27731**]* 32* 19* 36* 4* 3* 3*
2*
REACTIVE MESOTHELIAL CELL
REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] ON [**2110-5-19**]
MESOTHELIAL CELL,REFER TO CYTOLOGY REPORT
REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],MD ON [**2110-5-19**]
PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Albumin Cholest
[**2110-5-16**] 09:18 2.3 151 83 12
[**2110-5-15**] 16:56 2.6 166 100 1.7 21
pH
[**2110-5-16**] 12:41 7.471
[**2110-5-16**] 09:33 7.451
both pleural fluid analyses consistent with transudative
effusions
Brief Hospital Course:
Ms. [**Known lastname **] is a 62 yo f w/ h/o DM2, living unrelated kidney
transplant [**2106**], pvd s/p several toe amputations, CAD s/p CABG,
dCHF, HTN, hyperlipidemia, obesity, OSA, current tobacco abuse,
presumed COPD with home O2 requirement, a fib s/p ablation, h/o
DVT on coumadin who was admitted [**2110-5-1**] to OSH with SOB now
being transferred for persistent dyspnea, ARF.
.
# Dyspnea/hypoxia- Despite 10kg wt loss on lasix gtt at OSH, pt
remained fluid overloaded on exam; however, review of records
showed discrepancy of weights at time of presentation at OSH, so
question degree of volume loss. No note made in OSH records of
thoracentesis of these in the past. Patient was hypoxic to 68%
on room air following transfer, improving with supplemental
oxygen. Suspect dyspnea is multi-factorial, and [**1-7**] effusions,
decreased vital capacity with elevated FRC (? component of
obstruction given tobacco abuse), and perhaps exacerbated by
OSA. No e/o infection. INR initially therapeutic, low
suspicion for thromboembolic disease. Suspect hypoxia [**1-7**] v/q
mismatch in setting of volume overload. Plain films showed
moderate sized effusions, right > left, and patient underwent
bilateral thoracentesis, with subsequent recurrence of pleural
effusions. Aggressive diuresis with metolazone and furosemide,
then Diuril with furosemide, with 1 to 1.5 liters of urine
output daily. TTE showed diastolic dysfunction, notable MR,
providing likely etiology of effusions in setting of diastolic
left heart dysfunction. Pleural fluid cytology negative for
malignant cells, and fluid was transudative. Cardiac enzymes
were negative. Optimized hemodynamics with good BP and HR
control. Cardiology was consulted and recommended a right heart
catheterization, which was performed and showed elevated wedge
and pulmonary artery pressures. Patient was subsequently
transferred to the CCU. While in the CCU, patient was diuresed
initially with metolazone and lasix and subsequently with bumex
and metolazone. She was diuresed with a goal of diastolic PAP
15-20. Her pleural fluid was re-tapped on [**5-23**] for comfort. A
repeat Chest CT was done that showed pleural effusions, air
trapping. Diuresis was continued but with very little
improvement in her PAP and wedge. It was suspected that mitral
regurgitation contributes to her shortness of breath. Patient
was electively intubated for [**Month/Year (2) **] to evaluate degree of MR. [**Name13 (STitle) **]
showed mild MR. Ultimately, [**5-26**], patient was started on
hemodialysis. Pt was electively intubated for [**Month/Year (2) **] on [**5-26**], she
was on mask ventilation beforehand and would not have tolerated
procedure without intubation due to impaired oxygenation. She
was difficult to wean off intubation immediately after the
procedure. She was changed to pressure support only on [**5-28**] but
was not awake enough to attempt extubation. Sedation was
progressively decreased until she was successfully extubated on
[**5-30**]. After extubation, pt failed a swallowing assessment and
had a NG tube placed to provide feedings and medications. She
pulled out her NGT during episode of delirium/sundowning s/p
extubation but was able to resume PO 3 days later. Her SOB has
been improving until day of discharge and she has adequate
oxygen saturations (high 90s).
.
# ARF with h/o Type II DM, ESRD s/p renal transplant - pt with
Cr nadir 1.7 at OSH trended to above 4 during her course.
Suspect vascular congestion, volume overload contributing to
poor renal perfusion and suggestion of intravascular volume
depletion based on urine lytes. Pt just completed 10D course of
bactrim and ceftriaxone at OSH. Ultrasound read suggests
rejection, no e/o hydronephrosis. Initial biopsy result not
consistent with acute rejection, more consistent with chronic
allograft nephropathy. Tacrolimus was converted to sirolimus. A
temporary HD line was placed and ultrafiltration was started.
First day 4L were taken off. Pt continued to receive rapamycin
and her levels were monitored daily. Pt was continued on
dialysis in the CCU because of rising Cr levels and electrolyte
imbalances. Renal team was following pt and thought that she may
require permanent HD though kidney may recover some function in
the future. A permanent tunneled cath was placed and she was
continued on HD with plans to continue as outpt. At the time of
d/c, she was producing urine but incontinent. She will aslo
follow with transplant nephrology.
.
# CHF- likely cause of SOB - see above. Pt currently not
eligible for ACEi/[**Last Name (un) **] for medical optimization given renal
issues. Continued metoprolol, simvastatin, hydralazine, and
isosorbide dinitrite with diuresis as above. Her SOB has
improved since HD and fluid removal, but she continues to have
some peripheral edema. CXR immediately prior to discharge showed
resolved pulmonary effusions and is much improved from last
study. Pt was started on ipratropium nebs as she reports hx of
COPD but does not use nebs at home. We monitored closely her
I+Os and daily weights. Overall, she is improved from admission.
.
# [**Name (NI) 3674**] pt trending Hct down over last several days at OSH
from 32 [**5-7**] to 29 here. Pt with high risk for bleeding on
anticoagulation but also getting phlebotomized. INR normalized
following discontinuation of warfarin in setting of renal
biopsy. Her coumadin was restarted for a fib on tele [**6-5**]. INR
was monitored and stable. Pt was started on epogen infusions
with HD to improve anemia.
.
# OSA- empirically started on BiPAP at OSH prior to transfer.
Patient likely has component of OSA given body habitus. Mild
hypercarbia on ABGs. Monitored on continuous pulse oximetry
overnight, with one desat to 88% overnight, no indication for
positive airway pressure as inpatient, plan for outpatient
evaluation. Pt is s/p intubation and extubation for [**Month/Day (4) **], she was
successfully extubated.
.
# [**Name (NI) 1568**] Pt had fairly steady blood sugar measurements during
admission. She was restarted on glargine at 10U and titrate up
to her home dose of 50U. Finger sticks were measured QID.
.
# [**Name (NI) 12329**] Pt's BP was controlled throughout admission on amlodipine
10mg QD and metoprolol tartrate 75mg [**Hospital1 **].
.
# anxiety- Cont duloxetine and SW consulted. Pt became depressed
after learning that she may need permanent HD. Duloxetine was
changed to Venlaxafine because of HD. Lyrica was added, which
she was taking at home.
.
# h/o A fib- on warfarin; had ablation earlier this year for a
flutter. Warfarin and [**Hospital1 **] were discontinued in setting of renal
biopsy and continued to be held for procedures
(thoracocentesis). Pt had an episode of a fib on [**5-31**] and
Coumadin was restarted at 5mg, INR closely monitored. Dose later
increased to 10mg, which is her home dose.
.
#UTI - pt had cloudy urine in Foley on [**5-31**], culture was
positive for enterococcus on 6.27. Pt was started on ampicillin
(despite unclear documentation of previous [**Name (NI) 26204**] allergy bc
cultures were sensitive to amp) but had severe nausea as
reaction. She was switched to vanco 1g daily, dosed with her HD.
Trough levels came back low (7) after 3 days of vanco so her
total daily dose of 1.25G - she should receive 1G with HD and
250mg ([**12-7**] of 500mg tablet) after HD. Vanco trough levels should
be measured before HD at outpt center.
Medications on Admission:
Atorvastatin 20 mg Tablet QPM
Bupropion HCl 100 mg Tablet 1.5 Tablet(s) by mouth twice a day
Duloxetine 60 mg Capsule, Delayed Release(E.C.) 1.5 Capsule(s)
by mouth
Furosemide 40 mg Tablet 2 Tablet(s) by mouth once a day
Insulin Glargine 100 unit/mL Solution 50 q am
Insulin Lispro 100 unit/mL Solution per sliding scale
Lisinopril 20 mg Tablet 1 Tablet(s) by mouth once a day
Metoprolol Tartrate 50 mg Tablet 1 Tablet(s) by mouth twice a
day
Mycophenolate Mofetil 500 mg Tablet 1 Tablet(s) by mouth twice a
day
Omeprazole 20 mg Capsule, [**Hospital1 **]
Pregabalin [Lyrica] 75 mg Capsule 1 Capsule(s) by mouth once a
day Risperidone 0.5 mg Tablet 1 Tablet(s) by mouth once a day
Sulfamethoxazole-Trimethoprim [Bactrim] 400 mg-80 mg Tablet 1
Tablet(s) by mouth once a day
Tacrolimus [Prograf] 1 mg Capsule 1 Capsule(s) by mouth twice a
day Warfarin 10 mg Tablet 1 Tablet(s) by mouth once a day
Aspirin 325 mg Tablet, Delayed Release (E.C.) 1 Tablet(s) by
mouth once a day
Multivitamin Tablet 1 Tablet(s) by mouth once a day (OTC)
.
Medications on transfer:
.Albuterol neb Q 4 hrs PRN
.Ascorbic acid 500mg [**Hospital1 **]
.Aspirin 325 daily
.amlodipine 10mg daily
.duloxetine 60mg daily
.hydralazine 50mg po TID
.Insulin glargine 20u QHS
.Humalog insulin SS 4 times daily
.lactulose 20gm [**Hospital1 **]
.metoprolol tartrate 75mg [**Hospital1 **]
.cellcept 500mg [**Hospital1 **]
.nystatin topical TID
.pregabalin 75mg [**Hospital1 **]
.ranitidine 150mg daily
.simvastatin 20mg QHS
.Bactrim DS MWF
.tacrolimus 1mg Q 12 hrs
.Coumadin doses daily ranging from 5mg to 10mg
.Zinc 220mg daily
Discontinued inpatient meds incl bumetanide, docusate,
clonidine, MVI, risperdal
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily) as needed for constipation.
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day): Hold SBP <100, HR < 55.
7. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for Fungal rash.
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAYS (MO,WE,FR).
12. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Sirolimus 1 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
15. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Heparin (Porcine) 1,000 unit/mL Solution Sig: 4,000-11,000
units Injection PRN (as needed) as needed for line flush.
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
19. Warfarin 10 mg Tablet Sig: One (1) Tablet PO once a day.
20. Ipratropium Bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for SOB.
21. Venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO DAILY (Daily).
22. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed for anxiety.
23. Nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): stop after 2 weeks.
24. 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.
25. 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.
26. Vancomycin 1000 mg IV HD PROTOCOL
27. Lorazepam 0.5-1 mg IV Q12H:PRN nausea
hold for somnolence
28. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): Please give after dialysis on dialysis days. .
29. Vancomycin 500 mg Recon Soln Sig: [**12-7**] Intravenous once a
day for 2 days: Please give 250mg after dialysis sessions where
pt receives 1g. Total daily dose should be 1.25g. Please check
vanco trough levels before HD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary:
Acute on Chronic Diastolic Congestive Heart Failure
End Stage Renal Disease
.
Secondary:
Coronary Artery Disease
Hypertension
Chronic Obstructive Pulmonary disease
Mild mitral regurgitation
Urinary tract infection
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 hospital because of your shortness of
breath. We treated you with intravenous medications to get rid
of the fluid in your lungs. We also drained some of the fluid
in your lungs. We believe that your shortness of breath was
from heart failure. Your kidney transplant is failing and we had
to place a tunnelled catheter and resume dialysis. Please talk
to your kidney doctors about whether they think your kidneys
will recover.
We have made the following changes to your medications:
1. Start vancomycin for enterococcus in your urine. Your last
day will be [**2110-6-9**] for total of 7 day course.
2. Stop taking Isordil, chlorthiazide, furosemide, Hydralazine
Duloxitine, and albuterol nebs.
3. Start taking vitamin C, Zinc and MVI for wound healing.
4. Start senna, colace and lactulose as needed for constipation
5. Start Miconazole powder for your rash
6. Start sevelamer to lower your phosphate
7. Start Tylenol for your pain
8. change Cymbalta to Vanlafaxine for your depression.
9. Start Vancomycin for a urinary tract infection
10. Start Lorazepam as needed for anxiety
11. Decrease your Glargine to 10 Units in the morning
12. Start Humalog sliding scale before meals.
....
Weigh yourself every morning, notify provider if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Urology:
Department: SURGICAL SPECIALTIES
When: [**Month/Day/Year **] [**2110-7-7**] at 1:30 PM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Primary Care:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 29149**]
Date/Time:[**2110-6-24**] 4:30
[**Hospital1 29147**], [**Location (un) **],[**Numeric Identifier 29148**]
Phone: [**Telephone/Fax (1) 29149**]
Fax: [**Telephone/Fax (1) 29155**]
.
[**Hospital1 18**]:
Department: HEMODIALYSIS
When: SATURDAY [**2110-6-7**] at 12:00 PM
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2110-7-15**] at 11:00 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Cardiology
.
Cardiology:
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3549**]
When: Thursday [**2110-7-3**] at 11:15 AM
Location: [**Hospital **] MEDICAL
Address: [**Location (un) **], [**Apartment Address(1) 29156**], [**Location (un) **],[**Numeric Identifier 2876**]
Phone: [**Telephone/Fax (1) 14967**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
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81,012
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Discharge summary
|
report
|
Admission Date: [**2134-7-30**] Discharge Date: [**2134-8-10**]
Date of Birth: [**2068-12-13**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Codeine / Penicillins / IV Dye, Iodine Containing
Contrast Media
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
Fever.
Major Surgical or Invasive Procedure:
TEE (transesophageal echocardiogram) [**2134-8-6**].
PICC IV line placement [**2134-8-9**].
Port removal [**2134-8-9**].
History of Present Illness:
65F with recurrent breast cancer on chemo with carboplatin,
taxotere, Herceptin (last chemo [**2134-7-19**], Neulasta [**2134-7-20**])
transferred to the [**Hospital Unit Name 153**] from the radiology suite after a
questionable anaphylactic reaction (dyspnea, hypoxia,
tachycardia, and flushing) to IV contrast for CTA vs worsening
volume overload.
Briefly, she presented to the ED with fever to 104 and rigors at
home, with no obvious source of infection except for HSV-2
vaginal rash and chest rash. She had been seen by dermatology
the day prior who recommended Valtrex 1g po BID x 5 days; it is
unclear whether this had been started. She was also being
evaluated for a rash on her chest thought to be a
hypersensitivity rash related to chemotherapy; she was supposed
to start a course of oral prednisone but had not yet started. Pt
denies dyspnea, cough and chest pain (other than at the skin at
the site of rash). Patient denied any urinary symptoms except
some burning related to vaginal herpes rash; also complained of
abdominal pain and loose stools over the last few days. She did
endorse nausea at the time but denied emesis, and had not had
nausea at home.
In the ED, vital signs were T 100.9 HR 133 BP 89/53 RR 18 O2sat
93% RA. Patient received 2L IVF fluid, blood/urine cultures were
sent and she was given a dose of cefepime and vancomycin. She
was admitted to the [**Location **] service for further
management. On the floor, she was given 20mg IV Lasix for
possible fluid overload (she was recently started on a thiazide
over the last few weeks due to some edema). She was persistently
tachycardic to the low 100s and somewhat short of [**Last Name (LF) 1440**], [**First Name3 (LF) **] was
sent for CTA to rule out PE. Apparently after receiving IV
contrast, she became dyspneic and tachycardic to the 170s. She
was placed on a non-rebreather and a Code Blue was called for
anaphylaxis. During the code, she got an EpiPen, hydrocortisone
100mg IV, Benadryl 25mg IV x2, and famotidine IV, and was
transferred to [**Hospital Unit Name 153**] for further management.
On arrival to the MICU, patient's VS were T 102.9, HR 169,
113/75, RR 34, 92% 2L NC. ABG on arrival to the [**Hospital Unit Name 153**] (on 2L NC)
was 7.39/29/70/18, lactate 4.7 (increased from 2.4 earlier in
the day). Patient appeared less tachypneic and stated that her
dyspnea was improving.In the [**Name (NI) 153**] pt continued broad spectrum
antibiotics which were narrowed to vancomycin after blood
cultures returned back positive for MSSA. She was gently
diuresed. She also developed a.fib adn was started on short
acting diltiazam. She was followed by both dermatology and the
ID service.
On arrival to the floor pt reports that she is feeling better
overall.Breathing has improved significantly as well as the
rash. She has no chest pain or other pain.
Review of systems:
(+) Per HPI, rigors, fevers, dyspnea. +weight gain.
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough or wheezing. Denies chest pain, chest pressure,
palpitations. Denies constipation, dark or bloody stools.
Past Medical History:
- High grade DCIS (left breast) diagnosed [**1-/2127**], s/p partial
mastectomy, XRT, Arimidex x 5 years; recurrent left breast
carcinoma [**3-/2134**], now s/p 3 cycles neoadjuvant chemo with
carboplatin, taxotere, Herceptin q3weeks (last chemo [**7-19**],
Neulasta [**7-20**]) and plan for mastectomy; BRCA1 and BRCA2 normal
- Hypersensitivity rash to chemotherapy ( likely taxotere)
- HSV-2 vaginal rash
- Hypertension
- H/o postpartum cardiomyopathy (echo from [**2134-6-24**] LVEF >55%)
- Fatty liver (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at Liver Center
[**2131-1-16**] Liver biopsy showed grade I inflammation and stage II
fibrosis)
- GERD
- Heterozygous for hemochromatosis
Social History:
Lives at home with husband. Previous [**Name2 (NI) 1818**] x15yrs, [**11-30**] ppd,
quit 30 yrs ago. No alcohol or illicit drug use.
Family History:
H/o BRCA in family (patient is BRCA negative) with many cancers
including pancreatic and breast.
Physical Exam:
ADMISSION EXAM:
VS: T 98 BP 107/76 P 109 RR 18 O2 sat 97 4lits
GEN: AAOx3, able to complete full sentences without
difficulties, no asd.
SKIN: Anterior chest- numerous erythematous papules some w/
superficial erosions and crusting. Back- are many bright red
macules and patches, scattered over upper back and bilateral
dorsal forearms and hands.
HEENT: op clear, no exudates, erythema or ulcerations
CHEST: Bibasilar crackles.
CV: rrr no m/r/g
ABD: nabs, soft, nt/nd
EXT: wwp biltaral nonpitting edema
NEURO: alert and oriented x3, CN 2-12 grossly intact,strength
[**4-3**] overall, non focal exam
PSYCH: appropriate and calm
Pertinent Results:
ADMISSION LABS
[**2134-7-30**] 08:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2134-7-30**] 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2134-7-30**] 08:30AM URINE RBC-0 WBC-24* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2134-7-30**] 06:57AM LACTATE-2.4*
[**2134-7-30**] 06:43AM GLUCOSE-157* UREA N-11 CREAT-1.0 SODIUM-137
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2134-7-30**] 06:43AM WBC-14.3* RBC-3.49* HGB-10.7* HCT-30.9*
MCV-89 MCH-30.6 MCHC-34.5 RDW-17.1*
[**2134-7-29**] 11:54AM ALT(SGPT)-103* AST(SGOT)-50* ALK PHOS-106*
TOT BILI-0.9
[**2134-7-29**] 11:54AM WBC-10.8 RBC-3.61* HGB-11.2* HCT-32.3* MCV-90
MCH-31.1 MCHC-34.8 RDW-16.8*
.
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2 (Final
[**2134-7-30**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2134-7-30**] 1120AM.
POSITIVE FOR HERPES SIMPLEX TYPE 2 (HSV2).
Viral antigen identified by immunofluorescence.
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final [**2134-7-30**]):
Negative for Varicella zoster by immunofluorescence
.
MICRO
[**2134-7-29**] 2:52 pm SWAB Source: skin - ulcer.
**FINAL REPORT [**2134-8-2**]**
GRAM STAIN (Final [**2134-7-29**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
WOUND CULTURE (Final [**2134-7-31**]):
STAPH AUREUS COAG +. MODERATE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final [**2134-8-2**]): NO ANAEROBES ISOLATED.
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Final [**2134-7-30**]):
TEST CANCELLED, PATIENT CREDITED.
Refer to direct HSV and/or direct VZV antigen test results
for
further information.
[**2134-7-30**] 6:43 am BLOOD CULTURE
**FINAL REPORT [**2134-8-1**]**
Blood Culture, Routine (Final [**2134-8-1**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final [**2134-7-30**]):
Reported to and read back by DR. [**First Name (STitle) **] [**Name (STitle) **] @ [**2066**],
[**2134-7-30**] .
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2134-7-30**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**2134-7-30**] 8:30 am URINE
**FINAL REPORT [**2134-7-31**]**
URINE CULTURE (Final [**2134-7-31**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2134-7-31**] 3:00 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
IMAGING
[**2134-7-30**] CXR: FINDINGS: In comparison with the study of earlier
in this date, the patient has taken a somewhat lower
inspiration. Port-A-Cath remains in place. Elevation of the
left hemidiaphragm with mild atelectatic changes at the bases.
No evidence of vascular congestion. Unusual metallic
opacification projected over the area of the left cardiophrenic
angle, of uncertain etiology.
.
[**2134-7-30**] CTA CHEST: IMPRESSION:
1. Limited evaluation of pulmonary embolism. No large main or
segmental pulmonary embolism.
2. Small right basilar atelectasis.
3. No explanation for shortness of [**Month/Day/Year 1440**] and acute hypoxemia.
.
[**2134-7-31**] CXR: There are lower lung volumes. Small bilateral
pleural effusions have increased, they are larger on the right
side. There is bibasilar atelectases, larger on the right side,
worsened from before. Right Port-A-Cath tip is in the right
atrium.
.
[**2134-7-31**] BILATERAL LE DOPPLER U/S:
1. No evidence of deep vein thrombosis. Calf veins not well
visualized.
2. Small amount of fluid within the left popliteal region.
.
[**2134-8-3**] CXR: CONCLUSION: Except for slightly improved bibasilar
atelectasis the rest of the exam is unchanged.
.
[**2134-8-4**] TTE: IMPRESSION: Suboptimal image quality. No obvious
evidence of endocarditis in a technically limited study.
Preserved global left ventricular systolic function. Right
ventricular dilation with borderline normal function. Compared
with the prior study (images reviewed) of [**2134-6-24**], the right
ventricle now appears dilated with borderline normal function.
.
[**2134-8-6**] TEE: Overall left ventricular systolic function is normal
(LVEF>55%). IMPRESSION: Mild mitral regurgitation with normal
valve morphology. No echocardiographic evidence of endocarditis.
.
DISCHARGE LABS:
[**2134-8-10**] 05:09AM BLOOD WBC-6.8 RBC-2.59* Hgb-8.5* Hct-24.3*
MCV-94 MCH-32.9* MCHC-35.0 RDW-19.8* Plt Ct-213
[**2134-8-10**] 05:09AM BLOOD Glucose-88 UreaN-7 Creat-0.6 Na-139 K-3.8
Cl-104 HCO3-29 AnGap-10
[**2134-8-10**] 05:09AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.6
[**2134-8-3**] 07:15AM BLOOD ALT-58* AST-27 LD(LDH)-246 AlkPhos-83
TotBili-0.4
[**2134-8-10**] 05:09AM BLOOD ALT-18 AST-34 AlkPhos-75 TotBili-0.5
[**2134-8-2**] 05:31AM BLOOD proBNP-1459*
[**2134-8-4**] 07:11AM BLOOD %HbA1c-6.3* eAG-134*
[**2134-8-2**] 05:31AM BLOOD TSH-0.27
[**2134-7-31**] 12:03PM BLOOD Lactate-1.3
[**2134-7-31**] 02:32AM BLOOD freeCa-1.19
Brief Hospital Course:
65yo woman with recurrent Her2+ breast cancer receiving
neoadjuvant chemotherapy (last treatment [**2134-7-19**], Neulasta
[**2134-7-20**]) admitted from the ED for fever. She developed
tachycardia and dyspnea/hypoxia during a CTA chest to rule out
PE, so was transferred to the ICU from the radiology suite. In
the ICU, she had fever to 104, rigors, and hypotension, then
developed worsening dyspnea/hypoxia after fluid rescusitation in
the ED and was found to have MSSA sepsis.
.
# Hypoxia/dyspnea: Transferred to ICU for dyspnea and hypoxemia
to mid-80s during CTA chest, initially thought to be anaphylaxis
from IV contrast. CTA was negative for PE. New O2 requirement
of 4L since admission with evidence of small b/l pleural
effusions and volume overload on exam. She had received 10L IV
fluids in first 24hr of admission to ICU for severe sepsis. BNP
1459. Echo showing new RV dilatation, but normal EF. History
of post-partum cardiomyopathy and has been getting trastuzumab.
Hypoxia/dyspnea improving with furosemide. Cardiology
consulted; they felt the RV dilation was minimal and trastuzumab
could be safely continued. Diuresed with furosemide for acute
diastolic CHF (apical ballooning syndrome/Takotsubo?). Weight
returned back to baseline. Stopped furosemide at discharge.
Daily weights and strict Ins/Outs. Changed diltiazem to
metoprolol for CHF management. Titrated up metoprolol from 25mg
[**Hospital1 **] to TID. Continued aspirin as long as PLTs remain >50.
Ipratroprium PRN. Restarted [**Last Name (un) **] at 1/2 dose as outpatient given
new metoprolol. Losartan was held since 1st day of admission
due to hypotension.
- SHE WILL NEED A REPEAT ECHO IN ONE MONTH.
.
# Bacteremia: MSSA in blood, source pustular rash, which also
grew MSSA. Vancomycin started [**2134-7-30**], then changed to
cefazolin due to sensitivities and PCN allergy. TTE negative
for endocarditis, but did show new RV dilatation (see above).
TEE negative for endocarditis. Most recent cultures negative.
Port was accessed and used for antibiotics to decontaminate
port. However, ID advised port removal. Port was removed
[**2134-8-9**]. Repeat U/A still showing WBCs, but now symptoms, so no
change in antibiotics.
- F/U SURVEILLANCE CULTURES AND PORT TIP CULTURE.
- Plan for surveillance cultures to be drawn through the PICC
after antibiotics are completed.
- F/U URINE CULTURE.
.
# Atrial fibrillation: Started [**2134-7-31**]. IV diltiazem given in
the ICU. Outpatient PO diltiazem 240mg daily was changed to
60mg q6h with good rate control. CHADS2 score 1 indicates ASA
vs. anticoagulation. TSH normal. Received a dose of oral
metoprolol on evening of transfer to floor. Albuterol stopped.
Since then remains in sinus. Changed diltiazem to metoprolol
for CHF management (see above). Monitored on telemetry.
.
# Rash: Worsening after each cycle of chemotherapy. Skin biopsy
was consistent with a chemotherapy reaction. Dermatology
recommended a 7-day course of steroids: Started
methylprednisolone [**2134-7-30**], changed to prednisone [**2134-8-2**]. Wound
culture grew MSSA. Mupirocin cream. Dermatology prefered
ointment to cream, but this was non-formulary and unavailable.
She was given a prescription for the ointment as an outpatient.
Fexofenadine for pruritis.
.
# Genital herpes: She had DFA of vaginal lesions that revealed
herpes simplex virus 2. She received a 7-day course of
acyclovir IV [**2134-7-30**] to [**2134-8-5**]. Changed to suppressive doses
until chemotherapy finishes.
.
# Breast cancer: Last received chemotherapy [**2134-7-19**] with
carboplatin, docetaxel, and trastuzumab. Received Neulasta
injection the following day. Plan is for neoadjuvant chemo and
then ultimately mastectomy for recurrent left breast cancer.
Outpatient oncologist is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Given
trastuzumab 6mg/kg [**2134-8-9**]. Next dose in q3wks.
.
# Anemia/thrombocytopenia: Chemo-induced. PLTs improving. HCT
stable. HCT slowly decreasing. Ms. [**Known lastname **] did not want a
transfusion as she has never had one, but she did realize that
she may need one soon.
.
# Leukocytosis: Due to infection and peg-GCSF. Resolved.
.
# Red eyes: Blepharitis/conjunctivitis L>R associated with
chemo-induced rash. Ophthalmology consulted. Artifical tear
drops.
.
# LFT abnormalities: History of fatty liver, diagnosed by liver
biopsy 2/[**2130**]. Possibly worse from chemo. Resolved.
.
# Hyperglycemia: Elevated blood sugars with recent steroids.
HbA1c 6.3. Started insulin sliding scale. Resolved off
steroids.
.
# GERD: Continued outpatient pantoprazole. D/C'd H2 blocker
(started for presumed anaphylaxis).
.
# FEN: Regular diet. Repleted hypophosphatemia, hypokalemia,
and hypomagnesemia.
.
# GI PPx: Started bowel regimen for constipation.
.
# DVT PPx: Heparin SC.
.
# Precautions: None.
.
# Lines: Peripheral IV. Port removed [**2134-8-9**]. PICC placed
[**2134-8-9**].
.
# CODE: FULL.
Medications on Admission:
1. Dexamethasone 4 mg PO Q12H
3 days prior to start of chemotherapy
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Lorazepam 0.5 mg PO Q6H:PRN nausea/anxiety
4. Losartan Potassium 100 mg PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Pantoprazole 40 mg PO Q24H
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Aspirin EC 81 mg PO DAILY
9. vitamin E *NF* Topical daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Ondansetron 8 mg PO Q8H:PRN nausea
3. Pantoprazole 40 mg PO Q24H
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
6. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth q8HR Disp #*90 Tablet
Refills:*1
7. Artificial Tear Ointment 1 Appl LEFT EYE PRN red, itchy eye
RX *artificial tear ointment Apply OINTMENT LEFT EYE PRN Disp
#*2 Tube Refills:*1
8. Artificial Tears 1 DROP BOTH EYES TID
RX *dextran 70-hypromellose [Artificial Tears] Apply DROPS
BOTH EYES three times a day Disp #*2 Tube Refills:*1
9. Docusate Sodium 100 mg PO BID
10. Senna 1 TAB PO BID:PRN Constipation
11. Lorazepam 0.5 mg PO Q6H:PRN nausea/anxiety
12. Vitamin E *NF* 0 TOPICAL DAILY
13. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*1
14. Vitamin D 400 UNIT PO DAILY
15. Metoprolol Tartrate 25 mg PO TID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*2
16. CefazoLIN 2 g IV Q8H Duration: 10 Days
Last day [**2134-8-19**].
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2g IV q8HR Disp
#*60 Gram Refills:*0
17. Mupirocin Nasal Ointment 2% 1 Appl NU QID
RX *mupirocin calcium [Bactroban Nasal] 2 % Apply OINTMENT
TOPICALLY four times a day Disp #*2 Tube Refills:*1
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 6438**] infusion
Discharge Diagnosis:
1. Fever.
2. Staphylococcus aureus sepsis (severe blood infection).
3. Drug rash infected with Staph aureus bacteria.
4. Shortness of [**Last Name (un) 1440**] and hypoxia (low oxygen levels).
5. Hypotension (low blood pressure).
6. Congestive heart failure.
7. Breast cancer.
8. Genital herpes.
9. Anemia (low red blood cell count).
10. Abnormal liver function tests.
11. Port pocket infection.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for for fever. You developed
shortness of [**Last Name (un) 1440**], low oxygen levels, and a fast heart rate.
During a CT scan, your vital signs and symptoms worsened. So
you were transferred to the Intensive Care Unit (ICU) and
started on antibiotics for sepsis, a severe infection of the
blood. Blood and skin cultures grew Staphylococcus aureus, a
bacteria known to stick to different parts of the body. An echo
of the heart on the skin surface and one internally (TEE) were
both negative for infections of the heart valves, but did show a
mild dilation of the right ventricle heart chamber. Cardiology
was consulted and they felt that the right ventricle dilation
was very mild and required no specific therapy. They did
recommend changing your blood pressure medicine to metoprolol
and repeating an echo in one month. While you were in the ICU,
your heart rate became very fast and irregular (atrial
fibrillation). This resolved with medication. Your breathing
and oxygen levels improved with furosemide (Lasix), a diuretic.
You should weigh yourself daily to ensure an even fluid balance
and call your doctors if your [**Name5 (PTitle) 4977**] increases by more than 5
lbs or if your ankles become more swollen. You will need to
complete a 3 week course of IV antibiotics for the sepsis.
Although the source of the infection was likely the skin rash,
your port was removed in case the bacteria seeded it and when it
was removed, it looked like infection may have been present in
the area of the port. That is why a drain was left in place.
You will need the drain managed by home nurses and the Surgery
team as an outpatient. You were also seen by Dermatology, who
recommended continuing mupiricin ointment for the rash. Prior
to going home, you were given trastuzumab (Herceptin)
chemotherapy for breast cancer.
.
WEIGH YOURSELF DAILY AND CALL A PHYSICIAN FOR WEIGHT GAIN >5
LBS.
.
YOUR DOCTORS NEED TO ARRANGE A REPEAT ECHO IN ONE MONTH. PLEASE
ENSURE YOU HAVE THIS DONE.
Followup Instructions:
Please call and make an appointment to see Dr. [**Last Name (STitle) **] next
monday in clinic for wound evaluation and removal of the wound
drain.
We are working on a follow up appt in the with Dr. [**Last Name (STitle) **] in
[**3-7**] days. You will be called at home with the appointment. If
you have not heard or have questions, please call [**Telephone/Fax (1) 2981**].
.
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2134-8-13**] at 2:00 PM
With: [**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2134-8-30**] at 8:15 AM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2134-8-30**] at 9:00 AM
With: [**First Name8 (NamePattern2) 306**] [**Last Name (NamePattern1) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
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[
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icd9pcs
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[
[]
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66,174
| 103,907
|
38404
|
Discharge summary
|
report
|
Admission Date: [**2145-6-9**] Discharge Date: [**2145-6-14**]
Date of Birth: [**2094-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 [**2145-6-10**] with the left
internal mammary artery to the second diagonal artery and
reverse saphenous vein grafts to the posterior descending
artery, left anterior descending artery, and the first obtuse
marginal artery.
History of Present Illness:
History of Present Illness: New onset chest and back pain
associated with indigestion and diaphoresis over the last
several
weeks. Seen by PCP and in ER where he ruled in for MI. Then
brought to cardiac catheterization lab where he was found to
have
three vessel coronary artery disease. In ER Trop 0.1, CK 303,
CK-MB 18.7
Past Medical History:
none
Social History:
Race: caucasian
Last Dental Exam:
Lives with: wife and 3 children
Occupation: commercial banker
Tobacco: denies
ETOH: [**2-3**] glasses of wine/night
Recreational drugs: denies
Family History:
father had MI at age 55
Physical Exam:
Pulse: 58 Resp: 16 O2 sat: 99% RA
B/P Right: 112/78 Left:
Height: 5'[**46**]" Weight: 84.4K
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, nonfocal exam
Pulses:
Femoral Right: cath site Left: 2+
DP Right: - Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit no Right: Left:
Pertinent Results:
intraop ECHO
PRE BYPASS 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. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe apical, mid and distal anterior, and distal anteroseptal
and anterolateral hypokinesis. Left ventricular ejection
fraction is in the 40 to 45% range. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. There are simple atheroma in the
ascending aorta. There are simple atheroma in the aortic arch.
There are simple atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). Dr. [**Last Name (STitle) **] was
notified in person of the results in the operating room at the
time of the study.
Post bypass
Patient is A paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Aorta is intact
post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting
physician
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2145-6-10**] where the patient underwent Coronary
artery bypass grafting x4 with the left
internal mammary artery to the second diagonal artery and
reverse saphenous vein grafts to the posterior descending
artery, left anterior descending artery, and the first obtuse
marginal artery [**2145-6-10**].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found
the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable on no inotropic or vasopressor support.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD #4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged home in good condition with appropriate
follow up instructions.
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] of [**Hospital3 **]
Discharge Diagnosis:
Coronary artery disease
Coronary artery bypass grafting x4 [**2145-6-10**] with the left
internal mammary artery to the second diagonal artery and
reverse saphenous vein grafts to the posterior descending
artery, left anterior descending artery, and the first obtuse
marginal artery.
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
You have a follow up appointment with your surgeon Dr.[**Last Name (STitle) **]
[**2145-7-28**] at 1:00pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**First Name (STitle) **] [**Last Name (NamePattern4) 85529**] [**Telephone/Fax (1) 43460**] in [**1-2**] weeks
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] [**Telephone/Fax (1) 3658**] in [**1-2**] weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2145-6-14**]
|
[
"285.1",
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icd9cm
|
[
[
[]
]
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[
"36.13",
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icd9pcs
|
[
[
[]
]
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5729, 5796
|
3459, 4761
|
331, 593
|
6124, 6223
|
1900, 3436
|
6763, 7347
|
1185, 1210
|
4816, 5706
|
5817, 6103
|
4787, 4793
|
6247, 6740
|
1225, 1881
|
281, 293
|
649, 946
|
968, 974
|
990, 1169
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,340
| 196,048
|
7417
|
Discharge summary
|
report
|
Admission Date: [**2179-7-20**] Discharge Date: [**2179-7-22**]
Date of Birth: [**2111-4-14**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin / Dilantin / Amoxicillin / Lorazepam /
Gadolinium-Containing Agents
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hematemesis and Hypotension
Major Surgical or Invasive Procedure:
EGD: No active bleed but visible vessel at GE junction. 3 clips
placed, epi injected. No residual bleeding
History of Present Illness:
CC:[**CC Contact Info 27228**].
HPI:
Mr. [**Known lastname 7796**] is a 68 year old man with a history of Alport syndrome
on hemodialysis now presenting with several hours of
hematemesis. He awoke this morning feeling well and then had a
sudden onset of malaise and lightheadedness around 8AM. Shortly
thereafter, he felt nauseous and began vomitting frank red
[**Last Name (LF) **], [**First Name3 (LF) **] he called EMS. He reportedly vomitted an additional
500 cc of [**First Name3 (LF) **] while int he ambulance, though EMS and ED
records are not currently available for review.
.
In the ED, he was initially hypotensive to 81/41 and tachycardic
(records from the ED are not currently available for review).
He completed a 1000cc NS bolus that was started by EMS. He
received pantoprazole 40 mg IV and three units of uncrossed
pRBCs. His BP was reportedly 78/45 prior to transfer with HR
108, though he did not have any lightheadedness or further
bloody emesis.
.
He denies any NSAID or alcohol use (he does take a baby aspirin
daily). Of note, he has been having "stomachaches" and
intermittent "dry heaves" over the past month since starting
imatinib off-label for nephrogenic systemic fibrosis. Due to
these symptoms, he self-reduced the dose down to 200 mg daily
about 5-6 days ago.
.
Review of Systems: Denies any headaches, visual changes, leg
edema, chest/abdominal pain, dyspnea.
Past Medical History:
.
Past Medical History:
- Alport syndrome with bilateral hearing loss
- CKD V on HD for over 40 yrs; left AV fistula; started
off-label imatinib on [**2179-6-15**] for nephrogenic systemic fibrosis
- one prior episode of hematemesis in [**2140**] when uremic after a
failed renal transplant
- s/p L-spine fusion
- s/p CCY
- ? amyloidosis
- grand mal seizure during hemodialysis in [**5-/2176**]
- spontaneous retroperitoneal/iliopsoas bleed in [**5-/2176**]
- history of C2 vertebral body instability in [**5-/2176**]; cause
unclear
- colonic polyps by report in [**2170**]
- s/p right hip arthroplasty
- s/p bilateral carpal tunnel surgeries
- mild aortic stenosis (per pt) on TTE at [**Hospital1 2025**] in [**2177**]
- mild mitral stenosis (per pt)
- secondary hyperparathyroidism s/p 3.5 gland parathyroidectomy
in [**2140**]
Social History:
Lives with wife. Professor of mathematics. Does not smoke or
drink alcohol.
Family History:
NC
Physical Exam:
.
Physical Examination:
T 97.3 (axillary) BP 154/73 HR 104 RR 16 Sat 100% on 2 L/min
nc
Weight: 65.3 kg (bed scale)
General: thin man in no acute distress but intermittently with
spontaneous painful full-body muscle contractions
HEENT: negative Chvostek's sign
Neck: JVP 9 cm, no cervical/supraclavicular lymphadenopathy
Chest: pes excavatum; clear to auscultation throughout without
wheezes, rales, or ronchi
CV: tachycardic, regular, III/VI systolic murmur loudest at
RUSB; no rubs
Abdomen: soft, nontender, nondistended, normal bowel sounds, no
HSM
Extremities: left AV fistula (+) thrill; 2+ right radial pulse;
1+ PT pulses bilaterally; no edema
Skin: no rashes or jaundice; thick fibrotic skin diffusely
Neuro: alert & oriented x3, CN 2-12 intact (except for bilateral
hearing difficulty requiring hearing aides), 5/5 strength in
bilateral deltoids, biceps, triceps, hip flexors/extensors,
ankle flexors/extensors; negative Chvostek's sign
Pertinent Results:
[**2179-7-20**] 08:53AM HGB-7.1* calcHCT-21
[**2179-7-20**] 02:39PM HCT-23.9*
.
[**2179-7-20**] 08:50AM WBC-5.6 RBC-2.23*# HGB-6.8*# HCT-20.3*#
MCV-91 MCH-30.5 MCHC-33.5 RDW-17.6*
[**2179-7-20**] 08:50AM NEUTS-62 BANDS-0 LYMPHS-30 MONOS-4 EOS-4
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
.
[**2179-7-20**] 08:50AM GLUCOSE-145* UREA N-41* CREAT-4.2*#
SODIUM-141 POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-34* ANION GAP-13
[**2179-7-20**] 08:50AM CALCIUM-7.1* PHOSPHATE-1.8* MAGNESIUM-1.4*
[**2179-7-20**] 08:53AM freeCa-0.84*
.
[**2179-7-20**] 08:50AM ALT(SGPT)-14 AST(SGOT)-20 LD(LDH)-188
CK(CPK)-76 ALK PHOS-214* TOT BILI-0.4
[**2179-7-20**] 08:50AM LIPASE-108*
.
[**2179-7-20**] 08:50AM cTropnT-0.06*
.
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2179-7-22**] 06:45AM 4.6 3.22* 9.5* 27.8* 87 29.5 34.1 17.2*
124
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2179-7-22**] 06:45AM 82 35* 3.5*# 144 3.9 104 32 12
Calcium Phos Mg
[**2179-7-22**] 06:45AM 8.9 2.2* 1.7
.
.
Studies:
ECG ([**2179-7-20**]): Sinus tachycardia at 107 bpm, nl axis, nl
intervals, ST segment depressions V2-V4. No T wave changes.
EGD [**2179-7-20**]:
Esophagus:
Lumen: A small size hiatal hernia was seen.
Mucosa: A 1.5 cm adherent clot was found at the level of the
schatzki's ring in the distal esophagus near the GE junction.
Epinephrine was injected and the clot fell off on its own into
the stomach. Underlying the site of prior clot was a tear in the
mucosa of the esophagus with no visible vessel identified.
Epinephrine, total of 15cc, was injected at the site and 3 slips
were deployed with good effect and no residual bleeding.
Brief Hospital Course:
68yo male with h/o alports syndrome on HD for 40years, and
nephrogenic systemic fibrosis treated with imatinib admitted
with hematemesis and hypotension and found to have a GE junction
visible vessel on EGD. He was treated with 3 clips and epi for
hemostasis. He received 4U pRBC and stabilized. After the
procedure Pt reported chest discomfort ultimately believed to be
due to his EGD but concerning for ACS-no EKG changes.
.
Plan:
UPPER GI BLEED- endoscopy showed a 1.5 cm adherent clot was
found at the level of the schatzki's ring in the distal
esophagus near the GE junction. Epinephrine was injected and the
clot fell off on its own into the stomach. Underlying the site
of prior clot was a tear in the mucosa of the esophagus with no
visible vessel identified. Epinephrine, total of 15cc, was
injected at the site and 3 slips were deployed with good effect
and no residual bleeding. pantoprazole 40 mg IV q12h
subsequently switched to PPI [**Hospital1 **] PO. received 4units pRBCs and
2L NS with resultant hematocrit 20->23.9.-->29-->27.8 at time of
discharge. his imatinib was held since it can cause hemorrhage.
Post EGD tolerated soft mechanical diet well, per GI to have
soft mechanical diet, discussed with outpatient GI physician,
[**Name10 (NameIs) **] regular diet at home and continue omeprazole [**Hospital1 **] until
seen by outpatient gastroenterologist.
.
HYPOTENSION: Treated with fluids and [**Hospital1 **] transfusion. Likely
due to volume depletion from brisk upper GI bleed; resolved
since coming to MICU. fluid resuscitation as above. held
lisinopril. restarted prior to discharge as he remained
hemodynamically stable.
.
CHEST PAIN: sounds more like post-procedural after clips placed.
changed with inspiration not with activity. Troponins slightly
positive in setting of ESRD with dialysis. EKGs with no change
from priors. Remained chest pain free.
.
HYPOCALCEMIA: on admission symptomatic causing tetanic spasming
4 grams calcium gluconate x2 given. Followup ionized calcium
later in day was 1.02. held cinacalcet which he was on for his
parathyroid disease.
.
CKD V due to Alport syndrome: On dialysis qMWF with L foreare AV
fistula
held phosphate binders since patient was NPO and
hypophosphatemic. At time of discharge his Ca [**Hospital1 **] normal and
phos slowly increased but still low post HD. Plan to have lytes
checked at HD prior to resuming phos binders.
.
NEPHROGENIC SYSTEMIC FIBROSIS: Longstanding, treated with
imatinib per research protocol at [**Hospital1 2025**]. held imatinib as above to
resume per PCP. [**Name10 (NameIs) **] aware not to resume this medication.
.
FEN: NPO including meds. Advanced to clears as tolerated
post-EGD. Tolerated soft mechanical diet prior to discharge,
plan to resume regular diet at home, discussed with GI and outpt
GI physician. [**Last Name (NamePattern4) **]/Mg repletion; held phosphate binders.
.
Code: Full, confirmed with patient
Communication: with patient; wife [**Name (NI) 553**] [**Name (NI) 7796**] (home
[**Telephone/Fax (1) 27229**]; cell [**Telephone/Fax (1) 27230**])
.
DISPO: Home
.
Medications on Admission:
Medications:
- imatinib 200 mg daily (just self-reduced from 400 mg 5-6 days
ago; began therapy early [**6-/2179**])
- cinacalcet 60 mg qhs
- sevelamer 1600 mg [**Hospital1 **] with meals
- venlafaxine 300 mg daily
- aspirin 81 mg daily
- mirtazipine 30 mg qhs
- omeprazole 20 mg daily
- folic acid 1 mg daily
- lisinopril 2.5 mg qhs (only on non-dialysis days)
- nephrocaps 1 daily
- docusate
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Four (4)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO NON-HD DAYS ().
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: until you see
your GI physician.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-UGIB
-Hypotension
-Chest pain NOS
.
Secondary:
-Alport's syndrome
-ESRD on HD
-Nephrogenic sclerosis
-Secondary hyperparathyroidism
-AS
Discharge Condition:
Stable, tolerating soft mechanical diet well.
Discharge Instructions:
You were admitted for an upper GI bleed, you received 4units
packed red cell transfusions, you had no further bleeding
subsequent to an upper endoscopy.
.
If you have further emesis of [**Hospital1 **], black stools or [**Hospital1 **]
noticed from your rectum, feel lightheaded, dizzy, have chest
pain or other concerning symptoms, call your physician or go to
the emergency department.
.
Please note the following medication changes:
-Your aspirin was held--discuss this with your primary care
physician to resume
[**Name9 (PRE) 27231**] imitinab was also held-discuss this with your [**Hospital1 2025**]
specialist-when safe to resume
-Your sevelemer was held due to low phosphate--have your labs
checked at Dialysis to resume
-Per the GI team you may continue omeprazole twice per day,
until you see your Gastroenterologist, Dr. [**Last Name (STitle) 23**] next week.
.
You may resume a regular diet at home.
Followup Instructions:
Follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**12-9**] weeks, call
his office for an appointment at [**Telephone/Fax (1) 2378**].
.
Follow up with your Gastroenterologist, Dr. [**Last Name (STitle) 23**] in 1 week,
he is expecting to see you in follow up as discussed with the GI
physicians.
Completed by:[**2179-7-22**]
|
[
"585.5",
"275.41",
"578.0",
"285.1",
"276.50",
"759.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
9805, 9811
|
5606, 8698
|
369, 477
|
10001, 10049
|
3861, 4572
|
11010, 11364
|
2871, 2875
|
9143, 9782
|
9832, 9980
|
8724, 9120
|
10073, 10489
|
4612, 5583
|
2890, 2892
|
2914, 3842
|
1825, 1907
|
10509, 10987
|
302, 331
|
505, 1806
|
1953, 2761
|
2777, 2855
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,690
| 143,484
|
21560
|
Discharge summary
|
report
|
Admission Date: [**2146-9-17**] Discharge Date: [**2146-10-5**]
Date of Birth: [**2086-6-30**] Sex: M
Service: TSURG
Allergies:
Penicillins / Iodine
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
Left empyema
Fevers
Major Surgical or Invasive Procedure:
Bronchoscopy
Video assisted thoracoscopy
Decortication with empyema drainage
Endotracheal tube placement
Chest tube placement
Foley catheter placement
Dobhoff feeding tube placement
Central venous line placement
Peripherally inserted central catheter placement
Rectal tube placement
History of Present Illness:
60-year-old gentleman who recently underwent a left upper
lobectomy for primary lung cancer ([**2146-9-5**]). He subsequently
developed a staph aureus left empyema postoperatively requiring
re-exploration and drainage. He was recovering from that when
he again developed fevers to 103. Repeat imaging demonstrated
residual pockets within the chest space. He was transferred to
the [**Hospital1 69**] on [**2146-9-17**] for further
care and evaluation.
Past Medical History:
Primary lung cancer
Diabetes
Bronchitis/COPD
Arthritis
Hemorrhoids
Cholelithiasis
Pilonidal cyst
Pelvic fracture secondary to MVA s/p repair [**2140**]
L4-L5 disc disease
Sinusitis
Hepatomegaly
Family History:
Mother with pancreatic cancer
Physical Exam:
On admission, the patient's vital signs were as follows:
Vitals: T=39.3C, BP=, P=80-110, R=23, TV=620, PEEP=5, SpO2=97%,
FiO2=0.5, ABG=7.41/33/167/97%/6
Gen: NAD, intubated, sedated
Neuro: has purposeful spontaneous movements, opens eyes to pain
HEENT: PERRL, sclera anicteric, conjunctiva clear, MMM
CVS: RRR, no MRG, +DP pulses bilaterally
Pulm: rales on right, decreased lung sounds on left
Abd: soft, moderately distended, +BS
Ext: +2 bilateral pitting edema
Pertinent Results:
[**2146-9-17**] 04:51PM WBC-13.7* RBC-3.15* HGB-9.9* HCT-29.9* MCV-95
MCH-31.6 MCHC-33.2 RDW-14.2
[**2146-9-17**] 04:51PM NEUTS-85* BANDS-1 LYMPHS-6* MONOS-2 EOS-3
BASOS-1 ATYPS-0 METAS-1* MYELOS-1*
[**2146-9-17**] 04:51PM PLT COUNT-304
[**2146-9-17**] 04:51PM PT-12.6 PTT-21.9* INR(PT)-1.0
[**2146-9-17**] 04:51PM GLUCOSE-339* UREA N-26* CREAT-0.5 SODIUM-146*
POTASSIUM-4.6 CHLORIDE-111* TOTAL CO2-30* ANION GAP-10
[**2146-9-17**] 04:51PM ALT(SGPT)-16 AST(SGOT)-12 LD(LDH)-235
CK(CPK)-51 ALK PHOS-79 AMYLASE-39 TOT BILI-0.3
[**2146-9-17**] 04:51PM ALBUMIN-2.6* CALCIUM-7.8* PHOSPHATE-3.3
MAGNESIUM-2.1
[**2146-9-17**] 04:51PM LIPASE-65*
[**2146-9-17**] 07:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG
[**2146-9-17**] 10:36PM TYPE-ART TEMP-39.3 RATES-/23 TIDAL VOL-620
PEEP-5 O2-50 PO2-167* PCO2-50* PH-7.41 TOTAL CO2-33* BASE XS-6
Pathology Examination [**2146-9-21**]
Pleural tissue, left: Fibrin, inflammatory cells and pleural
tissue with inflammation and reactive changes. Clinical: Left
empyema.
CHEST (PORTABLE AP) [**2146-9-20**] 5:28 AM
Continued evidence of layering left pleural effusion with
associated volume loss and unchanged tube positions.
CHEST (PORTABLE AP) [**2146-9-21**] 6:15 AM
Unchanged evidence of layering left pleural effusion with
associated volume loss.
VIDEO OROPHARYNGEAL SWALLOW [**2146-9-27**] 10:34 AM
Moderately impaired oral phase. Aspiration of all consistencies
of barium.
Brief Hospital Course:
The patient was admitted to the Thoracic Surgery Service at
[**Hospital1 18**] on [**2146-9-17**] under Dr.[**Name (NI) 1816**] care. Patient was
sedated/intubated upon arrival and on clindamycin-he was
switched to vancomycin and meropenem upon admission. A chest CT
scan again demonstrated residual areas, particularly in the left
lower paravertebral sulcus, along the edge of the diaphragm. A
second chest tube was then placed on the left and drained a
significant amount of fluid. Over the next few days, attempts
to wean from the ventilator had failed. Because of continuing
low grade temperatures, elevated white blood cell counts and
failure to wean from the ventilator, it was decided to return to
the operating room. On [**2146-9-21**], the patient underwent a video
assisted thoracoscopy, decortication/clean-out and empyema
drainage. A flexible bronchoscopy was also done to rule-out a
bronchopleural fistula. For details of the procedures, see
operative note.
Patient's post-operative course was significant for continued
fevers (for which multiple cooling modalities were tried),
elevated blood sugar levels (on insulin gtt while in unit, SQ
NPH insulin while on floor), pulmonary edema following
extubation on [**2146-9-23**] (treated with lasix and face mask
oxygen), intermittent states of confusion/ICU psychosis (which
completely resolved by [**2146-10-1**]), and a sacro-coccygeal
decubitus ulcer.
Patient finally defervesced on [**9-23**] and has remained afebrile
throughout the remainder of his hospital course. Blood and
urine, C. difficile and pleural fluid cultures have been
negative to date. A sputum culture sent on [**9-22**] grew
methicilin resistant Staph. aureus. He was finally transferred
to the floor on [**2146-9-26**].
On [**2146-9-26**], a Speech and Swallow study had been performed for
inability to clear secretions, concerns of aspiration and
aphonia following extubation. This was followed by a video
swallow study on [**2146-9-27**]. Both reports showed overt
aspiration; patient was maintained NPO. ENT evaluated the
patient on [**2146-9-28**] and felt that his aphonia was due to
pulmonary deconditioning and that it would slowly resolve. He
is asked to follow-up with Dr. [**First Name (STitle) **] in ENT in [**12-10**] weeks. On
follow-up video swallow ([**2146-10-3**]) patient was phonating much
better and clearing secretions spontaneously. His diet was
advanced to a regular diet following teaching strategies for
eating and medications were allowed to be given whole with
pureed foods.
On [**2146-9-29**], the patient had fallen out of bed despite
restraints. Follow-up films were negative for any traumatic
injury. The remainder of his hospital course was benign; he
continued with physical therapy and conditioning.
On [**2146-10-4**], Vascular surgery had kindly seen the patient
regarding complaints of the patient's left 5th toe being dusky
black/purple. He was deemed as having a small blister that was
resolving and in no immediate threat of limb loss, etc. He is
asked to follow-up with Dr. [**Last Name (STitle) 1391**] in Vascular Surgery in [**12-10**]
weeks for further care and evaluation especially given his
history of diabetes and slight peripheral neuropathy.
Furthermore, he was deemed able to go to rehab by the surgical
team and was discharged on [**2146-10-4**], POD#14-ambulating with
assistance, tolerating a regular diabetic diet and voiding
spontaneously. He is also to continue on linezloid for another
14 days and his current regimen of 18 units of NPH insulin [**Hospital1 **].
He is asked to follow-up with Dr. [**Last Name (STitle) 952**] in [**12-10**] weeks.
Medications on Admission:
Meropenem
Vancomycin
Pantoprazole
Insulin
Tylenol
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. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Left empyema
Decubitus ulcer
Aphonia
Diabetes
Chronic obstructive pulmonary disease
Pulmonary edema
Discharge Condition:
Good and ambulating with assistance, tolerating a regular
diabetic diet and voiding spontaneously
Discharge Instructions:
You may restart any home medications you were on prior to your
hospital admission.
You may have a regular diabetic diet.
You may shower.
You may ambulate as tolerated and with assistance as needed.
Continue the linezolid for another 14 day course.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 952**] in [**12-10**] weeks. Please call
[**Telephone/Fax (1) 170**] for an appointment.
|
[
"V10.11",
"707.03",
"510.9",
"496",
"518.5",
"997.3",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.51",
"96.04",
"34.21",
"33.23",
"96.71",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7782, 7894
|
3366, 7038
|
306, 591
|
8038, 8137
|
1839, 3343
|
8433, 8567
|
1308, 1339
|
7138, 7759
|
7915, 8017
|
7064, 7115
|
8161, 8410
|
1354, 1820
|
247, 268
|
619, 1075
|
1097, 1292
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,914
| 132,096
|
23979
|
Discharge summary
|
report
|
Admission Date: [**2139-3-15**] Discharge Date: [**2139-3-19**]
Service: MEDICINE
Allergies:
Amiodarone / Zithromax
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
The patient is an 88 yo man with h/o CAD, hyperlipidemia, and
colonic diverticula, who was transferred from [**Hospital3 **]
with BRBPR. The patient states that he was in his normal state
of health until last Friday, [**2139-3-13**], when he was grocery
shopping and felt cramping in his lower abdomen. He went back to
his house, where he had a large bowel movement with BRBPR. He
called EMS and was taken to [**Hospital3 **] for further
evaluation. Per report, his SBP was in the 60s at the time EMS
arrived at his house but improved to the mid-80s with IVFs.
.
At [**Hospital3 **], he had a NG lavage, which was negative. He
was initially admitted to the MICU, where his Hcts were
monitored TID, and he was transfused 1 U PRBCs for a Hct
decrease from 35 to 29. He had a tagged RBC scan, which
demonstrated a possible upper GI bleed. He was started on a PPI
gtt and underwent endoscopy on [**3-14**], which did not demonstrate
any evidence of active bleeding. He was then scheduled for a
colonoscopy on [**3-15**] and was scheduled to be prepped tonight.
.
This morning, the patient got out of bed to go to the bathroom
and felt diaphoretic and lightheaded. He subsequently had a
large episode of BRBPR and was transferred back to the MICU.
There, he had another 4 episodes of BRBPR and reportedly lost
approximately 1500 cc of blood. Two 18 gauge PIVs were placed
and he was transferred to [**Hospital1 18**] for further managment.
.
On the floor, the patient states that he feels very weak and
tired but otherwise has no acute complaints.
Past Medical History:
CAD s/p CABG (LIMA/LAD, SVG/OM1, SVG/RCA) in [**4-11**], recent
P-MIBI [**12-13**] with normal EF of 66% no perfusion defects
Hypercholesterolemia
Esophageal stricture s/p dilatation
s/p bilateral knee replacements
Social History:
The patient lives with his daughter in [**Name (NI) 392**]. Wife passed away
2 days ago after suffering stroke. He does not smoke
cigarettes. He drinks EtOH rarely. He was previously a
construction worker and WWII vet. He is reportedly very active
at home and is able to perform all of his ADLs.
Family History:
Mother died at 88. Father died at 93 from head trauma after
fall. His father had [**Name (NI) 5895**] disease. No premature CAD. No
sudden cardiac death.
Physical Exam:
Admission PE:
AFVSS
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2139-3-15**] 05:16PM WBC-9.2 RBC-3.11*# HGB-9.7*# HCT-27.9*#
MCV-90 MCH-31.3 MCHC-34.9 RDW-15.0
[**2139-3-15**] 05:16PM NEUTS-82.1* LYMPHS-12.2* MONOS-5.3 EOS-0.2
BASOS-0.2
[**2139-3-15**] 05:16PM PLT COUNT-114*
[**2139-3-15**] 05:16PM PT-14.7* PTT-26.5 INR(PT)-1.3*
[**2139-3-15**] 05:16PM UREA N-26* CREAT-1.0 SODIUM-143 POTASSIUM-4.1
CHLORIDE-117* TOTAL CO2-17* ANION GAP-13
[**2139-3-15**] 05:16PM ALBUMIN-2.6* CALCIUM-6.7* PHOSPHATE-4.2
MAGNESIUM-1.9
[**2139-3-15**] 05:16PM GLUCOSE-157*
[**2139-3-15**] 05:16PM ALT(SGPT)-8 AST(SGOT)-19 LD(LDH)-130 ALK
PHOS-43 TOT BILI-1.0
[**2139-3-15**] 09:40PM HCT-22.9*
Angio [**2139-3-15**]:
FINDINGS:
1. The celiac, SMA, and [**Female First Name (un) 899**] angiography was performed and
demonstrated no
evidence of active extravasation at the time of the procedure.
2. Successful placement of a non-tunneled right internal jugular
vein central
line. The line is ready to use.
IMPRESSION:
1. No angiographically visible active mesenteric hemorrhage.
2. Central line placed via the right internal jugular vein, with
the tip in
the SVC. The line is ready to use.
Colonoscopy [**2139-3-17**]:
Findings:
Contents: There was stool in the colon liquid and brown in
color.
Excavated Lesions Multiple non-bleeding diverticula were seen
in the sigmoid colon at 30 cm to splenic flexure. Diverticulosis
appeared to be severe.
Impression: Diverticulosis of the sigmoid colon at 30 cm to
splenic flexure
Stool in the colon
Otherwise normal colonoscopy to cecum
Recommendations: Numerous diverticula noted from 30 cm to
splenic flexure. No active bleeding noted. Brown stool in colon.
Likely source of bleeding which appears to have ceased is
diverticular. If recurrent bleeding CTA appropriate and surgical
discussion regarding hemi-colectomy.
Labs on transfer to floor [**2139-3-18**]:
[**2139-3-18**] 03:52AM BLOOD WBC-9.0 RBC-3.39* Hgb-10.6* Hct-29.8*
MCV-88 MCH-31.3 MCHC-35.5* RDW-16.2* Plt Ct-159
[**2139-3-18**] 10:33AM BLOOD Hct-31.2*
[**2139-3-17**] 12:14PM BLOOD PT-13.3 PTT-26.7 INR(PT)-1.1
[**2139-3-18**] 03:52AM BLOOD Plt Ct-159
[**2139-3-18**] 03:52AM BLOOD Glucose-82 UreaN-14 Creat-0.9 Na-141
K-3.9 Cl-109* HCO3-25 AnGap-11
[**2139-3-18**] 03:52AM BLOOD Calcium-7.4* Phos-2.8 Mg-2.0
Brief Hospital Course:
88 yo M with CAD s/p CABG and colonic diverticula transferred
from an OSH to the [**Hospital1 18**] MICU with BRBPR likely due to a
diverticular bleed whose hospital course involved angiogram and
colonscopy.
.
ACTIVE ISSUE
#. Lower GI Bleed: The patient was transferred from [**Hospital1 **] on [**2139-3-15**] with approximately 5 episodes of BRBPR since
the morning of transfer. The source was presumed to be a lower
GI bleed, as he had a negative NG lavage and EGD at the OSH, and
he has evidence of colonic diverticula on colonoscopy from [**2136**].
IR was consulted and pt was taken for urgent angiography however
no area of active bleed was seen. GI was consulted recommended a
colonoscopy and IV PPI. Colonoscopy revealed 30+ diverticula
with no active bleed. However findings, bleeidng source was
thoguht to be diverticular bleed. Of note during his ICU course,
he required 12 units of pRBCs, and several units of FFP and
platelets. He remained hemodynamically stable and did not any
further evidence of bleeding and was therefore transferred out
of hte ICU. On the general medicine floors, patient was observed
and did not have any further episodes of BRBPR. He was continued
on PO PPI. Hct also stayed stable. No further interventions were
necessary and patient was discharged home. Of note during his
hospitalization, surgery was consulted and commented that if he
re-bled, patient would likely require colectomy.
.
INACTIVE ISSUES: The following were inactive issues during this
stay; no changes in medication or interventions were necessary:
#. visual hallucinations: Patient noted to have these during his
stay however did note that he had had this issue for several
years.
#. Hyperlipidemia.
#. CAD
.
Transitional Issues:
1) Code status: FULL CODE - confirmed
2) Pending: No outstanding labs or reports
3) Transition of care: PT saw patient while admitted and
confirmed that patient was safe to go home on his own. He should
have his Hct rechecked as an outpatient.
Medications on Admission:
ASA 162 mg PO daily x
Pravastatin 40 mg PO daily x
Prilosec 20 mg PO daily --> changed to protonix 40mg
Glucosamine Chondroiten 500 mg-400 mg PO BID x
Cod liver oil
Senna tablets x
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
2. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. 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*
5. Glucosamine-Chondroitin Complx 500-400 mg Capsule Sig: One
(1) Capsule PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
Diverticulosis
Lower GI Bleed
Secondary Diagnosis
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you had bloody bowel movements and low
blood pressure. You required several blood transfusions because
your bleed. You had several procedures to find out where you
were bleeding from. We believe that you bled from a diverticulum
(an outpouching) in your colon. At the time of your discharge,
your blood counts were stable.
.
During your hospital stay, you noted that you had some visual
hallucinations. This appears to be a chronic issue for you and
you will need to follow up with an eye doctor as an outpatient.
.
The following changes were made to your medications:
---- STOPPED Prilosec
---- STARTED Protonix 40mg daily
.
No other changes were made to your medications. Please be sure
to take them as directed.
Followup Instructions:
Please be sure to keep the following appointments:
Name: [**Doctor Last Name 9529**],MADHVENDRA
Location: [**Hospital3 **] MEDICAL ASSOCIATES
Address: [**Street Address(2) 17502**], [**Location (un) **],[**Numeric Identifier 17464**]
Phone: [**Telephone/Fax (1) 17503**]
When: Wednesday, [**3-25**], 1:45PM
Department: CARDIAC SERVICES
When: WEDNESDAY [**2140-2-10**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2139-3-20**]
|
[
"414.00",
"272.4",
"V43.65",
"V45.81",
"790.01",
"562.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"45.23",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
8103, 8109
|
5352, 6782
|
236, 249
|
8246, 8246
|
3067, 5329
|
9162, 9821
|
2390, 2546
|
7573, 8080
|
8130, 8225
|
7364, 7550
|
8397, 9139
|
2561, 3048
|
7092, 7338
|
191, 198
|
277, 1821
|
6799, 7071
|
8261, 8373
|
1843, 2060
|
2076, 2374
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,119
| 164,611
|
50344
|
Discharge summary
|
report
|
Admission Date: [**2174-2-18**] Discharge Date: [**2174-2-26**]
Date of Birth: [**2119-3-3**] Sex: F
Service: SURGERY
Allergies:
Diamox Sequels / Vitamin C
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
Cadaveric renal transplant
History of Present Illness:
Dx in [**2168**] with ESRD - incidentally found on routine phycial
exams. Afterwards was on HD with multiple AVF revisions.
Past Medical History:
Obesity
CSxn x 3
3 HD CVL
AVF x6 revisions
T&A
Social History:
no t, d, occasion etOH
Family History:
Mother with non-specific [**Last Name 4006**] problem
Physical Exam:
NAD AAOx3 obese
RRR
CTAB
soft, NT/ND, no masses or hernia
5/5 strength U and LE B/L, LUE AVF
Neuro intact
Pertinent Results:
[**2174-2-26**] 06:16AM BLOOD WBC-4.8 RBC-2.48* Hgb-9.1* Hct-25.6*
MCV-103* MCH-36.6* MCHC-35.4* RDW-17.2* Plt Ct-164
[**2174-2-25**] 06:00AM BLOOD WBC-4.8 RBC-2.55* Hgb-9.3* Hct-26.6*
MCV-104* MCH-36.5* MCHC-35.1* RDW-17.0* Plt Ct-144*
[**2174-2-24**] 06:00AM BLOOD WBC-5.2# RBC-2.54* Hgb-9.1* Hct-26.6*
MCV-105* MCH-36.0* MCHC-34.4 RDW-17.3* Plt Ct-116*
[**2174-2-23**] 05:30AM BLOOD WBC-1.8*# RBC-2.61* Hgb-9.5* Hct-27.1*
MCV-104* MCH-36.2* MCHC-34.8 RDW-17.3* Plt Ct-96*
[**2174-2-19**] 11:08AM BLOOD WBC-4.6 RBC-2.92*# Hgb-11.1*# Hct-31.8*#
MCV-109* MCH-38.0* MCHC-34.9 RDW-15.5 Plt Ct-131*#
[**2174-2-19**] 02:00AM BLOOD WBC-8.2 RBC-4.03* Hgb-15.2 Hct-43.7
MCV-108* MCH-37.6* MCHC-34.7 RDW-15.6* Plt Ct-286
[**2174-2-26**] 06:16AM BLOOD Plt Ct-164
[**2174-2-22**] 05:55AM BLOOD PT-11.6 PTT-19.8* INR(PT)-1.0
[**2174-2-20**] 01:34AM BLOOD PT-14.2* PTT-23.4 INR(PT)-1.3*
[**2174-2-19**] 07:43AM BLOOD PT-19.4* PTT-22.8 INR(PT)-1.9*
[**2174-2-19**] 06:30AM BLOOD PT-20.4* INR(PT)-2.0*
[**2174-2-19**] 02:00AM BLOOD Plt Ct-286
[**2174-2-19**] 02:00AM BLOOD PT-25.1* PTT-25.0 INR(PT)-2.5*
[**2174-2-22**] 05:55AM BLOOD Fibrino-571*
[**2174-2-19**] 07:43AM BLOOD Fibrino-466*
[**2174-2-19**] 02:00AM BLOOD Fibrino-573*
[**2174-2-25**] 06:00AM BLOOD Glucose-68* UreaN-60* Creat-8.3*# Na-140
K-4.0 Cl-100 HCO3-25 AnGap-19
[**2174-2-24**] 06:00AM BLOOD Glucose-84 UreaN-41* Creat-6.3*# Na-138
K-3.5 Cl-99 HCO3-28 AnGap-15
[**2174-2-19**] 11:08AM BLOOD Glucose-140* UreaN-27* Creat-6.4* Na-141
K-4.2 Cl-99 HCO3-27 AnGap-19
[**2174-2-19**] 02:00AM BLOOD UreaN-24* Creat-6.2* Na-142 K-3.9 Cl-94*
HCO3-31 AnGap-21*
[**2174-2-19**] 02:00AM BLOOD ALT-22 AST-20 LD(LDH)-197 AlkPhos-133*
Amylase-145* TotBili-0.3
[**2174-2-19**] 02:00AM BLOOD Lipase-137*
[**2174-2-26**] 06:16AM BLOOD Calcium-8.3* Phos-2.9# Mg-1.6
[**2174-2-25**] 06:00AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.9
[**2174-2-24**] 06:00AM BLOOD Calcium-8.7 Phos-3.3# Mg-1.7
[**2174-2-20**] 01:34AM BLOOD Phos-4.6* Mg-1.5*
[**2174-2-19**] 11:08AM BLOOD Phos-3.5 Mg-1.4*
[**2174-2-19**] 02:00AM BLOOD Albumin-4.4 Calcium-9.8 Phos-4.7* Mg-2.0
Cholest-188
[**2174-2-19**] 02:00AM BLOOD Triglyc-284*
[**2174-2-26**] 06:16AM BLOOD FK506-PND
[**2174-2-25**] 06:00AM BLOOD FK506-6.2
[**2174-2-23**] 05:29AM BLOOD FK506-LESS THAN
[**2174-2-22**] 05:55AM BLOOD FK506-LESS THAN
[**2174-2-19**] 09:52AM BLOOD Type-ART pO2-124* pCO2-42 pH-7.46*
calHCO3-31* Base XS-6
[**2174-2-19**] 08:10AM BLOOD Type-ART pO2-188* pCO2-38 pH-7.55*
calHCO3-34* Base XS-10
[**2174-2-19**] 09:52AM BLOOD Glucose-130* Lactate-4.7* Na-138 K-4.4
Cl-97*
[**2174-2-19**] 08:10AM BLOOD Glucose-127* Lactate-3.2* Na-141 K-3.9
Cl-96*
[**2174-2-19**] 09:52AM BLOOD freeCa-1.23
[**2174-2-19**] 08:10AM BLOOD freeCa-1.11*
[**2174-2-19**] 10:22PM BLOOD HEPARIN DEPENDENT ANTIBODIES-HEPDEP -
Brief Hospital Course:
Pt under went renal txp on [**2174-2-19**] without complications. Post
op she went back to the PACU for management of hypotension. She
was put on Neo to titrate BP to >100, highest was 0.8. She was
txf to an ICU bed where she could get dialysis. Her diet was
advanced as tolerated and her pain was well controlled. She has
some exudate in the wound and the wound was opened on POD 3 and
a vac was placed after it was further opened on POD4. She had
low UOP throught her hospital course and was dialyzed. Her
immunosuppression was per the renal txp protocol and was
adheared to. She was weaned off of neo with Mitodrine 10 mg TID
and was tx to the floor. She ambulate with PT and on her own.
She left on Wet to dry dressing changes and willstart vac theary
again in her RLQ on Monday. SHe is in good condition for D/C
home with VNA on [**2174-2-26**].
Medications on Admission:
Renagel
Epogen
Coumadin
Vit D
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*21 Tablet(s)* Refills:*0*
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*600 ML(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2 times
a day).
Disp:*240 Capsule(s)* Refills:*2*
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours).
Disp:*15 Tablet(s)* Refills:*2*
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
10. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*14 Tablet(s)* Refills:*0*
12. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS). Capsule(s)
13. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) **] vna
Discharge Diagnosis:
End stage renal disease
Discharge Condition:
Good
Discharge Instructions:
Please call or return if you have fever >101, severe pain, pus
or an increased amount of bleeding from wound, chest pain,
shortness of breath, or anything else that causes you concern.
Please continue on your immunosuppressive medications as order
and follow-up with Dr. [**Last Name (STitle) 816**].
You will have wet to dry dressing chnages until Monday when you
will begin the vac.
Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2174-2-28**] 1:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2174-3-10**]
9:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2174-3-15**] 3:20
|
[
"276.7",
"458.29",
"278.01",
"535.60",
"V18.69",
"996.81",
"V85.4",
"285.9",
"288.0",
"585.6",
"535.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"00.93",
"99.07",
"86.04",
"45.16",
"39.95",
"38.93",
"93.59"
] |
icd9pcs
|
[
[
[]
]
] |
6053, 6109
|
3616, 4478
|
290, 319
|
6177, 6184
|
797, 3593
|
6617, 7039
|
600, 655
|
4558, 6030
|
6130, 6156
|
4504, 4535
|
6208, 6594
|
670, 778
|
246, 252
|
347, 473
|
495, 544
|
560, 584
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,286
| 117,293
|
6291
|
Discharge summary
|
report
|
Admission Date: [**2104-6-25**] Discharge Date: [**2104-8-2**]
Date of Birth: [**2040-6-10**] Sex: F
Service: MEDICINE
Allergies:
Nsaids / Nut Flavor / Lactose / Corn / Radioactive Diagnostics,
General Classif / Vancomycin
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Laparoscopic ileostomy on [**2104-6-23**]
Central line placement (now removed)
PICC line placement on [**2104-7-28**] for long-term antibiotics
History of Present Illness:
HPI: Pt is a 64 year old female with a history of Crohn's
colitis who was transferred from [**Hospital3 7571**]Hospital after
she was observed to have stool discharging from the vagina. Pt
had previously been hospitalized at [**Hospital6 6689**]
numerous times for Crohn's colitis and resultant diarrhea,
deyhydration, and electrolyte abnormalities. Pt's most recent
admission at [**Location (un) **] was for Klebsiella urosepsis, which
responded well to Levoflox and IVF. During the admission, she
was clinically thought to have a vesicular-sigmoid fistula,
although this was not demonstrated on CT scan. According to OSH
records, pt may also have had feculent material which drained
from a foley cath. Due to pt's complicated clinical course
(including recent MI), she was transferred to [**Hospital1 18**] for further
management of her presumed vesicular-sigmoid fistula.
Past Medical History:
1. Crohn's Disease (diagnosed [**2104-3-19**])
2. Enterovesicular fistula
3. h/o recent Klebsiella UTI, c/b sepsis
4. Anteroseptal MI resulting in cardiogenic shock - [**2104-5-21**],
recent Persantine MIBI shows small-to-moderate inferolateral
reversible defect. EF 20-25% from [**5-21**] echo
5. Bipolar Disorder
6. h/o c diff, now with c diff toxin negative x2 but persistent
diarrhea, s/p tx with flagyl
7. h/o VRE
8. h/o MRSA
9. HTN
10. gallstones
11. fibromyalgia
12. scoliosis
13. depression
Social History:
Ms. [**Known lastname 24414**] lives alone. She is married but her husband has
[**Name (NI) 2481**] and is living at a nursing home. She has a daughter
who lives nearby and a son who lives in [**State 2690**]. Ms. [**Known lastname 24414**]
has never smoked and does not drink alcohol.
Family History:
No family history of Crohn's disease. Positive family history
for heart and vascular disease: mother died of MI in her 80s,
father died of MI at 58, and her grandmother died of stroke.
Physical Exam:
Vitals: Temp 99.7, BP 74/doppler, Pulse 106, RR 20, O2 sat 97%
2L
Gen: slightly lethargic, but responds appropriately to
questions.
HEENT: PERRL
Cardio: RRR, nl S1S2, no m/r/g
Resp: mild rhonchi BL
Abd: soft, mild diffuse tenderness, no rebound/guarding, +BS.
Ext: no c/c/e
Neuro: A&Ox3
Rectal (from OSH records): guaiac +
Pertinent Results:
[**2104-6-25**] 11:59PM WBC-5.3 RBC-3.09* HGB-9.7* HCT-28.2* MCV-91
MCH-31.3 MCHC-34.3 RDW-15.9*
[**2104-6-25**] 11:59PM PLT COUNT-313
[**2104-6-25**] 08:12PM GLUCOSE-66* UREA N-7 CREAT-0.2* SODIUM-132*
POTASSIUM-4.0 CHLORIDE-95* TOTAL CO2-29 ANION GAP-12
[**2104-6-25**] 08:12PM CALCIUM-7.1* PHOSPHATE-3.5 MAGNESIUM-1.4*
[**2104-6-25**] 08:12PM WBC-5.3 RBC-3.67* HGB-11.4* HCT-33.3* MCV-91
MCH-31.1 MCHC-34.2 RDW-16.0*
[**2104-6-25**] 08:12PM PLT COUNT-355
.
[**2104-6-30**] ECHO:
Preserved global and regional biventricular systolic function.
Mild mitral regurgitation. Pulmonary artery systolic
hypertension. Mildly dilated ascending aorta. Compared with the
report (images unavailable) of [**2096-12-19**], the findings are new.
LVEF 55%
Based on [**2094**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate a low risk (prophylaxis not recommended).
Clinical decisions regarding the need for prophylaxis should be
based on clinical and echocardiographic data.
.
RUQ U/S:
1. Cholelithiasis without evidence of cholecystitis.
2. Incidental small right pleural effusion.
.
[**2104-6-30**] SIGMOIDOSCOPY:
Opening consistent with fistula was visualized in the distal
portion of the rectum, erythema in distal descending colon
compatible with indeterminate colitis.
Descending colon mucosal biopsy:
Focal architectural distortion and Paneth cells, suggestive of
chronic inactive colitis. No granulomas or dysplasia.
.
CT C/A/P [**2104-7-9**]:
1. There is a filling defect in the left common femoral vein
most likely representing a thrombosis. Recommend left lower
extremity ultrasound to better characterize.
2. There is an airspace opacity in the right middle lobe most
likely
consistent with pneumonia. Clinical correlation is suggested.
3. There is symmetric thickening of the wall of the sigmoid
colon with pockets of diverticula without stranding of the
surrounding fat and without abscess formation. Patient has a
known diagnosis of Crohn's but given only the sigmoid
involvement and lack of asymmetry and skip lesions,
diverticulitis should also be considered.
4. Severe left convex scoliosis of the lumbar spine.
.
LOWER EXTREMITY U/S [**2104-7-17**]:
The left common femoral vein demonstrates intraluminal thrombus
and is not
completely compressible, although it is patent. This finding is
consistent with short-segment, nonocclusive thrombus of the
proximal left common femoral vein that does not extend into the
superficial femoral vein. The remaining lower extremity deep
veins, namely the superficial femoral and popliteal, are patent
and compressible. Left calf veins are also patent. The right
common femoral, superficial femoral, and popliteal veins are
widely patent, compressible and demonstrate normal venous flow
and augmentation.
.
TTE [**2104-7-18**]: The left atrium is elongated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Trivial mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is a small
pericardial effusion. There is brief right atrial diastolic
collapse. Compared with the findings of the prior study (images
reviewed) of [**2104-6-30**], no major change is evident.
.
SHOULDER 1 VIEW LEFT [**2104-7-29**] 1:55 PM
Two radiographs of the left shoulder demonstrate anatomic
alignment of the glenohumeral joint. Assessment of the
acromioclavicular joint is limited by patient positioning.
Visualized lung is clear. Of note, the two images represent a
single projection. No fracture identified. The adjacent ribs are
grossly unremarkable. Soft tissues are unremarkable.
Technologist note indicates the patient could not tolerate
additional imaging.
.
IMPRESSION:
Limited study given single angle of projection. No fracture or
dislocation demonstrated.
.
ECHO Study Date of [**2104-7-28**]
Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets
are mildly thickened. There is a small (~3mm) somewhat mobile
echodensity on
the left ventricular side near the coaptation of the aortic
valve leaflets.
Trace aortic regurgitation is seen. The mitral valve appears
structurally
normal. No mass or vegetation is seen on the mitral valve. Mild
(1+) mitral
regurgitation is seen. There is no pericardial effusion.
.
IMPRESSION: Small, partially mobile echodensity on the aortic
valve as
described above c/w (but not diagnositic of) a vegetation. ( A
benign fibrin
strand would also be in the differential).
.
UNILAT UP EXT VEINS US [**2104-7-28**] 1:43 PM
LEFT UPPER EXTREMITY ULTRASOUND: [**Doctor Last Name **] scale and Doppler
ultrasound of the left internal jugular, subclavian, brachial,
basilic, and cephalic veins was performed. There is normal flow,
augmentation, compressibility, and waveforms. No intraluminal
thrombus is identified.
.
IMPRESSION: No left upper extremity DVT.
.
ECG Study Date of [**2104-7-24**] 7:44:44 PM
Sinus tachycardia. Delayed anterior precordial R wave
progression.
Non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2104-7-22**] no diagnostic change.
Brief Hospital Course:
This is a 64 year old female with a history of Crohn's colitis
who was transferred from [**Hospital3 7571**]Hospital after she was
observed to have stool discharging from the vagina. Pt had
previously been hospitalized at [**Hospital6 6689**]
numerous times for Crohn's colitis and resultant diarrhea,
deyhydration, and electrolyte abnormalities. Pt's most recent
admission at [**Location (un) **] was for Klebsiella urosepsis, which
responded well to Levoflox and IVF. During the admission, she
was clinically thought to have a vaginal/sigmoid fistula,
although this was not demonstrated on CT scan. According to OSH
records, pt may also have had feculent material which drained
from a foley cath. Due to pt's complicated clinical course
(including recent MI), she was transferred to [**Hospital1 18**] for further
management of her presumed vaginal/sigmoid fistula.
.
Shortly after admission to [**Hospital1 18**], the pt had episode of
hypotension with BP 60/doppler. She received 500cc NS x 2, with
little improvement in BP. Pt was mentating during the episode,
but was more somnolent according to nursing staff. She
complained of only "gas pains" in her abdomen. She denied SOB or
CP at that time. Pt reportedly pulled out her PICC half-way
prior to this episode. Of note, pt had received both carvedilol
and lisinopril on admission.
.
She was transferred on night of admission to the ICU and was
given approx 2L of NS, with SBP remaining in the 70's to 80's.
She was placed on peripheral dopamine to achieve SBP>90. A right
subclavian line was placed, dopamine was d/c'd, and pt was
placed on levophed. Shortly after starting levophed, she
experienced [**3-31**] chest pressure and experienced increased ectopy
on telemetry. There were no EKG changes. Levophed was stopped,
and SBP decreased to the 70's. She was given more NS bolusus,
and started back on dopamine gtt. Pt's chest pressure resolved,
however she became tachy to 120's and remained hypotensive.
Dopamine was d/c'd, she was given another NS bolus, and was
placed on Neo gtt.
.
She was briefly back on the floor on [**7-6**] but was quickly
returned to the ICU for persistent hypotension. During her
second stay in the ICU, she was started on Neosyn drip for 24
hours with SBPs between 70s to 100s. Off pressors she maintained
MAPs >55. Vancomycin was added to her antibiotic coverage. She
also had urine cultures positive for >100k yeast, that was
treated with one dose of fluconazole. On [**7-9**] she was restarted
on lopressor (at 12.5mg TID). She then had episodes of
bradycardia with HR in the 40s o/n that were asymptomatic.
.
To look for possible abscess around her fistula, the pt
underwent a Abd/pelvic CT scan on [**7-9**] that did not show any
evidence for abscess, but a DVT in her LLE was found
incidentally. After refusing LENI for further evaluation, the pt
was started on heparin drip and returned to the medicine floor.
.
Her Vancomycin was discontinued a few days later with the idea
that she had completed a two-week course since her admission and
there were no recent positive blood cultures to indicate its
use. Two days later she again became hypotensive and
tachycardia on with no improvement after 2.5 L of fluid
resuscitation. At this time, it was noted that her stress-dose
steroids had been stopped 24 hours beforehand at the completion
of the planned 7-day course. She was given Decadron 4 mg and
transferred briefly to the MICU where she almost immediately
stabilized. Vancomycin was restarted. Blood cultures taken
during this episode of tachycardia and hypotension subsequently
grew vancomycin resistant enterococcus and coag-positive staph,
and sepsis vs. adrenal insufficiency were suspected to be the
precipitation factor.
.
A TTE was performed on [**7-15**] to evaluate her for endocarditis in
the setting of MRSA and VRE bacteremia but showed no evidence of
valve vegetation. She also consented to doppler ultrasound of
her lower extremities at this time which revealed a partial
thrombus in her left common femoral vein; the heparin gtt was
continued. During a subsequent hypotensive episode, antibiotic
coverage was broadened by exchanging levofloxacin for cefepime,
providing new coverage against pseudomonas (then on
cefepime,vancomycin,flagyl). In light of new sensitivities for
enterococcus organism and drug rash suspected to be due to
vancomycin, ID approved the initiation of daptomycin for staph
areus and enterococcus coverage. Cefepime & vancomycin d/c'd on
[**7-19**]. Flagyl was continued for coverage of enteric bacteria
secondary to vesicular-colonic fistual and potential for
urosepsis.
.
Once back on the regular floor on [**7-20**], her BP remained stable
with intermittent periods of hypotension and tachycardia.
Surgery evaluated patient for repair of rectovaginal fistula but
was not able to go intially due to concern about nutritional
status, given low albumin level. ID was consulted for underlying
VRE and MRSA bacteremic sepsis as cause of her hypotension
despite being on multiple broad-coverage antibiotics, including
daptomycin, flagyl, and levoquin.
.
She had surgery on [**2104-7-23**] with placement of ileostomy and
diversion of rectovaginal fistula. Patient is now POD #4 and has
shown clinical improvement with stable BPs and lack of fevers.
She is being transferred back to medicine for management of her
bacteremia, cardiovascular and nutritional status.
.
Below is a list of her medical problems with management plan
prior to discharge:
.
# Bacteremia: hypotension, tachycardia
Positive blood cultures from [**7-15**] have grown VRE/MRSA; suspected
sepsis as cause of hypotensive episodes. TTE on [**7-15**] showed no
evidence of valve vegetation. Antibiotic coverage was broadened
by exchanging levofloxacin for cefepime, providing new coverage
against pseudomonas. In light of new sensitivities for
enterococcus organism and drug rash suspected to be due to
vancomycin, placed on daptomycin for MRSA and VRE. Cefepime &
vancomycin d/c'd on [**7-19**]. On flagyl for coverage of enteric
bacteria secondary to vesicular-colonic fistual and potential
for urosepsis.
.
She remained afebrile with normal WBC count. ID consulted
regarding modifying antibiotic coverage or adding antifungal
med. Elderly patients have a higher threshold for mounting a
fever and patient may be septic based on hemodynamic
instability. Patient had central line removed prior to PICC line
placement on [**7-28**] and sent for culture. PICC line placed for
long-term antibiotics. Daily blood cultures since [**7-16**] have been
negative. Concerned remained high for endocarditis since patient
had unchecked VRE in blood prior to surgery which may also be
contributing to hypotension in setting of sepsis. A
tranesophageal echocardiogram revealed small, partially mobile
echodensity on the aortic valve as described above c/w (but not
diagnositic of) a vegetation. Her current antiobiotic course
would provide coverage of VRE or MRSA as source of valvular
vegetations.
- Close monitoring of BP, patient remained normotensive post-op
- Antibiotic course:
-- Levo/Flagyl x 2 weeks from surgery [**7-23**], on day 10
-- Dapto X 6 weeks after central line was taken out, on day 5
- Central line tip culture no growth to date
.
# Crohn's colitis:
Patient found to have fistula in distal portion of rectal wall.
Since there has been a history of non-compliance and lack of
follow-up, surgery was consulted for surgical intervention, as
opposed to starting infliximab. Patient is POD #11 s/p ileostomy
which has had adequate output, without obstruction and minimal
drainage from fistula.
- Continue Mesalamine
.
# DVT:
Filling defect in left femoral vein found incidentally on CT
pelvis. Doppler u/s reveals partial non-occlusive thrombus in
left common femoral vein. Left upper extremity ultrasound to
evaluate for clot was negative which decreased concern for HIT
and checking heparin dependent antibody was not clinically
indicated given normal platelet counts. Xray of left shoulder
negative for joint effusion. Patient was advised to keep left
arm elevated on pillow and over the next couple of days, the
swelling in left arm decreased considerably, suggesting it was
due to venous stasis since she has limited range of motion in
left arm compared to right. Pt refused coumadin, so she is being
discharged on Lovenox.
.
# CAD, s/p recent MI at OSH :
After reevaluating reports from outside hospital, it appears
that patient sustained a small infoerolateral ischemic event,
now with preserved EF documented on arrival to [**Hospital1 18**] and again
on [**7-18**] TTE. Per Cardiology input, she is at moderate cardiac
risk for peri-operative complications; however, cardiac
catheterization is not indicated. Patient had episoses of
tachycardia in 130s [**1-24**] volume depletion, remained hypotensive
with increased HR despite fluid resuscitation. Pt had adequate
UOP lessening cocnern for volume overload. BP stabilized after
starting stress dose steroids prior to surgery and she has
remained normotensive post-op.
- Continued on home meds ASA, lipitor discontinued due to
elevated LFTs
- Beta-blocker was continued throughout her hospitalization, and
lisinopril was restarted on discharge
.
# Adrenal insufficiency:
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test suggestive of adrenal insufficiency. It
may have been contributing to her persistent hypotension with
SBP in 90s before surgery. She is now hemodynamically stable
with SBP 130s. She was on low-dose steroids, hydrocortisone and
fludrocortisone, prior to surgery given hypotension. Patient was
switched to a prednisone taper on POD #7 to end at 10mg daily
and be followed up by GI. She was placed on calcium and vitamin
D therapies as corticosteroids can accelerate bone loss and
decrease serum calcium levels.
.
# Bipolar d/o:
Continue outpatient regimen of VPA and Risperdal.
.
# Stage 1 sacral decubitus ulcers:
Should be treated daily by wound care
.
# FEN:
Patient switched to soft PO diet on [**7-27**] and off TPN given
functionality of ileostomy. She continued to receive D5 1/2NS
with 20meq KCL to maintain electrolyte balance.
.
# Anemia:
Patient's Hct has remained stable s/p 1u pRBC transfusion post
sx. Persistent anemia also a cause of tachycardia, as it may
lead to high output cardiac failure. Iron studies indicated
anemia of chronic disease. Hct stable at discharge. Continue
Epogen.
.
# Prophylaxis: Heparin gtt, PPI
Monitor PTT, goal of 70-80
.
# Code:
DNR (but can be intubated, can have pressors), discussed with
HCP (daughter, [**Name (NI) 24415**] [**Name (NI) **])
.
# Dispo:
Family meeting was on Sunday, [**7-20**] at 3 to 4 p.m. Patient
was been given option of palliative care vs. surgery and stated
that she understands surgical risk and very much would like to
proceed with surgery.
.
She will be discharged to [**Hospital 5130**] [**Hospital 4094**] Hospital in
[**Hospital1 **]. She will followup with Dr. [**Last Name (STitle) **] in 2 weeks for
assessment and consideration of fistula repair.
.
Patient will need to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] on [**9-9**], [**2103**] at the [**Hospital1 18**] infectious disease clinic; the rehab
facility needs to fax weekly labs to Dr. [**Last Name (STitle) 9404**] for the
following labs: liver function tests, creatine kinase,
electrolytes, complete blood count. Results should be faxed to
([**Telephone/Fax (1) 4591**], his office number is ([**Telephone/Fax (1) 6732**].
Medications on Admission:
MEDS (on transfer to ICU):
Mesalamine DR 800 mg PO TID
Valproic Acid 500 mg PO QHS
Aspirin EC 81 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Risperidone 1 mg PO DAILY
Levofloxacin 500 mg PO Q24H
Enoxaparin Sodium 40 mg SC DAILY
Lisinopril 2.5 mg PO QHS
Carvedilol 3.125 mg PO BID
Methylprednisolone Sodium Succ 10 mg IV Q6H
Insulin SC sliding scale
Atorvastatin 10 mg PO DAILY
tramadol 50 mg PO Q4-6H:PRN pain
Acetaminophen 650 mg PO Q4-6H:PRN fever
Enoxaparin Sodium 40 mg SC QD
Lisinopril 2.5 mg PO QHS
Carvedilol 3.125 mg PO BID
Discharge Medications:
1. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
2. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO QHS (once
a day (at bedtime)).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Risperidone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for thigh rash.
6. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
8. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 6 days.
11. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 6 weeks.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 6 days.
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
14. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
15. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID with meals.
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO twice a day.
18. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day:
Please take 6 pills on [**2104-8-2**] to [**2104-8-5**]. Please take 4 pills
on [**2104-8-6**] to [**2104-8-12**]. Please take 3 pills on [**2104-8-13**] to
[**2104-8-15**]. Please take 2 pills on [**2104-8-16**] to [**2104-8-18**]. Please
take 1 pill on [**2104-8-19**] and continue on this dose of 10mg daily.
19. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
20. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary diagnoses:
Rectovaginal fistula, secondary to Crohn's colitis
VRE/MRSA endocarditis
Adrenal insufficiency
Hypotension [**1-24**] sepsis, now resolved
.
Secondary diagnoses:
1) ? vesicular-sigmoid fistula
2) Hx recent Klebsiella UTI, c/b sepsis
3) Crohn's Disease - diagnosed [**2104-3-19**], on steroids
4) Anteroseptal MI resulting in cardiogenic shock - [**2104-5-21**],
recent Persantine MIBI shows small-to-moderate inferolateral
reversible defect. EF 20-25% from [**5-21**] echo (unclear if pt has
more recent echo)
5) Bipolar Disorder
6) h/o c diff, now with c diff toxin negative x2 but persistent
diarrhea, s/p tx with flagyl
7) h/o VRE
8) h/o MRSA
9) HTN
10)Gallstones
11)Fibromyalgia
12)Scoliosis
13)Depression
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as prescribed. You were admitted for
a recto-vaginal fistula as a result of Crohn's disease. You had
bacterial infection in your blood that resulted in low blood
pressures and had to be monitored and treated in medicine ICU.
Once stable, surgery was done to create a ileostomy to prevent
diarrhea and infection in your lower GI tract and blood.
.
You are currently on a taper of steroids for adrenal
insufficiency. You are being given a prescription for 10mg
tablets. Please take 6 pills on [**2104-8-2**] to [**2104-8-5**]. Please
take 4 pills on [**2104-8-6**] to [**2104-8-12**]. Please take 3 pills on
[**2104-8-13**] to [**2104-8-15**]. Please take 2 pills on [**2104-8-16**] to [**2104-8-18**].
Please take 1 pill on [**2104-8-19**] and continue on this dose of 10mg
daily. You will need to follow up with your GI doctor to
determine when to stop this medication.
.
Please have your platelets checked once a week while you are
taking exonaparin for your blood clot.
.
Please have your chem-7 labs checked once a week while for 4
weeks while you are on lisinopril for blood pressure.
.
Please contact your PCP or return ot the [**Name (NI) **] if you experience
low blood pressures, fevers, or persistent diarrhea.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **] MD, Phone: ([**Telephone/Fax (1) 1483**],
Date/Time:[**2104-8-11**] 3:45
.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name 9406**] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2104-9-9**]
9:00
Patient will need to followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] on [**9-9**], [**2103**] at the [**Hospital1 18**] infectious disease clinic; the rehab
facility needs to fax weekly labs to Dr. [**Last Name (STitle) 9404**] for the
following labs: liver function tests, creatine kinase,
electrolytes, complete blood count. Results should be faxed to
([**Telephone/Fax (1) 4591**], his office number is ([**Telephone/Fax (1) 6732**].
.
Follow-up with PCP for further medical management:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 24416**]
.
Test for consideration post-discharge: anti-Tissue
Transglutaminase Antibody, IgA
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
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1,798
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19639
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Discharge summary
|
report
|
Admission Date: [**2194-1-25**] Discharge Date: [**2194-1-25**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
woman with a history of hypertension and alcohol use
transferred from an outside hospital on [**2194-1-25**]
secondary to hyperbilirubinemia, newly diagnosed pancreatic
head mass, a CBD occlusion, hepatic abscess with blood
cultures positive for E. coli, [**Female First Name (un) 564**] glabrata,
Lactobacillus. The patient subsequently had a common bile
duct drain placed at the outside hospital. The patient was
subsequently treated with ampicillin, gentamicin, Flagyl,
AmBisome and was followed by Infectious Disease. The patient
was intubated for subsequent ARDS on [**2194-2-1**] and
subsequently had an ERCP with bronchial brushings revealing
atypical cells consistent with adenocarcinoma, CA99 of
36,000. The patient was subsequently transferred to [**Hospital1 18**] on
[**2194-1-26**] and taken to the ICU on [**2193-2-1**]
after hypoxic respiratory failure. The patient was
subsequently extubated, transferred to the Medicine Floor.
Blood cultures and urine cultures were negative since then.
Per ID consult, the patient's antibiotic regimen was changed
to Unasyn, vancomycin, and Voriconazole. Over the past eight
days, the patient's T bilirubin and alkaline phosphatase have
slowly risen which was thought secondary to worsening biliary
obstruction. Plans had been made for another palliative
stent. The patient subsequently developed increased
diarrhea. Clostridium difficile was negative times three,
thought secondary to pancreatic insufficiency.
The patient was started on Pancrease as well as TPN with
improving p.o. intake subsequently. Today, the covering
Medicine Team was called at bedside secondary to decreased
mental status and hypotension with blood pressure down to
70/40, tachycardia 158. The patient had a fingerstick blood
glucose at that time of 10. The patient was given 2 amps of
D50 with blood glucose returning to about 170 and resolution
of mental status change. The patient had a right femoral
line placed, given 3 liters of normal saline, and the blood
pressure improved to 90/50. Peripheral dopamine was started.
EKG revealed normal sinus rhythm at 158, rate-related ST
depressions in the lateral walls, CKs and troponins were
negative. CBC, further blood cultures, Chem-7 was taken.
The chest x-ray revealed mild volume overload. ABG revealed
the following numbers: 7.36, 29, 210, on a nonrebreather.
The patient was transferred to the ICU given the hypotension
requiring pressors, mental status change, and profound
hypoglycemia most likely secondary to hepatic failure due to
hepatic abscesses.
PAST MEDICAL HISTORY: Metastatic pancreatic cancer per
bronchial brushings, CA99, and imaging studies.
Hypertension.
Alcohol abuse.
Chronic pancreatitis.
MEDICATIONS ON TRANSFER TO THE ICU:
1. Celexa 20 mg p.o. q.d.
2. Protonix 40 IV q. 24 hours.
3. Heparin 5,000 units subcutaneously q. eight hours.
4. Vancomycin 1 gram IV q. 12 hours.
5. Lorazepam 0.5 to 2 mg q. 2 to 4 hours p.r.n.
6. Morphine IR p.o. q. eight hours p.r.n.
7. Regular insulin sliding scale.
8. Unasyn 3 grams IV q. six hours.
9. Pancrease t.i.d.
10. TPN.
11. Voriconazole 100 p.o. q. 12 hours.
PHYSICAL EXAMINATION: Vital signs: Upon admission,
temperature 100.4, temperature maximum 100.4, 64/20, 114, 97
percent on room air on Levophed. General: The patient was
alert and oriented times three. HEENT: The sclerae were
icteric. The mucous membranes were very dry. Heart: Normal
S1 and S2. No murmurs, rubs, or gallops. Lungs: Clear to
auscultation anteriorly. Abdomen: Positive bowel sounds.
Soft, tender in epigastrium, an epigastric mass is palpable.
No rebound or guarding. Extremities: No clubbing, cyanosis,
or edema. Very cachectic.
LABORATORY DATA: White count 12.5, hematocrit 26.5,
platelets 284,000. Sodium 139, potassium 3.8, chloride 97,
bicarbonate 17, down from 29 earlier today, BUN 14,
creatinine 1.0, glucose 78. PT 13.6, PTT 49.6, INR 1.2. The
differential on the white count revealed 35 percent
neutrophils, 58 percent bands, 3 percent lymphocytes, 10
percent monocytes. ALT 69, AST 148, LDH 415, alkaline
phosphatase 2,123. T bilirubin 8.0, calcium 7.3, phosphorus
4.2, magnesium 2.3. ABGs 7.36, 29, 210, on 100 percent
nonrebreather.
EKG revealed normal sinus rhythm at 158, rate-related ST
depressions in V4-V6.
Chest x-ray revealed mild volume overload. No pleural
effusions.
Blood cultures and urine cultures revealed no growth to date.
Stool cultures times three for C. difficile were negative.
HOSPITAL COURSE: The patient was admitted to the Fenard ICU
for severe sepsis with profound bandemia, profound
hypoglycemia, and acidosis. The cause of the patient's
severe sepsis was most assuredly her numerous hepatic
abscesses and the metastatic cancer that she had most likely
involving biliary obstruction. The patient was started on
sepsis protocol, aggressive IV fluid hydration was given to
the patient. The patient received approximately 10 liters of
IV fluid in the next 24 hours. The patient was also
continued on Levophed and Vasopressin. The case was
discussed with the ERCP fellow, attending, and ICU attending.
A CT of the abdomen was thought safest and highest yield at
that time. CT of the abdomen revealed unchanged nodules
throughout the liver which were thought once again to be
secondary to hepatic abscesses. The GI fellow and attending
felt that emergent ERCP would not change the patient's
prognosis and it was held off.
The plan was to do ERCP early the next morning. The patient
was continued on the antibiotic regimen that they had been on
for the time being. Unasyn was also added. The ID fellow
was consulted and followed along during the next 24 hours.
Since there were no huge abscesses on CT, there was no
benefit for Interventional Radiology placing a drain to drain
abscesses. Per the ICU attending, Zygress was held off
secondary to high INR and what appeared to be fulminant liver
failure. Blood cultures and urine cultures were taken.
As far as the patient's profound hypoglycemia, it was most
likely due to liver failure secondary to her metastatic
pancreatic disease as well as her hepatic abscesses. The
patient was placed on an insulin drip with tight glucose
control and despite a D10 drip, the patient's blood sugar
continued to dip down as low as the 20s with episodic mental
status change. Further cause of the patient's profound
hypoglycemia was thought secondary to severe sepsis and this
was being treated. As far as the patient's acidosis, the
patient was given bicarbonate ampules throughout the night
and was subsequently started on a bicarbonate drip. The
patient subsequently went into acute renal failure. There
was thought to be a postobstructive component to the renal
failure but most likely the patient was in ATN secondary to
profound hypotension. Nephrotoxins were avoided and Mucomyst
was given prior to dye loads.
The patient underwent an ERCP the next morning which revealed
ischemic gut. The patient was deemed not a candidate for
surgery. The patient's lactate remained approximately 8.5
despite 10 liters of IV fluids and a bicarbonate drip. It
was thought at that time by concensu's decision that the
patient should be made comfortable. The family agreed with
this decision. The propofol drip was increased. Pressors
were discontinued. The patient succumbed painlessly to her
profound sepsis. The family agreed to a follow-up autopsy
which will be done.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981
Dictated By:[**Last Name (NamePattern1) 48405**]
MEDQUIST36
D: [**2194-5-30**] 16:33:24
T: [**2194-5-30**] 17:16:31
Job#: [**Job Number **]
|
[
"038.8",
"112.5",
"572.0",
"577.0",
"996.59",
"518.81",
"157.0",
"197.7",
"584.5"
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icd9cm
|
[
[
[]
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[
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"54.91",
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icd9pcs
|
[
[
[]
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4699, 7858
|
3346, 4681
|
155, 2741
|
2764, 3323
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,018
| 173,153
|
10720
|
Discharge summary
|
report
|
Admission Date: [**2106-4-29**] Discharge Date: [**2106-6-2**]
Date of Birth: [**2052-5-24**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Plasmapheresis catheter placement
Plasma exchange
History of Present Illness:
53 year-old right-handed woman with myasthenia [**Last Name (un) 2902**] who
presented with increasing weakness and dyspnea. Mrs. [**Known lastname 35087**] was
diagnosed with myasthenia [**Last Name (un) 2902**] after presenting with diplopia
on [**2106-4-3**]. She was found to have positive Ach-R Abs. She
was admitted to the Neurology service from [**4-10**]
with complaints of shortness of breath as well as left lid
droop. It was felt that her shortness of breath was likely due
to anxiety rather than myasthenia and she was started on Paxil.
At that time, NIFs and vital capacity were normal and she had no
other fatiguable weakness besides the ocular symptoms. She was
also found to have a thymoma at that time.
.
She stated that for the past two weeks prior to this
presentation, she has had significant drooping of both eyelids,
which tends to be maximal at the end of the day. Over the past
two or three days, it has been so severe, that she needs to be
guided or carried by her husband in order to get around as she
cannot see. She has not noted any diplopia.
.
She also noted that for the past week or so prior to
presentation, she has experienced noticeable dyspnea on
exertion. She does not feel that she has been weak in the arms
or legs, but that her tolerance for physical activity has
lessened.
.
For the past two days prior to presentation, she said that she
has had difficulty holding her head up straight. She often needs
to hold her head up with her hands to look straight.
.
The afternoon of admission, she became more short of breath,
mostly after short periods of exertion. She did mention that
this has made her somewhat anxious. She tried to lay down to
rest early in the evening, and said that not only did she have
difficulty breathing, but she was having difficulty clearing the
saliva from her throat. She said that this had never happened to
her in the past. She said that at present, her swallowing is
normal. She has not noticed any recent difficulty with chewing
or speaking.
.
On review of systems, the pt denied recent fever or chills. No
night sweats or recent weight loss or gain. 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, but endorses urinary
frequency and hesitancy. Denied arthralgias, myalgias, or rash.
Past Medical History:
-myasthenia [**Last Name (un) 2902**] as above
-cholelithiasis
-? of hypertension
-hyperlipidemia
-elevated HbA1c (6.4% in [**3-20**])
-anxiety
Social History:
Pt lives at home with her husband and two children. She works in
customer service at [**Company 11293**], but has not been working over the
past two weeks due to her illness. She denied use of tobacco,
alcohol, or illicit drugs.
Family History:
Dad who is healthy. Mom had lung cancer with brain mets and
died at 52. Two brothers - one with hypercholesterolemia and
one with obesity and diabetes.
Physical Exam:
Vitals: T: 97.7F P: 88 R: 26 BP: 161/75 SaO2: 96% RA
General: Awake, anxious but cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and comprehension. Speech was not dysarthric. Able to
follow both midline and appendicular commands.
-Cranial Nerves: Olfaction not tested. PERRL 3.5 to 2mm and
brisk. VFF to confrontation. There is marked ptosis bilaterally,
such that her upper lids completely cover her pupils and only a
small amount of [**Doctor First Name 2281**] is visible. On testing of EOM, she has
impaired upgaze bilaterally and impaired adduction of the right
eye. Facial sensation intact to light touch. I was easily able
to overcome orbicularis oculi bilaterally as well as lip
closure. Hearing intact to finger-rub bilaterally. Palate
elevates symmetrically. Very weak cough. 4+/5 strength in SCM
bilaterally. Tongue protrudes in midline and had full strength
with lateral movements.
-Motor: Normal bulk, tone throughout. Neck flexor strength was 4
and neck extensor strength was 4-. Strength was otherwise full,
except at the deltoids bilaterally, which were 4+. No
adventitious movements noted. No pronator drift bilaterally.
-Sensory: No deficits to light touch throughout (remainder of
sensory examination deferred given clinical situation).
-Coordination: No dysmetria on FNF bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Gait: Good initiation. Narrow-based, normal stride, and arm
swing.
Pertinent Results:
Admission labs: [**2106-4-29**] 10:00PM
WBC-12.3*# RBC-5.72* Hgb-16.9* Hct-48.2* MCV-84 MCH-29.5
MCHC-35.0 RDW-13.7 Plt Ct-272
Neuts-54.2 Lymphs-39.2 Monos-5.0 Eos-1.3 Baso-0.3
PT-12.4 PTT-27.2 INR(PT)-1.1
Glucose-132* UreaN-11 Creat-0.7 Na-138 K-4.1 Cl-100 HCO3-27
AnGap-15
Calcium-10.2 Phos-4.4 Mg-2.2 freeCa-1.17
ALT-69* AST-47* LD(LDH)-294* AlkPhos-64 Amylase-84 TotBili-0.7
Lipase-40
IgA-220
.
Micro:
Ucx [**4-29**]: pan-sensitive E coli
Ucx [**5-9**]: pan-sensitive (except to gentamycin) E coli
Ucx [**5-22**]: pan-sensitive (except to gentamycin) E coli
Sputum cx [**5-10**]: MSSA, resistent to penicillin
BAL [**5-11**]: MSSA as above
Catheter tip [**5-11**]: gram positive bacteria
Blood cultures 5/28, [**5-12**]: NGTD
.
CXR on admission: 1. Endotracheal tube tip 1 cm above the
clavicular heads.
2. New moderate bilateral pleural effusions with bibasilar
atelectasis.
Brief Hospital Course:
Mrs. [**Known lastname 35087**] is a 53 year-old woman with myasthenia [**Last Name (un) 2902**] who
presented with myasthenic crisis. She has had a progressively
worsening course since diagnosis in late [**Month (only) 547**], though it is
possible that this exacerbation was secondary to a urinary tract
infection.
.
On arrival to the ED, the pt appeared tachypneic. Respiratory
mechanics were performed immediately and she had a NIF of -34
and FVC of 550cc (which is in [**Doctor Last Name 29943**] contrast to reportedly
normal values during admission in late [**Month (only) 547**]). She was
electively intubated for airway protection as respiratory
failure was deemed imminent given her examination and
respiratory mechanics.
.
She was admitted to the Neurology ICU for further management.
.
Hospital course is reviewed below by problem:
.
1. myasthenia crisis: After admission to the ICU, a
plasmapheresis catheter was placed and plasma exchange was
initiated on [**4-30**]. She was treated with five sessions every
other day, with last session [**5-8**]. She was also started on
prednisone at 10mg every other day with increase by 10mg every
three days (at 90 mg QOD on discharge, with goal to titrate to
100 mg QOD on [**6-2**]). She was also started on cellcept with
titration after one week to a goal of 1000mg [**Hospital1 **]. At the end of
her first session of plasmapheresis she had an episode of sepsis
(see below) and a subsequent deterioration in her strength. She
made only slow improvement after this, so a decision was made to
proceed with a second course of plasmapheresis, which she
received from [**Date range (1) 35088**]. Her exam slowly improved with this.
Her mestinon was initially held given that it was felt to
increase her risk of secretions while intubated. After she was
stable post-tracheostomy for several days it was restarted on
[**5-24**] at 30 mg Q8, and then titrated up a few days later to 30 mg
Q6H. On day of discharge she had fatiguable ptosis, R > L,
diplopia with R gaze and with 10 seconds of sustained upgaze,
incomplete abduction her R eye with R gaze, EOM otherwise intact
in horizontal plane, and limited upgaze L > R. She had 4+/5
strength in her neck flexors and 5-/5 in neck extensors, 4+/5
strength in her R deltoid, 4+/5 R finger extensors, and
otherwise full strength throughout.
.
2. ventilator dependence: Ms. [**Known lastname 35087**] failed spontaneous
breathing trials after her first plasmapheresis sessions. She
then developed a ventilator-associated pneumonia (see below).
She was not felt safe to be extubated and a tracheostomy was
placed on [**2106-5-17**]. Her ventilation improved with her second
course of plasmapheresis, and she was able to wean to CPAP + PS
[**11-17**], with trials of trach collar each day (tolerating trach
collar for 8-10 hours/day for several days prior to discharge).
Our goal is to wean her entirely off of the vent as her
myasthenia continues to improve.
.
3. infection: Initial UTI was treated with bactrim for 3 days.
She developed another UTI on [**5-9**], but at that time was also
found to have a pneumonia. This was thought to be
ventilator-associated and vancomycin and zosyn were initiated.
She had sputum cultures sent and a bronchoalveolar lavage. These
eventually grew staph aureus. However, on [**5-11**], her blood
pressures dropped and she was thought to be in septic shock (see
below). She was treated with vancomycin and meropenem, changed
to nafcillin and meropenem after sputum cultures grew
methacillin-sensitive staph aureus. She finished a course of
Nafcillin and Meropenem, and had no further fevers or
leukocytosis. A surveillance urine culture grew E coli for a
3rd time, and was felt to be a colonizer. Her foley was
therefore d/ced and she was treated with a 3rd course of Abx
(Cipro x 5 days, [**Date range (1) 14706**])
.
4. septic shock: On [**5-11**], she became hypotensive. Zosyn was
changed to meropenem. Her plasmapheresis line was discontinued
and another central venous catheter was placed. She defervesced
the next day. She was able to be weaned off the levophed on
[**5-12**].
.
5. hyperglycemia: As the prednisone was increased, she had
elevated blood sugars. She was initially treated just with
sliding scale insulin, but NPH was started on [**5-12**] with good
effect.
.
6. mild ARF: She had mild elevations in her creatinine after she
became hypotensive from sepsis; she was treated with IV fluids
and lasix was held with resolution of the ARF.
.
7. anemia: Her hematocrit drifted down over several days while
she was menstruating. Iron studies were consistent with iron
deficiency anemia and anemia of chronic inflammation. She was
not started on iron due to constipation, but this could be
restarted after discharge.
Medications on Admission:
-lorazepam prn
-ASA 81mg po daily
-MVI 1 tab po daily
-vitamin C, E, and lecithin supplements
Discharge Medications:
1. Prednisone 20 mg Tablet Sig: Five (5) Tablet PO every other
day: starting [**2106-6-2**].
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
Sig: Five (5) mL PO BID (2 times a day).
4. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Eighteen
(18) units Subcutaneous QAM.
5. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Fifteen
(15) units Subcutaneous QPM.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Pyridostigmine Bromide 60 mg Tablet Sig: 0.5 Tablet PO Q6H
(every 6 hours).
8. Regular Insulin Sliding Scale
Check FS QIDACHS and administer regular insulin per sliding
scale attached
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed: while on trach mask.
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day): while on trach mask.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Myasthenic crisis
Discharge Condition:
Stable, exam as listed in discharge summary
Discharge Instructions:
Please contact your rehab doctors if your [**Name5 (PTitle) 35089**] vision gets
worse, you become more short of breath, develop any worsening
weakness, or have any other symptoms that concern you.
Please take all medications as prescribed and attend all follow
up appointments
Followup Instructions:
Neurology: Dr. [**Last Name (STitle) 1206**], [**Hospital Ward Name 23**] 8, [**Hospital1 18**] [**Hospital Ward Name 516**],
[**Telephone/Fax (1) 558**], [**2106-6-23**] at 8:30 AM.
CT surgery: Please call Dr.[**Doctor Last Name 4738**] office at [**Telephone/Fax (1) 4741**] to
set up a follow up appointment in the next 8-12 weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2106-6-2**]
|
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6348, 11119
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323, 412
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12479, 12525
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2855, 3000
|
3016, 3246
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,170
| 130,390
|
45128
|
Discharge summary
|
report
|
Admission Date: [**2141-10-23**] Discharge Date: [**2141-11-1**]
Service: MEDICINE
Allergies:
Penicillins / Keflex / Clindamycin / Vancomycin / Lipitor /
Bacitracin
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
Hypoxic respiratory failure
Major Surgical or Invasive Procedure:
endotracheal intuabtion
central venous line placed (right IJ)
History of Present Illness:
This is a [**Age over 90 **] yo female with a recent hospitalization for
healthcare-associated pneumonia ([**Date range (1) 79563**]) who presented to the
ED this morning with palpitations and SOB. Per her grand
daughter who lives with her, Mrs. [**Known lastname 4020**] was in her usual
state of health until this morning when she asked her
granddaughter to feel her chest as she felt her heart was
beating very quickly and she was short of breath.
.
The patient had been feeling fine as as of last night and went
to Church yesterday which requires her to walk up 17 steps which
she did without too much difficulty though she had some left leg
weakness which is her baseline. In the ED, initial VS were: 98.8
108 184/80 40 98% 15L NRB. CXR showed a large right sided
infiltrate. She was given levofloxacin and was ordered to
receive vancomycin and metronidazole. Diphendydramine was being
given prior to vancomycin due to history of vancomycin allergy,
and this pretreatment has been successful in the past. Her RR
remained in the 40s, so she was intubated. There was transient
hypotension to SBP 70s-80s prior to intubation, which resolved
with IVF. Another transient dip occurred when starting fentanyl
and on the way out of the ED he pressure dropped again to the
80's and she was started on levophed. She is on
fentanyl/midazolam for sedation and current VS are: T 101 (given
650mg APAP PR) BP 126/60 HR 112 RR 16 O2 100% on CMV Vt 450 with
PEEP 5. She has 2 PIVs for access.
.
Review of OMR shows that she recently had her furosemide dose
increased in the setting of [**Known lastname 9140**] LE edema. She was also
given TMP-SMX to use if she developed increased LE skin
breakdown or infection, but it is not clear if this was taken.
In addition to recent PNA hospitalization, she also was recently
hospitalized for cellulitis.
.
On arrival to the ICU, patient is intubated therefore unable to
give history. However she is awake and denies pain.
Past Medical History:
Recent PNA ([**7-/2141**])
Hypercholesterolemia
Venous insufficiency
Obesity
GERD
Eczema dermatitis
H/o breast CA s/p resection [**2124**]
Recurrent cellulitis
Urinary Incontinence
Spinal Stenosis
Atrial Fibrillation
ABDOMINAL AORTIC ANEURYSM s/p endovascular repair [**11/2140**]
Multiple UTIs
S/p TAH/BSO
Cervical myelopathy
Anemia, h/o occult blood positive stool
Social History:
She is living with her grand-daughter and son. She is
independent with her activities of daily living, except Coumadin
which her grand-daughter helps with. She doesn't smoke or drink
alcohol.
Family History:
There is an extensive history of cardiac disease.
Physical Exam:
Admission Physical:
GEN: intubated, sedated, NAD
HEENT: dry mm, PERRL, no JVP though difficult to asses given
body habitus
RESP: rhonchorous throughout with bronchial bs on right
CV: irregularly irregular, no mrg
ABD: obese, NABS, soft, NTND
EXT: 2+ [**Location (un) **] with chronic venous stasis changes, no ulcerations
SKIN: no rashes or jaundice
NEURO: withdraws to pain
RECTAL: deferred
.
DISCHARGE PHYSICAL:
Gen: asleep, easy to arouse, attentive, oriented X 3
HEENT: Right eye strabysmus, no pharyngeal erythema, dry mucous
membranes, white plaques on tongue
CV: irregular, s1/s2 normal in quality/intensity, no MRG
appreciated
Pulm: diffuse inspiratory wheezes and crackles, R>L
Abd: BS normoactive, soft, non-tender, no guarding
Ext: [**1-14**]+ pitting with chronic venous stasis changes
Neuro: able to move all extremities, [**4-17**] UE strength, 2-3/5 LE
strength
Psych: mood and affect appropriate
Pertinent Results:
Admission labs:
[**2141-10-23**] WBC-8.8# RBC-3.31* Hgb-8.8* Hct-28.3* MCV-86 MCH-26.5*
MCHC-31.0 RDW-19.4* Plt Ct-245#
[**2141-10-23**] Neuts-88.6* Lymphs-6.6* Monos-3.1 Eos-1.3 Baso-0.4
[**2141-10-23**] PT-31.5* PTT-47.4* INR(PT)-3.2*
[**2141-10-23**] Glucose-115* UreaN-17 Creat-0.7 Na-145 K-3.5 Cl-107
HCO3-31
[**2141-10-23**] CK(CPK)-31
[**2141-10-23**] CK-MB-2 cTropnT-<0.01
[**2141-10-24**] proBNP-1489*
[**2141-10-23**] Calcium-7.3* Phos-2.6* Mg-1.8
[**2141-10-23**] ART pO2-359* pCO2-47* pH-7.41 calTCO2-31* Base XS-4
[**2141-10-23**] freeCa-1.06*
[**2141-10-23**] URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2141-10-23**] URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2141-10-23**] URINE RBC-8* WBC-4 Bacteri-FEW Yeast-NONE Epi-<1
[**2141-10-23**] URINE CastGr-1* CastHy-10*
.
MICRO:
[**10-23**] BCx: Final No Growth
[**10-23**] UCx: No Growth
[**10-23**] ULegionella: Negative
[**10-24**] Sputum: GRAM STAIN (Final [**2141-10-24**]): >25 PMNs and <10
epithelial cells/100X field. NO MICROORGANISMS SEEN.
[**10-26**] RESPIRATORY CULTURE: NO GROWTH.
.
[**10-23**] ECG: Atrial fibrillation. Left axis deviation. Possible
left anterior fascicular block. Intraventricular conduction
delay. Non-specific ST-T wave changes in the high lateral leads.
Compared to the previous tracing of [**2141-7-19**] the findings are
similar.
.
[**10-23**] CXR: Interval development extensive right mid and lower
lung consolidations, compatible with right middle and lower lobe
pneumonia. Possible additional consolidation is seen at the left
base. Hiatal hernia.
.
[**10-23**] CXR: 1. Slight improvement in airspace consolidation
within the right lung, sparing extreme right apex and right
base, and likely due to pneumonia. 2. Resolution of interstitial
edema.
.
[**10-25**] CXR: Large right mid lung consolidation has improved.
Left retrocardiac opacities are unchanged. Moderate right
pleural effusion is probably unchanged allowing the difference
in positioning of the patient. Left pleural effusion is small.
Cardiomediastinal contours are unchanged. ET tube is in a
standard position. NG tube tip is out view below the diaphragm.
Right IJ catheter remains in place.
.
[**10-27**] CXR: 1. CHF with interstitial edema, right greater than
left pleural effusions, and underlying collapse and/or
consolidation. Possibility of underlying pneumonic infiltrate
cannot be excluded. Allowing for technical differences, no
definite change in the degree of consolidation c/w [**2141-10-25**]. 2.
Gas over cardiac silhouette may represent a hiatal hernia.
.
[**10-30**] CXR PA & Lat: In comparison with the study of [**10-27**], there
is again substantial enlargement of the cardiac silhouette with
bilateral pleural effusions, more prominent on the right, and
basilar compressive atelectasis. Central catheter remains in
place. Evidence of elevated pulmonary venous pressure is again
noted. The possibility of supervening pneumonia can certainly
not be excluded.
.
[**2141-11-1**] transthoracic echocardiogram: The left atrium is mildly
dilated. The right atrium is moderately dilated. The estimated
right atrial pressure is 10-20mmHg. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis. The aortic arch is mildly dilated.
The aortic valve leaflets (3) are mildly thickened. There is no
valvular aortic stenosis. The increased transaortic velocity is
likely related to high cardiac output. Mild to moderate ([**1-14**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. 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: Severe pulmonary hypertension (TR gradient + RA
pressure). Moderate right ventricular dilation and mild global
hypokinesis. Concentric left ventricular hypertrophy with
preserved left ventricular function. Moderate tricuspid
regurgitation. Mild to moderate aortic and mitral regurgitation.
.
Compared with the prior study (images reviewed) of [**2137-8-28**],
the estimated pulmonary artery pressures are markedly higher.
The right ventricle is now dilated and hypokinetic. The severity
of mitral, aortic, and tricuspid regurgitation have all
increased.
.
.
DISCHARGE LABS ([**2141-11-1**]):
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
3.9* 2.91* 7.9* 25.1* 86 27.0 31.3 19.3* 207
.
PT PTT INR(PT)
18.8* 37.2* 1.7*
.
Glucose UreaN Creat Na K Cl HCO3
83 12 0.6 145 3.5 102 40*
.
Ca Phos Mg
8.1* 2.1* 1.8
Brief Hospital Course:
[**Age over 90 **] year-old W with a recent healthcare-associated pneumonia
([**2141-7-13**]), presented to the ED with dyspnea and palpitations,
was found to be in hypoxic respiratory failure and sepsis in
setting of a new large R-sided pneumonia. She was intubated in
the Emergency Room and transferred to the Medical Intensive Care
Unit (MICU) where she spent a brief period of time on levophed
to keep her blood pressures adequate. She was started on broad
spectrum antibiotics, extubated without difficulty, and
transferred to the Medicine floor for further management.
.
# Pneumonia: Possibly occurred secondary to aspiration, although
unable to tell definitively per a Speech and Swallow evaluation.
The patient received eight days of intravenous vancomycin,
aztreonem, and ciprofloxacin to treat her large right-sided
pneumonia. These antibiotics were chosen in light of her many
antibiotic allergies. She also received schedueled nebulizer
treatments, chest physical therapy, beside respiratory
suctioning, and an acapella valve. She never had a leukocytosis
or fever. Her blood and sputum cultures were all negative.
Repeat chest imaging suggested an increasing component of fluid
overload, for which she was treated with diuretics. Her oxygen
requirement was slowly weaned from 2 liters via nasal canula to
1 liter at the time of discharge. This should continue to be
weaned, as tolerated, at rehab. She did not have a home oxygen
requirement prior to admission.
.
# Acute on chronic diastolic congestive heart failure: The
patient's diuretics were held upon admission to the hospital
secondary to low blood pressures and concern for sepsis. After
transfer to the floor the patient began to demonstrate signs of
increasing volume overload on her CXR and physical exam. She was
diuresed with IV lasix then transitioned to her oral home
regimen. Her dyspnea and peripheral edema improved. A repeat
echocardiogram was obtained and showed severe pulmonary
hypertension, moderate right ventricular dilation and mild
global hypokinesis, concentric left ventricular hypertrophy with
preserved left ventricular function, moderate tricuspid
regurgitation, and mild to moderate aortic and mitral
regurgitation. She will need continued monitoring of her daily
weight, Ins and Outs (weigh diapers/pads), and physical exam to
determine her current volume status and need for additional
diuresis.
.
# Atrial Fibrillation: Once her blood pressures were stable, the
patient was continued on her home regimen of Metoprolol 25 mg
twice daily for rate control, and Coumadin for anticoagulation.
Her INR level fluctuated, likely secondary to concurrent
antibiotics, so this will need to be monitored and re-dosed as
needed in the future (goal INR [**2-15**]).
.
# Acute exacerbation of chronic venous stasis: Upon transfer to
the floor it was evident that the patient was experiencing an
acute [**Month/Day (3) 9140**] of her chronic venous stasis. This improved with
initiation of diuresis and topical triamcinolone applied twice
daily.
.
# Delirium (resolved): During majority of her hospital admission
the patient was alert, attentive, and oriented to person,
location, and date. She did experience an episode of visual
hallucinations and waxing/[**Doctor Last Name 688**] consciousness in the setting of
not having a bowel movement in two days. Additionally, she had
been receiving ciprofloxacin, which can cause such effects in
elderly individuals. A more aggressive bowel regimen was started
and the patient improved to baseline.
.
# Anemia: The patient has evidence of a chronic normocytic
anemia. Her hematocrit remained close to baseline 25-30 during
this admission. Fe studies revealed a low Fe (19), low-normal
ferritin (74), and decreased TIBC. The benefit of starting iron
supplementation, or pursuing a further evaluation should be
addressed in the future by her outpatient provider. [**Name10 (NameIs) **] studies
should be repeated when not actively ill.
.
# HTN: The patient's blood pressures remained in the systolic
range of 90-110 and diastolic range of 50-60 while being
actively diuresed.
.
# GERD: The patient's home PPI regimen of Omeprazole was
continued.
.
# Hx of Breast CA: The patient was on Exemestane prior to
admission. This was not continued during her hospital admission,
but re-started upon discharge.
.
# Speech and Swallow: The patient was evaluated a number of
times by Speech who advanced her diet to soft solids and thin
liquids, meds whole with puree, and recommended swallow follow
up in rehab to ensure diet tolerance and consider further
upgrades.
.
# Physical Therapy: The patient was evaluated by physical
therapy who suggested rehab for continued strength building.
.
# Code status: The patient was full code during this admission.
.
# Health Care Proxy: Granddaughter [**First Name9 (NamePattern2) 96454**] [**Name (NI) **])
[**Telephone/Fax (1) 96455**]
.
# Other Considerations: Prior to hospitalization that patient
was quite physically functional, able to climb 17 stairs without
getting dyspneic. She went to church weekly. She had an aide
come to bath her, and occasionally help her dress, but most of
the time she could dress herself. She has help with cooking and
cleaning, but can feed herself.
Medications on Admission:
COLCHICINE 0.6 mg qd
EXEMESTANE 25 mg qd
FUROSEMIDE 80 mg Tues, Thurs, Saturday and Sunday
FUROSIMIDE 160mg on Mon, Wed and Friday
METOPROLOL 25 mg [**Hospital1 **]
OCCUVITE
OMEPRAZOLE 40 mg qd
SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - 1
Tablet(s) by mouth twice a day 10 day course
WARFARIN 2.5 -5 mg qd
ASCORBIC ACID
CALCIUM CITRATE-VITAMIN D3
CYANOCOBALAMIN- 1,000 mcg qd.
Discharge Medications:
1. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
3. exemestane 25 mg Tablet Sig: One (1) Tablet PO once a day.
4. furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
6. ascorbic acid Oral
7. calcium carbonate-vitamin D3 Oral
8. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation: please give if patient
has not had bowel movement by 5PM daily.
12. ipratropium bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q4H (every 4 hours).
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) inhalation Inhalation Q2H (every 2
hours) as needed for dyspnea, wheezing.
14. guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
15. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 1 weeks.
16. warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO Once Daily at 4
PM: To be adjusted as needed based on INR. Dose adjustment to be
determined by MD.
17. Outpatient Lab Work
Patient needs PT/INR, CBC, and Chem 10 (Na, K, Cl, HCO2, BUN,
Cr, Glucose, Ca, Mg, Phos) every M, W, F. Please notify MD with
results.
18. OCCUVITE Sig: 1-2 drops as directed as directed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary:
-Pneumonia, possibly aspiration
-Acute on chronic diastolic congestive heart failure
-Acute stasis dermatitis
.
Secondary:
-Atrial fibrillation (on coumadin)
-Gastroesophageal reflux disease
-History of breast cancer
-History of hypercholesterolemia
-Urinary incontinence
-Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname 4020**],
.
You were recently admitted to the Medical Intensive Care Unit of
[**Hospital1 69**] for palpitations and were
found to have a pneumonia. You were provided respiratory support
by intubation, and started on intravenous antibiotics, and you
improved. You were doing well and so you were transferred to the
General Medicine floor, where we continued your antibiotics and
re-started medications to remove excess fluid from your body.
Your breathing and leg swelling improved. We also obtained a
picture of your heart called an echocardiogram, which showed
slight [**Hospital1 9140**] of your valve function which you should follow
up with your cardiologist. You are being discharged to a
rehabilitative facility for continued care. There they will
provide you with your medications, and additional physical
therapy services to help you build strength. You will need to
follow up with your primary care physician after you leave
rehab.
.
We are only making one change to your home medications regimen.
We are discharging you on a higher dose of Furosemide for
continued fluid removal.
-Please INCREASE the FREQUENCY of Furosemide to 80 mg twice
daily
-You will be discharged to the rehab facility with nebulizers to
help your breathing as your pneumonia resolves
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please schedule an appointment with your primary care physician
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**] to follow up after you leave rehab.
.
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2141-11-7**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4853**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PODIATRY
When: FRIDAY [**2141-12-1**] at 9:30 AM
With: [**Hospital 1947**] CLINIC (SB) [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"507.0",
"530.81",
"278.00",
"458.9",
"285.9",
"518.81",
"401.9",
"427.31",
"038.9",
"272.0",
"780.09",
"428.33",
"721.1",
"428.0",
"414.01",
"995.91",
"V85.0",
"V10.3",
"459.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.04",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
16268, 16339
|
8908, 13495
|
307, 371
|
16672, 16672
|
3971, 3971
|
18259, 19055
|
2972, 3023
|
14592, 16245
|
16360, 16651
|
14178, 14569
|
16848, 18236
|
3038, 3952
|
13513, 14152
|
240, 269
|
399, 2355
|
3987, 8885
|
16687, 16824
|
2377, 2746
|
2762, 2956
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,100
| 132,614
|
22453
|
Discharge summary
|
report
|
Admission Date: [**2179-7-22**] Discharge Date: [**2179-7-26**]
Date of Birth: [**2137-12-10**] Sex: M
Service: NMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
left sided weakness, acute onset
Major Surgical or Invasive Procedure:
MRI/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
t-PA
TEE
History of Present Illness:
This is a 41 year-old RH man with a history of DM, HTN, high
cholesterol, current heavy smoker, obesity who presents with
sudden onset left- sided weakness. Pt lives in [**State 531**] and was
in [**Location (un) 86**] on business. He went to sleep at 11pm Wed night and
awoke at ~11:50 with a feeling that his left arm was not his and
belonged to someone else. He called his wife who noted his
speech sounded slurred. He attempted to walk over to the door
but was unable to and eventually crawled to his door. His wife
called the hotel who then called EMS, and EMS busted down the
door. Patient arrived in the ED at 1am and was found to have
left hemiplegia and sensory loss, slurred speech, and a left
field cut, NIHSS score of 16. He was given t-PA within 25 min
of arriving to the ED. Prior to t-PA a head CT was obtained
that showed hypodensity and sulcal effacement in right temporal
lobe, no bleed. Blood glucose was 209, BP 158/78, HR 85, INR
1.2. Transferred to the ICU for monitoring. His exam improved
remarkably.
This afternoon he has no complaints - no chest pain,
palpitations, SOB, abdominal pain, HA, tinnitus, numbness or
weakness, no visual distrubances. He only asks to go outside
for a smoke.
Past Medical History:
HTN
DM, adult onset
High cholesterol
CRI
Gout
Hep C s/p interferon therapy
low platelets secondary to liver disease (per patient)
prio ETOH withdrawl seizure 6 yrs ago for which he was on
dilantin for 6 months.
Social History:
Lives in [**Location 10022**] County, NY with his wife. In [**Name2 (NI) 86**] on
business. Heavy smoker 4ppd since age 12, polysubstance abuser
in the past, "you name it, I've done it." Not currently using
in drugs. ETOH in the past, none x 6 yrs.
Family History:
cousin with stroke at age 55, aunt with a stroke in her 80's.
Physical Exam:
BEFORE T-PA:
NIHSS 15
He is awake, alert, and follows commands. He is fluent.
Repetition and naming are normal. He neglects the left side but
complicated by left field cut. He has a moderate facial
weakness
of the left side. Ductions are full. He has moderate
dysarthria
but speech is comprehensible. He cannot suspend left arm or
left
leg against gravity. There is no movement of the left arm to
pain. Left leg flinches to pain. He holds right arm and leg off
bed without drift for 10 and 5 seconds, respectively. Sensation
to light touch is reduced on the left arm and leg. He
extinguishes on the left to DSS. Toe is briskly up on the left.
FTN is normal on the right.
AFTER TPA upon transfer to the floor:
VITALS: 98.9 138/80 86 18 98% on RA
GEN: no acute distress, obese man, irritable affect
SKIN: no rash
HEENT: NC/AT, anicteric sclera, mmm
NECK: supple, no carotid bruits
CHEST: normal respiratory pattern, CTA bilat
CV: regular rate and rhythm without murmurs
ABD: soft, nontender, nondistended, +BS, no HSM
EXTREM: trace pedal edema
NEURO:
Mental status:
Patient is alert, awake, irritable affect.
Oriented to person, place, time and president back to [**Doctor Last Name **].
Good attention.
Language is fluent with good comprehension, repitition, able to
no dysarthria.
No apraxia, agnosias, no neglect. Able to calculate, no
left/right mismatch.
Cranial Nerves:
I: deferred
II: Visual acuity: 20/50 OU without glasses. Visual fields:
full to left/right/upper/lower fields. Fundoscopic exam: discs
flat, fundi clear, no hemorrhages or exudates. Pupils: 4->2 mm,
consenual constriction to light. No scotomas.
III, IV, VI: EOMS full, gaze conjugate. No nystagmus. Mild
left ptosis.
V: facial sensation intact over V1/2/3 to light touch and pin
prick.
VII: mild lower face droop, mild upper left eye weakness with
squinting eyes
VIII; hearing intact to finger rubs
IX, X: normal labial/lingual/gutteral sounds. Symmetric
elevation of palate.
[**Doctor First Name 81**]: SCM and trapezius [**4-14**] bilaterally
XII: tongue midline without atrophy or fasciulations.
Sensory:
Normal sensation to touch, pinprick, proprioception.
Motor:
Normal bulk, tone. No fasciculations. Mild left arm drift. No
adventitious movements. No asterixis.
Strength: full [**4-14**] in all muscle groups (delt, [**Hospital1 **], tri, WE, WF,
FE, FF, interosseus, IP, Q, Ham, DF, PF, TE, TF).
Reflexes:
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 2 2 2 2 2 mute
LEFT: 2 2 2 2 2 up
Coordination:
Normal finger-to-nose, heel-to-shin. Slightly slowing of the
[**Doctor First Name **]
on the left
Gait:
Normal narrow based gait, slightly unsteady with tandem walking,
slightly wobbly with Rhomberg but did not fall or lean.
Pertinent Results:
[**2179-7-22**] 01:40AM WBC-8.7 RBC-4.35* HGB-13.4* HCT-37.2* MCV-86
MCH-30.8 MCHC-36.0* RDW-12.9
[**2179-7-22**] 01:40AM NEUTS-54.6 LYMPHS-30.3 MONOS-5.8 EOS-8.4*
BASOS-1.1
[**2179-7-22**] 01:40AM PLT COUNT-164
[**2179-7-22**] 01:40AM PT-13.5 PTT-26.7 INR(PT)-1.2
[**2179-7-22**] 01:40AM GLUCOSE-246* UREA N-54* CREAT-2.1* SODIUM-142
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-26 ANION GAP-15
[**2179-7-22**] 04:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2179-7-22**] 10:00AM TRIGLYCER-176* HDL CHOL-40 CHOL/HDL-4.0
LDL(CALC)-85
[**2179-7-22**] 10:00AM CHOLEST-160
[**2179-7-22**] 10:00AM ALT(SGPT)-29 AST(SGOT)-16 ALK PHOS-205* TOT
BILI-0.3
Carotid US: Minimal plaque with a left less than 40% carotid
stenosis. On the right, there is no evidence of carotid
stenosis.
MRI/A: Abrupt obstruction of the inferior division of the right
middle cerebral artery- embolus suspected. There is a large
territory of patchy areas of restricted diffusion in the right
temporal lobe in the distribution of the inferior division of
the right middle cerebral artery. There are also several subtle
patchy areas of increased FLAIR signal intensity in the right
temporal lobe which may reflect early evolution of infarct. A
small rounded focus of abnormal FLAIR signal intensity is also
noted along the periventricular white matter of the right
lateral ventricle which appears to correspond to a hypodensity
on the recent CT scan which could indicate a chronic lacunar
infarct. There is no shift of normally midline structures, mass
effect or hydrocephalus. There are no abnormal areas of
susceptibility. The visualized paranasal sinuses and osseous
structures are unremarkable.
TEE: 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 or patent foramen ovale is
seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending,
transverse and descending thoracic aorta are normal in diameter
and free of
atherosclerotic plaque. The aortic valve is bicuspid. Mild (1+)
aortic
regurgitation is seen. The mitral valve appears structurally
normal with
trivial mitral regurgitation. There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname **] came to the ED within the 3 hour window period for
t-PA, no bleed on head CT, was given t-PA with complete
resolution of his left hemiplegia. Repeat head CT showed no
post-t-[**MD Number(3) 58337**]. His stroke appeared to be embolic given its
location to the right MCA. However, TEE was NEGATIVE for
endocarditis/PFO/ASD/aortic atheroma. It was only positive for
a bicuspid aortic valve for which he should take antibiotcis
prior to dental procedures and the like. Carotid ultrasound -
no plaque in the right ICA, <40% stenosis in the left ICA. He
was placed on a baby aspirin and [**Name2 (NI) 12457**] for secondary stroke
prophylaxis. In addition, his tricor was continued and a statin
was added to his cholesterol medical management. His BP meds
were initially held given the acute stroke, then several days
later his BP rose to 180's. Ramipril was started. There is
some discreptancy as to what BP he was taking at home as his
pharmacist gave us a list with a CCB, ARD and an ACEI. His PCP
was [**Name (NI) 653**] re: the need for the patient to followup with him
re: his blood pressure management. The patient has an
appointment with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58338**] ([**Telephone/Fax (1) 58339**]) tomorrow
(day after discharge).
His hospitalization course was complicated by hematuria after a
foley was placed prior to t-PA. Urology was consulted and
recommended following his HCT and the hematuria. The hematuria
resolved and his hct remained stable.
He was encouraged to stop smoking, given the nicotine patch
while in house.
Medications on Admission:
(per his pharmacy as patient can't remember doses,
[**Telephone/Fax (1) 58340**])
diovan 240 mg a day
cardizem CD 360 mg a day
wellbutrin SR 150 mg a day (for smoking cessation)
amaryl 4mg [**Hospital1 **]
tricor 160mg a day
ramipril 2.5 mg a day
allopurinol 100 mg a day
colchicine 0.6 mg a day
Humalog 75/25 25units [**Hospital1 **]
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Dipyridamole-Aspirin 200-25 mg Capsule, Multiphasic Release
Sig: One (1) Cap PO BID (2 times a day).
Disp:*60 Cap(s)* Refills:*2*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
6. Fenofibrate Micronized 160 mg Tablet Sig: One (1) Tablet PO
QD (once a day).
7. Glimepiride 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
9. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
10. Insulin
Continue your home insulin regimen of Humalog 75/25 25 units
[**Hospital1 **].
Check your finger sticks before each meal and at bedtime.
11. Ramipril 5 mg Capsule Sig: One (1) Capsule PO QD (once a
day).
Disp:*30 Capsule(s)* Refills:*2*
12. Work Excuse
Please excuse Mr. [**Known firstname **] [**Known lastname **] from missed work. He suffered
a stroke and was admitted to [**Hospital1 1170**] from [**2179-7-22**] to [**2179-7-26**].
Please feel free to page me with questions/concerns.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**], MD
Pager [**Numeric Identifier 58341**]
Discharge Disposition:
Home
Discharge Diagnosis:
New Dx:
Right MCA cerebral infarction
Existing Dxs:
Diabetes Mellitus
Hypertension
Hypercholesterolemia
Chronic renal insufficiency
Gout
Hepatitis C s/p interferon therapy
Discharge Condition:
Improved, minimal residual weakness, ambulating, swallowing,
back to baseline.
Discharge Instructions:
1. Please take all medications including the new medications,
aspirin, plavix, statin. Please check your finger sticks 4
times a day and keep a log and call your PCP with results. We
have not restarted several blood pressure medications that you
were on. Please review with your PCP the blood pressure
medications you should and should not be taking.
2. Please attend all followup appointments.
3. Please return to the ED if you experience new weakness,
numbness, or other concerning symptoms.
Followup Instructions:
Please f/u with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58338**], [**Telephone/Fax (1) 58339**] in NY
Please f/u with a neurologist in [**State 531**], or, if you prefer you
can follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 657**] of the stroke
clinic.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"434.11",
"250.00",
"780.79",
"599.7",
"593.9",
"401.9",
"274.9",
"272.0",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11061, 11067
|
7558, 9178
|
345, 423
|
11284, 11364
|
5077, 7535
|
11911, 12367
|
2194, 2258
|
9565, 11038
|
11088, 11263
|
9205, 9542
|
11388, 11888
|
2273, 3345
|
273, 307
|
451, 1674
|
3672, 5058
|
3360, 3656
|
1696, 1909
|
1925, 2178
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,331
| 183,359
|
43059
|
Discharge summary
|
report
|
Admission Date: [**2156-2-17**] Discharge Date: [**2156-2-26**]
Date of Birth: [**2093-8-12**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
Bilateral chronic knee pain
Major Surgical or Invasive Procedure:
Bilateral Total Knee replacements
Cardiac catheterization
History of Present Illness:
62 year old male with aflutter s/p ablation, bronchiectasis,
HTN, hyperchol, chronic RBBB, OA s/p B TKR on [**2-17**] with post op
course complicated by anemia of unclear source and hypotension
as well as troponin leak. Pt surgery was uncomplicated with
baseline Hct 35 down to 29.6 post op with EBL 200cc. Post op the
pt was hypotensive which continued to [**2-19**] at which point she
was transferred to the SICU. As part of workup of hypotension
CE's were drawn and pt found to have troponin leak which cont to
climb now at .33 but CK's declining. Cardiology was consulted
and thought it was due to RV strain as seen on TTE as well as
demand ischemia in the setting of anemia. Pt also worked up for
PE with LENI's and CTA neg. At the same time the patient had
worsening renal failure with creat up to 2.5 but this improved
back to baseline with improved BP. Pt Hct has been stable now
for 48 hours after transfusion of 4 units PRBC's with suspected
sites of hemorrhage including epidural vs operative site. At the
same time hypotensive episode he developed elevated WBC to 12
but blood and UCX as well as CXR were neg. WBC has returned to
baseline although he cont to spike low grade fevers. Pain was
initially controled with IV narcotics but changed to epidural
due to hypotension but is now weaned to PO oxycodone.
Past Medical History:
hypertension
hypercholesterolemia
osteoarthritis bilateral knees
depression and anxiety
bronchiectasis
aflutter s/p ablation [**2151**]
Social History:
He is married. He works painting apartments that they recently
acquired. He does not smoke. He is a previous alcoholic, has a
60-pack-year history of smoking. He has a 17-year-old
stepdaughter at home whom he has had some problems with. [**Name2 (NI) **] has
a second 22-year-old stepdaughter and a 33-year-old daughter of
his own.
Family History:
N/C
Physical Exam:
VITAL SIGNS: Pulse rate was 72 and regular, blood pressure was
135/84, respiratory rate 12 and unlabored.
GENERAL: He is mildly anxious today and upset about some social
issues at home, but in no respiratory distress whatsoever. He is
a tall gentleman, slightly overweight.
HEENT: Sclerae anicteric. Extraocular movements were intact.
Mucous membranes moist. Oropharynx benign.
NECK: Supple. There are no lymph nodes in the anterior,
posterior, or supraclavicular region. No thyromegaly, no thyroid
nodules. No elevation in JVP with the patient sitting upright.
LUNGS: Clear to auscultation bilaterally without wheezes, rales,
or rhonchi.
CARDIOVASCULAR: Regular rate and rhythm. No displacement of
PMI. He had a [**11-27**] holosystolic murmur heard best at the apex.
No clear radiation was appreciated.
ABDOMEN: Soft, flat, nontender, nondistended. No
hepatosplenomegaly was appreciated.
EXTREMITIES: Without cyanosis, clubbing, or edema. He had 2+
pulses in DP, PT, and radial.
NEUROLOGIC: He is alert and oriented x3. Cranial nerves II
through XII are intact. Gait was normal.
Pertinent Results:
[**2156-2-19**] 05:10AM BLOOD WBC-12.8* RBC-2.95* Hgb-8.9* Hct-25.4*
MCV-86 MCH-30.1 MCHC-34.9 RDW-15.1 Plt Ct-200
[**2156-2-19**] 03:15AM BLOOD Hct-24.0*
[**2156-2-18**] 05:07AM BLOOD WBC-9.1 RBC-3.05*# Hgb-9.4*# Hct-26.7*
MCV-88 MCH-31.0 MCHC-35.3* RDW-14.5 Plt Ct-191
[**2156-2-17**] 05:55PM BLOOD Hct-29.6*
[**2156-2-19**] 05:10AM BLOOD PT-15.1* PTT-27.4 INR(PT)-1.4
[**2156-2-19**] 03:15AM BLOOD PT-14.9* PTT-26.1 INR(PT)-1.4
[**2156-2-19**] 05:10AM BLOOD Glucose-158* UreaN-35* Creat-2.5*#
Na-130* K-5.1 Cl-97 HCO3-25 AnGap-13
[**2156-2-18**] 05:07AM BLOOD Glucose-136* UreaN-26* Creat-0.9 Na-135
K-4.4 Cl-101 HCO3-29 AnGap-9
.
[**2-17**] knees b/l:
DIAGNOSIS:
1. Bone and soft tissue, left knee (A-B):
1. Bone with reparative changes and focal necrosis.
2. Degenerative fibrocartilage.
2. Bone and soft tissue, right knee (C-D):
1. Bone with reparative changes and focal necrosis.
2. Degenerative fibrocartilage.
Clinical: Osteoarthritis both knees.
.
[**2-19**] lung scan:
Ventilation images obtained with Tc99m aerosol in 8 views
demonstrate an area of decreased perfusion in the superior
segment of the left upper lobe,
consistent with the aorta. Perfusion images in the same 8 views
show a similar defect. Chest x ray showed no focal or
parenchymal abnormalities.
The above findings are consistent with a low likelihood of
pulmonary embolism.
.
TTE [**2156-2-19**]
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is normal (LVEF
ejection fraction 60 percent%). The right ventricular cavity is
dilated. Right ventricular systolic function appears depressed.
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. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion. Compared with the
findings of the prior report (tape unavailable for review) of [**2152-4-10**], the right ventricle appears hypokinetic.
.
EKG [**2-19**]
Sinus rhythm 69
First degree A-V block
Right bundle branch block
Inferior T wave changes are nonspecific
.
cxr [**2156-2-20**]: No radiographic evidence of pneumonia
.
pmibi [**2156-2-24**]:
SUMMARY OF THE PRELIMINARY DATA FROM THE EXERCISE LAB:
Dipyridamole was infused intravenously for 4 minutes at a dose
of 0.142 mg/kg per minute. Two minutes after the cessation of
infusion, Tc-[**Age over 90 **]m sestamibi was administered IV.
INTERPRETATION:
Imaging protocol: gated SPECT.
Resting perfusion images were obtained with thallium-201. Tracer
was injected 15 minutes prior to obtaining the resting images.
This study was interpreted using the seventeen-segment
myocardial perfusion model.
DECISION: Initial stress images showed soft tissue attenuation
and
subdiaphragmatic activity, which did not improve significantly
by attenuation correction. After a 4 hour delay, a perfusion
abnormality involving the inferior wall showed significant
improvement on additional stress images.
Left ventricular cavity size is enlarged with stress and rest.
At stress, there is a mild myocardial perfusion defect involving
the distal inferior wall. This perfusion abnormality shows
reversibility with rest. Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 64%.
There are no prior studies available for comparison.
IMPRESSION: 1. Probably abnormal study showing a reversible,
mild myocardial perfusion defect involving the apical portion of
the inferior wall. 2. Enlargement of the left ventricle with EF
of 64%.
IMPRESSION: No ischemic ECG changes and non-progressive atypical
chest
discomfort was present during the entire study. Nuclear report
sent
separately.
.
[**2156-2-25**] cardiac cath
COMMENTS:
1. Selective coronary angiography demonstrated single vessel
coronary
artery disease in this right dominant circulation. The LMCA was
heavily
calcified with a 30% distal stenosis. The LAD was a serpiginous
vessel
that was moderately calcified. A large septal and two small
diagonal
branches were without angiographically flow limiting disease.
The LCX
was a modest vessel through the AV groove. A single moderate
sized OM
was seen without flow limiting disease. There was collateral
filling
from the LCX to the RPL branch. The ramus intermedius was
without flow
limiting disease. The RCA was a heavily calcified vessel with a
mid 60%
stenosis and a distal 90% stenosis before the takeoff of the
PDA. There
was an extensive focally ectatic RPL system. The PDA had a mild
origin
stenosis and an early bifurcation.
2. Left ventriculography demonstrated normal systolic function
with
LVEF of 62%. Mitral regurgitation was unable to be assessed due
to
catheter position likely producing artifactual mitral
regurgitation.
3. Resting hemodynamics from right and left heart
catheterization
demonstrated elevated right- and left-sided filling pressures
with
RVEDP 13 and LVEDP 20 mmHg. There was mild pulmonary arterial
hypertension with marked respiratory variation in PA systolic
pressure
(40/15 mmHg). The PCW waveform showed marked catheter fling but
there
was a suggestion of a modest dynamic PCW-LV diastolic gradient
during
the respiratory cycle. The RV and LV systolic pressures were
concordant,
however, and there were no traditional signs of constrictive
physiology.
Cardiac output and index were 7.2 L/min and 3.1 L/min/m2
respectively,
using an assumed oxygen consumption. No aortic stenosis gradient
was
seen on catheter pullback from the LV to the ascending aorta.
4. During right heart catheterization, the PWP catheter
crossed the
atrial septum, consistent with a patent foramen ovale. Oxygen
saturations were not measured from this location, however.
5. Successful stenting of the distal RCA was performed with
two
overlapping 3.5x8 mm Cypher DES, along with stenting of the mid
RCA with
a 3.5x13mm Cypher DES, all postdilated using a 3.75 mm NC
balloon. Final
angiography revealed no residual stenosis in the distal stents,
5%
residual stenosis in the mid RCA stents, no dissection and
TIMI-3 flow
(see PTCA comments)
.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease with diffuse coronary
artery
plaquing and calcification.
2. Normal left ventricular systolic function.
3. Moderate left ventricular diastolic dysfunction.
4. Mild pulmonary arterial hypertension.
5. Patent foramen ovale without evidence of significant
right-to-left or
left-to-right shunting.
6. No convincing evidence of constrictive physiology.
7. Successful deployment of 3 sirolimus-eluting stents in the
RCA.
Brief Hospital Course:
A/P 62 year old male with aflutter s/p ablation, bronchiectasis,
HTN, hyperchol, chronic RBBB, OA s/p B TKR on [**2-17**] with post op
course complicated but anemia of unclear source and hypotension
as well as troponin leak.
CV-
CAD:Pt troponinc and CK leak in the setting of hypotension and
anemia which has responded well to transfusion but suggests that
the patient has underlying CAD as further supported by MIBI
result of apical inferior wall suggesting an RCA lesion. Pt
never had chest pain suggesting more demand ischemia although
pain may have been blunted by pain regimen. Echo findings of a
hypokinetic RV were concerning for right sided infarct with
normal LV EF and is consistent with volume sensitive
hypotension. BP now improved with uptitration of metoprolol and
then change to atenolol per cardiology. Pt cont to be total body
volume overloaded due to aggressive hydration in SICU but he
continued to diurese well with I/O -1800cc and will cont to
allow to self diurese. Cont on current antiHTN regimen of
amlodipine, valsartan, metoprolol. Also cont atorvastatin and
ASA for thrombosis prophylaxis. Unclear why troponins cont to
climb despite declining CK's so awaiting am labs, but MIBI
findings with persistent troponin elevation led to a cardiac
cath with PCI x3 to the RCA, after which he was transferred to
the [**Hospital Unit Name 196**] for further management.
His post cath medical regimen was as follows:
Aspirin 325mg po qd indefinitely
Plavix 75mg po qd x 3 months
Atenolol 50mg po qd
Atorvastatin 40mg po qd, consider increase to 80mg po qd
Valsartan 160mg po qd and amlodipine for BP
He will need cardiac rehab. He will follow up with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1968**].
.
Pump: His EF was preserved but he did have mild overload bacse
on his PCWP. His valsartan was continued and he was allowed to
reach euvolemia on his own post cath.
.
Aflutter-Pt had episode of ?afib post op with recurrence of what
looks like coarse afib overnight vs aflutter with variable
block. He did not have any further events post cath. He was
continued on plavix and aspirin. He may need anticoagulation.
An outpatient holter monitor may be considered if he has
recurrence. His heart rate was controlled with a Beta blocker.
.
Bronchiectasis-Pt low grade fever now recurred but no sputum
production to suggest exacerbation. Continued on pulmocort.
.
Bilat TKR-Pt now ambulating 30feet with PT and using commode on
his own. No erythema surrouding incision site. Pain well
controlled on oxycodone and tylenol. He is partial weight
bearing on both legs at discharge
.
Fever-previously elevated WBC due to stressed state with
infectious workup including CXR, Bld CX and UA neg to date. Pt
had infected rt antecub IV which was pulled on [**2-22**] and may have
been source although fevers persist with erythema and induration
resolving.
.
Depression-cont on paroxetine
.
GERD-Cont on famotidine
.
Constipation-Most likely due to heavy narcotic use post op. Pt
tolerating PO well with no abdominal pain suggesting no ileus or
obstruction. Pt had large BM on dulcolax and docusate with
lactulose, thus resolving this issue.
.
ARF-due to hypotension and anemia. Stabilized at his baseline
with normalized BP and transfusion so no need for further
intervention.
.
Anemia: His hematocrit dropped postoperatively, thought
secondary to blood loss. He was transfused 4 units. His
hematocrit remained stable post transfusion.
Medications on Admission:
Diovan, norvasc, paxil, rolaids, pulmacort
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
5. Budesonide 0.25 mg/2 mL Nebu Soln Sig: Two (2) ML Inhalation
QD ().
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Diovan 160 mg Capsule Sig: One (1) Capsule PO once a day.
8. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. 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*
13. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Bilateral osteoarthritis of the knees
Blood loss anemia
Hypotension
Coronary Artery Disease
Acute renal failure
Discharge Condition:
Good
Discharge Instructions:
take all medications as prescribed. You have been started a
number of new medications for your heart including: atenolol,
plavix, aspirin, as well as medication for pain (percocet), to
prevent constipation (colace, dulcolax) and for reflux symptoms
(fafmotidine).
You may partially bear weight to both legs until you are seen in
follow up with Dr. [**Last Name (STitle) 7111**].
Please call the clinic if you notice any drainage or increased
redness at the incision site.
If you experience any chest pain, tightness or shortness of
breath you should call your doctor and if no doctor is available
you should go back to the emergency room.
You should discuss your heart rhythm with Dr. [**Last Name (STitle) 1968**] and Dr.
[**Last Name (STitle) **], aprticularly in regards to your need for blood
thinners. You will need to undergo monitoring of your heart
rhythm as an outpatient
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Where: [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE Date/Time:[**2156-3-17**] 12:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**]
[**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2156-4-28**]
10:10
You should call for an poointment with Dr. [**Last Name (STitle) **] in
approximately 4 [**Known lastname **] to furhter evaluate your heart. Phone:
[**Pager number 285**]
|
[
"494.0",
"276.5",
"300.4",
"427.31",
"272.4",
"285.9",
"745.5",
"780.57",
"715.96",
"584.9",
"998.11",
"410.71",
"414.01",
"401.9",
"780.6",
"458.9",
"285.1",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"81.54",
"88.56",
"37.23",
"36.07",
"03.90",
"99.20",
"88.53",
"36.05"
] |
icd9pcs
|
[
[
[]
]
] |
15085, 15159
|
10204, 13670
|
309, 369
|
15315, 15321
|
3368, 9704
|
16256, 16918
|
2243, 2248
|
13763, 15062
|
15180, 15294
|
13696, 13740
|
9721, 10181
|
15345, 16233
|
2263, 3349
|
242, 271
|
397, 1718
|
1740, 1877
|
1893, 2227
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,817
| 125,287
|
10942+56190
|
Discharge summary
|
report+addendum
|
Admission Date: [**2117-8-2**] Discharge Date: [**2117-8-6**]
Date of Birth: [**2046-6-8**] Sex: F
Service: MEDICINE
CHIEF COMPLAINT: Diarrhea, purple stools, and
lightheadedness.
HISTORY OF PRESENT ILLNESS: This is a 71 -year-old woman
with a history of hypertension, diabetes, and a
cerebrovascular accident for which she was taking Coumadin.
She was in her usual state of health until one day prior to
admission when she began experiencing diarrhea and purple
stools, along with lightheadedness and dizziness with each
bowel movement. She denies any loss of consciousness, chest
pain, abdominal pain, nausea or vomiting. She denies any
prior similar episodes. Her prodrome included several days
of a nonproductive cough for which she was taking Robitussin.
PAST MEDICAL HISTORY:
1. Diabetes mellitus for which she was taking oral agents.
2. Hypertension.
3. Cerebrovascular accident which occurred eleven years ago.
The patient currently has residual leg weakness. The patient
is on Coumadin status post cerebrovascular accident.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Last Name (NamePattern1) 20615**]
MEDQUIST36
D: [**2117-8-6**] 19:44
T: [**2117-8-10**] 22:13
JOB#: [**Job Number 35540**]
Name: [**Known lastname 6309**], [**Known firstname 6310**] Unit No: [**Numeric Identifier 6311**]
Admission Date: [**2117-8-2**] Discharge Date:
Date of Birth: [**2046-6-8**] Sex: F
Service:
PAST MEDICAL HISTORY:
1. Cerebrovascular accident, occurred eleven years ago.
There is minimal residual leg weakness on examination. The
patient is also anticoagulated on Coumadin currently.
2. Hypertension.
3. Diabetes for which the patient is taking oral agents.
4. Peripheral vascular disease with bilateral symptoms.
5. Subtotal thyroidectomy.
6. Abdominal aortic aneurysm repair fifteen years ago.
7. Cataracts, O.S..
ADMITTING MEDICATIONS: Avandia 4.0 mg po q day, Glucotrol 10
mg po bid, Avalide one tablet po q day, and thyroid hormone
2.0 mg po q day. Also additional medication, Robitussin prn.
ALLERGIES: The patient has no known drug allergies; however,
reports an allergy to crabs as well as paper tape.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: The patient is visiting [**State 1145**] from
[**State 5945**] where she normally lives. She quit smoking eleven
years ago, has an approximately 50 to 100 pack year history
of smoking and reports minimal alcohol consumption.
PHYSICAL EXAMINATION: Vital signs were temperature of 100.3
F, blood pressure 152/57, heart rate equal to 100,
respirations 19, and oxygen saturation 92% on room air. In
general, the patient is an obese woman in no apparent
distress. Head, eyes, ears, nose and throat examination
showed normocephalic, atraumatic, pupils were equal, round,
and reactive to light, extraocular movements were intact, and
the oropharynx was non-erythematous. She had no goiter and
the neck was supple. Respiratory: she was clear to
auscultation bilaterally, had no wheezing and had positive
mild bibasilar crackles. Cardiovascular: regular rate and
rhythm, S1, S2 normal, no S3 or S4 and no murmurs, rubs, or
gallops.
Abdominal examination: obese, positive bowel sounds,
nontender, nondistended, no hepatosplenomegaly, and no
masses. Extremities were warm and showed no cyanosis,
clubbing or edema. Neurologic examination: the patient was
alert and oriented times three, cranial nerves II through XII
were intact, had normal motor strength throughout the upper
and lower extremities bilaterally. She also showed a smooth
and accurate finger-to-nose test.
ADMISSION LABORATORY DATA: On admission, the patient had a
white blood cell count of 16.4, a hematocrit of 22.3, and a
platelets of 500,000. PT was 33, PTT was 38.7, INR was 7.2.
Sodium was 138, potassium 5.1, chloride was 98, bicarbonate
was 25, BUN 53, creatinine was 1.7, and glucose was 423.
Chest x-ray did not show any evidence of consolidation or
mass; however, there was question of mild pulmonary
congestion. Nasogastric lavage was also negative for blood
at the time of admission.
HOSPITAL COURSE: In the Emergency Department, the patient
was initially treated with intravenous fluids and packed red
blood cells, fresh frozen plasma, and vitamin K for an INR of
7.2, as well as a hematocrit of 22 which was down from her
baseline of approximately 42. The patient was then
transferred to the Medical Intensive Care Unit where she was
found to have a hematocrit of 18 and received three
additional units of packed red blood cells.
In the Medical Intensive Care Unit subsequent nasogastric
lavage was performed and revealed positive clots and blood in
her gastric contents. The patient's hematocrit was then
found to be 25 and she received two additional units of
packed red blood cells. In addition, in the Medical
Intensive Care Unit, the patient also received three units of
fresh frozen plasma and was started on Protonix 80 mg IV q
day, Robitussin 5.0 mL to 10 mL po q six to twelve hours, and
an insulin sliding scale.
1. Gastrointestinal: After the patient's hematocrit
stabilized and her INR was normalized, she went for a
colonoscopy and esophagogastroduodenoscopy on hospital day
three. The colonoscopy revealed several non-bleeding polyps
in the sigmoid colon which were not removed or biopsied. The
esophagogastroduodenoscopy revealed an ulceration located in
the gastroesophageal junction which was not actively
bleeding. The patient was then started on Protonix 80 mg IV
which was later changed to 80 mg po q day. In addition, an
Helicobacter pylori titer was sent and is still pending and
will be followed up by her primary care physician in
[**Name9 (PRE) 5945**].
During the remainder of her hospitalization, her hematocrit
remained stable and there was no evidence of further bleeding
from this ulcer located at the gastroesophageal junction.
Her diet was slowly advanced from clears to soft solids to
full diet at the time of discharge.
2. Pulmonary: At the time of her hospitalization, the
patient had been taking Robitussin for several days for a
nonproductive cough. During her hospitalization, the patient
experienced significant shortness of breath and desaturations
into the 80s on two to three liters of supplemental oxygen.
She also developed significant inspiratory and expiratory
wheezes on examination, as well as mild bibasilar crackles
thought to be related to mild congestive heart failure. Her
maintenance IV fluids were decreased and she was started on
Albuterol and Atrovent nebulizers and responded well to
these. While she experienced continued dyspnea on exertion,
her oxygen requirement decreased from four to one to two
liters at the time of discharge. She was discharged on
supplemental oxygen, Albuterol and Atrovent metered dose
inhalers, as well as Flovent.
3. Endocrine: At the time of admission, the patient was
started on an insulin sliding scale to control her blood
glucose. She was also restarted on her thyroid hormone
medicine. On the day prior to discharge, she was restarted
on her oral hypoglycemic agents, Avandia and Glucotrol.
4. Infectious Disease: At the time of admission, the
patient had a white blood cell count of 12.6. During her
hospitalization she remained afebrile, although her white
blood cell count varied from 17.1 down to 11.2 at the time of
discharge. A follow-up chest x-ray revealed no changes,
despite her continued dry cough. Urine cultures were
negative and blood cultures were negative at the time of
discharge.
5. Cardiovascular: While in the hospital, the patient
underwent an echocardiogram, which revealed a mildly dilated
left atrium, mild left ventricular hypertrophy, with mild
systolic dysfunction and an overall left ventricular ejection
fraction of 40%. Resting wall motion abnormalities included
mid and distal, septal and inferoseptal akinesis. Right
ventricular systolic function was normal. Aortic valve
leaflets were mildly thickened, mitral valve leaflets are
moderately thickened. There was also moderate 2+ mitral
regurgitation noted.
DISPOSITION: The patient was discharged on hospital day five
and will follow-up in clinic with Dr. [**First Name8 (NamePattern2) 3964**] [**Name (STitle) **] next
Thursday, where she will have follow-up labs checked and her
pulmonary status will be reassessed.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Protonix 80 mg po q day, Avandia 4.0
mg po q day, Glucotrol 10 mg po bid, thyroid hormone 2.0 mg
po q day, Robitussin AC 10 mL po q four hours, Flovent 110
mcg two puffs [**Hospital1 **], Atrovent metered dose inhaler two puffs
[**Hospital1 **], Albuterol metered dose inhaler two puffs q six hours,
Avalide one tablet po q day.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1809**]
Dictated By:[**Last Name (STitle) 6312**]
MEDQUIST36
D: [**2117-8-7**] 12:55
T: [**2117-8-10**] 08:28
JOB#: [**Job Number **]
cc:[**Numeric Identifier 6313**]
|
[
"531.40",
"211.3",
"250.00",
"285.1",
"V12.59",
"V58.61",
"401.9",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13",
"96.34"
] |
icd9pcs
|
[
[
[]
]
] |
8478, 8487
|
2303, 2318
|
8511, 9133
|
4222, 8456
|
2585, 3450
|
152, 199
|
228, 784
|
3474, 4204
|
1577, 2286
|
2335, 2562
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,208
| 144,407
|
67
|
Discharge summary
|
report
|
Admission Date: [**2199-3-18**] Discharge Date: [**2199-3-25**]
Date of Birth: [**2139-8-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hypertensive urgency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 59 yo F with a history of DM2 and HTN who presents
with L greater than R flank pain, associated with nausea and
visual blurring. Patient has had L sided flank pain since the
night prior to admission. This was associated with blurry vision
for the past 1-2 days, and headache over the last few hours. She
has not had dysuria, hematuria, vomiting, or fevers. No
abdominal pain. No diarrhea.
She does have a history of HTN and is compliant with her
antihypertensives.
Of note, she had much more severe flank pain 6 weeks ago. She
was told to drink fluids for potential kidney stone. She had
imaging done in [**State 760**], at her home, that showed no obvious
stones. Apparently she was referred to a nephrologist at that
time and was told she had some evidence of kidney failure. She
was first told she may have kidney failure in [**2198-4-22**]. She was
seen by nephrology, but does not know any further details. She
has never been on dialysis before. She did not have this flank
pain at that time.
Patient brought labs from previous appointments.
[**1-16**] Cr 3.29.
[**2-4**] Cr 3.07, HCT 31.1.
In the emergency department BP was 221/71. She recived 200mg IV
labetalol and was started on a 1mg/min labetalol gtt. BP came
down to 176/92. HR 77. RR21. O2 sat 88%.
On arrival to the MICU, patient's flank pain is much improved.
No headache, nausea, vomiting, chest pain, or shortness of
breath.
Past Medical History:
1. Diabetes
2. Asthma
3. Depression
4. History of pulmonary nodules consistent with calcified
granuloma
5. Menorrhagia
6. Hypertension
7. Hypercholesterolemia.
8. Chronic lower back pain.
9. CRI, most recent Cr values in the low 3's.
10. Thyroid mass - she reports she was told she had a 2 cm
thyroid mass and needed to have this biopsied.
11. Osteoporosis
Social History:
She lives in NJ currently with a roommate, but wants to move
back to MA. Smokes 1 ppd. Denies alcohol or drug use.
Family History:
Uncle and two cousins had kidney disease requiring dialysis.
Physical Exam:
Vitals - T: BP: HR: RR: 02 sat:
GENERAL: Pleasant, well appearing female sitting on the bed in
NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
NECK: Full thyroid bilaterally with a focal small nodule on the
left lobe.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Patient breathing comfortably. CTAB, good air movement
biaterally.
ABDOMEN: +BS, soft ND. Slight tenderness to palpation in her
LUQ. No rebound or guarding.
BACK: + some left flank tenderness, no spinal tenderness
EXTREMITIES: Slight non-pitting edema, 2+DP.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Decreased
sensation to light touch in her left lower extremity, otherwise
intact.. 5/5 strength in her upper and lower extremities
throughout
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2199-3-18**] 02:32PM GLUCOSE-116* UREA N-51* CREAT-3.4*#
SODIUM-141 POTASSIUM-4.7 CHLORIDE-111* TOTAL CO2-22 ANION GAP-13
[**2199-3-18**] 02:32PM CK(CPK)-63
[**2199-3-18**] 02:32PM CK-MB-4 cTropnT-<0.01
[**2199-3-18**] 02:32PM CALCIUM-9.1 PHOSPHATE-4.2 MAGNESIUM-2.2
IRON-57
[**2199-3-18**] 02:32PM calTIBC-317 VIT B12-768 FOLATE-GREATER TH
FERRITIN-60 TRF-244
[**2199-3-18**] 02:32PM WBC-6.9 RBC-3.67*# HGB-10.3*# HCT-30.8*#
MCV-84 MCH-28.2 MCHC-33.6 RDW-13.7
[**2199-3-18**] 02:32PM NEUTS-62.1 LYMPHS-29.8 MONOS-4.7 EOS-2.7
BASOS-0.7
[**2199-3-18**] 02:32PM PLT COUNT-231
[**2199-3-18**] 07:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2199-3-18**] 07:20PM URINE RBC-[**5-1**]* WBC-[**10-11**]* BACTERIA-FEW
YEAST-NONE EPI-[**5-1**]
[**2199-3-18**] 07:20PM URINE OSMOLAL-301
[**2199-3-18**] 07:20PM URINE HOURS-RANDOM UREA N-340 CREAT-37
SODIUM-65 POTASSIUM-25 CHLORIDE-61 TOT PROT-173 PROT/CREA-4.7*
Discharge labs:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
[**2199-3-25**] 07:00AM 5.9 3.37* 9.3* 27.8* 83 27.7 33.6 13.8 247
BASIC COAGULATION PT PTT INR(PT)
[**2199-3-25**] 07:00AM 11.8 23.6 1.0
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3
[**2199-3-25**] 07:00AM 123* 45* 3.4* 143 4.5 112* 19*
Fe 57
Ferritin 60
TIBC 317
TRF 244
Hapto 77
Vitamin B12 768
HbA1c 6.6%
TSH 3.5
PTH 252
[**Doctor First Name **] negative
C3 89
C4 26
Protein Electrophoresis
ABNORMAL BAND IN GAMMA REGION BASED ON IFE (SEE SEPARATE
REPORT),
IDENTIFIED AS MONOCLONAL IGG LAMBDA NOW REPRESENTS, BY
DENSITOMETRY, ROUGHLY 5% (265 MG/DL) OF TOTAL PROTEIN
INTERPRETED BY [**Name6 (MD) 761**] [**Name8 (MD) 762**], MD, PHD
Immunoglobulin G 1020 mg/dL [**Telephone/Fax (1) 763**]
Immunoglobulin A 86 mg/dL 70 - 400
Immunoglobulin M 117 mg/dL 40 - 230
Immunofixation
MONOCLONAL IGG LAMBDA IDENTIFIED
Prot. Electrophoresis, Urine
MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING BASED ON
IFE (SEE SEPARATE REPORT), MONOCLONAL IGG LAMBDA AND TRACE
BENCE-[**Doctor Last Name **] LAMBDA DETECTED BASED ON THIS SAMPLE'S
PROTEIN/CREATININE RATIO WE ESTIMATE IGG LAMBDA PROTEIN
EXCRETION AS 3% * 3.2 * 1000 = 100 MG/DAY BENCE-[**Doctor Last Name **] PROTEIN
BELOW DETECTION LIMIT OF PEP
Immunofixation, Urine
MONOCLONAL IGG LAMBDA
AND FREE (BENCE-[**Doctor Last Name **]) LAMBDA DETECTED
Length of Urine Collection RANDOM
Creatinine, Urine 61 mg/dL
Total Protein, Urine 195 mg/dL
Protein/Creatinine Ratio 3.2*
Albumin, Urine 116.0 mg/dL
Albumin/Creatinine, Urine [**2090**].6*
[**2199-3-18**] URINE URINE CULTURE- < 10,000 organisms
Urine cytology ([**3-21**]) - pending
STUDIES:
CT abd/pelvis ([**3-18**]):
IMPRESSION:
1. No evidence of diverticulosis or urinary tract calculi.
2. Unchanged large calcified fibroid uterus.
3. 2.9-cm low-attenuation left renal lesion larger than prior
study. Further evaluation with MR would be optimal. However,
given the patient's renal failure, US as an initial study is
recommended.
Head CT ([**3-18**]): IMPRESSION: No acute intracranial process.
CXR ([**3-18**]): IMPRESSION:
1. No acute cardiopulmonary process.
2. Sclerotic focus in the left humeral head, could reflect a
bone island given lack of underlying risk factors for
metastasis. Correlation with prior imaging to confirm stability
is recommended.
Renal US and doppler ([**3-19**]):
FINDINGS: There is a partly cystic/partly solid isoechoic mass
again seen in the mid portion of the left kidney which
corresponds with the recent CT
findings. This mass measures 3.4 x 2.7 x 2.8 cm and demonstrates
some
vascular flow within it on color Doppler imaging. The appearance
of this mass may be suggestive of cystic renal cell carcinoma.
No additional focal
abnormality is seen in the left kidney and there is no
hydronephrosis. The
left kidney measures 9.2 cm. The right kidney measures 10.0 cm.
There is no hydronephrosis and no stone or mass is seen in the
right kidney.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were
obtained. Arterial waveforms of the main renal artery in the
right kidney
demonstrates a slight delay in upstrokes which may indicate some
renal artery stenosis. Sharp upstrokes are identified in the
arterial waveform of the renal artery in the left kidney.
Resistive indices of the intraparenchymal arteries on the right
kidney are slightly elevated ranging from .78-.80. The resistive
indices of the intraparenchymal arteries in the left kidney are
also slightly elevated ranging from .73-.83.
IMPRESSION: 1) Slight upstroke delay of the arterial waveforms
in the main
renal artery of the right kidney may indicate some renal artery
stenosis on the right side. Bilateral moderately elevated RI's.
2. Cystic and solid mass in the mid-left kidney, concerning for
neoplasm.
Bone Scan ([**3-21**]): No scintigraphic evidence of osseous
metastatic disease.
Renal Scan ([**3-26**]): IMPRESSION:
1. Reduced renal function bilaterally consistent with chronic
renal
impairment.
2. Differential renal function of 39% left kidney and 61% right
kidney.
Brief Hospital Course:
59 yo F with hypertensive urgency found to have a new renal
mass.
# Renal mass: The patient was found to have a new renal mass on
the CT of her abdomen/pelvis done in the ED to evaluate her
flank pain. On ultrasound the mass was seen to be approximately
2x2x3 cm and had both solid and cystic portions. The size and
characteristics of the mass are concerning for renal cell
carcinoma. Her renal mass was thought to account for her flank
pain.
On her admission CXR she was found to have a sclerotc focus in
her left humeral head which was concerning for metastesis. This
was evaluated with a bone scan which showed no evidence of
metastesis. Urology was consulted and felt that more
information was needed before a definitive plan for diagnosis
could be developed so a renal scan was preformed to assess the
functionality of her kidneys and showed differential renal
function of 39% from the left kidney and 61% from the right
kidney.
Because she currently has [**State 760**] Medicaid, we were unable to
schedule outpatient follow-ups for her with doctors [**First Name (Titles) **] [**Name5 (PTitle) 764**]. Once she moved back to [**State 350**] she was
asked to contact Financial Services at [**Telephone/Fax (1) 765**] to apply
free care through this hospital. However she was asked to
follow up with her PCP in NJ until this time and an appointment
was made for her with her NJ PCP on [**Name9 (PRE) 766**] [**4-1**] at 1:00 PM.
He was contact[**Name (NI) **] and asked to give her a referral to a
nephrologist and urologist in [**State 760**] until she moves her
care to [**State 350**].
# Hypertensive urgency: Her initial BP was 221/71 with worsening
of visual blurring and flank pain. No papilledema on exam.
Patient reports SBPs in 180s for several months and her PCP
notes confirm this. She states she had been taking her blood
pressure medications regularly, however her PCP notes document
that she often runs out of her medicaitons and has difficulty
regularly taking her medications. She was on maxed doses of
linsinopril and diovan as an outpatient and large doses of
atenolol. In the ED she was placed on a labetalol gtt with
decrease in her SBPs. Renal was consulted and recommended only
starting the lisinopril as it was unclear how compliant she had
been on her previous regimen. As she remained hypertenisve on
lisinopril, long-acting dilitazem was added and uptitrated to
240 mg daily. Atenolol was stopped given that it is renally
cleared and diovan was stopped. She may continue to require
titration of her antihypertensive medications as an outpatient.
# Chronic renal failure: The patient had an admission creatinine
of 3.4. Patient had brought labs with her showing Cr 3.0-3.29 in
[**2198-12-23**]. FENA of 4.24 consistent with intrinsic or
postrenal etiology. This may be consistent with chronic diabetic
or hypertensive nephropathy. CT abdomen showed no stones, or
obvious obstruction. Renal was consulted and recommended
starting sodium bicarbonate 650 mg tid, vitamin D. She was
given epo while hospitalized for anemia, however this was
stopped at discharge due to concern for insurance reimbursement.
She was asked to follow up with a nephrologist for further
managment of her renal disease.
# Normocytic Anemia: HCT 30.8. HCT of 31.1 on [**2199-1-20**]. Likely
anemia of chronic renal disease. She had no evidence of
bleeding. She was treated with epo per renal as above. This
remained stable.
# MGUS: As part of the workup for her chronic renal
insufficiency UPEP and SPEP were sent which returned showing a
monoclonal IgG lambda protein spike. Hematology/oncology were
consulted to ascertain the significance of this finding and they
felt this represented MGUS because the level of protein seen was
small. There is concern that her kidney disease could be due to
amyloidosis or light chain deposition disease, however a kidney
biopsy would be necessary to diagnosis this and at this time
cannot be preformed given her renal failure. She will need
yearly UPEP and SPEP to monitor for developement of multiple
myeloma.
# Type 2 Diabetes: The patient is on glipizide as an outpatient.
This was held while she was hospitalized and she was covered
with a sliding scale, monitored with qid fingersticks, and kept
on a diabetic diet.
# Code: Full code
# Primary care doctor [**First Name (Titles) 767**] [**Last Name (Titles) **]: [**Last Name (LF) **],[**First Name3 (LF) 768**] [**Telephone/Fax (1) 769**]
Medications on Admission:
Lisinopril 40mg po daily
Atenolol 100mg po bid
Nephrocaps 1 cap daily
Tylenol #3 tid PRN pain
Omeprazole 20mg po daily
Lipitor 40mg po daily
Glipizide 5mg po daily
Actonel 35mg po q week
Pristiq 50mg po daily
Diovan 320mg po daily
Discharge Medications:
1. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Pristiq 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week.
4. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
8. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary -
Renal mass concerning for renal cell carcinoma
Hypertensive urgency
Monoclonal gammopathy of unknown significance
Chronic renal insufficency, Stage IV
Secondary -
Diabetes
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital due to elevated blood pressure
and back pain. Your blood pressure was controlled with
medications. Your scans showed a mass in your left kidney which
was concerning for cancer. We were also concerned about a mass
seen on your left arm X-ray. A bone scan done for this was
normal, which is good.
For the kidney mass, we contact[**Name (NI) **] the urologists, who specialize
in kidney surgery. We did a special kidney scan to take a
closer look at the kidney mass. You will need to see the
urologists (kidney surgeons) in follow-up after you get
discharged from the hospital.
While you were hospitalized you were also found to have abnormal
protein in your blood and urine. The cancer specialists were
called and felt you have a disease called Monoclonal Gammopathy
of Unknown Significance (MGUS). People with this condition have
a small chance of developing a cancer of the blood called
multiple myeloma and need to be screened yearly to check for
this.
Due to your chronic kidney failure you should avoid taking
antiinflammatory medications such as Motrin, Alleve, ibuprofen,
or naproxen. For pain you can take Tylenol or ask your primary
care physician what to take.
Medication changes:
1. You were started on diltiazem 240 mg by mouth daily. You
should take this in addition to lisinopril 40 mg daily for
control of your blood pressure. It is very important that you
take these medications regularly.
2. Your diovan and atenolol were stopped.
3. You were started on sodium bicarbonate 650 mg by mouth three
times daily due to your kidney disease.
4. You were started on Vitamin D
Followup Instructions:
Because you currently have [**State 760**] Medicaid, we were unable
to schedule outpatient follow-up for you with doctors [**First Name (Titles) **] [**Name5 (PTitle) 764**]. Once you have a place to live in [**State 350**],
you will need to contact Financial Services at [**Telephone/Fax (1) 765**] to
apply free care through this hospital. However, until that is
arranged, you will need to continue seeing your doctors [**First Name (Titles) **] [**Last Name (Titles) **]
[**Name5 (PTitle) **].
An appointment was made for you to follow up with your primary
doctor [**First Name (Titles) **] [**Last Name (Titles) 760**], Dr. [**First Name (STitle) **] for a blood pressure and blood
work check on Monday [**4-1**] at 1:00 PM. You will also need to
ask him for a referral to a kidney specialist (nephrologist) and
a kidney surgeon (urologist) in [**State 760**].
As you will be moving to [**State 350**] soon you can schedule an
appointment with a new primary doctor at [**Hospital6 **]
([**Telephone/Fax (1) 250**]) once the above are resolved.
It is important that you follow up with urology to discuss a
plan for diagnosis and management of your renal mass. If you
will be getting care in [**State 350**], please schedule an
appointment with a urologist, Dr. [**Last Name (STitle) 770**], at [**Hospital1 771**]: ([**Telephone/Fax (1) 772**].
You will also need to follow-up with your nephrologist in New
[**Telephone/Fax (1) **]. If you will be transferring your care to [**State 350**],
you can make an appointment with kidney doctors [**First Name (Titles) **] [**Hospital1 771**] ([**Telephone/Fax (1) 773**].
Completed by:[**2199-3-26**]
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
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[
[
[]
]
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14182, 14188
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8527, 12997
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335, 341
|
14415, 14424
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3346, 4342
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16108, 17767
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2307, 2369
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14209, 14394
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275, 297
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369, 1778
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1800, 2159
|
2175, 2291
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,091
| 168,925
|
46187
|
Discharge summary
|
report
|
Admission Date: [**2100-9-25**] Discharge Date: [**2100-10-1**]
Date of Birth: [**2032-2-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Scopolamine / Lisinopril
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
tongue swelling x 15 minutes
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
68 year old male from home with tongue swelling x 15 minutes.
Able to swallow. No difficulty breathing. Started on lisinopril
4 days ago. Hx of renal cancer on chemo on tuesday. Woke up
from nap and noticed tongue swollen and then presented to ED 30
minutes later. Initially R>L swelling, got 1.5g solumedrol, 50mg
IV benadryl, pepcid. Swelling progressed and was fiberoptically
nasally intubated w/ 2mg versed p/t intubation. Now on propofol
drip. HD stable. VS in ED: Afebrile, 62, 162/73, 12, 98% AC
500/12, 5, 40%. 18g IV x2.
.
Per wife pt. had been feeling well, had not tried new foods and
no insect bites.
.
.
Review of systems: unobtainable
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CAD s/p 5 vessel CABG [**09**] years ago, single stent 6 years ago
3. OTHER PAST MEDICAL HISTORY:
- Melanoma x 2 ([**4-27**] Stage IIA, [**4-/2095**] Stage IB) s/p wide local
excision and sentinel node biopsy, with no evidence of nodal
involvement.
-Retinal arteriolosclerosis
- type 2 papillary renal cell carcinoma, stage IV- diagnosed on
biopsy [**2099-11-5**]
Social History:
He works for the VA, in the IT department. He lives with his
wife. [**Name (NI) **] a son who lives in [**Name (NI) 620**] and daughter in [**Name2 (NI) **]
[**Name (NI) **]. Quit smoking long ago, denies alcohol or drug use.
Family History:
Significant for several relatives (mother, maternal
grandmother) with CLL; one aunt with breast cancer.
Physical Exam:
IN ICU:
Vitals: T:98.7 BP: 182/84 P: 69 R: 18 O2: 99% on AC TV 500,
[**11-28**], 40% FiO2
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:
VS: T: 96.1, BP: 118/52, P: 60, RR: 18, 97% on RA
GEN: AOx3, NAD
HEENT: PERRLA. MMM. oropharynx clear.
Pulm: decreased BS at RLL, CTAB in upper lung fields
Abd: soft, NT, ND +BS.
Extremities: wwp, no edema. DPs, PTs 2+
Pertinent Results:
Hematology:
[**2100-10-1**] 07:10AM BLOOD WBC-9.1 RBC-3.07* Hgb-9.1* Hct-27.3*
MCV-89 MCH-29.7 MCHC-33.5 RDW-16.9* Plt Ct-291
[**2100-9-30**] 06:05AM BLOOD WBC-11.4* RBC-3.27* Hgb-9.7* Hct-29.6*
MCV-91 MCH-29.6 MCHC-32.6 RDW-16.8* Plt Ct-277
[**2100-9-29**] 06:15AM BLOOD WBC-12.6* RBC-3.33* Hgb-9.9* Hct-29.8*
MCV-89 MCH-29.7 MCHC-33.2 RDW-16.4* Plt Ct-241
[**2100-9-28**] 03:02AM BLOOD WBC-14.3* RBC-3.32* Hgb-10.2* Hct-29.6*
MCV-89 MCH-30.6 MCHC-34.3 RDW-16.7* Plt Ct-232
[**2100-9-27**] 02:51AM BLOOD WBC-14.3* RBC-3.61* Hgb-11.2* Hct-32.5*
MCV-90 MCH-30.9 MCHC-34.3 RDW-17.0* Plt Ct-265
[**2100-9-25**] 04:15PM BLOOD WBC-11.1* RBC-3.52* Hgb-10.7* Hct-30.8*
MCV-88 MCH-30.5 MCHC-34.8 RDW-17.2* Plt Ct-312
[**2100-9-27**] 02:51AM BLOOD Neuts-81* Bands-10* Lymphs-7* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2100-9-25**] 04:15PM BLOOD Neuts-65 Bands-8* Lymphs-16* Monos-6
Eos-1 Baso-0 Atyps-2* Metas-2* Myelos-0
[**2100-10-1**] 07:10AM BLOOD PT-13.6* PTT-33.7 INR(PT)-1.2*
[**2100-9-30**] 06:05AM BLOOD PT-12.1 INR(PT)-1.0
Chemistries:
[**2100-10-1**] 07:10AM BLOOD Glucose-87 UreaN-25* Creat-1.2 Na-139
K-4.2 Cl-106 HCO3-21* AnGap-16
[**2100-9-30**] 06:05AM BLOOD Glucose-84 UreaN-27* Creat-1.2 Na-139
K-4.1 Cl-106 HCO3-23 AnGap-14
[**2100-9-25**] 04:15PM BLOOD Glucose-109* UreaN-28* Creat-1.4* Na-143
K-4.3 Cl-109* HCO3-22 AnGap-16
[**2100-10-1**] 07:10AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9
[**2100-9-26**] 02:18AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.5*
[**2100-9-25**] 04:15PM BLOOD C3-191* C4-40
[**2100-9-28**] 03:38PM BLOOD Vanco-13.7
ABG:
[**2100-9-26**] 10:28PM BLOOD Type-ART pO2-94 pCO2-33* pH-7.36
calTCO2-19* Base XS--5 Intubat-INTUBATED
[**2100-9-26**] 01:49AM BLOOD Type-ART pO2-146* pCO2-31* pH-7.41
calTCO2-20* Base XS--3
[**2100-9-25**] 08:53PM BLOOD Type-ART pO2-180* pCO2-34* pH-7.39
calTCO2-21 Base XS--3
CXR [**2100-9-27**]:
Increasing parenchymal opacities are seen at both lung bases.
This increase makes the findings suspicious for pneumonia or
aspiration. This favors pneumonia over atelectasis. No evidence
of pleural effusion.
Brief Hospital Course:
#Angiodema: Patient presented with tongue swelling consistent
with angioedema. No evidence of urticaria, anaphylaxis, or SVC
syndrome. He was electively intubated for airway protection.
Angioedema was likely secondary to lisinopril given temporal
correlation though he is on temsirolimus and avastin. Sirolimus,
everolimus and biologics have been associated w/ angioedema w/o
urticaria.
We held his Lisinopril and biologics. He was also treated with
steroids and bendaryl. Patient's edema improved over the next
two days. He was successfully extubated. Post-extubation, he
required oxygen supplementation which was weaned off prior to
discharge.
#Pneumonia: Patient developed a pneumonia during this admisson,
likely related to his intubation. He was treated with iv vanco
and meropenemm then switched to oral levofloxacin which was
continued on discharge for a 10 day total course.
#Renal Cell Carcinoma: metastatic to lungs, invading IVC, has
been on treatement with avastin and torisel. He will follow-up
with outpatient oncology regarding when to restart treatment.
#Hypertension: continued on Atenolol 50 mg po BID, HCTZ 25 mg po
daily, diltiazem 180 mg po daily. Lisinopril held in setting of
angioedema.
Medications on Admission:
Medications:
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
AVASTIN - - 10 mg kg/IV every two weeks
BRIMONIDINE-TIMOLOL [COMBIGAN] - (Prescribed by Other Provider)
- 0.2 %-0.5 % Drops - one drop both eyes twice daily.
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - 1 Tablet(s) by mouth once
a
day
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - IM see
below Daily x 7 days, then weekly x 4 weeks, then monthly.
*DILTIAZEM HCL - 180 mg Capsule, Sust. Release 24 hr - 1
Capsule(s) by mouth daily - dose increase since [**2100-9-8**].
DIPHENHYDRAMINE HCL [BENADRYL] - (Prescribed by Other Provider:
[**Name Initial (NameIs) 1729**]) - 50 mg/mL Solution - 25-50 mg IV 30 minutes prior to
infusion
FLUVASTATIN [LESCOL] - 40 mg Capsule - 2 Capsule(s) by mouth at
bedtime
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth once a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day
MEGESTROL - 400 mg/10 mL (40 mg/mL) Suspension - 10 ml by mouth
twice a day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sublingually q5min as needed for chest pain call 911 if chest
pain does not resolve after 1 tab.
ONDANSETRON [ZOFRAN ODT] - 8 mg Tablet, Rapid Dissolve - 1
Tablet(s) by mouth every eight (8) hours as needed for nausea
PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) -
1 Tablet(s) by mouth once a day as needed
TORISEL - (Prescribed by Other Provider: [**Name Initial (NameIs) 1729**]) - - 25 mg IV
Weekly
TRAVATAN - (Prescribed by Other Provider) - 0.004 % Drops - 1
gtt in each eye once daily
LISINOPRIL ? dose
.
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth daily
DOCUSATE SODIUM [COLACE] - (OTC) - 50 mg Capsule - 2 Capsule(s)
by mouth twice daily
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - 1
Tablet(s) by mouth once a day
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- 1,000 mg Capsule - 2 Capsule(s) by mouth twice a day
VITAMIN E-400 - (Prescribed by Other Provider) - 400 unit
Capsule - 1 Capsule(s) by mouth daily
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Combigan 0.2-0.5 % Drops Sig: One (1) [**Hospital1 **] Ophthalmic every
twelve (12) hours.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. AVASTIN 25 mg/mL Solution Sig: One (1) Intravenous every 2
weeks: 10 mg/ kg iv .
6. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) Injection
once a month.
7. fluvastatin 80 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO at bedtime.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 4-6 hours as needed for chest pain.
10. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. travoprost 0.004 % Drops Sig: One (1) Ophthalmic qHS ().
14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a
day.
16. Fish Oil 1,000 mg Capsule Sig: Two (2) Capsule PO once a
day.
17. multivitamin Capsule Sig: One (1) Capsule PO once a day.
18. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Ten (10)
ml PO twice a day.
19. Torisel 30 mg/3 mL (10 mg/mL) (Final) Recon Soln Sig: Twenty
Five (25) mg Intravenous once a week.
20. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
21. levofloxacin 500 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:
PRIMARY: Angioedema
SECONDARY: Renal Cell Carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 98217**],
It was a pleasure taking part in your care. You were admitted
with swelling of the tongue and anioedema. This was caused by an
allergic reaction to lisinopril. You were intubated. While you
were intubated, you developed a pneumonia. You were treated with
antibiotics and you will continue to take antibiotics as an
outpatient. The instructions for your antibiotics are:
-Levofloxacin 750 mg once a day for 6 more days (stop [**2100-10-6**])
The following changes were made to your medications:
-STOPPED lisinopril
DO NOT TAKE THIS MEDICATION ANYMORE.
Followup Instructions:
Please follow-up as below:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2100-10-6**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2100-10-12**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name6 (MD) **] [**Name8 (MD) **], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2100-12-20**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,676
| 114,825
|
27005
|
Discharge summary
|
report
|
Admission Date: [**2151-2-15**] Discharge Date: [**2151-2-25**]
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Neomycin
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Sepsis
Major Surgical or Invasive Procedure:
[**2151-2-15**] Placement of left suclavian line, right radial arterial
line.
History of Present Illness:
[**Age over 90 **] y/o F w/COPD, CHF, recent admit for COPD/pna and hip pain,
sent from NH where she was noted to be "unresponsive, inaudible
bp, pulse 47, 67% on RA." Transferred to [**Hospital1 18**] ER for urgent
care.
.
She was admitted from [**Date range (1) 66385**] and discharged to a nursing home
with a prednisone taper and levofloxacin and pain service f/u
for likely radicular pain.
.
In the ED she was hypotensive to 70s, sat 88%RA. BP raised to
90s with 3L IVF, UOP 35 cc while in ED, lactate 2.0. New ARF -
Cr 3.6(baseline 1.4), K 8.3 (not hemolyzed, given calcium,
glucose/insulin, bicarb), WBC 20.
.
Given vanc/zosyn in ER, started on peripheral dopamine given
hypotension. Also found to have guaiac positive brown stool on
exam (per NH has had recent blood in stool accompanied by
constipation).
.
Transferred to ICU for further management. Arterial line and L
SC catheters placed. On arrival, patient intubated, sedated,
but able to respond yes/no to posed questions appropriately:
notes hip pain, denies any other pain. She denies any
antecedent trauma.
Past Medical History:
1. COPD
2. CHF - EF 50%
3. CKD
4. Spinal Stenosis
5. HTN
Social History:
Used to work at a factory, no smoking, no EtOH. Remainder of SH
unable to be obtained secondary to mental status.
Family History:
Non-contributory
Physical Exam:
T 97.2 BP 109/54 P 88-104 RR 21 O2 sat 90% on A/C, FiO2 0.5, Vt
480, PEEP 5
General: Intubated, lying in bed, responsive, following
commands.
HEENT: Pupils reactive bilaterally. No neck stiffness, negative
Brudzinski's sign.
Heart: S1 S2 with no MRG, no S3/S4.
Lung: CTA anteriorly.
Abd: Soft, nondistended.
Ext: No edema, 1+ distal pulses.
Neuro: Somewhat sedated but following commands, moving all four
extremities.
Skin: Scattered ecchymoses on stomach consistent with heparin /
SC injection irritation.
Pertinent Results:
[**2151-2-24**] 05:16AM BLOOD WBC-12.0* RBC-2.70* Hgb-8.4* Hct-25.2*
MCV-94 MCH-31.1 MCHC-33.2 RDW-15.0 Plt Ct-332
[**2151-2-15**] 07:50PM BLOOD WBC-20.0*# RBC-3.31* Hgb-10.5* Hct-30.3*
MCV-92 MCH-31.6 MCHC-34.5 RDW-14.7
[**2151-2-20**] 03:41AM BLOOD PT-11.8 PTT-23.4 INR(PT)-1.0
[**2151-2-24**] 05:16AM BLOOD Glucose-80 UreaN-20 Creat-0.8 Na-141
K-4.1 Cl-102 HCO3-33* AnGap-10
[**2151-2-15**] 07:50PM BLOOD Glucose-146* UreaN-106* Creat-3.6*#
Na-129* K-8.3* Cl-87* HCO3-31 AnGap-19
[**2151-2-16**] 11:54AM BLOOD ALT-18 AST-21 LD(LDH)-225 AlkPhos-50
TotBili-0.4
[**2151-2-15**] 09:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2151-2-15**] 09:10PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
.
MICROBIOLOGY:
[**2151-2-16**] 3:35 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2151-2-19**]**
GRAM STAIN (Final [**2151-2-16**]):
[**10-6**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): YEAST(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Final [**2151-2-19**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
Imaging:
CXR [**2-15**]
1. Interval improvement in right base opacity.
2. Subtle left mid zone opacity that may represent an early
pneumonic process.
3. Vascular redistribution without overt CHF.
.
Renal U/S [**2-16**]
IMPRESSION: Normal renal ultrasound.
.
Head CT [**2-16**]
IMPRESSION: No evidence of acute intracranial hemorrhage.
.
Brief Hospital Course:
[**Age over 90 **] yo with h/o COPD, CHF (EF 50%) presents with hypotension,
hyperkalemia, and sepsis from unknown source, likely pulmonary /
pneumonia.
.
1. Hypotension/Sepsis:
On presentation, pt was found down. Pt was admitted to the [**Hospital Unit Name 153**]
and treated with initial pressors, and intubated for pulmonary
support. Pt was placed on IV Vanco/Zosyn for presumptive
empiric coverage and was pancultured. Sputum cultures later
returned back MRSA and patient was treated as presumptive MRSA
pneumonia complicated by sepsis. Pt responded well to
aggressive fluid hydration and was able to be extubated, with
pressors weaned 1 day after initiation. Her Zosyn was
discontinued and pt was transferred to the floor and continued
on IV Vanco to complete a 14 day course. Pt continued to
improve clinically, remained afebrile, and blood cultures
remained negative on day of discharge. Pt was eventually
discharged to a rehab hospital once stable for continued rehab
after discharge.
.
2. COPD Exacerbation
Pt with symptoms consistant with a COPD exacerbation and had
previously still been on an prednisone taper from her previous
discharge. Pt was placed on IV solumedrol while in the ICU but
gradually transitioned to Prednisone 40mg daily when she was
transferred to the floor. Nebulizers, and inhaled steroids were
continued throughout her admission. Pt's symptoms improved and
patient was discharged on Pred 20mg daily to complete a slow 2
week taper off of steroids.
.
3. Acute renal failure:
Has baseline CRI but creatinine acutely elevated on elevated
which was largely attributed to prerenal azotemia from
hypotension and volume depletion. Pt was aggressively hydrated
while in the ICU and her Creatinine rapidly returned to [**Location 213**].
A renal u/s was obtained that was negative for any postrenal
obstruction.
.
4. CHF -
Pt with a h/o CHF with a baseline EF of 50%, with some chronic
vascular markings c/w chronic changes attributable to CHF.
Despite aggressive hydration, clinically pt did not exhibit any
signs of CHF. Pt was continued on her home dose of ASA and ACE.
Pt is not on a bblocker due to her COPD. Pt to continue to f/u
as an outpt.
.
5. Proph: Per Dr. [**Last Name (STitle) **], MRSA precautions not indicated unless
patient has cough.
.
6. Dispo/Code: Full Code. Pt was to be discharged to rehab to
complete a 14 day course of IV Vanco for her MRSA pneumonia. Pt
is to f/u with her outpt PCP once able.
Medications on Admission:
Meds per nursing home.
1. Aspirin 325 mg po qd
2. Pantoprazole 40 mg po qd
3. Acetaminophen 500 mg po q 6 hrs
4. Levofloxacin 250 mg q 48 for 7 days (finish [**2-17**])
5. Tizanidine 2 mg po qHS
6. Lisinopril 2.5 mg po qd
7. Prednisone (has received 40 mg qd since [**2-10**])
Disp:*30 tabs* Refills:*1*
8. Gabapentin 300 mg po HS
9. Oxycodone 10 mg po q4-6 hr prn
10. MOM 30 cc prn, dulcolax, fleet enema prn.
11. Duonebs q 4 hr prn.
12. Spiriva inhaler qd.
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
Disp:*qs units* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
10 days: Please take as taper after the 10 days of prednisone
20mg daily.
Disp:*10 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) nebulizer
treatment Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*qs nebulizer treatments* Refills:*0*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours).
Disp:*qs nebulizer* Refills:*2*
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours) for 3 days: Begin with
dose on [**2-25**].
Disp:*3 gram* Refills:*0*
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
14. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
15. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
16. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Sepsis secondary to MRSA Pneumonia
COPD Exacerbation
.
Secondary Diagnosis:
CHF EF 50%
COPD
Discharge Condition:
Stable to be discharged to rehab
Discharge Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 5351**] after discharge. Please
call [**Telephone/Fax (1) **] to schedule that appointment.
.
2. Please take medications as below.
.
3. Per Dr. [**Last Name (STitle) **], MRSA precautions
.
4. If develop chest pain, fever or chills, shortness of breath,
or any other symptoms, please call Dr. [**Last Name (STitle) 5351**] or report to the
nearest ER.
Followup Instructions:
(Your pain management appointment needs to be rescheduled)
Please follow-up with Dr. [**Last Name (STitle) 5351**] within 1 week.
Completed by:[**2151-2-25**]
|
[
"482.41",
"276.50",
"428.0",
"995.92",
"585.9",
"491.21",
"401.9",
"518.81",
"276.7",
"038.9",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"38.93",
"00.17",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9912, 10006
|
4776, 7243
|
245, 324
|
10161, 10196
|
2224, 4753
|
10651, 10813
|
1662, 1680
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7752, 9889
|
10027, 10027
|
7269, 7729
|
10220, 10628
|
1695, 2205
|
199, 207
|
352, 1433
|
10122, 10140
|
10046, 10101
|
1455, 1513
|
1529, 1646
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,280
| 185,830
|
11078
|
Discharge summary
|
report
|
Admission Date: [**2165-11-6**] Discharge Date: [**2165-11-7**]
Date of Birth: [**2092-11-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Bradycardia and hypotension s/p cath, SOB at initial
presentation
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
72-year-old male w/ hx of HTN, dyslipidemia, CAD s/p q-wave IMI
and CABG in 01 (LIMA --> LAD, SVG --> OM, SVG --> distal RCA)
and s/p Cypher DES to the right posterior lateral branch in '[**63**]
presented to CMI service last night for outpt cath after having
dyspnea on exertion and mild ST depressions in aVR during
recovery during stress test. At cath today became hypotensive to
70s and bradycardic when inserting catheter into the groin. Was
given atropine x 2 and placed on dopamine drip during the
procedure. After procedure the dopamine drip was weaned off and
pt again become hypotensive, another atropine amp was given
without good effect, therefore dopamine drip was restarted at
20, and pt transferred to the floor. At cath had no obstructive
disease in SVGs nor LIMA. CI was 2.7.
Prior to coming to the floor had CT scan of abdomen that was
negative for an RP bleed. CT scan did however reveal subtantial
scarring, interstitial disease, ?glass-ground appearance at the
base of the lungs although there were only a couple of cuts of
the lower lung included on the film. On review of the medical
chart there is a pre-op CXR in '[**59**] with "bilateral hazy and
reticular opacity in the mid and lower lung zones" but did not
have further work-up at that time. Of note, pt was started on
lasix 2 days ago since his cardiologist (Dr. [**Last Name (STitle) 11493**] though he
might have fluids in his lungs and wanted to give it a try but
pt does not have a dx of CHF. No other changes in meds. In
addition to poosibly being dehydrated from lasix, pt has over
the past few days pt has been spending a lot of time in the sun
and was NPO after MN for the procedure today.
.
Regarding the initial presentation, pt has had increasing
shortness of breath over the past month. Several weeks ago had
an URI with nasal secretions, was prescribed Advair by his PCP.
[**Name10 (NameIs) **] rhinitis improved but the shortness of breath did not. He
reports currently developing dyspnea with any exertion such as a
flight of stairs, inclines or heavy lifting. He initailly stated
he has never been short of breath prior to a month ago, but when
pressed further states he has had occasional episodes for which
he appararently had PFTs [**2-16**] yrs ago (records are not
available). He denies any hx of joint pains or ahces, rashes,
blood in urine, fevers. His profession was running cranes in
[**Location (un) 86**] and worked as an apple farmer as well. 9 years ago
developed neuropathy and during the work-up had a spinal which
revealed high levels of mercury, lead and other metals per wife.
Stress test on [**2165-11-4**], where he was able to exercise 3 minutes
on a standard [**Doctor First Name **] protocol stopping due to fatigue and dyspnea
achieving a peak heart rate of 122 bpm. He had 0.5-0.[**Street Address(2) 35782**]
depressions in aVR during recovery. Frequent PVC??????s, bigeminy,
couplets, pairs and APB??????s were noted.
.
When seen on the floor the dopamine had been weaned to 4. Pt had
an echo with normal EF (actually >65%) and no sign of tamponade.
Pt stated he had no CP, sob, palp, but was complaining of severe
leg cramps that he has from time to time but usually not this
bad. Pt was given 2mg of morphine for the leg pain and 500cc
bolus of NS with systolic pressures staying in 80s although pt
was completely asymptomatic and with UOP 260cc's over 2-3hrs
after arriving to CCU. EKG without change, enzymes negative at
cath. Dopamine drip was stopped and pt was given another 250cc's
of NS.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope
Past Medical History:
# CAD
- s/p q-wave IMI
- s/p CABG in [**2159-7-15**] (LIMA-LAD, SVG-OM, SVG-RCA)
- s/p Cypher DES to the right posterior lateral branch in '[**63**]
# Neuropathy approximately 9 years ago with mercury, zinc, lead
and arsenic levels elevated in spinal fluid
# Hx of presyncopal episode thought [**2-15**] vasovagal episode
# GERD
# Barrettes esophagus
# ? Arthritis (pt denies any previous hx of joint pains or
aches)
# S/P Right rotator cuff repair
# Tonsillectomy
Social History:
Previous smoker. Rare alcohol. Married with three grown
children. He is a retired [**Doctor Last Name 9808**] operator.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 98.4 , BP 91 , HR 80/52 , RR 22 , SaO2 89% on RA
Gen: Pt lying in bed in NAD. Oriented x3. Mood, affect
appropriate. Pleasant.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
Neck: No JVD
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: Fine mid-insipratory "dry" crackles. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use.
Abd: Obese, soft, NTND, No HSM or tenderness.
Ext: No c/c/e. No femoral bruits. R groin without audible bruit.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: 2+ femoral, 1+ DP,PD
Pertinent Results:
[**2165-11-6**] 10:10AM GLUCOSE-178* UREA N-17 CREAT-1.1 SODIUM-133
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-25 ANION GAP-15
[**2165-11-6**] 10:10AM estGFR-Using this
[**2165-11-6**] 10:10AM CK(CPK)-90
[**2165-11-6**] 10:10AM CK-MB-NotDone cTropnT-<0.01
[**2165-11-6**] 10:10AM WBC-8.1 RBC-5.07# HGB-15.8# HCT-45.2 MCV-89
MCH-31.1 MCHC-34.9 RDW-13.2
[**2165-11-6**] 10:10AM NEUTS-78.0* LYMPHS-16.3* MONOS-4.2 EOS-0.8
BASOS-0.6
[**2165-11-6**] 10:10AM PLT COUNT-296
[**2165-11-6**] 09:20AM TYPE-ART PO2-82* PCO2-45 PH-7.39 TOTAL CO2-28
BASE XS-1 INTUBATED-NOT INTUBA
[**2165-11-6**] 09:20AM HGB-15.7 calcHCT-47 O2 SAT-94
Brief Hospital Course:
Pt was admitted to the CCU for further work-up and treatment of
his hypotension and bradycardia. The impression of the CCU team
was that this was most consistent with a vagal response in the
setting of likely dehydration from recent lasix therapy, sun
exposure and NPO status for cath. Pt was completely asymptomatic
aside form leg cramps [**2-15**] dehydration. The sheath in the groin
was removed quickly, then pt was given a fluid bolus of 750cc
with reolution of hypotension and bradycardia, then weaned off
the dopamine drip. Maitainance fluids were kept overnight.
Also had nl echo, EKG unchanged, negative troponins to tamponade
and ROMI. Tele overnight wihtout any events. Beta blocker was
held overnight and then restarted on dischareg after resolution
of bradycardia and hypotension.
The cath that was done for dyspnea on exertion and mild ST
changes in single lead during recovery did not reveal any
lesions. The CCU team felt likely dyspnea was related to the
pulmonary process including substantial scarring seen on cuts of
CT abd and bilateral hazy and reticular opacity in the mid and
lower lung zones seen on CXR in '[**59**]; likely an ILD. The team
agreed pt need w/u for this including high-resolution CT chest,
PFT's and labs including [**Doctor First Name **], ACE, ANCA, RF, anti-GBM, HIV (+/-
BAL and/or biopsy if w/u inconclusive). The pt and his HCP
(wife) declined any work-up in hospital and wanted to have care
at [**Hospital3 7569**] under the care of Dr. [**Last Name (STitle) **]. The
discharge summary was sent to PCP. [**Name10 (NameIs) **] was sent out on home
advair, although he was asymptomatic when leaving the hospital.
.
Given cath results, unchanged EKG, and neg troponins did not
have an ACS and hypotensive episode not related to cardiac event
given start of vasovagal episode with insertion of catheter into
groin
.
Calf cramping was ikely related to dehydration as it resolved
with rehydration.
Medications on Admission:
Metoprolol 50 mg ?????? tab three times daily
Lovastatin 40 mg 1 tab daily
Lisinopril 10 mg 1 tab daily
Plavix 75mg 1 tab daily
Omeprazole 20 mg 1 tab daily
MVI 1 tab daily
ASA 81 mg 1 tab daily
Sucralfate 1 gm 2 tab [**Hospital1 **]
Advair 100/50 1 puff [**Hospital1 **]
Loratadine 10 mg 1 tab daily
Lasix 20 mg 1 tab daily **** started this med 2 days prior to
presentaton****
Discharge Medications:
1. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO three times a day.
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Omeprazole 10 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Sucralfate 1 gram Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Hypotension [**2-15**] vagal response and
dehydration
Secondary Diagnosis: Coronary Artery Disease
Gastroesophageal reflux disease
Intersitial lung disease
Discharge Condition:
stable
Discharge Instructions:
You were admitted for elective cardiac catheterization. During
the procedure, your blood pressure dropped and you required IV
medication to keep your blood pressures normal. Over the course
of your hospital stay, your blood pressure improved and at
discharge you had a normal blood pressure. A CT scan of your
abdomen also showed some fibrotic changes to your lungs. You
will need follow up with your PCP for [**Name Initial (PRE) **] further workup of this
pulmonary fibrosis.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 35783**] to make an
appointment to followup with your CT results and workup of the
pulmonary findings
Please call your cardiologist Dr. [**Last Name (STitle) 11493**] [**Telephone/Fax (1) 11650**]
|
[
"E879.0",
"427.69",
"414.00",
"530.81",
"401.9",
"427.89",
"458.29",
"276.51",
"272.4",
"V15.82",
"496",
"V45.81",
"412",
"716.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
9774, 9780
|
6585, 8538
|
382, 408
|
9999, 10008
|
5928, 6562
|
10538, 10839
|
5128, 5210
|
8968, 9751
|
9801, 9801
|
8564, 8945
|
10032, 10515
|
5225, 5909
|
277, 344
|
437, 4486
|
9895, 9978
|
9820, 9874
|
4508, 4975
|
4991, 5112
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,455
| 122,530
|
5271+5272+5273
|
Discharge summary
|
report+report+report
|
Admission Date: [**2135-2-23**] Discharge Date: [**2135-2-25**]
Service: [**Doctor Last Name **] Medicine
HISTORY OF PRESENT ILLNESS: This is a 76-year-old female
with a history of severe chronic obstructive pulmonary
disease with a FEV1 of 0.5, home O2, brought in by EMS after
calling for increased respiratory distress upon arrival and
there was a question of chest pain. Upon arrival, the EMS
nitroglycerin and 10 liters O2. Upon arrival to the
Emergency Room, the patient was breathing at 18, saturating
99% on 100% nonrebreather and denied any chest pain. She
reports that she called EMS because she was not feeling well.
Upon arrival to the Emergency Room, her temperature was 104??????
rectal. Her blood pressure was 140/70 and arterial blood gas
at this time was 748, 37, 207; this was on 100%
to the 80s systolic. Intravenous boluses were given to
increase her blood pressure to 130 systolic. She had no
electrocardiogram changes. Her chest x-ray was initially clear
however ?
Congestive heart failure after hydration. The patient was
given a dose of levofloxacin and clindamycin for the
questionable sepsis and she was given nebulizers and
prednisone 60 mg. Her O2 saturation increased to 95%. She
was weaned to 4 liters and she had improved subjective
respiratory status.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease. FEV1 of 0.5,
increased RV, decreased DLCO.
2. Hypertension.
3. Gastroesophageal reflux disease.
4. Increased lipids.
5. Catheterization in [**2128**], no coronary artery disease,
complicated by right femoral pseudoaneurysm.
6. Questionable congestive heart failure. Echocardiogram
[**11/2134**], normal LV, RV function, mild LA enlargement no left
ventricular hypertrophy, no mitral regurgitation.
7. Anxiety disorder
ADMISSION MEDICATIONS:
1. Albuterol metered dose inhaler 2 puffs q4.
2. Atrovent metered dose inhaler 3 puffs qid.
3. Serevent metered dose inhaler 2 puffs [**Hospital1 **].
4. Flovent 220 4 puffs [**Hospital1 **].
5. Lipitor 10 mg po q day.
6. Accolate 20 mg q day.
7. Lasix 40 mg q day.
8. KCL 20 mg qd.
9. Aspirin 325 q day.
10. Prilosec 20 q day.
11.xanax 0.5 mg qd
REVIEW OF SYSTEMS: No fevers, chills, night sweats, no
recent cough, denies vomiting or change in bowel habits, no
urinary symptoms. No increasing edema, no chest pain per
patient.
SOCIAL HISTORY: Lives alone, retired [**Hospital1 **] cafeteria
worker, greater than 50 pack years tobacco, quit '[**28**], no
alcohol.
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Temperature 99.8??????, heart rate 100, blood
pressure 130/65, respiratory rate 16, O2 saturation 95% on 4
liters.
GENERAL: She is an alert anxious female in mild respiratory
distress
with pursed lip breathing.
HEAD, EARS, EYES, NOSE AND THROAT: Normocephalic,
atraumatic. Extraocular movements were intact. Pupils
equal, round and reactive to light. Dry mucous membranes, no
lesions, rales.
NECK: There was no jugular venous distention.
LUNGS: Poor air movement, increased E:I ratio with
inspiratory wheezes, faint diffusely, no crackles. Decreased
breath sounds, expiratory at bases.
CARDIOVASCULAR: Distant heart sounds, regular rate, normal
S1, S2, no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended, normoactive bowel
sounds.
EXTREMITIES: 1+ pitting edema to mid calf bilaterally.
SKIN: Dry, well perfuse.
NEUROLOGIC: Alert and oriented to person and place, moving
all extremities on command. Cranial nerves II through XII
grossly intact.
ADMISSION LABS: White count 11, hematocrit 34; differential
86 polys, no bands, 9 lymphocytes, MCV 89, platelets 237.
INR 1.2, sodium 139, potassium 4.1, chloride 97, CO2 29, BUN
16, creatinine 1.2, ranging between 0.9 and 1.1, glucose 114.
Urinalysis: No whites, no reds, no nitrites, no bacteria,
CK1 119, troponin less than 0.3.
IMAGING: Chest x-ray right middle lobe infiltrate.
Electrocardiogram sinus tachycardia, low voltage diffusely. no
ischemic changes.
HOSPITAL COURSE: This is a 76-year-old female with chronic
obstructive pulmonary disease and hypertension who presents
with shortness of breath and fevers.
1. PULMONARY: Chronic obstructive pulmonary disease flare.
The patient was started on intravenous Solu-Medrol and was
later changed to po prednisone. Her shortness of breath greatly
diminished. She was given albuterol and Atrovent nebulizers
and was given her inhalers. Her O2 was weaned to her
baseline levels. Pneumonia: The patient was started on po
Levaquin and she will continue this for a 14 day course.
Given the acute onset shortness of breath,and history or
recurrent episodes of similar sxs pulmonary embolism needed to
be excluded. She had a CT angiogram performed which
demonstrated no pulmonary embolism, however demonstrated two
pulmonary nodules that could represent inflammatory change
and 19 mm epicardial lymph node. This will need to be
followed up in three months with a follow up scan.
2. INFECTIOUS DISEASE: The patient remained afebrile. She
continued on Levaquin for a 14 day course for the infiltrate.
Blood cultures were sent, no growth to date.
3. CARDIOVASCULAR: Her enzymes were cycled, which were
flat.
4. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
continued on a regular diet.
5. DISPOSITION: The patient had a PT consult who
recommended that she would benefit from [**Hospital 3058**]
rehabilitation.
6. Anxiety Disorder: Pt with significant anxiety requiring xanax
at baseline. This was increased to TID dosing in house.
7. GERD: pt with h/o GERD. While here she did c/o epigastric
burning. her prilosec was doubled prior to discharge.
8. Guaiac + stool noted X1 during this admit. In addition she is
anemic with Hct 29-30. Iron studies suggest anemia of chronic
disease. She will need outpatient GI eval with colonoscopy after
her pulmonary issues stablize.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease exacerbation.
2. Pneumonia.
3. Anxiety disorder
4. Anemia
5. Guaiac Positive stool
6. Lung nodules on chest CT
DISCHARGE MEDICATIONS:
1. Albuterol metered dose inhaler 2 puffs q4.
2. Atrovent metered dose inhaler 3 puffs qid.
3. Serevent metered dose inhaler 2 puffs [**Hospital1 **].
4. Flovent 220 4 puffs [**Hospital1 **].
5. Lipitor 10.
6. Accolate 20.
7. Lasix 40 mg po q day.
8. KCL 20 mg po q day.
9. Levaquin 500 mg po q day x14 days.
10. Aspirin.
11. Prilosec 20.
12. O2 to maintain saturation greater than 90%.
13. Prednisone 50 mg po q day x2 days, then 55 mg po x2 days,
then 50 mg po x2 days, then 45 mg po x2 days, then 40 mg po
x2 days, then 35 mg po x2 days, then 30 mg po x2 days, then
25 mg po x2 days, then 20 mg x2 days, then 15 mg po x2 days,
then 10 mg po x2 days, then 5 mg po x2 days, then off.
14. Xanax 0.5 PO bid with 3rd dose prn
DIET: She should be on a low cholesterol, low salt diet.
FOLLOW UP: The patient will follow up with her primary care
provider (Dr. [**Last Name (STitle) **] in two weeks. She will follow up sooner if
she has
any other concerns.
The patient will be discharged to rehabilitation.
ADDENDUM: On the day of expected transfer pt developed severe
SOB and CP (?epigastric vs chest). She improved with maalox and
xanax but continued to feel that her breathing was worse than
the prior day. We elected to keep her in house for continued
observation. her solumedrol was re-started and her prilosec was
doubled. of note her EKG was unchanged at the time of her sxs.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 3023**]
Dictated By:[**Last Name (NamePattern1) 20334**]
MEDQUIST36
D: [**2135-2-25**] 07:41
T: [**2135-2-25**] 07:38
JOB#: [**Job Number 21531**]
Admission Date: [**2135-2-23**] Discharge Date:[**2135-3-18**]
Service:
ADDENDUM: This is a 76-year-old female with a history of
chronic obstructive pulmonary disease, hypertension,
gastroesophageal reflux disease and hyperlipidemia, who was
admitted with a chronic obstructive pulmonary disease flare
on [**2135-2-23**]. The patient was treated initially with
improved clinically over two days.
On [**2135-2-25**] the patient was close to discharge when, on the
evening of [**2135-2-25**], she developed an acute episode of
tachypnea, shortness of breath, hypertension and poor air
movement that did not respond to nebulizers. Arterial blood
gases at this time revealed a pH of 7.2, a pCO2 of 96 and a
6.97, a pCO2 of 118 and a pO2 of 91. The patient was
intubated and transferred to the Medical Intensive Care Unit.
The patient remained intubated for 12 days. She was treated
with intravenous Solu-Medrol, theophylline and nebulizers.
She received a total of ten days of ceftriaxone and
azithromycin. The hospital course was complicated by an
Methicillin resistant Staphylococcus epidermidis sepsis. The
patient will need to complete a 14 day course of vancomycin
for this.
The patient also had her Medical Intensive Care Unit course
complicated by thrush that persisted after five days of
treatment with fluconazole. In addition, the patient
experienced glucose intolerance and was started on a regular
insulin sliding scale. The patient was extubated without any
problems and two days later was transferred to the medical
floor rule out continued management. The patient also had
hypertension tachycardia, for which she was started on
Norvasc and ACE-I.
MEDICATIONS ON TRANSFER FROM MEDICAL INTENSIVE CARE UNIT:
Aspirin 325 mg p.o. q.d..
Accolate 20 mg.QD
Prilosec 20 mg.QD
Lipitor 10 mg.QD
Norvasc 5 mg b.i.d.
Prednisone 20 mg QD.
Tylenol 650 mg.
Valium 2.5 mg every six hours.prn
Albuterol.
Insulin sliding scale.
Atrovent.
TUMS
Mycelex.
Fluconazole and vancomycin.
Klonopin 0.5 [**Hospital **]
HOSPITAL COURSE THROUGH [**2135-3-13**]:
1. PULMONARY/CHRONIC OBSTRUCTIVE PULMONARY DISEASE: The
patient was continued on prednisone at 30 mg q.d. This will
need to be tapered prior to discharge. She will continue on
Flovent, Atrovent, accolate and Serevent inhalers as well as
p.r.n.
albuterol. The patient's oxygen was weaned as tolerated.
2. CARDIOVASCULAR: The patient was started no Norvasc 5 mg
b.i.d. for hypertension. An ACE inhibitor, Captopril, was
also started and medications were titrated as her blood
pressure tolerated.
3. INFECTIOUS DISEASE: The patient had Methicillin
resistant Staphylococcus epidermidis line sepsis and will
need a total of 14 days of intravenous vancomycin. The
patient had oral thrush and was currently being treated for
Fluconazole. She will need to remain on this until the flush
had resolved.
4. ENDOCRINE: The patient had a glucose intolerance secondary
to steroids. She was continued on a regular insulin sliding
scale. Her fingersticks gradually improved throughout her
hospitalization.
5. ANXIETY: The patient had an episode in which she
expressed suicidal ideation. The Psychiatry Service was
consulted and at that time it was felt that the patient was
delirious. The patient denied any further thoughts of
suicidal ideation. Her Klonopin was discontinued and she was
started back on Xanax 0.5 mg p.o. b.i.d. for her anxiety.
6. OTHER: The patient had generalized weakness, most likely
secondary to deconditioning and steroids. A Physical Therapy
Service consultation was obtained. The patient was to be
discharged to rehabilitation.
7. LINES: The patient had a central line in place. This
will need to be changed over to a PICC line prior to
discharge to complete her 14 day course of vancomycin.
NOTE: This discharge summary will need to be addended. This
covers hospital course through 4/1/[**Numeric Identifier 13462**]. The patient is
currently being screened for rehabilitation.
Dictated By:[**Last Name (NamePattern1) 20334**]
MEDQUIST36
D: [**2135-3-13**] 14:31
T: [**2135-3-13**] 16:12
JOB#: [**Job Number 21532**]
Admission Date: [**2135-2-23**] Discharge Date: [**2135-3-18**]
Service: [**Doctor Last Name 1181**] MEDICINE SERVICE
ADDENDUM
ADMISSION DIAGNOSIS: Chronic obstructive pulmonary disease
exacerbation.
HOSPITAL COURSE: Continued from [**3-13**].
1. Chronic obstructive pulmonary disease: The patient
continued to do well on minimal oxygen supplementation which
is her baseline. She is currently on 2 L nasal cannula with
an oxygen saturation between 94 and 97%. An ABG was repeated
on the morning of [**2135-3-14**], which revealed a pH of 7.40,
and a slow taper decreasing by 5 mg every 7 days is to be
continued. She is back on her baseline dose of Serevent 2
puffs b.i.d., as well as Flovent 110 mcg 8 puffs b.i.d. She
continued on nebulizer treatments as needed, as well as
Accolate 20 mg p.o. q.d. There was no recurrence of wheezing
or respiratory distress. No PFTs were repeated during this
hospitalization.
2. Mental status changes/delirium: When I met the patient
on [**3-14**], she was disoriented times three and was unable to
follow commands and was somewhat lethargic. The differential
was brought at that point in time; however, her electrolytes
remained normal. She had no new infectious sources. She had
received Klonopin. Her last dose was [**3-12**]. She was
started on this for a long-standing history of anxiety. She
was switched to Xanax on [**3-13**], and this was discontinued,
the last dose being [**2135-3-15**]. After this was stopped,
her delirium cleared on a daily basis. She is now oriented
times three with self-correction and quite interactive. She is
still a bit slower than baseline at the time of discharge.
3. Upper extremity weakness: The patient had profound upper
extremity weakness noted during her delirious state; however,
was unable to further evaluate until her delirium cleared.
When it did clear, it was noted that she had no wrist flexion
or extension strength at all, as well as any interosseous
muscle strength bilaterally. She was able to lift her left
arm over head, however, not her right arm. She had
significant muscle atrophy in both hands, as well as her
forearm. She also had rpofound weakness of bilat lower
extremities but not as severe as the upper extremities. She has
known history of lumbar osteoarthritis. It
was felt that perhaps she is suffering from cervical
spondylosis. She did not have any asymmetric facial droop or
muscle weakness. She does have, in addition, lower extremity
weakness and no rigidity noted in her muscles. She has
normal muscle tone in her lower extremities.
At this point in time, a Neurology consult was obtained to
further assist in determining whether she had truly a
cervical process versus a peripheral myopathy/neuropathy.
Their impression, as well, was that she may have a cervical
process, and an MRI would be helpful to rule out osteophytes
in her cervical spine; however, the patient did not want to
undergo the MRI secondary to claustrophobia. We did offer
her a soft cervical neck collar which she will wear
throughout her rehabilitation until she has improved. The
other question was whether or not she had a myopathy, steroid
induced, or a peripheral neuropathy in the post Intensive
Care Unit setting. The patient was scheduled to undergo EMG
on the morning of discharge to help further delineate this
diagnosis however she refused this study. however, a quick taper
of her steroids is not in
her best interest, as we do not want her to go back into
chronic obstructive pulmonary disease exacerbation.
Therefore, there will be no management changes; this
particular test will just help diagnosis. She is a poor
surgical candidate, if indeed she does have significant
cervical spondyloarthropathy, and therefore, insisting on an
MRI is not indicated.Of note pt did not have any significatn
weakness or upper extremity dysfunction at the time of admission
so most of sxs likely related to steroids and effects of ICU.
Cardiovascular: She does have a history of hypertension;
however, with aggressive control of her hypertension, her
delirium did surface. She was on an ACE inhibitor and
Norvasc which were both discontinued as we wanted to eliminate
any new meds and her BP seemed to be normalizing with decrease
of steroids, and her blood pressures
are currently are running in the 130-140 systolic range. She
may require to have an antihypertensive re-added at a later
date; however, we will hold at this point in time.
Anemia: The patient's hematocrit continued to drift
downward. She required a transfusion of 1 U on [**2135-3-17**]. She has chronic OB positive stool noted prior to her
MICU stay. Lower GI scoping was deferred at this point in
time, as the patient is recuperating from her prolonged MICU
hospitalization. Perhaps this will be readdressed after her
rehabilitation stay; however, her overall prognosis is pretty
poor considering her extensive chronic obstructive pulmonary
disease, and this will need to be discussed between her and
her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
Infectious disease: She did have a central venous catheter
in from which 1 out of 4 bottles of coag negative staph grew.
She was started on Vancomycin in the Intensive Care Unit, in
the setting of multiple blood cultures being positive from
central line sites. She will finish her Vancomycin course on
[**2135-3-18**]. Otherwise, she had no other infectious
disease issues. She was on Fluconazole during her hospital
stay while on Prednisone for thrush; however, now she is on
Mycelex.
DISPOSITION: The patient will be discharged to [**Hospital 21533**]
Rehabilitation.
DISCHARGE DIAGNOSIS:
1. Chronic obstructive pulmonary disease exacerbation status
post 12-day intubation.
2. Hyperlipidemia.
3. History of gastroesophageal reflux disease.
4. possible Cervical spondylosis
5. Occult blood positive stool with anemia of chronic
disease on iron studies.
6. Severe anxiety disorder
7. Myopathy/neuropathy due to steroids +/_ ICU
8. GERD
9. Staph Epi bacteremia
8. Severe Oral Thrush
9. Delirium- resolved
DISCHARGE MEDICATIONS: Serevent 2 puffs b.i.d., Flovent 110
mcg 8 puffs b.i.d., Prednisone 15 mg p.o. q.d. until [**3-19**],
and then 10 mg q.d. for 7 days, then 5 mg p.o. q.d. for
another 7 days, and then off, Albuterol and Atrovent MDIs q.4
hours p.r.n., Accolate 20 mg p.o. q.d., Prilosec 20 mg p.o.
[**Hospital1 **], Lipitor 10 mg p.o. q.d., Aspirin 325 mg p.o. q.d.,
Multivitamin 1 tab p.o. q.d., TUMS 1000 mg p.o. t.i.d.,
Heparin 5000 U subcue b.i.d. until the patient is more
mobile.Xanax 0.5 mg po bid prn anxiety. Hold for
sedation/confusion.
DISCHARGE INSTRUCTIONS: She should continue having b.i.d.
sugar checks; however, in-house she has had very little
Insulin requirement.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) **], who
is her primary care physician.[**Name10 (NameIs) **] will need f/u of guaiac +
stools and f/u of 2 tiny nodules noted on CT angio of Chest
early in her admission.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 3023**]
Dictated By:[**Name8 (MD) 21534**]
MEDQUIST36
D: [**2135-3-17**] 17:06
T: [**2135-3-17**] 19:22
JOB#: [**Job Number 14500**]
cc:[**Hospital1 21535**]
|
[
"996.62",
"491.21",
"292.82",
"530.81",
"112.0",
"401.9",
"428.0",
"038.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5886, 5894
|
5915, 6073
|
18103, 18633
|
17662, 18079
|
12195, 17641
|
18658, 19329
|
1820, 2176
|
2523, 3513
|
6902, 12103
|
12125, 12177
|
2196, 2360
|
146, 1307
|
3530, 3981
|
1329, 1797
|
2377, 2508
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,054
| 178,387
|
32794
|
Discharge summary
|
report
|
Admission Date: [**2151-11-28**] Discharge Date: [**2151-12-1**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
PA catheter placement
History of Present Illness:
86 F NH resident with no previous diagnosis of CAD. Presents
with 2 weeks of intermittent chest pain, worse on the day of
presentation. Describes the pain as a pressure, heaviness,
non-radiating. Associated with nausea, emesis, and diaphoresis,
but no SOB.
.
On arrival, EMS found her seated in chair, vomiting. O2 sat 96%
on 4L by NC. 12-lead ECG showed anterior ST elevations. Received
ASA, SL NTG x 3, morphine 4 IV, with no relief in pain.
.
In [**Hospital1 18**] ED, received Plavix 600, metoprolol 5 IV x 2, heparin
IV bolus, and Integrillin IV bolus. Sent for cath, which
revealed ostial LAD TO which was POBA'ed. IABP placed given
depressed CI.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
She denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Depression requiring ECT
GERD
Osteoporosis
Diverticulosis
Dementia
? Hypothyroid
Social History:
Social history is significant for the absence of tobacco use.
There is no history of alcohol abuse or recreational drug use.
She was previously employed as a bank clerk, but retired at the
age of 65.
Family History:
Her mother died of heart disease at the age of 66.
Physical Exam:
VS: T , BP 83/51, assisted/augmented 82/137, HR 64, RR 21, O2
100% on NRB
Gen: elderly female in NAD, resp or otherwise. Mood, affect
appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with no JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: Cool.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Radial 2+, DP/PT dopplerable
Left: Radial 2+, DP/PT dopplerable
Pertinent Results:
[**2151-11-28**] 06:35PM BLOOD WBC-10.6 RBC-4.18* Hgb-12.5 Hct-36.7
MCV-88 MCH-29.8 MCHC-34.0 RDW-15.0 Plt Ct-556*
[**2151-11-30**] 04:25AM BLOOD WBC-9.7 RBC-3.29* Hgb-9.8* Hct-28.3*
MCV-86 MCH-29.9 MCHC-34.8 RDW-14.9 Plt Ct-254
[**2151-11-28**] 06:35PM BLOOD PT-14.4* PTT-150* INR(PT)-1.3*
[**2151-11-30**] 04:25AM BLOOD PT-14.8* PTT-79.3* INR(PT)-1.3*
[**2151-11-28**] 06:35PM BLOOD Glucose-187* UreaN-13 Creat-0.9 Na-132*
K-5.8* Cl-96 HCO3-21* AnGap-21*
[**2151-11-30**] 04:25AM BLOOD Glucose-127* UreaN-16 Creat-0.9 Na-131*
K-4.4 Cl-101 HCO3-21* AnGap-13
[**2151-11-29**] 02:30AM BLOOD ALT-63* AST-477* CK(CPK)-1354*
AlkPhos-11* TotBili-0.2
[**2151-11-30**] 04:25AM BLOOD ALT-44* AST-140* CK(CPK)-763* AlkPhos-53
TotBili-0.3
[**2151-11-28**] 06:35PM BLOOD CK-MB-192* MB Indx-20.7*
[**2151-11-28**] 06:35PM BLOOD cTropnT-1.27*
[**2151-11-29**] 02:30AM BLOOD CK-MB->500 cTropnT-14.15*
[**2151-11-29**] 11:03AM BLOOD CK-MB-229* MB Indx-13.9*
[**2151-11-29**] 04:36PM BLOOD CK-MB-102* MB Indx-48.8* cTropnT-4.02*
[**2151-11-29**] 09:59PM BLOOD CK-MB-60* MB Indx-7.2* cTropnT-4.10*
[**2151-11-30**] 04:25AM BLOOD CK-MB-32* MB Indx-4.2 cTropnT-3.37*
[**2151-11-28**] 11:04PM BLOOD Calcium-9.1 Mg-1.9
[**2151-11-30**] 04:25AM BLOOD Calcium-8.0* Phos-2.8 Mg-1.9
[**2151-11-29**] 03:30PM BLOOD %HbA1c-6.0*
[**2151-11-30**] 04:25AM BLOOD Osmolal-275
[**2151-11-29**] 11:03AM BLOOD TSH-3.1
[**2151-11-30**] 04:25AM BLOOD TSH-2.7
.
ECG initially demonstrated SR with RBBB & anterolateral ST
elevations up to 4mm in v2-v6, I & aVL. Qs v1-v5, I & aVL.
.
TELEMETRY demonstrated: SR in 70s.
.
CARDIAC CATH performed on [**11-28**] demonstrated:
.
LMCA:
LAD: 100% origin with R -> L collats to very distal LAD
LCx: nl
RCA: nl
.
HEMODYNAMICS:
.
RA: 13
PA: 43/19/29
PCW: 25
.
[**2151-11-29**] ECHO EF 30%
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
severe hypo/akinesis of the distal half of the septum and
anterior walls and distal inferior and lateral walls. The apex
is mildly aneurysmal and dyskinetic. The basal segments contract
well. No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is moderate thickening and
redundancy/systolic anterior motion of the mitral valve chordae.
The estimated pulmonary artery systolic pressure is normal.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Symmetric left ventricular hypertrophy with
extensive regional systolic dysfunction c/w CAD (mid-LAD
lesion). Increased LVEDP.
.
[**2151-11-30**] CXR
FINDINGS: Compared to the film from the prior day, there is a
new left effusion with new left lower lobe volume loss. A
femoral Swan-Ganz catheter with tip in the right pulmonary
artery is unchanged. The alveolar infiltrate on the right has
improved, but there continue to be interstitial markings that
are increased in both upper lobes. There is some moderate right
effusion that has also increased.
IMPRESSION: Likely CHF with volume loss in the left lower lobe.
While the alveolar infiltrate on the right has improved, the
increased interstitial markings and bilateral pleural effusions
have worsened.
Brief Hospital Course:
86 F w/o PMH of CAD presents with lg anterior STEMI. Hospital
course complicated by:
.
# STEMI: Presentation ECG showed ST elevations across anterior
precordial as well as high lateral leads, unfortunately already
with Qs. Presentation CK was already near 1000. Cath showed 1vd
with TO of ostial LAD. s/p POBA. Received ASA, Plavix, statin,
heparin gtt, integrillin x 18h. Initially started metoprolol &
captopril but then held [**1-8**] hypotension. ECHO showed depressed
EF w/ apical aneurysm so heparin ggt was continued with plan for
transition to coumadin.
.
# Respiratory: Was hypoxic/hypoxemic throughout hospital stay.
CXR showed ? RML PNA so was initially started on levo for CAP
coverage but then Vanc was added as she continued to spike
fevers and also with concern for line infection given her R
femoral line/PA catheter.
.
# Pump: EF 30%. Was continued on heparin ggt with eventual
transition to prevent apical thrombus.
.
On [**11-30**] a family meeting was held and the decision was made to
change goals of care to comfort measures only as this was
thought to be consistent with her wishes given her poor
prognosis. She had been very uncomfortable while in the CCU and
wished to be "left alone". She was initially treated with
morphine boluses and then transitioned to morphine ggt as she
continued to have respiratory distress. She passed on [**2151-12-1**]
with her granddaughter at her bedside.
Medications on Admission:
ASA 81
MVI
Lactulose 15 cc qam
Bupropion 100 [**Hospital1 **]
Fosamax 70 qwk
Vit D 800 qd
Sennakot qd
Prilosec 20 qd
Aricept 10 qhs
Seroquel 75 qhs
Remeron 7.5 qhs
Trazodone 50 qhs
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"428.0",
"294.8",
"244.9",
"562.10",
"785.51",
"780.6",
"V66.7",
"530.81",
"428.41",
"996.09",
"410.01",
"414.2",
"311",
"733.00",
"799.02",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.61",
"00.66",
"97.44",
"37.23",
"00.40",
"99.20",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7921, 7930
|
6242, 7663
|
254, 301
|
7976, 7980
|
2668, 6219
|
8031, 8036
|
1853, 1905
|
7894, 7898
|
7951, 7955
|
7689, 7871
|
8004, 8008
|
1920, 2649
|
204, 216
|
329, 1516
|
1538, 1620
|
1636, 1837
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,950
| 131,828
|
48519
|
Discharge summary
|
report
|
Admission Date: [**2123-2-26**] Discharge Date: [**2123-3-4**]
Date of Birth: [**2083-3-22**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Biliary obstruction
Major Surgical or Invasive Procedure:
[**2123-2-26**]: Cholecystectomy, Roux-en-Y hepaticojejunostomy to right
posterior hepatic duct and confluence of right anterior and left
hepatic ducts over two 5-French feeding tubes
History of Present Illness:
39-year-old male who underwent
a subtotal gastrectomy, omentectomy, radical lymph node
dissection of the left gastric area, multiple frozen sections,
and feeding jejunostomy on [**2120-10-1**] for a 4.5-cm
poorly
differentiated adenocarcinoma, diffuse type, signet ring cell
carcinoma with no evidence of lymph node metastases (pT2b pN0 G3
pMx). There were three out of nine lymph nodes involved.
However, the radial (omental) margin was involved by invasive
carcinoma. Because of the positive margins and relatively few
lymph nodes, he was treated for a high-risk stage IB with
adjuvant chemoradiation (concurrent 5-FU followed by two cycles
of 5-FU from [**2120-12-14**]-[**2121-4-15**]).
He presented in [**2122-10-15**] with jaundice and an elevated
bilirubin. An ERCP on [**2122-12-3**] demonstrated a tight
stricture in the common hepatic duct. A stent was placed and a
sphincterotomy performed. He presented on [**2122-12-8**]
with
fever, abdominal pain, and elevated liver function tests, and
repeat ERCP was required to replace the stent. He was placed on
antibiotics for Klebsiella bacteremia, and a percutaneous
cholecystostomy tube was placed on [**2122-12-11**]. Repeat
ERCP (his most recent) was performed on [**2122-12-12**] and
the
stent was changed. He has failed followup appointments for
repeat ERCP. It should be noted that cytology from the ERCPs on
[**2122-12-8**] and [**2122-12-12**] were negative for
malignancy.
Since his last hospitalization he has been doing well at home.
He
states that the cholecystostomy tube has not been draining over
the past several days. A CT scan of the abdomen on [**2122-12-16**] demonstrated intrahepatic biliary dilatation, although the
biliary stent and pigtail catheter within the fundus of the
collapsed gallbladder were in the expected position. He had no
evidence of a portal mass or evidence of metastatic disease.
Therefore, it was thought that this stricture is a benign
postradiation stricture. It should be noted that he has a
Billroth II reconstruction.
Past Medical History:
- ONCOLOGIC HISTORY: partially obstructing gastric cancer after
presentation with nausea/vomiting, epigastric discomfort,
intolerance of solid food and a 30lbs weight loss
- Diagnosed with gastric antral adenocarcinoma s/p subtotal
gastrectomy with a Billroth II anastomosis, omentectomy, and
radical lymph node dissection of left gastric area ([**2120-10-1**]) s/p
adjuvant chemo [**12-21**] to [**4-22**]
- Pathology revealed a exophytic (polypoid), infiltrative,
annular 4.5cm, pT2b, G3, pNO with 0 out of 9 lymph nodes
involved. However, the radial (omental) margin was involved by
invasive carcinoma (Cytokeratin stain). Because of the positive
margins and relatively few lymph nodes, he was treated for high
risk Stage IB with adjuvant chemoradiation (concurrent 5FU
followed by two cycles of 5FU)([**12-21**] to [**4-22**]). Repeat endoscopy
and CT imaging negative for recurrence in [**2122**]
- Found to have rising total bilirubin, jaundice, and worsening
pruritis, s/p ERCP [**2122-11-19**] (unsuccessful) and subsequently on
[**12-3**], at which time a biliary stent was placed under general
anesthesia
Social History:
He lives in [**Location 669**] with his wife and has an 11 year old son.
Denies ethanol, tobacco, and recreational drug use. Unemployed
chef.
Family History:
He has no family history of cancer. Father has diabetes, mother
had nephrectomy for nephrolithiasis. Maternal grandmother had
"stomach" cancer.
Physical Exam:
On discharge:
VS: T: 98.6, HR: 98, BP: 115/72, RR: 18, Sat: 94%RA
Gen: NAD
HEENT: MMM, no erythema
CV: RRR, no m/r/g
Resp: CTAB
Abd: soft, minimal tenderness, incision c/d/i. roux-tubes x2 in
place coiled under dressing, capped. +BS
Ext: wwp, no edema
Pertinent Results:
[**2123-2-27**] 04:50AM BLOOD WBC-18.3*# RBC-4.42* Hgb-12.0* Hct-38.7*
MCV-88 MCH-27.3 MCHC-31.1 RDW-14.4 Plt Ct-397
[**2123-3-3**] 06:10AM BLOOD WBC-9.1 RBC-4.37* Hgb-12.2* Hct-37.3*
MCV-85 MCH-28.0 MCHC-32.8 RDW-14.3 Plt Ct-472*
[**2123-2-28**] 05:55AM BLOOD PT-12.5 PTT-29.1 INR(PT)-1.1
[**2123-2-26**] 08:19PM BLOOD Glucose-133* UreaN-8 Creat-0.6 Na-142
K-3.9 Cl-106 HCO3-25 AnGap-15
[**2123-3-3**] 06:10AM BLOOD Glucose-98 UreaN-10 Creat-0.7 Na-136
K-4.3 Cl-97 HCO3-27 AnGap-16
[**2123-2-27**] 04:50AM BLOOD ALT-112* AST-104* AlkPhos-1024*
TotBili-1.8*
[**2123-3-4**] 06:25AM BLOOD ALT-48* AST-40 AlkPhos-524* TotBili-1.2
[**2123-2-26**] 08:19PM BLOOD Calcium-9.1 Phos-5.0* Mg-1.5*
[**2123-3-3**] 06:10AM BLOOD Albumin-3.3*
Hepatic U/S [**2123-2-27**]:
IMPRESSION: Slight dampening of the right hepatic artery
systolic upstroke
and increased diastolic flow, of uncertain etiology
Tube Cholangiogram [**2123-3-3**]:
CONCLUSION: Excellent drainage through the right as well as the
left
hepaticojejunal anastomosis with no evidence of leak.
Brief Hospital Course:
The patient was admitted to the Transplant Surgery Service on
[**2123-2-26**]. After a brief, uneventful stay in the PACU, the patient
arrived on the floor NPO with NGT in place, on IV fluids and
peri-operative Unasyn for antibiotics, with a foley catheter,
and dilaudid PCA for pain control. The patient was
hemodynamically stable.
Neuro: The patient received dilaudid PCA with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint, although he was persistently tachycardic to the
100s. EKG showed sinus tachycardia, the patient reported no
symptoms. Vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. NGT was placed in the OR and discontinued on POD2. His
diet was then advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Foley was removed on
POD3. Electrolytes were routinely followed, and repleted when
necessary. JP bilirubin was sent on POD1 which was normal. His
JP drain was removed on POD3. His roux tubes were capped after
tube cholangiography on POD5. He received an H2 blocker during
his stay for prophylaxis.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. He received 3 doses of
perioperative unasyn, and was placed on oral ciprofloxacin for
drain prophylaxis.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Tylenol PRN
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
h/o gastric ca
bile duct stricture from radiation
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you have any of
the warning signs listed below.
You may shower
Do not apply lotion/powder/ointment to incisions
No driving while taking pain medication
Followup Instructions:
Provider: [**Name10 (NameIs) 6122**] WEST INPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2123-3-3**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2123-3-10**] 9:40
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2123-4-7**] 2:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2123-3-5**]
|
[
"V10.04",
"576.2",
"909.2",
"E879.2",
"530.81",
"575.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"87.54",
"51.22",
"51.37"
] |
icd9pcs
|
[
[
[]
]
] |
8272, 8329
|
5399, 7735
|
332, 518
|
8423, 8423
|
4330, 5376
|
8818, 9419
|
3898, 4043
|
7797, 8249
|
8350, 8402
|
7761, 7774
|
8568, 8795
|
4058, 4058
|
4072, 4311
|
273, 294
|
546, 2584
|
8437, 8544
|
2606, 3722
|
3738, 3882
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,348
| 179,548
|
48049
|
Discharge summary
|
report
|
Admission Date: [**2182-8-1**] [**Month/Day/Year **] Date: [**2182-8-23**]
Date of Birth: [**2103-1-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / ciprofloxacin / Cephalosporins
Attending:[**First Name3 (LF) 3063**]
Chief Complaint:
Weakness/Fluid Overload
Major Surgical or Invasive Procedure:
drainage of pericardial effusion
drainage of plerual effusion
pleacement and removal of temporary dialysis catheter
placement of tunneled dialysis catheter
History of Present Illness:
79M with PHX h/o A Fib on Coumadin, moderate to severe AI s/p
AVR [**2182-6-27**], reccently readmitted [**7-15**] for BRBPR likely [**1-17**]
anticoagulation and diverticulosis and was discharged [**7-23**] to
[**Hospital1 100**] Home, now readmitted for worsening weakness and fluid
overload. Patient states that since he was sent to [**Hospital 100**] Rehab,
he has gotten worse, not better. He can participate in the
physical therapy, but he is not able to walk with his walker as
well as before. His breathing is not much worse than baseline-
he mostly feels weak.
He was seen by Dr [**Last Name (STitle) 911**] in office [**7-31**] who found the patient to
be in fluid overload and he is admitted for monitoring of his
fluid status in house with likely IV diuresis.
While in house previous admission, Aspirin was stoppd and
coumadin continued. Patient was also complaining of new stool
incontinence, was found to be c. diff positive per PCR and was
started on 2 weeks of metronidazole to be completed on [**2182-8-2**].
On the same admission patient had TTE's on [**7-19**] and [**7-22**] which
demonstarted moderate pericardial effusion without signs of
tamponade (likely [**1-17**] recent CT surgery). Admission was c/b
initially difficult to control Afib/RVR which was finally
controled with diltiazem CD 120 mg po daily and metoprolol
tartrate 75 mg po daily; also had fluid over load (known CHF
with LVEF 45%) which was treated with IV diureis. He was
discharged to [**Hospital 100**] Rehab on [**7-23**].
.
On arrival to the floor, patient is comfortable with no
complaints.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains, cough, or hemoptysis. S/he denies recent fevers, chills
or rigors. S/he denies exertional buttock or calf pain. All of
the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
syncope or presyncope.
The patient does have occasional PND, [**1-18**] pillow orthopnea,
occasional palpitations from his A Fib, and sometimes trouble
breathing on exertion.
Past Medical History:
- Moderate-to-severe aortic insufficiency with dilated LV (LVEF
50-55%), s/p bioprosthetic AVR on [**2182-6-27**]
- Recent cardiac catheterization showing no obstructive
coronary artery disease, however, found to have elevated filling
pressures, requiring diuresis
- Atrial fibrillation, currently on Coumadin for
thromboembolic prophylaxis
- Hypertension
- Kidney transplant in [**2155**] due to PCKD, the baseline
creatinine approximately 1.6
- Hyperlipidemia
- Peripheral neuropathy
- Diverticulitis
- Pseudogout
- Osteoporosis
Social History:
Patient previously worked as an engineer for channel 5. He
currently lives in a house himself. His wife passed away 9 years
ago. Prior history of 3 ppd X 20 years, quitting 34 years ago.
Occasional ETOH (few beers per week). No illicits. His daughters
([**Doctor First Name **] (daughter) - ([**Telephone/Fax (1) 101330**], [**Female First Name (un) **] (daughter)
[**0-0-**]) are very involved.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ON ADMISSION
VS- T=98.1 BP=103/69 HR=101 RR=18 O2 sat=97RA Pulsus-10mmHg
GENERAL- in mild resp distress. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple with JVP of 16 cm.
CARDIAC- PMI located in 5th intercostal space, midclavicular
line. irregularly irregular, normal S1, S2. No murmurs
appreciated. No thrills, lifts. No S3 or S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were somewhat labored, [**Month (only) **] breath sounds b/l bases
ABDOMEN- Soft, NTND. No HSM or tenderness, mild ascites
percussed, Abd aorta not enlarged by palpation. No abdominial
bruits.
EXTREMITIES- warm, pulses not well palpated, 3+ pitting edema
distal LE up to lower knee b/l
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
Back- 2+ pitting sacral edema
[**Month (only) 894**]
VITAL SIGNS: 98.0. 85. 140/76. 24. 98% RA
GENERAL: A&Ox3. NAD.
HEENT: Sclera anicteric. PERRL, EOMI, MMM. JVP not elevated.
CARDIAC: irregularly irregular, nl S1, S2. III/VI systolic
ejection murmur.
LUNGS: Decreased breath sounds bilaterally at bases.
ABDOMEN: +BS, soft, NTND. No HSM.
EXTREMITIES: 1+ lower ext edema bilaterally to ankles.
SKIN: large ecchymosis on left leg and small ecchmyosis around
tunneled cath site.
ACCESS: tunneled catheter in place.
Pertinent Results:
ON ADMISSION
[**2182-8-1**] 07:30PM GLUCOSE-150* UREA N-57* CREAT-1.8* SODIUM-141
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
[**2182-8-1**] 07:30PM CALCIUM-8.3* PHOSPHATE-3.5 MAGNESIUM-1.7
[**2182-8-1**] 07:30PM WBC-5.5 RBC-3.65* HGB-11.3* HCT-36.7*
MCV-101* MCH-31.0 MCHC-30.8* RDW-19.4*
[**2182-8-1**] 07:30PM PLT COUNT-162
[**2182-8-1**] 07:30PM PT-40.4* INR(PT)-4.0*
OTHER LABS:
[**2182-8-23**] 06:07AM BLOOD WBC-6.6 RBC-2.60* Hgb-7.9* Hct-25.7*
MCV-99* MCH-30.5 MCHC-30.9* RDW-19.7* Plt Ct-169
[**2182-8-23**] 06:07AM BLOOD PT-33.8* PTT-36.0 INR(PT)-3.3*
[**2182-8-22**] 05:51AM BLOOD PT-27.4* PTT-34.1 INR(PT)-2.6*
[**2182-8-21**] 07:10AM BLOOD PT-23.5* PTT-32.9 INR(PT)-2.2*
[**2182-8-20**] 06:00AM BLOOD PT-22.1* INR(PT)-2.1*
[**2182-8-18**] 05:58AM BLOOD PT-17.3* PTT-31.2 INR(PT)-1.6*
[**2182-8-17**] 06:39AM BLOOD PT-15.5* PTT-31.8 INR(PT)-1.5*
[**2182-8-15**] 02:51AM BLOOD PT-16.5* PTT-99.3* INR(PT)-1.6*
[**2182-8-14**] 05:19AM BLOOD PT-17.5* PTT-32.2 INR(PT)-1.6*
[**2182-8-13**] 05:05AM BLOOD PT-17.3* PTT-34.4 INR(PT)-1.6*
[**2182-8-23**] 06:07AM BLOOD Glucose-76 UreaN-33* Creat-3.2* Na-135
K-4.8 Cl-97 HCO3-26 AnGap-17
[**2182-8-13**] 05:05AM BLOOD ALT-13 AST-23 AlkPhos-283* TotBili-0.8
[**2182-8-23**] 06:07AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1
[**2182-8-18**] 05:58AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.2 Iron-37*
[**2182-8-18**] 05:58AM BLOOD calTIBC-131* Ferritn-748* TRF-101*
[**2182-8-11**] 06:07AM BLOOD Hapto-173
[**2182-8-1**] 07:30PM BLOOD TSH-2.3
[**2182-8-13**] 03:45PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
PERICARDIAL FLUID CYTOLOGY:
NEGATIVE FOR MALIGNANT CELLS.
PLEURAL FLUID CYTOLOGY:
NEGATIVE FOR MALIGNANT CELLS.
Paucicellular specimen with scattered mesothelial cells,
histiocytes, and predominantly blood.
[**2182-8-2**] 5:15 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final [**2182-8-2**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2182-8-5**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2182-8-8**]): NO GROWTH.
FUNGAL CULTURE (Final [**2182-8-16**]): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2182-8-3**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**2182-8-4**] 10:55 am BLOOD CULTURE Source: Line-picc.
**FINAL REPORT [**2182-8-10**]**
Blood Culture, Routine (Final [**2182-8-10**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES STRAIN 2.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES STRAIN 3.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| | KLEBSIELLA
PNEUMONIAE
| | |
AMPICILLIN/SULBACTAM-- 4 S 8 S 4 S
CEFAZOLIN------------- <=4 S <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final [**2182-8-5**]):
Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 101334**] ON [**2182-8-5**] AT
0530.
GRAM NEGATIVE ROD(S).
[**2182-8-4**] 10:54 am URINE Source: Catheter.
**FINAL REPORT [**2182-8-6**]**
URINE CULTURE (Final [**2182-8-6**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final [**2182-8-4**]):
Test performed only on suprapubic and kidney aspirates
received in a
syringe.
TEST CANCELLED, PATIENT CREDITED.
[**2182-8-7**] 6:09 pm PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT [**2182-8-13**]**
GRAM STAIN (Final [**2182-8-7**]):
2+ (1-5 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 (Final [**2182-8-10**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2182-8-13**]): NO GROWTH.
[**2182-8-6**] 11:38 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2182-8-12**]**
Blood Culture, Routine (Final [**2182-8-12**]): NO GROWTH.
[**2182-8-6**] 2:52 am CATHETER TIP-IV Source: left picc line.
**FINAL REPORT [**2182-8-8**]**
WOUND CULTURE (Final [**2182-8-8**]): No significant growth.
[**2182-8-5**] 10:10 am BLOOD CULTURE Source: Line-white port
PICC.
**FINAL REPORT [**2182-8-11**]**
Blood Culture, Routine (Final [**2182-8-11**]): NO GROWTH.
Echo [**2182-8-2**]
There is moderate global left ventricular hypokinesis (LVEF =
35%). Right ventricular chamber size is normal. with moderate
global free wall hypokinesis. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis cannot be
adequately assessed. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Tricuspid regurgitation is
present but cannot be quantified. There is a large pericardial
effusion. The effusion appears circumferential. No right
ventricular diastolic collapse is seen.
IMPRESSION: Large circumferential pericardial effusion. No
echocardiographic signs of tamponade. Right ventricular
hypertrophy and enlargement raise suspicion of underlying
pulmonary hypertension (not confirmed on this study), which may
limit the sensitivity of echocardiographic evaluation for
tamponade.
CXR [**2182-8-1**]:
Large right pleural effusion has markedly increased. Moderate
cardiomegaly is
partially obscured by the right pleural effusion. There are
atelectasis in
the lower lobes bilaterally, right greater than left, and in the
right upper
lobes. There is probably a small left pleural effusion. There
is no
pulmonary edema. Sternal wires are aligned.
IMPRESSION: Markedly increase in size in large right pleural
effusion.
CXR [**2182-8-14**]:
Small-to-moderate bilateral pleural effusions have decreased
substantially.
Although the cardiac silhouette remains enlarged, there is less
distention of
mediastinal veins and previous mild pulmonary edema has largely
cleared. Left
lower lobe remains collapsed. A supraclavicular central venous
dual-channel
catheter has replaced a small-bore catheter, ending in the
mid-to-low SVC.
TTE [**2182-8-5**]:
Left ventricular wall thicknesses and cavity size are normal.
There is a very small (<0.5cm) pericardial effusion along the
basal inferolateral wall, basal lateral, and apical lateral
wall. There is no evidence for hemodynamic compromise.
IMPRESSION: Very small pericardial effusion without evidence of
hemodynamnic compromise
RENAL ULTRASOUND [**2182-8-9**]:
1. Persistent though improved high resistance waveforms
throughout the
arterial system including intrarenal and main renal arteries.
2. Irregularly irregular waveforms suggests arrhythmia.
3. Stable large rounded calcifications are of unclear etiology.
Predominantly
pyramidal location is suggestive of medullary nephrocalcinosis;
however, the
scattered cortical calcifications are not consistive with this
diagnosis. No
hydronephrosis.
RIGHT AND LEFT CARDIAC CATH [**2182-8-12**]:
1. Resting hemodynamics revealed markedly elevated left and
right-sided
filling pressure consistent with severe diastolic heart failure.
There
was also moderate pulmonary arterial hypertension.
2. The cardiac output and cardiac index were preserved.
FINAL DIAGNOSIS:
1. Severely elevated filling pressures consistent with diastolic
heart
failure.
2. Preserved cardiac output and cardiac index.
Brief Hospital Course:
79 yo M with a PMHx of moderate to severe AI with decreased EF
s/p bioprosthetic AVR [**2182-6-27**], recently admitted [**Date range (1) 57819**] for
BRBPR, now presenting with weakness and fluid overload, cardiac
echo significant for worsening pericardial effusion, going for
pericardiocentesis on the day of admission, with hospitalization
complicated by renal failure requiring dialysis, klebsiella
urosepsis, atrial fibrillation with RVR.
#Acute on Diastolic Heart Failure: Patient presented to Dr. [**Name (NI) 39743**] office weighing 15 lbs more than previous [**Name (NI) **] and
was edemetous on exam. He was admitted to [**Hospital1 1516**] for diuresis. He
was transferred to the CCU following pericardial drainage for
aggressive diuresis. He was started on a Lasix ggt with moderate
UOP. He was below goal of 2L daily and metolazone was added with
minimal improvement. Diuresis was eventually held in the setting
of rising creatinine and poor UOP and ultimately dialysis was
initiated for removal of fluid (see below). It was believed that
symtoms might be secondary to a constrictive cardiomyopathy.
Cath [**8-12**] showed elevated R and L-sided pressures but preserved
CI and CO. Due to progressive renal failure of his renal graft,
he commenced HD via temporary catheter and had a tunnelled line
placed for more durable access. With volume removal during HD,
his respiratory status and peripheral edeam improved.
#Moderate Pericardial Effusion: Previously visualized but
increased based on echo done this admission. Small amount of RV
diastolic collapse. Pulsus 10mmHg, ECG shows mild electrical
alternans. Voltage unchanged from prior ECG. Pt had bloody
pericardial drainage with drain placement, felt to be [**1-17**] high
INR (4). Repeat echo showed resolution of the effusion.
#Respiratory distress: When pt was admitted he required several
liters of 02 via face mask to maintain saturations in the low
90's. CXR was consistent with pulmonary edema. Oxygen
saturations improved following pericardial drainage and
diuresis. He continued to have SOB and and an O2 requirement and
a right sided thoracentesis was performed which drained 2L of
exudate with many RBCs. With diuresis and later HD, his volume
overload and oxygen requirement likewise improved.
#Klebsiella sepsis: Pt had a positive blood culture and urine
culture for Klebsiella, with the blood growing three
pan-sensitive strains. He was febrile and hypotensive at time of
diagnosis and treated broadly with vanc/cefepime prior to
narrowing to ceftriaxone. Pt remained afebrile and normotensive
following initiation of abx. Pt's PICC line was removed as (+)
BC was drawn from it. He completed a total 2 week course of CTX
ending [**2182-8-18**].
#Atrial Fibrillation with RVR: CHADS2 score of 3, on coumadin at
home. Coumadin was held intially as INR was supratherapeutic on
admission, but resumed prior to d/c. Prior to admission, pt was
rate-controlled with metoprolol 75mg [**Hospital1 **] and 120mg daily of
diltiazem. His dilt was held briefly to allow pt to tolerate
HD, but resumed after the first few HD sessions. On [**Hospital1 **],
doses adjusted to toprol xl 100mg daily and diltiazem CR 180mg
daily. He does occasionally have RVR to 110-120 if he is late
for his doses, but responds quickly to oral meds. His INR was
3.3 on [**Hospital1 **] and had been increasing slowly over the past
few days of hospitalization despite decreasing warfarin. Will
need 1mg daily with daily INR checks until stabilized.
Nutritional optimization will be necessary.
#Renal Failure: He is s/p renal transplant 25 years ago for PKD
and has a baseline creatinine of 1.6. He was initally kept on
home cyclosporine and prednisone for immunosupression. Renal
transplant service followed pt throughout admission. Pt's Cr
continued to trend up with diuresis to 3.9. The etiology was
initially felt to be ATN, but given lack of renal recovery, the
eitology became unclear. Further diuresis was held at as pt was
believed to be pre-renally intravascularly depleted despite
being fluid overloaded. he did not respond to albumin and
ultimately became oliguric. Given anasarca and lack of response
to diuretics, HD was initiated. He received a tunnelled HD line
on [**8-20**] for durable access. His CSA was discontinued initially
but was restarted on [**Month/Day (4) **] to attempt a 2 week trial course
to rescue his graft. He will continue 100mg daily. If no urine
output increase noted over 2 weeks, he probably will discontinue
cyclosporin. but the prednisone was continued at 5mg daily. He
may regain some renal function, but remains oligo-anuric at
[**Month/Day (4) **]. If anuric x24hr or greater, please bladder scan to
rule out obstruction/retention. Will need HD MWF at LTAC,
followup with renal and transplant surgery.
#Recent GI Bleed: H/H was monitored. He recieved 1 unit pRBCs
this admission for anemia felt to be [**1-17**] decreased epo in the
setting of renal failure and phelbotomy. He had marroon stools
for about 5 days without signfiicant HCT drop in the setting of
heparin gtt, likely diverticular. GI was consulted and no
intervention taken. Will f/u with GI as outpatient.
#Delirium: Felt to be multifactorial, ICU delerium as well as
uremia. Pt's mental status improved with HD. He was not
aggitated but rather endorsed delusions of grandeur and
hypoactivity. Care was taken to maintaine sleep-wake cycle.
#Hyperlipidemia: Patient was maintained on home on atorvastatin
20mg daily.
#Depression: SW provided support to the pt and his famiyl during
his hospital stay. He was maintained on home SSRI.
#Gout: Febuxostat was changed to renally-dosed allopurinol in
the setting of renal failure
#depression: started citalopram 10mg daily, will need titratrion
up if depressive symptoms continue over next several weeks.
# Code status: Pt had intially been full code on admission. As
he became mroe ill in the setting of his renal failure, he
expressed wishing to die but also endorsed wanting things done
that could prolong his life. Multiple conversations were had
with the pt and his family, particularly prior to starting HD.
Ultimately, the pt endorsed wanting to be DNR/DNI and, given
episodes of delerium, the pt's daughters felt this was
consistant with their father's wishes. All were in agreement
with going forward with HD.
# dysphagia: diet advanced to regular at time of discharge1. PO
diet: thin liquid and regular consistency solids.
2. Meds whole with thin liquid or applesauce.
Transitional Issues:
- will need titration of warfarin for INR goal [**1-18**]
- f/u with renal and transplant surgery
- f/u with cardiology and CHF for volume management
- HD MWF
- Trial of cyclosporin 100mg daily for roughly 2 weeks. Check
24hr trough in one week with level goal of <100. If oliguria
persists in 2 weeks, likely will stop cyclosporin.
.
MEDICATIONS STARTED
Allopurinol 150 mg PO EVERY OTHER DAY
.
MEDICATIONS CHANGED
Diltiazem ER increased from 120mg daily to 180 mg daily
Metoprolol Tartrate 75 mg PO BID to Metoprolol Succinate XL 100
mg PO DAILY
Warfarin 2.5mg to 1mg daily
.
MEDICATIONS STOPPED:
Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
Flagyl course completed
Furosemide
Febuxostat
.
Pending tests at [**Hospital1 **]:
-none
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Ascorbic Acid 500 mg PO TID
3. Calcium Carbonate 1000 mg PO DAILY
4. Cholestyramine 4 gm PO DAILY
5. CycloSPORINE (Sandimmune) 100 mg PO Q24H
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Febuxostat 40 mg PO DAILY
8. Ferrous Sulfate 325 mg PO TID
9. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
10. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
11. Furosemide 40 mg PO BID
12. Lovastatin *NF* 20 mg ORAL DAILY Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
13. Metoprolol Tartrate 75 mg PO BID
14. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 40 mg PO DAILY
17. PredniSONE 5 mg PO DAILY
18. Vitamin D 800 UNIT PO DAILY
19. Warfarin 2.5 mg PO DAILY16
[**Hospital1 **] Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol 150 mg PO EVERY OTHER DAY
3. Citalopram 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Nephrocaps 1 CAP PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
7. Senna 1 TAB PO BID:PRN constipation
8. Ascorbic Acid 500 mg PO TID
9. Calcium Carbonate 1000 mg PO DAILY
10. Ferrous Sulfate 325 mg PO TID
11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
12. PredniSONE 5 mg PO DAILY
13. Vitamin D 800 UNIT PO DAILY
14. Lovastatin *NF* 20 mg ORAL DAILY Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
15. Omeprazole 40 mg PO DAILY
16. Diltiazem Extended-Release 180 mg PO DAILY
hold for SBP < 100, HR < 60.
17. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
18. Cholestyramine 4 gm PO DAILY
19. Metoprolol Succinate XL 100 mg PO DAILY
hold for SBP < 100, HR < 60
20. Warfarin 1 mg PO DAILY16
21. CycloSPORINE (Sandimmune) 100 mg PO Q24H
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital **] rehab macu
[**Hospital **] Diagnosis:
primary: pericardial effusion with tamponade s/p drainage
renal failure
.
secondary: Klebsiella UTI and bacteremia
atrial fibrilation
acute on chronic dialstolic heart failure
[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Hospital **] Instructions:
Mr. [**Known lastname 57554**],
.
It was a pleasure taking care of you at [**Hospital1 **]. You were admitted to the hospital after you were
found to have too much fluid on your body in clinic. You were
found to have fluid around your heart, which was drained.
Unfortunately, while you were here, your kidney failed and you
were started on dialysis. We also treated you for an infection
in your blood and urine while you were here.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
.
You will need to continue your dialysis on Monday, Wednesdays
and Fridays. You will also need to follow up with your
cardiologist as an outpatient.
You had some mild bleeding of your intestines, we will have you
see a GI doctor as an outpatient. You will also see a heart
failure specialist as an outpatient.
You will now spend time getting stronger in rehab with more
physical therapy.
Many changes were made to your medications and are explained on
the following sheet.
We wish you the best of luck, Mr. [**Known lastname 57554**]!
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2182-8-28**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2182-9-5**] at 3:00 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Congestive Heart Failure Clinic
[**2182-9-10**] at 1pm with Dr. [**Last Name (STitle) **]
[**Location (un) 436**] [**Hospital Ward Name **] center, [**Hospital Ward Name **]
Phone: ([**Telephone/Fax (1) 2037**]
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2182-8-27**] at 2:00 PM
With: [**Doctor First Name 23138**] [**First Name8 (NamePattern2) 23139**] [**Name8 (MD) 815**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2182-8-25**]
|
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"E878.0",
"511.89",
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"428.0",
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"562.10",
"423.3",
"275.3",
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"996.81",
"428.33",
"427.31",
"416.8",
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"285.29",
"753.12",
"584.5",
"E879.1",
"995.91",
"425.4",
"733.00",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95",
"38.95",
"38.97",
"88.73",
"88.55",
"34.04",
"37.23",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
15056, 21560
|
340, 498
|
5198, 5590
|
25981, 27277
|
3661, 3778
|
22353, 23327
|
14904, 15033
|
3793, 5179
|
7498, 14887
|
21581, 22327
|
277, 302
|
24426, 24711
|
23357, 24396
|
526, 2674
|
24726, 25958
|
2696, 3229
|
3245, 3645
|
5602, 7462
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,772
| 181,662
|
35218
|
Discharge summary
|
report
|
Admission Date: [**2109-11-11**] Discharge Date: [**2109-11-21**]
Date of Birth: [**2036-1-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Intubation [**2109-11-11**]
History of Present Illness:
Initial Histpry and physical is as per ICU resident, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
73 yo W with PMH of CAD, CM, COPD, DM, afib, s/p pacemaker [**11-1**]
brought in by ambulance with AMS since this AM. Hx previous fall
from wheelchair 1 week ago without evaluation. Noted lethargy,
labored breathing. FS was 41 at NH. Pt given D50.
On arrival, VS: T 97, HR 85, BP 114/82, RR 17 98 RA, FS 29. She
received 2 amps D50 with repeat FS 179. Despite correction of
hypoglycemia, she remained altered. Utox positive for opiates
and she was given narcan with little response. Initially placed
on BiPAP, but then intubated for airway protection. She was
noted to have ST depressions in leads V3-V6. Cards felt this was
not ACS and CE's could be followed. Patient was transferred to
the [**Hospital Unit Name 153**] for further management.
Past Medical History:
CAD s/p cath on [**8-2**] with non obstructive CAD
DM Type 2
COPD
Afib on ASA/plavix
s/p pacemaker on [**11-1**]
Osteoporosis
Chronic joint pain
Hyperlipidemia
GERD
Anxiety
Social History:
Nursing home resident
Family History:
NC
Physical Exam:
Initial exam in ICU
VS: Afebrile, 77, 127/60
GEN: Elderly woman, sedated, intubated, minimally responsive to
voice
HEENT: PERRL, OG, ETT in place
NECK: Supple, No JVD
CHEST: CTA anteriorly, no w/r/r
CV: irregular, no m/r/g
ABD: Soft/NT/ND, + BS
EXT: Cool, palpable pulses
SKIN: mottled, blue toes, no rashes
NEURO: Intubated, sedated
Pertinent Results:
[**2109-11-11**] 01:00PM WBC-13.3* RBC-3.45* HGB-10.1* HCT-34.3*
MCV-100* MCH-29.3 MCHC-29.5* RDW-13.9
[**2109-11-11**] 01:00PM NEUTS-90.0* LYMPHS-4.8* MONOS-4.9 EOS-0.2
BASOS-0.1
[**2109-11-11**] 01:00PM PLT COUNT-323
[**2109-11-11**] 01:00PM PT-13.5* PTT-33.6 INR(PT)-1.2*
[**2109-11-11**] 01:00PM SED RATE-20
[**2109-11-11**] 01:00PM CK(CPK)-40
[**2109-11-11**] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2109-11-11**] 01:00PM GLUCOSE-413* UREA N-34* CREAT-0.9 SODIUM-147*
POTASSIUM-4.3 CHLORIDE-111* TOTAL CO2-31 ANION GAP-9
[**2109-11-11**] 01:27PM PO2-291* PCO2-66* PH-7.23* TOTAL CO2-29 BASE
XS--1
EKG: Atrial fibrillation with controlled ventricular response
at 89bpm. Left ventricular hypertrophy with secondary ST-T wave
abnormalities. No change from previous.
CXR: Limited study with bibasilar atelectasis and vague right
upper lung opacity. Cardiomegaly.
CT head: No acute intracranial hemorrhage or infarction
CT chest: Scattered ground glass and nodular opacities are
worrisome for multifocal pneumonia. Cardiomegaly with bilateral
small pleural effusions.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 73 year old female with a PMH significant for
COPD, CAD, Type 2 DM, afib s/p pacer admitted with hypoglycemia
and altered mental status likely secondary to aspiration
pneumonia.
1. Healthcare associated pneumonia: This was the most likely
cause of the patient's altered mental status and respiratory
failure. Patient had a leukocytosis, and CXR findings revealed
a vague right upper lung opacity. Patient was intially
intubated for respiratory failure and treated in the ICU.
Patient is s/p bronchoscopy with BAL and blood cultures NGTD.
Sputum culture from [**11-14**] with sparse coag neg Staph. Patient is
a NH resident, and was treated empirically for healthcare
associated pneumonia with vancomycin and ceftazidime. Her Vanco
trough was checked [**2109-11-20**] and was elevated to 24 so Vanco was
held. Another vanco trough should be checked at the NH the
morning of [**2109-11-22**] and Vanco should be restarted at 750mg iv
q12h if trough is <20. Patient will need three more days of
antibiotics to finish her course.
2. RUE Swelling: Patient developed RUE swelling and discomfort.
A right upper extremity duplex was obtained and no DVT was
found. The swelling may have been due to trauma. The swelling
was subsiding at discharge. The patient had some discomfort
which was helped by Tylenol #3 (which she was already on at her
nursing home for chronic joint pain.
3. COPD: The patient was not felt to be having a COPD
exacerbation at admission. She was continued on her home
regimen of Advair, low dose prednisone, diamox and
albuterol/atrovent prn.
4. Atrial fibrillation: Patient was monitored on telemetry.
She became tachycardic to 110-130s during admission and her
metoprolol was titrated upward for better rate control. She
will be discharged on Lopressor 200mg po bid. The patient was
not anticoagulation at admission and this is reportedly due to
fall risk.
5. CAD: At admission ECG showed ST depression in II, III, avL,
v3-v4. Cards was consulted and recommended following CE.
Cardiac biomarkers x4 drawn with rise in troponin to 0.04 with
flat CK likely representing demand ischemia or LV strain. The
patient was continued on her home regimen of metoprolol, ASA,
Plavix, and Lipitor.
6. Type 2 Diabetes mellitus: Patient hypoglycemic on
presentation on home basal NPH, which was initially held. NPH
was reintroduced slowly and was titrated based on ISS
requirement during admission. She will be discharge on NPH
25units [**Hospital1 **] (Her admission regimen was 40u qam and 25u qpm)
This should continue to be adjusted as necessary at the NH. The
patient was also covered with a RISS.
7. Anxiety: The patient was restarted on her home regimen of
Paxil adn prn Klonopin prior to discharge.
8. Chronic joint pain: The patient complained of joint pain all
over which was controlled once we restarted the Tylenol #3 which
she was on at her NH. It is unclear if she carries a diagnosis
of osteoarthritis or not.
9. Hypernatremia: The patient had a serum Na of 150 at admission
whioh was treated with free water and self correction with po
intake. Her Na should be monitored periodically at the NH.
10. Constipation: Patient was continued on Senns, Colace with
prn Miralax.
11. F/E/N: The patient had a speecha dn swallow eval whcih
revealed mild dysphagia. Her recommended diet is ground solids
and thin liquids with pills whole with thin liquid. She may
need assistance with meals. If her upper dentures are found, and
if they fit well when placed, it would be safe to upgrade her
diet to soft or regular consistency solids
12. Prophylaxis: Patient treated with heparin SQ for DVT
prophylaxis during admission.
13. Code: Full
14. Dispo: Patient to be discharged back to the [**Location (un) 745**] Health
Care Center in stable condition
Medications on Admission:
Paxil 40mg PO daily
Lidoderm Patch TD q12
Lasix 40mg PO daily
Fosamax 70mg PO q week
Diamox 250mg PO daily
Senna 1 tab PO daily
Colace
KCL SR 20mg PO daily
Lipitor 40mg PO daily
Lopressor 100mg PO bid
Insulin NPH 40U qAM, 25U qPM
Regular insulin sliding scale
Prednisone 5 PO bid
Klonopin 0.5mg po bid prn anxiety
Advair 100-50 mcg/Dose Disk 1 puff inh [**Hospital1 **]
Tylenol #3 1-2 tabs po q6h prn pain
Fosamax 70mg po weekly
Plavix 75mg po daily
Albuterol nebs prn
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
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. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
8. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
9. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
14. Metoprolol Tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day).
15. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
neb Inhalation q6h prn as needed for shortness of breath or
wheezing.
18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Five (25) units Subcutaneous twice a day.
19. Ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours).
20. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection as directed: For FSBS<150 0 U
FSBS 150-200 2 U
200-250 4 U
250-300 6 U
300-350 8 U
350-400 10U
>400 notify MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Altered mental status
Hospital acquired pneumonia
Discharge Condition:
Good
Discharge Instructions:
-Continue all medications as prescribed
-Follow up with physician at long term care facility
-Continue antibiotics (vancomycin/ceftazadime) for 3 more days
-The patients vancomycin is being held for now. Your facility
should check a Vancomycin trough the morning of [**2109-11-22**]. IF
the level is less than 20 then her Vancomycin should be
restarted at 750mg iv bid.
-Encourage po free wated intake to prevent hypernatremia.
-Return to the ED if you have worsening shortness of breath,
chest pain, palpitations, or other worrisome signs/symptoms.
Followup Instructions:
-Follow up with physician at long term care facility
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2109-11-21**]
|
[
"V45.01",
"272.4",
"300.00",
"276.3",
"276.0",
"427.31",
"250.80",
"729.81",
"414.01",
"518.81",
"496",
"425.4",
"733.00",
"564.09",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"33.24",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9308, 9372
|
3023, 6856
|
307, 337
|
9466, 9473
|
1859, 2790
|
10074, 10301
|
1486, 1490
|
7375, 9285
|
9393, 9445
|
6882, 7352
|
9497, 10051
|
1505, 1840
|
246, 269
|
365, 1235
|
2800, 3000
|
1257, 1431
|
1447, 1470
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,002
| 122,161
|
7513
|
Discharge summary
|
report
|
Admission Date: [**2116-7-13**] Discharge Date: [**2116-7-21**]
Date of Birth: [**2072-8-10**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Trauma: s/p fall down stairs
Major Surgical or Invasive Procedure:
[**2116-7-13**] Placement of left-sided chest tube
[**2116-7-14**] Open reduction internal fixation right intra-articular
distal radius fracture 2 or more fragments.
History of Present Illness:
44F w/ hx of polysubstance abuse, fell down 15 stairs. The event
was unwitnessed. She was transferred from an OSH with a hematoma
on her forehead, periorbital ecchymoses b/l, and L leg
laceration. Her scans showed multiple facial fractures, IPH,
SAH, SDH, and distal radius fracture.
Past Medical History:
polysubstance abuse, EtOH, depression, anxiety
Social History:
Unemployed
Lives at home with grandmother and friend
History of polysubstance abuse
Family History:
non-contributory
Physical Exam:
On transfer to [**Hospital1 18**]:
HR: 78 BP: 122/79 Resp: 15 O(2)Sat: 100% on vent Normal
Constitutional: Comfortable
HEENT: Bilateral. Orbital ecchymosis and edema, Pupils
equal, round and reactive to light, Extraocular muscles
intact Oropharynx within normal limits C-spine collar is on
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Extr/Back: Pelvis is stable and nontender, has full range
of motion through all major joints
Skin: Bilateral periorbital ecchymosis, scattered abrasions
Neuro: Pupils equal react to light, moving all 4
extremities when sedation light
Pertinent Results:
CT Torso [**2116-7-13**]: 1. No acute intra-abdominal, intrapelvic, or
intrathoracic process detected. 2. Hepatic steatosis.
CTA Head [**2116-7-13**]: 1. In comparison to study obtained five hours
prior, there is significant interval progression of extensive
intracranial hemorrhage including bilateral hemorrhagic
contusions, areas of intraparenchymal, subarachnoid and subdural
hemorrhage. There is no evidence of hydrocephalus or
herniation. Stable appearance of numerous cranial fractures. 2.
No evidence of dissection, stenosis, or aneurysm formation.
[**2116-7-13**] Chest XRAY:
Moderate left pneumothorax following left subclavian line that
is
well positioned.
CTA Head [**2116-7-14**]: 1. Minimal change in size and appearance of
multiple intraparenchymal hematomas. Subdural and subarachnoid
collections are less conspicuous. 2. Numerous facial bone
fractures, described in detail on the [**2116-7-13**] 6:15 a.m.
examination.
[**2116-7-13**] Wrist X-ray (Right):
Mild volarly displaced impacted intraarticular distal radius
fracture.
[**2116-7-15**] Chest XRAY:
In comparison with the earlier study of this date, with the
chest
tube on waterseal there is no evidence of pneumothorax.
Atelectatic changes are again seen at the left base.
Endotracheal tube and nasogastric tube have been removed.
[**2116-7-13**] 03:35AM WBC-12.8* RBC-3.33* HGB-10.5* HCT-31.4*
MCV-94 MCH-31.6 MCHC-33.5 RDW-12.5
[**2116-7-13**] 03:35AM PT-11.3 PTT-28.8 INR(PT)-1.0
[**2116-7-13**] 03:35AM PLT COUNT-204
[**2116-7-13**] 03:35AM FIBRINOGE-131*
[**2116-7-13**] 03:35AM ASA-NEG ETHANOL-309* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2116-7-13**] 03:35AM PHENYTOIN-32.5*
[**2116-7-13**] 03:35AM LIPASE-25
[**2116-7-13**] 03:35AM UREA N-5* CREAT-0.5
[**2116-7-13**] 03:50AM GLUCOSE-121* LACTATE-3.4* NA+-130* K+-3.5
CL--97 TCO2-20*
[**2116-7-13**] 11:25AM CALCIUM-6.1* PHOSPHATE-3.1 MAGNESIUM-1.5*
Brief Hospital Course:
Ms. [**Known lastname 4781**] was admitted intubated and sedated on [**2116-7-13**]
under the Acute Care Surgery service to the TSICU for close
monitoring. Her injuries included:
- SDH
- SAH
- comminuted R distal radius fx
- L thigh lac
- Displaced fracture of L zygomatic body extending posterior
into temporal bone, fracture at zygomatic-sphenoid suture
She was extubated on [**2116-7-15**] and transferred to the floor that
afternoon hemodynamically stable. See below for hospital course
by details:
Neuro: She was initially intubated and sedated. When sedation
was weaned, she woke up and was responsive and moving all
extremities. For her head injuries, neurosurgery was consulted
and she was started on dilantin for seizure prophylaxis which
was continued for 1 week total. Her head CT was stable and she
was getting q4h neuro checks. She was on oxycodone and dilaudid
for pain control. She had a c-collar in place. Her c-spine was
cleared after extubation. She was responsive to commands but
confused intially after extubation. She was thought to be
withdrawing from alcohol and was placed on a CIWA protocol. By
hospital day 7 she was no longer [**Doctor Last Name **] on the CIWA scale or
requiring benzo administration. Her mental status cleared
significantly. She did have intermittent episodes of anxiety for
which she was started on zyprexa. She was also started on ambien
to regulate her sleep/wake cycle which was effective in doing
so. She was evaluated by occupational therapy who recommended
outpatient follow up with cognitive neurology and 24 hours
supervision at home.
Pulm: A L subclavian was placed. She developed a L pneumothorax
and a chest tube was placed. After her surgery, she was
transferred back to the ICU and successfully extubated. She
saturated well on nasal cannula and eventually room air. Her
chest tube was removed and she continued to remain without
respiratory compromise. Her supplemental oxygen was weaned and
her oxygen saturation remained within normal limits on room air.
Cardiovascular: She was initially on phenylepherine but that was
successfully weaned. She remained hemodynamically stable. Her
vital signs were monitored routinely while she was on the floor
and remained stable.
GI: Once extubated, her diet was advanced to a soft diet, per
plastic surgery recommendations. She was able to tolerate a soft
diet.
MSK: She was taken to the OR on HD 2 by ortho for ORIF of her
distal radius fracture. She was placed in an Orthoplast splint
postoperative and follow up was scheduled with orthopedics after
discharge.
On [**2116-7-21**] she is afebrile with stable vital signs. Her mental
status is clear. Her pain is well controlled with an oral pain
regimen. She is tolerating a regular diet. She is out of bed
ambulating with supervision. She is being discharged home under
the supervision of her grandmother, who has received teaching
regarding the needs of care of the patient.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Codeine Sulfate 15-30 mg PO Q4H:PRN pain
RX *codeine sulfate 15 mg [**1-6**] tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID constipation
4. Senna 1 TAB PO BID:PRN constipation
5. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN anxiety
RX *olanzapine 5 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
6. Zolpidem Tartrate 10 mg PO HS
RX *Ambien 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
s/p fall down stairs
Intraparenchymal hemorrhage
Subdural hematoma
Subarachnoid hemorrhage
Displaced fracture of left zygomatic body
Fracture at zygomatic-sphenoid suture
Right intra-articular distal radius fracture.
Left-sided pneumothorax s/p central line placement
Acute alcohol withdrawal
Conjunctival hemorrhage
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after falling down stairs and
sustaining facial fractures, a right arm fracture and a head
injury.
You had your right arm fracture repaired operatively by the
orthopedic surgeons. You should keep your arm in the splint that
was placed by orthopedics until your follow up appointment which
is listed below. You may perform range of motion exercises in
your arm as tolerated.
Please follow up with the plastic surgeons regarding your facial
fractures at the appointment scheduled for you below. You should
maintain a soft diet because of the facial fractures.
You had a central IV line placed while you were in the intensive
care unit which resulted in a small collapse in part of your
lung. You had a chest tube placed for this which was
subsequently removed.
You had some bleeding in your brain because of your fall which
is stable. You should follow up with neurosurgery at the
apppointment scheduled for you below for a repeat head CT scan.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining, or
excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (colace)
while taking narcotic pain medication.
Unless directed by your doctor, DO NOT take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen, etc.
Because of your head injury, you should avoid driving/operative
heavy machinery, making important or financial decisions and
other such activities for some time. Please see handout provided
on concussions for more specifics.
You were evaluated by occupational therapy for your head injury
who recommended outpatient follow up with a cognitive
neurologist. Please see follow up below.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
New onest of tremors or seizures.
Any confusion, lethargy or changes in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not relieved
by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Department: DIV OF PLASTIC SURGERY
When: FRIDAY [**2116-8-7**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern1) 6751**], MD [**Telephone/Fax (1) 6742**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2116-8-19**] at 8:30 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: WEDNESDAY [**2116-8-19**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2116-7-28**] at 12:20 PM
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 [**2116-7-28**] at 12:40 PM
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
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2116-8-6**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
You were evaluated by the ophthalmologists for your blurry
vision and conjunctival hemorrhage who recommended that you use
artifical tears as needed and follow up with your
ophthalmologist as an outpatient within the next month. If you
do not have an ophthalmologist and would like to be seen here at
[**Hospital1 18**] you may call the ophthalmology clinic at [**Telephone/Fax (1) 253**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2116-7-21**]
|
[
"512.1",
"802.4",
"E880.9",
"372.72",
"303.00",
"291.81",
"E879.8",
"801.26",
"300.00",
"813.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"79.32",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
7236, 7242
|
3692, 6629
|
340, 508
|
7603, 7603
|
1734, 3669
|
10010, 12364
|
1008, 1026
|
6684, 7213
|
7263, 7582
|
6655, 6661
|
7756, 9987
|
1041, 1715
|
272, 302
|
536, 821
|
7618, 7732
|
843, 891
|
907, 992
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,553
| 181,516
|
51415
|
Discharge summary
|
report
|
Admission Date: [**2121-1-25**] Discharge Date: [**2121-2-4**]
Date of Birth: [**2052-3-1**] Sex: F
Service: [**Location (un) **]
CHIEF COMPLAINT: Fever.
HISTORY OF PRESENT ILLNESS: This is a 68-year-old woman with
a past medical history of stage IV gastric cancer complicated
by superior vena cava syndrome and small-bowel obstruction
requiring colostomy as well as right internal jugular vein
deep venous thrombosis, bilateral malignant pleural
effusions, and hydronephrosis requiring bilateral stent
placement who presented to [**Hospital3 1196**] with a
chief complaint of fever.
The patient had been recently admitted to [**Hospital3 20445**] from [**1-13**] to [**1-23**] for superior vena
cava syndrome, pleural effusions, and extrinsic ureteral
compression, status post bilateral stent placement. At that
time, she received thrombolysis and had a superior vena cava
stent placed. During that hospitalization she had bilateral
thoracenteses which revealed metastatic adenocarcinoma. She
had bilateral renal stents placed as well for the extrinsic
compression.
Since that discharge she had been doing well without pain at
home or any specific complaints. She did note some bleeding
from her ostomy bag being changed several days ago, but
otherwise denies any complaints. No chest pain, abdominal
pain, nausea, vomiting, diarrhea, dysuria, etcetera. She
also denies headache, neck stiffness, sinus tenderness, sore
throat, rashes, cough, or change in her ostomy output, or
melena.
PAST MEDICAL HISTORY:
1. Stage IV gastric cancer diagnosed in [**2118**] with metastases
to her para-aortic and retroperitoneal lymph nodes.
2. Superior vena cava syndrome in [**2121-1-11**].
3. Small-bowel obstruction requiring colostomy.
4. Hydronephrosis in [**2120-12-12**] requiring bilateral
stent placement.
5. Right internal jugular vein deep venous thrombosis,
status post chemotherapy with Xeloda and Taxotere; stopped
secondary to adverse effects; changed to naboline.
6. Status post total abdominal hysterectomy/bilateral
salpingo-oophorectomy.
7. Status post appendectomy.
8. Bilateral malignant pleural effusions.
MEDICATIONS ON ADMISSION: Ativan, Compazine, Fentanyl at
50 mcg, MS Contin 10 mg p.o. b.i.d., Ditropan, oxycodone,
Coumadin 2 mg p.o. q.h.s., and Lasix.
ALLERGIES: Allergy to SULFA and INTRAVENOUS CONTRAST.
SOCIAL HISTORY: Positive 40-pack-year tobacco history; quit
in [**2110**]. No alcohol. Lives with her husband and four
children who are very involved in her care. Daughter is her
health care proxy.
FAMILY HISTORY: Father died of lung cancer. Mother and
sister died of ovarian cancer, and mother also had gastric
cancer.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission revealed a temperature of 102.4, heart rate
of 112, respiratory rate of 27, blood pressure of 73/34, 88%
on 4 liters nasal cannula. In general, this was an awake and
alert female in mild distress. Pupils were equal, round, and
reactive to light. The oropharynx was clear. Dentures were
in place. Dry mucous membranes. Sclerae were anicteric.
Pale conjunctivae. Normocephalic and atraumatic. Neck was
supple. Neck veins were intact and flat. Chest was clear to
auscultation bilaterally, except dullness at the right vase.
Cardiovascular examination was regular, tachycardic. First
heart sound and second heart sound. Abdomen was soft,
nontender, and nondistended, positive bowel sounds.
Colostomy in place with brown stool. Extremities were warm,
2+ distal pulses, right greater than left edema.
Neurologically, cranial nerves II through XII were grossly
intact except for decreased hearing. Moved all extremities
well. Skin revealed no lesions or rashes.
PERTINENT LABORATORY DATA ON PRESENTATION: Notable
laboratories on admission from the outside hospital on
[**1-25**] revealed a white blood cell count of 0.5,
hematocrit of 32.2, and platelets of 186. Laboratories upon
admission to [**Hospital1 69**] revealed a
white blood cell count of 2.9, hematocrit of 27.6, platelets
of 149. Sodium of 137, potassium of 2.9, chloride of 104,
bicarbonate of 22, blood urea nitrogen of 18, creatinine
of 1.1, and blood sugar of 99. Alkaline phosphatase of 160,
ALT of 11, AST of 29, total bilirubin of 1.1, albumin of 2.4,
calcium of 10.4, phosphate of 1.8, magnesium of 1.3, uric
acid of 4.2.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for septic shock of unclear source.
1. INFECTIOUS DISEASE: The patient with febrile
neutropenia. The patient was started on vancomycin,
gentamicin, Flagyl, and piperacillin. Required Levophed for
pressure support. Urinalysis as well as blood cultures at
[**Hospital3 1196**] were reportedly positive for
gram-negative rods. Renal stents last replaced on [**1-17**]. Genitourinary was consulted regarding whether or not to
change the stents but did not feel that this was necessary
given her subsequent negative urinalyses and her good
response to antibiotics. Sensitivities returned for the
gram-negative rods at the outside hospital, and the patient
was found to have pan-sensitive Escherichia coli. The
patient was switched to p.o. levofloxacin, and vancomycin,
gentamicin, piperacillin, and Flagyl were all discontinued.
The patient continued to have good urine output, afebrile,
and stable blood pressure over the course of the next week.
2. HEMATOLOGY: INR found to be elevated upon admission
to 3.5. Coumadin was held. DIC panel was negative for DIC
cause of elevated INR. Vitamin K was administered, and INR
normalized or decreased to 2.6. PTT normalized at 31.6.
Coumadin was restarted later on in the course of the
patient's hospitalization for management of her superior vena
cava syndrome.
3. CARDIOVASCULAR: The patient initially with hypotension,
on Levophed and vasopressin. As urosepsis was treated with
antibiotics, and the patient stabilized, these medications
were discontinued. Further blood cultures were all negative.
(b) Pump: The patient was given 10 liters of intravenous
fluids in the Intensive Care Unit causing some fluid overload
which was diuresed with Lasix over the course of the next
week on the floor.
4. PULMONARY: The [**Hospital 228**] hospital course was exacerbated
by possible chronic obstructive pulmonary disease flare given
her significant wheezing. Other possibilities included
cardiac secondary to congestive heart failure. However,
prednisone taper and nebulizers were begun, and the patient
had a good response and maintained good oxygen saturations.
5. FLUIDS/ELECTROLYTES/NUTRITION: The patient with
hypokalemia during hospitalization and repleted daily with
potassium supplements as well as being discharged home on
potassium supplementation.
6. GASTROINTESTINAL: The patient with good colostomy output
during this hospitalization. No issues.
DISCHARGE FOLLOWUP: The patient was to follow up with her
primary care physician/oncologist, Dr. [**Last Name (STitle) 174**], at the end of
the week.
DISCHARGE STATUS/DISPOSITION: To home with [**Hospital6 1587**] for frequent INR checks until the patient has
followup; also with a prednisone taper for a chronic
obstructive pulmonary disease flare.
MEDICATIONS ON DISCHARGE:
1. Prednisone 40 mg p.o. q.d., to be tapered over the
course of the next week.
2. Coumadin 2 mg p.o. q.d., to be further adjusted by
primary care physician.
3. Potassium chloride 40 mEq p.o. q.d.
4. OxyContin 10 mg p.o. b.i.d.
5. Lasix 20 mg p.o. q.d.
6. Ativan 2 mg p.o. q.h.s.
7. Iron sulfate 325 mg p.o. t.i.d.
8. Epogen 20,000 units subcutaneous every week.
9. Albuterol nebulizers q.4h. p.r.n.
10. Protonix 40 mg p.o. q.d.
11. Levaquin 500 mg p.o. q.d. (for a total 14-day course).
12. Duragesic patch 75 mcg.
13. Lorazepam 3 mg p.o. q.h.s.
14. Colace 100 mg p.o. b.i.d.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 96853**]
MEDQUIST36
D: [**2121-6-9**] 12:33
T: [**2121-6-10**] 11:18
JOB#: [**Job Number **]
|
[
"038.9",
"197.2",
"599.0",
"591",
"285.9",
"493.20",
"276.1",
"V10.04",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2583, 4372
|
7264, 8124
|
2179, 2363
|
4391, 6881
|
165, 173
|
6903, 7237
|
202, 1515
|
1537, 2152
|
2380, 2566
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,564
| 125,028
|
1596
|
Discharge summary
|
report
|
Admission Date: [**2127-2-12**] Discharge Date: [**2127-2-18**]
Date of Birth: [**2068-1-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Melaoptysis (black flecked sputum) in context of productive
cough, some headache, myalgia.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 59 year old male with a history of esophageal and
prostate cancers in remission and recent admissions in [**Month (only) **]
and [**Month (only) 359**] for pneumonia who presents with two days of rapidly
progressive shortness of breath and cough productive of yellow
and black sputum. The patient reports that his breathing was
last at baseline one week ago when he developed a productive
cough. He denies associated fevers, chills or night sweats. He
thinks that he has likely lost weight but he cannot quantify. He
developed shortness of breath two days ago which has been
rapidly progressive to the point that he is no longer able to
talk comfortably. He denies orthopnea or paroxysmal nocturnal
dyspnea. He denies hemoptysis prior to the day of presentation.
He denies chest pain. He endorses myalgias and weakness. He
received both seasonal and H1N1 influenza vaccines. He denies
known sick contacts.
In the ED, initial vs were: T: 99.1 P: 75 BP: 117/90 R: 22 O2 sa
97% on NRB. He received one liter of normal saline. He received
levofloxacin 750 mg IV x 1 and vancomycin 1 gram x 1. He had CXR
which showed bilateral infiltrates worse on the left side. He
was noted to have frank hemoptysis which he reports as
consisting of blood on a tissue. He was admitted to the MICU for
further management.
On arrival to the floor he is speaking in short sentences,
complains of difficulty breathing. He denies fevers, chills,
night sweats, chest pain, pleurisy. He endorses nausea and
vomiting x 1. He denies abdominal pain, constipation, diarrhea,
dysuria, hematuria, leg pain, leg swelling or rashes. He
endorses myalgias. All other review of systems negative in
detail.
Past Medical History:
- Esophageal cancer, stage III: Diagnosed in [**2122**] and treated
with chemoradiation and transthoracic near-total esophagectomy
with right
thoracotomy, laparotomy, and left cervical esophagogastrostomy
and left tube thoracotomy with no radiographic or clinical
evidence of recurrent disease as of [**4-/2126**]
- Hepatitis C- stable
- Prostate cancer status post brachytherapy in [**2121**].
- Hypertension.
- Gastroesophageal reflux disease.
- Nephrolithiasis: 1 episode in [**2125**], required urol intervention
per pt.
- Hypothyroidism
- Soft tissue mass in mouth; not evaluated yet
Social History:
The patient is a widowed and lives alone. He had three
daughters; in [**2126-8-14**] lost his oldest daughter who passed away
from "stomach cancer". He formerly worked on keyboards for
Digital Corporation but is now disabled and spends most of his
time watching television. He drinks 6 beers nightly. He smokes
[**2-15**] pack cigarettes daily, has 30+ pack year smoking history. He
formerly used many illicit substances including crack cocaine,
but now states only using crack cocaine and sniffing small
amount heroin. Denies h/o IVDU.
Family History:
Remarkable for two brothers with prostate cancer. His daughter
age 35 recently passed away from "stomach cancer".
Physical Exam:
On admission to ICU:
Vitals: T: 99.1 BP: 149/99 P: 82 R: 23 O2: 90% on 6L
General: Intermittently somnolent, oriented x 3, using accessory
muscles
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse ronchi throughout left > right, wheezes
throughout, no rales, no dullness to percussion
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Lab during ICU stay:
[**2127-2-12**] 03:20AM BLOOD WBC-7.3 RBC-4.30*# Hgb-13.4*# Hct-45.8#
MCV-106* MCH-31.3 MCHC-29.4* RDW-14.3 Plt Ct-185
[**2127-2-13**] 05:05AM BLOOD WBC-10.3 RBC-3.30* Hgb-10.4* Hct-32.7*#
MCV-99*# MCH-31.6 MCHC-31.9 RDW-14.3 Plt Ct-152
[**2127-2-12**] 03:20AM BLOOD Neuts-80* Bands-13* Lymphs-3* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2127-2-12**] 03:20AM BLOOD Plt Smr-NORMAL Plt Ct-185
[**2127-2-12**] 08:36AM BLOOD PT-19.4* INR(PT)-1.8*
[**2127-2-12**] 04:25AM BLOOD Glucose-115* UreaN-29* Creat-1.7* Na-142
K-5.5* Cl-108 HCO3-18* AnGap-22*
[**2127-2-12**] 08:36AM BLOOD ALT-568* AST-1093* AlkPhos-34*
TotBili-0.3
[**2127-2-12**] 04:09PM BLOOD Calcium-6.9* Phos-2.0* Mg-1.5*
[**2127-2-12**] 04:25AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2127-2-12**] 07:07AM BLOOD Type-ART pO2-63* pCO2-39 pH-7.28*
calTCO2-19* Base XS--7
[**2127-2-12**] 01:59PM BLOOD Type-ART pO2-85 pCO2-35 pH-7.37
calTCO2-21 Base XS--3 Intubat-NOT INTUBA
[**2127-2-12**] 03:32AM BLOOD Lactate-4.0*
[**2127-2-12**] 01:59PM BLOOD Lactate-2.4*
[**2127-2-12**] 01:59PM BLOOD O2 Sat-95
.
Lab results on discharge:
[**2127-2-18**] 06:20AM BLOOD WBC-4.3 RBC-3.30* Hgb-10.0* Hct-32.5*
MCV-99* MCH-30.4 MCHC-30.9* RDW-14.0 Plt Ct-339
[**2127-2-18**] 06:20AM BLOOD Glucose-86 UreaN-7 Creat-0.9 Na-141 K-4.1
Cl-108 HCO3-26 AnGap-11
.
CXR admission
INDICATION: 59-year-old male with history of esophageal cancer
and multiple pneumonias in the past presents with shortness of
breath and cough with wheeze and rales. Evaluate for pneumonia.
COMPARISON: Multiple studies including most recent chest
radiograph of
[**2126-12-8**].
CHEST, PA AND LATERAL VIEWS: There is bilateral multifocal
airspace opacity which is most pronounced in the left upper lobe
and concerning for pneumonia. There may be a small right
pleural effusion. The heart size is normal. Two crescentic
opacities projecting over the right upper mediastinum are likely
related to prior gastric pull-through. The aorta is slightly
tortuous, but the mediastinal silhouette is otherwise
unremarkable. Hilar contours and pulmonary vasculature are
normal.
IMPRESSION: Multifocal airspace opacity concerning for
pneumonia.
CXR [**2127-2-16**]
Final Report
STUDY: PA and lateral chest, [**2127-2-16**].
HISTORY: 59-year-old man with crack lung. Evaluate for acute
cardiopulmonary
process.
FINDINGS: Comparison is made to previous study from [**2127-2-13**].
There are again seen bilateral asymmetric airspace opacities
affecting the
left lung greater than the right. The opacities in the right
lung at the
upper lobe are slightly more apparent. There is a persistent
unchanged right-
sided pleural effusion. There is also some thickening of the
right apex,
which is unchanged. Cardiac silhouette is enlarged, but also
stable.
Brief Hospital Course:
59 year old man with a history of esophageal and prostate
cancers in remission and recent admissions in [**Month (only) **] and
[**Month (only) 359**] for pneumonia who presents with two days of rapidly
progressive shortness of breath and cough productive of yellow
and black sputum in the setting of recent crack cocaine use. On
balance, we think that this presentation is likely ??????crack lung??????
vs CAP.
.
# Respiratory Failure/Pneumonia: Initially concerning for PNA,
therefore pt was started on treatment for HAP given a recent
hospital admission two months ago. There was initially some
concern for sepsis given elevated lactate, therefore pt was
admitted to the ICU. While in the ICU, pt required
non-rebreather to maintain sats in the 90s, and was able to be
transferred to the floor on 2L NC after one day. He did not
manifest septic physiology or symptoms. He has had two
presentations for pneumonia since [**Month (only) **] of unclear etiology,
raising concern for atypicals and chronic processes. HIV,
legionella, influenza A/B, AFBs x3, PPD all negative.
Alternatively, interstitial pneumonitis and acute lung injury
from crack use is possible, perhaps with a superimposed
infection, a repeat CXR later in admission showed improvement of
opacities; however, the pt still had an oxygen requirement (no
WBC, afebrile) which was ultimately weaned off to room air. In
lieu of his chronic infections, would recommend f/u as an outpt
with pulmonology. During this admission, he received three days
of intravenous antibiotics (cefepime and vancomycin) and
ciprofloxacin. Given his rapid clinical improvement, we felt
comfortable changing antibiotics to levofloxacin. He was watched
for one day on this regimen, and as he remained stable he was
discharged to complete an eight-day course total of antibitics
for probable CAP versus crack lung.
.
# Transaminitis: Elevated LFTs, ALT>AST, however enzymes trended
down during the admission without a clear etiology for the
transient elevation. Iron studies were not consistent with iron
overload or deficiency. RUQ ultrasound was deferred given the
rapid resolution of his transaminitis.
# Abdominal Pain: Likely rectus soreness from cough ?????? as
worsened pain over muscle when coughing.
# Acute Renal Failure: Pre-renal, likely related to
infection/poor PO intake, but markedly improved during the
admission with fluids.
# Alcohol Abuse: hx of alcohol abuse without hx of withdrawl.
Started on CIWA but did not require. He was started on thiamine,
folate and a multivitamin.
# Esophageal cancer: s/p chemoradiation and esophagectomy in
[**2122**], in remission.
# Hypertension: Anti-hypertensives were initially held out of
concern for sepsis, then restarted on transfer to the floor
given that pressures were stable.
# Gastroesophageal reflux disease: home PPI was continued.
# Hypothyrodism: home levothyroxine 100 mcg daily was continued
# Pain: patient given Rx for 15 tablets of oxycodone which he
states he takes at home for chronic pain secondary to operations
undergone for his esophageal cancer.
# Social: pt has questionable social/housing situation and is
expressing interest in moving in with his girlfriend. he is
quite sensitive about his crack cocaine use if it is brought to
his attention as he expresses much underlying shame about this.
he expressed interest in enrolling in a addictions program and
this should be followed up by the pt's PCP. [**Name10 (NameIs) **] was seen by
social work and provided with information regarding addiction
programs.
Medications on Admission:
(patient cannot confirm):
1. Multivitamin daily
2. Levothyroxine 100 mcg daily
3. Metoprolol 25 mg PO BID
4. Oxycodone 5 mg PO BID
5. Albuterol inhaler
6. Amlodipine 5 mg daily
7. Nexium 40 mg PO BID
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*30 Capsule(s)* Refills:*0*
9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for pain: This medicine is sedating and
will alter your concentration. Do not drive after taking it.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: pneumonia
SECONDARY: poly-substance abuse, acute renal failure,
transaminitis, anemia
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted for shortness of breath and were treated for
pneumonia and lung injury thought to be form crack cocaine use.
Additionally, while in the hospital you were found to have
elevated liver enzymes and renal failure, both of which improved
with treatment for your pneumonia.
Please take your medications as prescribed. You will be taking
the antiobiotic levofloxacin for 2 days. You should also take
the vitamins thiamine, folate, and a general multivitamin.
Finally, you can take benzonatate for cough relief.
.
Please follow up with your physicians as outlined below.
.
You were seen by social work while in the hospital and we
recommend that you continue to seek help with overcoming your
drug addictions. As we explained it is imperative that you do
not use any illicit drugs such as crack cocaine as they may be
life threatening and lead to death.
.
Followup Instructions:
Please follow up with your primary care physican 1-2 weeks after
discharge. Please keep the following previously scheduled
appointments:
.
-Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 3581**], on [**2126-2-25**] at 4pm
-[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**] Date/Time:[**2127-2-20**]
11:30
-[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2127-7-15**] 1:00
-[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**] Date/Time:[**2128-2-3**] 1:00
|
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11,891
| 121,360
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53302
|
Discharge summary
|
report
|
Admission Date: [**2167-7-16**] Discharge Date: [**2167-7-23**]
Date of Birth: [**2090-9-8**] Sex: F
Service: MEDICINE
Allergies:
Lasix / Persantine I.V. / Theophylline / Nystatin
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
s/p Cardiac Catheterization (stable CAD, no intervention)
History of Present Illness:
76 year old female with history of CAD status post CABG in [**2145**]
(SVG-LAD/D1), CHF (EF 30%), DM2, [**Hospital 109679**] transferred from [**Hospital1 56809**] for consideration of cardiac cath. The
patient says that 2 nights prior to admission, while straining
to have a bowel movement she suddenly became short of breath.
She describes associated chest pain over her left precordium
without radiation, as well as bilateral shoulder pain, abdominal
pain, and back pain. She did have associated dizziness and
diaphoresis, as well as nausea and vomiting. She was brought to
the hospital that night by her family.
On arrival at Sturdy, she had mild rales, with CXR demonstrating
mild CHF. EKG demonstrated old LBBB, without new ST/T changes.
Initial troponin was < 0.02, with BNP of 432. She was given an
additional dose of 0.5 mg IV bumetanide and admitted to
telemetry for cycling of cardiac enzymes. Unfortunately no
documentation is provided for the proceding 36 hours, however
per report from the family, over the course of the following day
she experienced several episodes of shortness of breath
associated with chest pain. Her troponin rose from < 0.02 to
1.3, with CK and MB remaining within normal limits. She was
thought to be having episodes of acute pulmonary edema and was
given extra doses of bumetanide. On the night of [**7-15**], however,
her shortness of breath was severe enough to require ICU
transfer for BIPAP initiation. She was started on heparin and
integrillin drips at this point secondary to concern for
ischemia, with troponin peaking at 1.5, with normal CKs. EKGs
were unchanged throughout. It was eventually decided to
transfer her to [**Hospital1 18**] for catheterization to rule out ischemia.
Of note, about 1 month ago her cardiologist (Dr. [**Last Name (STitle) **] cut her
bumetanide dose in half secondary to rising creatinine, and her
aldactone was discontinued completely secondary to hyperkalemia.
Also of note, P-MIBI in [**4-17**] revealed a fixed large severe
defect in the LAD territory, as well as a reversible small mild
defect in the PDA territory. She underwent catheterization in
[**6-17**] which demonstrated an unchanged chronic 90% lesion in the
non-dominant proximal RCA, diffuse disease in the LAD with a
50-60% mid-distal lesion, with likely total occlusion of D2, as
well as diffuse disease in the LCx and LPDL. No intervention
was performed.
Past Medical History:
1)CAD:
[**2145**]: CATH/PTCA: Patient underwent PTCA which was complicatd by
abrupt closure requiring CABG (SVG->LAD/D1).
[**2154**]: CATH: Patient presented with recurrent angina and
underwent catherization, which revealed moderate LAD disease, a
60-70% OM stenosis, and a 90% stenosis proximally in a
diminutive non-dominant RCA. She underwent DCA of the OM in
lesion [**2155-7-8**]. Subsequently, patient underwent relook procedure
and found to have patent DCA site.
.
[**4-17**] ECHO: Patient underwent echo which showed overall left
ventricular systolic function is moderate to severely depressed
(EF 30%). Resting regional wall motion abnormalities include
septal, anterior and mid and apical lateral and apical
inferolateral severe hypokinesis to akinesis.
.
[**4-17**] P-MIBI: IMPRESSION:
1. Fixed, large, severe defect involving the LAD territory.
2. Reversible, small, mild defect involving the PDA territory.
3. Increased left ventricular cavity size. Moderate left
ventricular systolic dysfunction with inferior hypokinesis and
anterior and apical akinesis.
.
[**6-17**] CATH: Patient admitted to outside hospital for CHF
excaerbation and underwent cardiac catherization. The cath
showed the following results: LMCA demonstrated a 30% mid vessel
stenosis, the LAD showed diffuse disease throughout the vessel
with a mid-distal 50-60% lesion along with a likely total
occlusion of the D2, the LCX showed diffuse plaguing with a 30%
stenosis at two hinge points in the major inferolateral OM, the
LPDA and LPL were small in diameter with diffuse disease, and
the RCA was a very small non-dominant vessel with a chronic 90%
proximal lesion. Resting hemodynamic measurements showed
elevated right and left filling pressures (mean RA 8mm Hg / mean
PCWP 18mm Hg / LVEDP 25mm Hg)and mild pulmonary hypertension
pulmonary artery pressure 48/17.
.
2) CHF: Last echo [**4-17**] with resting regional wall motion
abnormalities including septal, anterior and mid and apical
lateral and apical inferolateral severe hypokinesis to akinesis,
EF 30%.
3) DM2
4) Hypercholesterolemia
5) Lower extremity DVT x 2, last > 1 year ago
6) Anxiety disorder
7) Cataracts
8) Metastatic breast cancer to ribs, vertebrae, and pelvis.
Treated with modified radical mastectomy with skin graft;
Tamoxifen x 7 yrs; arimidex x 1.5 yrs, then taxotere, now
exemestane since [**1-19**].
9) Status post cholecystectomy
[**70**]) Pulmonary nodule
Social History:
Denies any smoking history, occasional alcohol, no IVDU. Lives
with her husband.
Family History:
+ CAD at the age of 70 in her father.
Physical Exam:
98.4, 136/60, 66, 18, 96% on 2L NC
GENERAL: Frail appearing elderly female resting comfortably in
bed.
HEENT: Moist mucous membranes.
COR: RR, normal rate, distant heart sounds.
LUNGS: Mild rales at the bases bilaterally.
ABDOMEN: Normoactive bowel sounds, soft, non-tender.
GROIN: No bruits.
EXTR: No edema. 2+ DP pulses bilaterally.
Pertinent Results:
Labs:
[**2167-7-20**] WBC-3.9 RBC-3.60 Hgb-10.2 Hct-29.1 MCV-81 MCH-28.4
MCH 35.1 RDW-17.2 Plt Ct-100
[**2167-7-19**] PT-13.4 PTT-73.5 INR(PT)-1.2
[**2167-7-20**] Glucose-179 UreaN-34 Creat-1.7 Na-135 K-4.1 Cl-95
HCO3-27
[**2167-7-16**] Glucose-156 UreaN-26 Creat-1.5 Na-141 K-3.9 Cl-101
HCO3-29
AnGap-15
[**2167-7-16**] ALT-42 AST-29 CK(CPK)-115 AlkPhos-35 TotBili-1.2
[**2167-7-17**] CK-MB-5 cTropnT-0.08
[**2167-7-20**] Calcium-8.9 Phos-3.2 Mg-2.0
[**2167-7-18**] URINE RBC->1000* WBC-124* Bacteri-NONE Yeast-NONE
Epi-0
[**2167-7-18**] URINE Blood-LGE Nitrite-NEG Protein-500 Glucose-NEG
Ketone-TR
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2167-7-18**] URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2167-7-22**] URINE CULTURE Final: NO GROWTH.
[**2167-7-21**] URINE CULTURE Final: STAPH AUREUS COAG +.
>100,000ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES.
Sensitivity: MSSA
[**2167-7-22**] AEROBIC BOTTLE: STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED
FROM ONE SET ONLY.
ANAEROBIC BOTTLE (Preliminary): STAPHYLOCOCCUS,
COAGULASE
NEGATIVE.
[**2167-7-23**] CEA: 7.8, CA 27.29:45
.
Imaging:
EKG: ([**2167-7-18**])
Sinus rhythm.
Left axis deviation
Left bundle branch block with ST-T wave changes
Since previous tracing, no significant change
.
Echo ([**2167-7-17**]):
Conclusions:
1. The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is severe regional left
ventricular systolic
dysfunction. Overall left ventricular systolic function is
severely depressed. Resting regional wall motion abnormalities
include the akinesis of the apical portion of the LV with
anteroseptal and mid inferior wall akinesis
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
6.There is mild to moderate pulmonary artery systolic
hypertension.
7.There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2166-4-14**], no obvious change in wall motion or overall EF.
However, there is an increase in the PA pressures.
.
MRA ([**2167-7-17**]):
No significant renal artery stenosis bilaterally, however, the
distal renal arteries are not well seen due to patient motion.
Small posterior plaque just beyond the ostium of the left renal
artery, but only estimated to represent a 5% stenosis.
Dilated biliary tree without definite cause.
Osseous metastatic disease.
.
Cath ([**2167-7-20**]):
1. Selective coronary angiography of this right dominant system
demonstrated no significant change in her coronary lesions.
Specifically the right coronary artery demonstrated a 70%
proximal
lesion with normal flow in the distal portion of the vessel.
The left
main demonstated no flow limiting lesions. The LAD demonstrated
mild
disease with a 50% mid vessel lesion along with a totally
occluded D2.
The LCX also demonstrated mild disease throughout the vessel.
2. The SVG-Lima was known occluded from prior catheterization
and was
not engaged.
3. Limited hemodynamics demonstrated a mildly elevated central
pressure
(140/50 mmHg).
4. LV ventriculography was deferred.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
.
Renal Ultrasound [**2167-7-21**]:
IMPRESSION: Normal color flow to both kidneys. Small
nonobstructing
bilateral renal stones
.
CT chest/abd/pelvis w/contrast ([**2167-7-22**]):
1. No acute change from multiple prior studies. No evidence of
new intra-abdominal/thoracic infection.
2. Unchanged sclerotic lesions in bone and prior radiation in
right lung apex.
Brief Hospital Course:
76 year old female with history of CAD status post CABG in [**2145**]
(SVG-LAD/D1), CHF (EF 30%), DM2, [**Hospital 109679**] transferred from [**Hospital1 56809**] for consideration of cardiac cath in the
setting of recurrent episodes of shortness of breath and chest
pain, thought to be acute pulmonary edema.
1) Dyspnea/chest pain: Story consistent with episodes of acute
pulmonary edema, likely attributable to worsening diastolic
dysfunction in the setting of poorly controlled hypertension.
Her episodes occur frequently in the setting of
valsalva/straining, with acute increase in afterload. Unstable
angina thought possible, though less likely, given the p-MIBI
about 1 year prior with a large fixed defect in the LAD
territory and only a mild reversible defect in the PDA
territory. After reviewing the prior cath films ([**6-17**]) with the
attending, it was determined to send the patient for
catherization on [**2167-7-20**]. An echo was done ([**2167-7-17**]) prior to cath
which showed no new changes except mild increased elevation PA
pressure. EF was measured to be 25%. She was evaluated for renal
artery stenosis as a cause of her recurrent acute pulmonary
edema by MRA, which demonstrated no stenotic arteries. She was
managed medically with hypertension control with medication
changes as follows: Added Lisinopril 10mg.
.
On the night of her admission she had transient hypotension in
response to morphine 2 mg IV that responded to narcan reversal.
Future IV narcotics should be given judiciously.
.
On [**2167-7-20**], patient sent for diagnostic cath only 2nd to febrile
episodes. Prior, patient recieved full pre-cath hydration. Cath
showed no new lesions and no further intervention was
recommended. Post-cath check was normal. Daily EKGs were
performed. On [**2167-7-21**], patient experienced additional episodes of
chest pain, but unlikely to be of cardiac origin. EKG taken
during episode showed no new changes. Etiology likely due to
anxiety, metastatic breast cancer or GI disease, which could be
further worked up as an outpatient. Patient has been set up with
[**Hospital3 **] [**Hospital **] clinic for outpatient follow up, scheduled for
[**2167-8-15**].
2) Febrile episode x 2 recorded on [**2167-7-19**]. Patient was sent for
stat chest xray, UA, Blood&urine cultures. Chest xray results
were negative. UA indicated few WBCs, +leukocyte esterase. It
was determined that given the UA and impending catherization to
start empiric therapy with Ciprofloxacin 250mg [**Hospital1 **]. Initially,
it was thought the febrile episode was due to the recent
addition of Procrit and it was discontinued. Urine cultures
indicated S. Aureus coagulase positive, sensitive to oxacilin.
Immediately, 1gm of Vancomycin IV was started. 2 out 4 blood
cultures grew coagulase negative staph. Given her prior history
of S. Aureus in her cultures, patient was sent for renal
ultrasound, which was negative for renal abscess. Additionally,
TTE done on [**2167-7-20**] indicated no valvular diseases. The
department of Infectious Diseases was consulted and they
indicated to repeat cultures and to label the sites from which
they were drawn. The positive cultures were determined to be
skin contaminants. All subsequent cultures have been negative
and ID recommended stopping vancomycin. Further, they indicated
that the patient should have follow up blood and uring cultures
drawn [**12-15**] wks and report those results with her primary care
provider. [**Name10 (NameIs) **] those cultures are positive, it may be advisable to
have her Port-A-Cath changed.
3) Chronic renal insufficiency: Creatinine at baseline of 1.5,
clearance is approximately 30. Patient given mucomyst for renal
protection, as well as 1/2 NS in a.m prior to catherization.
Subsequent creatinine was found to be 1.3.
4) HTN: On admission, it was decided to hold valsartan for now,
start hydral/isordil. Continued beta blockade with metoprolol.
On [**2167-7-17**], it was decided to discontinue hydralazine and start
Lisinopril 5mg qd and Bumex 0.5mg [**Hospital1 **]. On the morning of [**7-18**],
patient experienced episode of hypotension after am dose of
hypertension meds. Other blood pressure meds were held. Patient
experienced an additional hypotensive episode and has been
discontinued off Bumex. Daily weights and intake/output were
monitored and patient found to be euvolemic. After [**2167-7-19**],
patient's blood pressure was stable on the following regimen:
Metoprolol 12.5mg [**Hospital1 **], isorbide dinitrate 10mg tid, and
Lisinopril 5mg qd. Upon discharge, patient to be discontinued
off metoprolol and started on Toprol XL 25mg and Lisinopril 10mg
daily.
5) History of DVT: In lower extremity, more than 1 year ago.
Patient started on heparin gtt sliding scale. Due to elevated
PTT (>150), heparin had been withheld. However, it was
determined that access (Port-A-Cath) contributed to falsley
elevated PTT and access was established on dorsum of hand. This
resulted in PTT of 26.6. Heparin gtt immediately restarted
according sliding scale protocol. Upon discharge, will restart
warfarin when able with Lovenox for anticoagulation until
therapeutic INR. Patient to follow up with primary care
physician for INR checks. INR goal is 2.0-3.0.
6) Pancytopenia: All cell lines are depressed at baseline,
possibly secondary to chemo versus MDS. Followed by
hematology/oncology. On iron supplements and procrit. Procrit
discontinued on [**2167-7-20**] due to febrile episodes x2. Hematocrit
and hemoglobin stable and procrit to be continued at the
discretion of outpatient physician [**Name Initial (PRE) **].
7) Breast Cancer: Admitted on examestane, which can rarely
cause CHF; could potentially be exacerbating the situation.
Discussed this with hematology/oncology, who recommended
continuing examestane. The patient's oncologist (Dr. [**Last Name (STitle) 109680**]
recommended a torso CT scan with contrast to evaluate for
possible additional metastases and other pathology. CT scan was
negative.
8)Regurgitation: Throughout hospitalization, patient had
episodes of regurgitation after eating. It was recommended by
her oncologist to obtain CT scan of torso to evaluate for
additional metastases. CT scan indicated no new lesions.
Discomfort thought to be due to dyspepsia/constipation. Reglan
was added to her bowel regimen and patient admitted to having a
bowel movement. Patient has been set up with [**Hospital3 **] [**Hospital **]
clinic for outpatient follow up, scheduled for [**2167-8-15**].
9) Physical therapy: Patient confined to bed for majority of
stay. PT consulted and recommended for patient to attend
rehand. Patient and family adamantly refused and home PT rehab
was set up. Family agreed to home rehab.
Medications on Admission:
1) Glimepiride 8 mg PO DAILY
2) Valsartan 160 mg PO BID
3) Toprol XL 25 mg PO DAILY
4) Bumetanide 1 mg PO DAILY
5) Xanax 0.25 mg PO TID
6) Kcl 10 meq PO DAILY
7) ASA 81 mg PO DAILY
8) Isosorbide mononitrate 30 mg PO DAILY
9) Pantoprazole 40 mg PO DAILY
10) Exemestane 25 mg PO DAILY
11) Atorvastatin 10 mg PO DAILY
12) Sertraline 100 mg PO DAILY
13) Warfarin 5 mg PO QMWF, 2.5 mg PO QTTH
14) Colace 100 mg PO BID
15) Senna 2 tabs PO QHS
16) FeSO4 325 mg PO BID
17) Oxycontin 20 mg PO QAM, 50 mg PO QPM
18) Oxycodone 5-10 mg PO Q6 hours prn
19) NTG SL 0.3 mg prn
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
3. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Two (2)
Tablet Sustained Release 12HR PO QAM (once a day (in the
morning)).
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
Disp:*500 ml* Refills:*2*
5. Levobunolol 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. Exemestane 25 mg Tablet Sig: One (1) Tablet PO qHS () as
needed for breast cancer.
7. Warfarin 5 mg Tablet Sig: 1 tablet alternating with 1/2
tablet Tablet PO 5 mg QMWFSun, 2.5 mg QTThSat: RESUME YOUR
PREVIOUS SCHEDULE/DOSING.
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Outpatient Lab Work
Please have your blood culture (peripheral site and Port-A-Cath
site) and urine culture drawn in 1week. Please have results
faxed to Dr. [**Last Name (STitle) **]. His phone number is listed below.
[**Last Name (LF) 4784**],[**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 109681**]
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
14. Reglan 5 mg Tablet Sig: One (1) Tablet PO qACHS.
Disp:*112 Tablet(s)* Refills:*2*
15. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
16. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous twice a day for 10 days.
Disp:*20 injections* Refills:*1*
17. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO QPM (once a day (in the
evening)).
18. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO qPM.
19. Amaryl 4 mg Tablet Sig: Two (2) Tablet PO once a day.
20. Outpatient Lab Work
Please have your blood culture (peripheral and Port-A-Cath)
drawn again in 2weeks. Please have results faxed to Dr. [**Last Name (STitle) **].
His phone number is listed below.
[**Last Name (LF) 4784**],[**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 109681**]
21. Outpatient Lab Work
Please have your INR drawn on Monday [**7-27**].
Please have results faxed to Dr. [**Last Name (STitle) **]. His phone number is
listed below.
[**Last Name (LF) 4784**],[**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 109681**]
Please have him continue to follow up on your INR
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Primary: CHF exacerbation
Secondary:
Coronary Artery Disease
Hypertension
Diabetes Mellitus Type 2
Breast Cancer
Discharge Condition:
The patient was discharged hemodynamically stable, afebrile with
appropriate follow up.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please take all medications as prescribed. We have made a
number of medication changes as follows:
1) Please stop taking your valsartan. We have replaced this
medication with lisinopril 10 mg once a day.
2) We have started you on a new medication called Reglan
(metoclopramide) to help you digest your food and hopefully help
decrease your stomach and chest pains. You should take this
medication just prior to meals, and at night before bed.
3) Please take only 81 mg of aspirin daily since you are also on
coumadin and don't want to keep your blood too thin.
4) You will be on lovenox injections until your INR is at goal
of [**1-16**]. Once your INR is at goal these can be stopped. You
will have your INR checked on Monday (we have provided you with
a prescription). The result will be faxed to Dr. [**Last Name (STitle) **].
You will need to have another blood (peripheral and port-a-cath)
and urine culture done in 1week. Then, also another blood
culture (peripheral and port-a-cath) done at 2weeks. Please see
the provided prescription to have this done. Please have the
results faxed to your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
([**Telephone/Fax (1) 109681**]). Please instruct your PCP to follow up on blood
culture data drawn on [**2167-7-21**] which is still pending. The final
results of the surveillance blood cultures drawn prior to [**2167-7-21**]
were negative.
We have set you with at home rehabilitation services. Please
follow their recommendations.
Please keep all follow up appointments (see below).
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] or seek medical attention in the
ED if you experience worsening shortness of breath, chest pain,
nausea, vomiting, diarrhea, abdominal pain, or any other
concerning symptom.
Followup Instructions:
Please see your cardiologist, Dr. [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 109682**],
within 30 days by calling him for a follow up appointment.
Please see your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-15**] weeks by calling
([**Telephone/Fax (1) 109683**] for an appointment.Please alert Dr. [**Last Name (STitle) **] about the
pending cultures.
You have the following appointment with Dr. [**Last Name (STitle) **].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2167-8-5**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19988**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2167-8-5**] 11:00
We have scheduled you for a visit to the GI (gastrointestinal)
clinic on [**8-19**] at 2:30, [**2166**] [**Hospital Ward Name 23**] [**Location (un) 436**] with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) 9916**].
Completed by:[**2167-8-3**]
|
[
"585.9",
"250.00",
"V10.3",
"996.72",
"401.9",
"414.01",
"428.0",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.52",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
19878, 19948
|
9692, 16223
|
340, 400
|
20106, 20196
|
5831, 9243
|
22178, 23280
|
5415, 5454
|
17058, 19855
|
19969, 20085
|
16471, 17035
|
9260, 9669
|
20220, 22155
|
5469, 5812
|
16241, 16445
|
269, 302
|
428, 2850
|
2872, 5299
|
5315, 5399
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,874
| 113,640
|
47005
|
Discharge summary
|
report
|
Admission Date: [**2121-10-15**] Discharge Date: [**2121-10-19**]
Date of Birth: [**2048-10-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Aortic valve replacement with a 27-mm [**Company 1543**] Ultra
Mosaic aortic valve bioprosthesis, serial number
[**Serial Number 99679**].
2. Coronary bypass grafting x1 with a reverse saphenous
vein graft from the aorta to the posterior left
ventricular coronary artery.
3. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
72 yo M with h/o CAD s/p BMS in LAD
and PTCA of D2 ostium, MR [**First Name (Titles) **] [**Last Name (Titles) **] presented today for
pre-admission testing. Patient reports feeling well overall
with
occasional
SOB with exertion (walking). He reports occasional palpitation.
However, there has not been any chest pain, orthopnea, PND,
swelling in the LE, syncope or pre-syncope. He is pre-op for
AVR/CABG.
Past Medical History:
Aortic Insufficiency
Coronary Artery Disease
s/p AVR, CABG this admission
PMH:
aortic insufficiency
mitral insufficiency
NSTEMI [**2113**]
coronary artery disease ( S/p BMS to LAD, PTCA to Diag)
mild normocytic anemia
chronic renal insufficiency ( baseline Cr 1.5)
hypertension
hyperlipidemia
pacemaker [**4-2**] ( first degree and type-1 second degree AVB)
Raynaud's syndrome
benign prostatic hypertrophy
RLL PNA [**2118**]
gastroesophageal reflux
left gynecomastia
right LE varicosities
Social History:
Lives with:wife
Occupation:investment manager
Tobacco:quit 50 yrs ago
ETOH:[**1-25**] glasses wine/day
Family History:
There is no family history of premature coronary artery disease,
unexplained heart failure, or sudden death.
Physical Exam:
Pulse: 60 Resp: O2 sat: 96% RA
B/P Right: 137/64 Left: 140/67
Height: 69" Weight: 140#
General:thin gentleman
Skin: Dry [x] intact [x]2 tiny bites at xyphoid area
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM []-no JVD noted
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- [**3-29**] diastolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema-none
Varicosities: RLE
Neuro: Grossly intact;nonfocal exam
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:
[**2121-10-18**] 04:30AM BLOOD Hct-25.8*
[**2121-10-17**] 05:55AM BLOOD WBC-9.9 RBC-2.90* Hgb-9.5* Hct-27.6*
MCV-95 MCH-32.7* MCHC-34.3 RDW-13.3 Plt Ct-120*
[**2121-10-18**] 04:30AM BLOOD UreaN-21* Creat-1.1 Na-134 K-4.2 Cl-98
Intra-Op TEE [**2121-10-15**]
Conclusions
Pre CBP:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 50 %).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Severe (4+) aortic regurgitation is seen. Flow
reversal was observed in the thoracic descending aorta.
Mild (1+) mitral regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
Post CPB:
The cardiac output is 4.8L/min, the patient is being AV paced.
There is mild MR.
There is a well seated bioprosthetic valve in the aortic
position, with a peak gradient of 10mmHg and a mean gradient of
6mmHg.
The thoracic aortic contours are intact.
The LVEF is 40% with mild hypokinesis in the inferior wall,
although it is difficult to assess wall motion abnormalities
accurately while pacing.
Brief Hospital Course:
The patient was brought to the operating room on [**2121-10-15**] where
the patient underwent CABG and AVR (27-mm [**Company 1543**] Ultra Mosaic
aortic valve bioprosthesis, serial number [**Serial Number 99679**]) with Dr.
[**Last Name (STitle) 914**]. See operative report for full details. Overall the
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Cefazolin was used for surgical antibiotic
prophylaxis.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. His permanent pacemaker was interrogated
and pacing wires discontinued. Beta blocker was initiated and
the patient was gently diuresed toward the preoperative weight.
The patient was transferred to the telemetry floor for further
recovery. Chest tubes were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to home in good condition with
appropriate follow up instructions.
Medications on Admission:
atenolol 12.5 mg daily
ASA 162 mg daily
lipitor 20 mg daily
lisinopril 20 mg daily
MVI daily
Vit D2 1000 units daily
omeprazole 20 mg daily
flomax 0.4 mg daily
fish oil 1200 mg/144 mg daily
SL NTG prn
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 Q4H (every
4 hours) as needed for pain.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
9. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5
Tablets PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic Insufficiency
Coronary Artery Disease
s/p AVR, CABG this admission
PMH:
aortic insufficiency
mitral insufficiency
NSTEMI [**2113**]
coronary artery disease ( S/p BMS to LAD, PTCA to Diag)
mild normocytic anemia
chronic renal insufficiency ( baseline Cr 1.5)
hypertension
hyperlipidemia
pacemaker [**4-2**] ( first degree and type-1 second degree AVB)
Raynaud's syndrome
benign prostatic hypertrophy
RLL PNA [**2118**]
gastroesophageal reflux
left gynecomastia
right LE varicosities
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
No LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2121-10-24**]
11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8708**], M.D. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2121-11-13**] 4:00
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2121-11-4**]
4:00
Please call to make an appointment with Dr. [**Last Name (STitle) 914**] in [**2-26**] weeks
[**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**
Completed by:[**2121-10-19**]
|
[
"454.9",
"396.3",
"414.01",
"V45.82",
"530.81",
"600.00",
"412",
"443.0",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
6814, 6872
|
4242, 5576
|
327, 685
|
7405, 7573
|
2689, 3811
|
8361, 9063
|
1776, 1886
|
5828, 6791
|
6893, 7384
|
5602, 5805
|
7597, 8338
|
1901, 2670
|
284, 289
|
713, 1126
|
1148, 1639
|
1655, 1760
|
3821, 4219
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,053
| 119,121
|
5844
|
Discharge summary
|
report
|
Admission Date: [**2146-5-12**] Discharge Date: [**2146-6-1**]
Date of Birth: [**2081-11-5**] Sex: M
Service: MEDICINE
Allergies:
Demerol / Haloperidol / Ativan / Percocet
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Recurrent HCV
Major Surgical or Invasive Procedure:
[**5-19**] - liver biopsy
History of Present Illness:
Mr. [**Known lastname 23171**] is a 64 yo M s/p liver transplantation [**2145-12-7**] with chronic HCV related cirrhosis and hepatocellular
carcinoma. He had excellent graft function. He did well until
[**Month (only) 116**] when abnormal liver function tests were noted. The tests
were specifically cholestatic with elevated alkaline
phosphatase. Hepatic artery stenosis was ruled out by hepatic
angiogram. A liver biopsy was performed on [**4-8**] which was
consistent with recurrent viral hepatitis C with grade 0-1
inflammation and stage 0 cirrhosis.
.
He had 2 admissions in the month prior to this admission for
elevated LFTs and pruritis. He underwent ERCP and stent
placement at each admission for possible stricture at site of
anastomosis. However, his LFTs remained elevated. His most
recent HCV viral load was 26,900,000 (stable from last count
from [**1-26**], elevated from [**9-27**]).
.
He presented for initiation of infergen/ribavirin therapy for
recurrent hepatitis C.
.
On admission he complained of continued pruritus and 3 episodes
of loose, [**Male First Name (un) 1658**] colored stools. He also reported continued
epigastric pain that is occasionally sharp. It was not
associated with food, and was often relieved by a bowel
movement. He has had no bloody bowel movements, dark stools. He
denied fevers, chills, sweats. He was otherwise in his usual
state of health.
Past Medical History:
Bipolar disorder: Diagnosed in [**2129**], past suicide attempt in
the 70s during a manic phase or s/t to drug and alcohol abuse.
Had been stable on Wellbutrin and Lithium since [**29**] and 93
respectively, except for during a trial of IFN therapy in [**2138**]
where hospitalization was required.
- HCV: Genotype unknown. Liver biopsy in [**9-/2144**] showed stage 4
cirrhosis and small well-differentiated hepatocellular
carcinoma. Found to have grade 1 esophageal varices on EGD in
4/[**2143**]. Developed hepatic encephalopathy in [**2142**] requiring
hospitalization at [**Hospital1 2025**], started on lactulose with good effect.
Past treatments include peg interferon and ribavirin in [**2139**].
These meds were discontinued due to suicidal ideation.
- HCC: Recently noted 1.4 cm enhancing lesion on liver imaging,
proved to be small, well-differentialed HCC on bx in [**9-26**] s/p
cadaveric liver transplantation on [**11-28**] (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**])
- Hypothyroidism. On levothyroxine as an outpatient.
-[**2145-12-7**] liver [**Month/Day/Year **]
-Psych: history of bipolar disorder managed with high dose
wellbutrin. prior suicide attempts requiring hospitalization.
Social History:
He lives [**Location (un) **] w/ wife, who is a nurse and two teenage
children. No [**Location (un) 23165**] beverage for 30 years. No tobacco use
ever.
Family History:
Non-contributory.
Physical Exam:
On Admission:
VS - Temp 97.6F, BP 117/73, HR 74, R 20, O2-sat 99% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, mild discomfort in epigastrium; no
masses or HSM, no rebound/guarding; well healed T shaped scar
from traspalnt
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
[**3-23**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
On Discharge:
Vital signs stable
Gen: Pt sitting up in bed, comfortable, talkative
HEENT: icteric sclera, L sided tongue hematoma, no change from
prior exam, no JVP
Lungs: clear to auscultation b/l, no wheezes/rales/rhonchi
CV: RRR, s1, s2, no murmurs/rubs/gallops
Abd: +BS, soft, non-tender, non-distended, improved from last
exam, no rebound, no guarding
Ext: Trace edema to ankes stable from prior, no cyanosis
Skin: Mildly jaundiced improved from prior, no bruising
Neuro: AOx3, CN II - XII grossly intact, no asterixis
Pertinent Results:
On Admission:
Chemistry: Na - 134, K - 5.8, Cl - 107, CO2 - 20, BUN - 45, Cr -
1.4, Glucose - 189,
CBC: WBC - 4.7, Hgb - 10.8, HCT 34.2, Plts - 204
LFTs: ALt - 55, AST - 1106, LDH - 294, AP - 859, TB - 9.2
Coags: PT - 11.3, INR - 0.9
[**5-19**] - Liver Bx - Mild portal and minimal lobular mononuclear
inflammation with scattered apoptotic hepatocytes, mild
hepatocellular and canalicular cholestasis, mild predominantly
macrovesicular steatosis c/w early recurrent viral hepatitis C.
[**5-30**] - Liver Bx - minimal, relative decrease in inflammation,
rare foci of dystrophic bile ductular changes and essentially
similar fibrosis and cholestasis. While the biliary features are
focal and may be secondary to HCV, evaluation to exclude a
component of biliary ischemia is recommended.
On Discharge:
[**2146-6-1**] 05:45AM BLOOD ALT-91* AST-170* LD(LDH)-323*
AlkPhos-1734* TotBili-5.1*
[**2146-6-1**] 05:45AM BLOOD WBC-3.7* RBC-2.96* Hgb-8.9* Hct-25.9*
MCV-88 MCH-30.2 MCHC-34.5 RDW-16.9* Plt Ct-223
[**2146-6-1**] 05:45AM BLOOD Glucose-90 UreaN-22* Creat-1.4* Na-141
K-4.6 Cl-113* HCO3-19* AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 23171**] is a 64 y/o gentleman w/ HCV and HCC s/p OLT [**11-28**],
who presented with recurrent HCV and was admitted on [**5-12**] for
initiation of infergen and ribavirin.
1. RECURRENT HEPATITIS C S/P OLT- transaminitis was likely
secondary to recurrent infection with HCV. Pt started
treatement with infergen and ribavirin on [**5-12**] but viral loads
did not seem to respond to this therapy. Hep C viral load was
trended during hospital course and increased from >20 million to
>42 million to >69,000,000.
Pt had abdominal imaging including doppler U/S to ensure graft
patency which was normal as well as KUB to visualize correct
placement of prior biliary stent via ERCP, and the stent was
confirmed to be in the correct position in the RUQ. However,
bilirubin and transaminases continued to rise. Pt's prograf
levels were carefully monitored and as his levels were
supratherapeutic at 11.9, prograf was decreased from 1mg [**Hospital1 **] to
0.5mg on [**5-17**] and then held starting on [**5-18**] as his levels
trended downward. In order to rule out rejection or potential
fibrosing cholestatic hepatitis, pt underwent bedside liver
biopsy on [**5-19**]. However, on the evening of [**5-19**], pt c/o severe
mid-epigastric pain and had a few episodes of vomiting, so stat
CT abd was ordered to rule out hemorrhage. As pt reached CT
scanner, he complained of anxiety and ringing in his ears, then
had a witnessed tonic-clonic seizure lasting <1 minute. Code
blue was called for airway protection and pt was transferred to
the MICU for closer monitoring (see below). In the ICU, Since
Cellcept can potentially interact with Colesevelam, Colesevelam
was discontinued. Additionally, Cellcept was discontinued [**5-20**].
Sirolimus 2mg PO daily was initiated on [**5-21**] per liver
recommendations, as pt was no longer on tacrolimus (since [**5-18**])
Lactulose and rifaximin were continued. Pt was on prophylactic
Bactrim, however this was held due to patient's decreasing renal
function (see below). LFTs were trended, and decreased during
his ICU stay, however still elevated at the time of transfer.
Final pathology demonstrated findings consistent with early
recurrent hepatitis C. Upon the patient's return to the floor,
his bilirubins began to slowly trend downward, but the patient's
alkphos continued to rise, raising concern for an ongoing acute
process, such as fibrosing cholestatic hepatitis (FCH). Also
considered at the time was the hypothesis that intrahepatic
cholestasis was being caused by an immune-mediated inflammatory
response to hepatitis C antigen. Given this concern, a repeat
liver biopsy was performed. Final pathology results were
consistent with the previous biopsy with mildly decreased
inflammation, in favor of recurrent hepatitis C and decreasing
the likelihood of FCH. At this time it was determined that the
patient should reach equilibrium levels on his keppra and that
his creatinine should be allowed to return to baseline prior to
initiating any infergen and ribavirin therapy again. On [**5-31**] he
was restarted on his rapamune at 3mg daily, but his tacrolimus
remained held. On discharge, he was to follow up as an
outpatient on [**6-3**] and [**6-6**] for monitoring of his liver
functions and drug levels, at which time a future date for
inpatient antiviral therapy will be decided upon. He was
continued on his cholestyramine, ursodiol (to be taken
separately from his cholestyramine), and rifaxamin.
.
2. [**Name (NI) 23172**] Pt does not have a h/o seizures, and in the context
of leukopenia and post-seizure febrile state to 101.8, multiple
etiologies had to be considered including mass, infection,
medication-related. Immediate tx for pt's seizure included
Keppra (loading dose) and Ativan; however, Ativan may be
responsible (paradoxically) for agitation seen well after
post-ictal period had passed. Keppra was started and has been
continued for SZ prophylaxis according to neurology
recommendations. Wellbutrin--which can lower the seizure
threshold--was tapered and discontinued. Per a discussion with
the patient's outpt psychiatrist, Dr. [**Last Name (STitle) 23168**], the patient was
started on venlafaxine, which is much less likely to decrease
the seizure thershold. Flagyl--which can increased
susceptibility to seizures--was also discontinued. Empiric
antibiotics (Ceftriaxone and Vancomycin) and Acyclovir were
begun as well. At the time of the seizure, there were no
obvious electrolyte abnormalities, tox screen was negative.
Tacrolimus level was 8.9 on the day of the seizure. CT on [**5-19**]
showed no acute intracranial process, and MRI on [**5-20**] revealed
increased putamenal signal bilaterally, consistent with
tacrolimus toxicity or acute hepatic encephalopathy. LP on [**5-20**]
demonstrated no evidence of organisms or PMNs. Antibiotics and
Acyclovir were discontinued with negative LP. EEG consistent
w/ toxic encephalopathy. Of note, pt also displayed asterixis
at this time. C3/4, cryoglobulin were normal.Etiology of
seizure was likely a combination of drugs that could lower the
seizure threshold. These were discontinued and pt had no further
episodes. He was discharged with 500mg [**Hospital1 **] keppra and neurology
follow-up.
3. ACUTE RENAL INSUFFICIENCY : Pt's creatinine had been
increasing since [**5-16**] (prior to ICU) with Cr 1.2 (at admission)
to 2.1. Etiology unclear, but may be related to prerenal
process (FEurea<35%), intrarenal process, or even potentially
HRS. Renal consulted on patient and suggested that there may be
a component of MGN from active hep c infection contributing to
renal failure, but this would not explain the acute nature of
the renal failure. C3/4 and cryoglobulin were still pending at
transfer, Cre was trended, and medications were continued with
renal dosing as needed. IV fluid trials were started, and
150mEq NaHCO3 was giver per renal. Bactrim was discontinued
because of elevated Cr. Cr peaked at 5.4 and trended down
daily. Renal was consulted who believed Cr would trend down
without intervention and that CVVH/HD was not indicated. The
likely etiology of renal failure was acute tubular necrosis
caused by decreased renal perfusion during a hypotensive episode
(although pt was not recorded to be hypotensive during his
episodes or in the ICU). Creatinine improved with gentle
hydration and was 1.4 on the day of discharge.
4. Diarrhea: Pt noted to be C.diff positive on [**5-15**], and was
started on PO vancomycin which was switched to PO Flagyl.
However, since Flagyl can lower the seizure threshold, patient
was switched to PO Vancomycin after the episode (Day [**12-2**] on [**5-19**]) and kept on contact precautions. 14 day course of
antibiotics was completed on [**5-28**], and repeat C. diff toxin was
negative. Patient reported an improvement in his symptoms but
still reported diarrhea with each meal. Fecal cultures were
negative, a repeat C. diff toxin was negative. Patient was
planned for a bacterial overgrowth test as an outpatient.
5. ABDOMINAL PAIN-epigastric pain resolved after episode of
coffee-ground emesis on morning of [**5-20**]. Coffee-ground emesis
likely from swallowing blood from tongue lacerations during
seizure; H/H remianed stable. However, given EKG axis change
with incr QRS duration also ruled out MI with troponins. Lower
quadrant abd pain has been stable since admission, and likely
related to hepatitis, although etiology unclear. [**Name2 (NI) **] acute tx
for lower quadrant abdominal pain that had no guarding/rebound,
with CT abd/pelvis on [**5-20**] negative for abdominal hemorrhage.
6. HYPOTHYROIDISM- continued home Synthroid.
7. DEPRESSION- Wellbutrin was slowly tapered down as this can
also lower seizure threshhold. [**Name (NI) **] pt's outpatient
psychiatrist to determine whether pt could tolerate an alternate
[**Doctor Last Name 360**] and she suggested desvenlafaxine (pristiq). Wellbutrin was
discontinued and pt was started on venlafaxine for
insurance/cost reasons which he tolerated well. On discharge he
was encouraged to make an appointment with outpt psychiatry so
his doses could be monitored.
Medications on Admission:
1. Tacrolimus 1.5 mg PO Q12H
2. Bupropion HCl 200 mg PO BID
3. Levothyroxine 100 mcg PO DAILY
4. Modafinil 100 mg PO qam
5. Mycophenolate Mofetil 500 mg PO BID
6. Quetiapine 25 mg PO QHS
7. Sulfamethoxazole-Trimethoprim 400-80 mg tab PO DAILY
8. Folic Acid 1 mg PO DAILY
9. Multivitamin 1 tab PO DAILY
10. Ursodiol 300 mg PO TID
11. Hydroxyzine HCl 25 mg PO BID
12. Omeprazole 20mg PO daily
13. Colesevalem 625 once a day
Discharge Medications:
1. Modafinil 100 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO Q AM ().
2. Folic Acid 1 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY (Daily).
4. Quetiapine 25 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Levetiracetam 500 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Venlafaxine 37.5 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Sirolimus 1 mg Tablet [**Doctor Last Name **]: Three (3) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Levothyroxine 100 mcg Tablet [**Doctor Last Name **]: One (1) Tablet PO DAILY
(Daily).
9. Rifaximin 550 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO BID (2 times a
day).
10. Ursodiol 300 mg Capsule [**Doctor Last Name **]: One (1) Capsule PO BID (2 times
a day).
11. Diphenhydramine HCl 25 mg Capsule [**Doctor Last Name **]: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
12. Hydroxyzine HCl 25 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO QID (4
times a day).
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Doctor Last Name **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
14. Cholestyramine-Sucrose 4 gram Packet [**Doctor Last Name **]: One (1) PO twice
a day as needed for itching: you must take this 4 hours after
ursodiol as these can interact.
Disp:*1 pack* Refills:*0*
15. Bactrim 400-80 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
PRIMARY: recurrent hepatitis C infection, seizure, acute renal
insufficiency, C. difficile colitis
SECONDARY: s/p OLT hepatitis C, depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was an absolute pleasure being involved in your care, Mr.
[**Known lastname 23171**]. You came to the hospital on [**5-12**] for initiation of
Infergen and Ribavirin to treat your recurrent Hepatitis C.
While in the hospital you developed an infection in your colon
with C. difficile, which was treated with a 14 day course of
antibiotics. You underwent liver biopsy on [**5-19**] and unfortunately
suffered two seizures later on that day and went to the
Intensive Care Unit. While in the ICU, your kidneys sustained
some injury, likely from having low blood pressures during the
seizure. You were seen by neurology and started on anti-seizure
medications which should be continued for 1 month. Your kidney
and liver function continued to improve.
Your Medications have CHANGED as follows:
1. We ADDED Keppra, a medication to take to prevent seizures at
500mg TWICE per day
2. We STOPPED tacrolimus (prograf) Do NOT take this medication
anymore
3. We STARTED Rapamycin (sirolimus) 3 mg DAILY.
4. We STOPPED Wellbutrin (buproprion) as this can lower the
seizure threshold
5. We STARTED venlafaxine (effexor) at 37.5mg twice per day, as
directed by your outpatient psychiatrist.
6. We STOPPED your cholesevalam
7. We STARTED cholestyramine instead. Please take this
medication 4 hours after ursodiol as they can interact
8. We ADDED Benadryl which you can use as needed for itching
Followup Instructions:
PLEASE FOLLOW-UP AS BELOW:
[**Month/Day (4) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-6-8**] 2:20
You will need to have labs drawn on Friday [**6-3**] and Monday [**6-6**]
including CBC, CHEM7 and RAPAMYCIN levels. You will also get TTG
testing and testing for bacterial overgrowth with the hydrogen
breath test.
Please also arrange to see your outpatient psychiatrist so she
can monitor you on Effexor.
Please follow-up with outpatient Neurology so they can follow
you on your anti-seizure medication and determine how long you
should be on it
Test for consideration post-discharge: Rapamycin
|
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,477
| 188,352
|
54775
|
Discharge summary
|
report
|
Admission Date: [**2149-7-25**] Discharge Date: [**2149-8-20**]
Date of Birth: [**2094-10-2**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
Diagnostic and therapeutic paracenteses
Bronchoscopy
History of Present Illness:
This is a 54 year old male with HTN, COPD, alcohol abuse
transferred from [**Hospital3 4107**] with jaundice, abdominal
distention and sodium of 104. Originally presented with two
weeks of abdominal pain with solid foods but not with liquids.
When eats solid food gets constant abdominal pain over upper
quadrants. Two weekends ago noticed that abdomen became
distended and remained so since. Abdomen feels "tight" and has
"pressure". Denies CP or SOB. No nausea, vomiting, diarrhea,
dysuria. No similar prior history of either the abdominal pain
or distension.
Went to ED today because pain was not getting better. At OSH ED
serum sodium was 104 and he was noted to be jaundiced. Denies
headache, confusion, falls, weakness, nausea, vomiting or
diarrhea. Transferred to [**Hospital1 18**] for further workup.
On arrival at the ED here VS were stable. He was started on
hypertonic 3% NS at 35cc/hr in the ED. Evaluated by hepatology.
Admitted to the ICU for treatment with hypertonic saline. On
arrival to the MICU he appeared comfortable and in no acute
distress.
He has a long history of alcoholism. Last drink 1 month ago.
Before that drank ~8 beers daily. Reports often starting and
stopping drinking in the past and states that there was no
reason in particular he stopped drinking 1 month ago.
Past Medical History:
Alcohol abuse
COPD
HTN
s/p Appendectomy
Social History:
Previously drank 8 beers daily. Smokes 1 PPD. Unemployed.
Previously worked as a machinist.
Family History:
Mother with gallstones. No family history of liver disease.
Family history otherwise noncontributory.
Physical Exam:
ADMISSION EXAM:
Vitals: T: afebrile BP: 120/56 P: 84 R: 18 O2: 94/ra
General: Alert, oriented, no acute distress
HEENT: +icteric sclera, MMM, oropharynx clear, EOMI, [**Last Name (un) 8763**]
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: faint bibasilar rales, occasional scattered expiratory
wheeze, moving good air, otherwise clear
Abdomen: distended, non-tender, +bowel sounds, no organomegaly,
negative [**Doctor Last Name **], positive fluid wave and shifting dullness
GU: no foley
Ext: 2+ pitting edema, warm, well perfused, 2+ pulses, no
clubbing or cyanosis
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred, finger-to-nose intact,
no asterixis
DISCHARGE EXAM:
no vitals as CMO
Gen: NAD comfortably watching television in bed
HEENT: Sclera icteric, EOMI, PERRLA, MMM, dobhoff removed,
spider angiomas over bridge of nose and cheeks
Neck: Supple, no [**Doctor First Name **]
Resp: Crackles at bilateral bases, moving air well, no increased
work of breathing
CV: rate fast and regular, NS1&S2, No MRG
GI: +BS, abdomen distended and soft with scattered spider
angiomas, shifting dullness, reducible umbilical hernia,
non-tender
Ext: 3+ BLE edema R greater than L
Neuro: no asterixis, A&Ox3.
Pertinent Results:
ADMISSION LABS:
[**2149-7-25**] 11:05AM BLOOD WBC-7.6 RBC-3.39* Hgb-13.3* Hct-36.5*
MCV-108* MCH-39.1* MCHC-36.3* RDW-13.7 Plt Ct-133*
[**2149-7-25**] 11:05AM BLOOD PT-26.2* PTT-46.3* INR(PT)-2.5*
[**2149-7-25**] 11:05AM BLOOD Glucose-105* UreaN-14 Creat-0.5 Na-104*
K-4.7 Cl-79* HCO3-23 AnGap-7*
[**2149-7-25**] 11:05AM BLOOD ALT-99* AST-189* AlkPhos-112
TotBili-17.1*
[**2149-7-25**] 04:00PM BLOOD Calcium-7.3* Phos-3.2 Mg-2.0
Discharge Labs:
[**2149-8-19**] 06:42AM BLOOD WBC-14.7* RBC-2.44* Hgb-9.6* Hct-27.8*
MCV-114* MCH-39.3* MCHC-34.4 RDW-17.3* Plt Ct-161
[**2149-8-17**] 06:37AM BLOOD Neuts-80.8* Lymphs-9.2* Monos-6.2 Eos-3.6
Baso-0.2
[**2149-8-19**] 06:42AM BLOOD PT-30.4* INR(PT)-2.9*
[**2149-8-19**] 06:42AM BLOOD Glucose-173* UreaN-111* Creat-2.3*
Na-120* K-3.9 Cl-82* HCO3-23 AnGap-19
[**2149-8-19**] 06:42AM BLOOD ALT-54* AST-75* AlkPhos-72 TotBili-11.2*
[**2149-8-19**] 06:42AM BLOOD Calcium-8.5 Phos-6.7* Mg-3.0*
Pertinent Labs:
[**2149-7-25**] 11:52PM BLOOD calTIBC-118* Ferritn-2135* TRF-91*
[**2149-7-25**] 11:52PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2149-8-15**] 11:23AM BLOOD HIV Ab-NEGATIVE
[**2149-7-25**] 11:52PM BLOOD HCV Ab-NEGATIVE
Micro:
[**2149-7-31**] 10:07 am BRONCHIAL WASHINGS FROM APICAL SEGMENT
RUL.
**FINAL REPORT [**2149-8-2**]**
GRAM STAIN (Final [**2149-7-31**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2149-8-2**]):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.
>100,000 ORGANISMS/ML..
BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.
GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #2. 10,000-100,000 ORGANISMS/ML..
[**2149-8-7**] 2:21 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
**FINAL REPORT [**2149-8-11**]**
Fluid Culture in Bottles (Final [**2149-8-11**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ENTEROBACTER AEROGENES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROBACTER AEROGENES
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Aerobic Bottle Gram Stain (Final [**2149-8-8**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 75863**] @ 0245 ON
[**8-8**] - [**Numeric Identifier 79728**].
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2149-8-8**]): GRAM
NEGATIVE ROD(S).
[**2149-8-10**] 5:39 pm PERITONEAL FLUID TUBE#3.
**FINAL REPORT [**2149-8-16**]**
GRAM STAIN (Final [**2149-8-10**]):
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 (Final [**2149-8-15**]):
[**Female First Name (un) **] ALBICANS. RARE GROWTH.
ANAEROBIC CULTURE (Final [**2149-8-16**]): NO ANAEROBES ISOLATED
[**2149-8-15**] 4:50 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Preliminary):
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **].
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
Aerobic Bottle Gram Stain (Final [**2149-8-17**]): BUDDING YEAST.
[**2149-8-12**] 12:19 pm SWAB Source: Rectal swab.
**FINAL REPORT [**2149-8-16**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2149-8-16**]):
ENTEROCOCCUS SP.. Sensitivity testing performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ R
Studies:
[**2149-7-25**] RUQ US: Nodular echogenic liver compatible with
cirrhosis. Slightly eccentrically located small filling defect
in the main portal
vein suggestive of a small chronic non-occlusive thrombus.
Flow is present in the main portal vein. If confirmation or
further delineation are needed clinically, CT or MR could be
considered. Adherent likely tumefactive gallbladder sludge
including part of with a polypoid configuration measuring about
1.8 cm. Attention on followup with
ultrasound within six months is suggested to confirm that this
is merely
sludge rather than a solid polyp; this is seen in the context of
more
extensive solid-like sludge within the gallbladder, however.
Moderate ascites.
.
[**2149-7-26**] CT Chest: Right upper lobe nodule on chest radiograph
corresponds to a right upper lobe cavitary lesion with slightly
spiculated borders. A second smaller cavitary lesion in the
left upper lobe is seen. The differential is broad and includes
cavitary infection (including TB), septic emboli, necrotic tumor
or metastases. Nonspecific ground-glass opacities in the left
upper lobe may be infection or other foci of the same process as
the cavitary lesion. 3-mm left lower lobe nodule. Trace
bilateral pleural effusions.
.
Pathology:
[**2149-7-29**] Sputum Cytology: Rare atypical squamous metaplastic
cells; squamous cells, pulmonary macrophages, bronchial
epithelial cells and many neutrophils.
.
[**2149-7-31**] BAL Cytology: NEGATIVE FOR MALIGNANT CELLS.
.
[**2149-8-11**] CTA torso
IMPRESSION:
1. No evidence for PE.
2. Increase of inflammatory changes involving the upper lobes.
Cavitary
lesions in the upper lobes bilaterally. The lesion in the right
upper lobe
has increased in size. Due to the rapid change in size of the
lesion, this is more consistent with an infectious process
including TB.
3. Increased subcarinal lymphadenopathy.
4. Stable 6-cm mass in the liver which is indeterminate.
Further evaluation with MRI is recommended to evaluate for
features of hepatocellular carcinoma.
5. Large amount of ascites. The previously identified free
intraperitoneal air has resolved.
6. Cholelithiasis without evidence for cholecystitis.
.
[**2149-8-9**] lower extremity US
IMPRESSION:
1. No DVT in the lower extremities.
2. Nonspecific subcutaneous edema within the right calf.
Brief Hospital Course:
54 year old gentleman with a history of alcohol abuse, HTN and
COPD who was transferred from [**Hospital3 3583**] after presenting
complaining of abdominal pain/distention and found to have a
sodium of 104, found to have alcoholic hepatitis and underlying
alcoholic cirrhosis. Course complicated by cavitary pneumonia
and secondary peritonitis. In light of poor prognosis and
non-candidacy for transplant, patient decided to withdraw
aggressive treatment and was discharged to hospice.
#Acute alcoholic hepatitis: Had 7-day prednisone course with
resultant Lille score 0.84, so prednisone discontinued,
especially in setting of acute infection. Dobhoff feeding tube
in place and enteral feeding initiated, stopped when
transitioned to CMO.
# EtOH cirrhosis: No recorded history of cirrhosis but patient
not followed closely by PCP in outpatient setting. RUQ U/S
showed diffuse nodularity consistent with cirrhosis. No
improvement of INR with IV vitamin K and high AST:platelet
ratio, physcial exam findings consistent with long standing
cirrhosis. Not currently eligible for transplant as was actively
drinking prior to this admission. Would require longer term
involvement with relapse prevention program. Patient aware that
his prognosis is grim enough that he would be unlikely to
survive long enough to qualify for transplant, and felt that
transplant itself would be a long challenging road.
- Hepatic encephalopathy: Discharged on lactulose and rifaximin
to maintain clear mental state. If unable to obtain rifaximin,
increase lacutlose as needed for confusion
- SBP: Patient had SBP this admission, as above, discharged on
cipro ppx to prevent SBP per discussion with family
- Varices: has not had EGD, no known GIB
- Ascites: diuretic refractory, s/p several large volume
paracenteses this admission
# Hyponatremia: Hypervolemic hypernatremia in setting of
alcoholic hepatitis with new onset ascites with intake of free
water in excess of sodium. ADH from [**7-28**] was 3.5 (within nl
range), so less likely SIADH. Sodium was gradually increased on
3% hypertonic saline and fluid restriction. Renal was consulted.
On [**7-29**] hypertonic saline was stopped and he was continued just
on fluid restriction and daily lasix, and Na increased to the
low 130s. Diuretics were held when patient had [**Last Name (un) **], sodium
gradually downtrended. Patient with sodium 120 when lab draws
stopped.
# Secondary peritonitis: Polymicrobial peritoneal infection with
E. coli, enterbacter, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] and [**Last Name (NamePattern1) 29361**], possibly
iatrogenic, as earlier paracentesis negative for SBP, vs.
microperforation. CT with contrast did not show evidence of
perforation, though one CT abdomen showed small amount of free
air thought to be consistent with recent paracentesis, and had
resolved on subsequent CT abdomen. Patient was treated with
Fluconazole, vancomycin and zosyn, ID was consulted.
-Dischaged on cipro only as above
# Cavitary Pneumonia: Noted to have cavitary lung lesions on
admission, pulmonary was consulted, BAL cytology negative for
malignancy, ruled out for TB early on. Initial plan was to treat
with clindamycin for 4 weeks then re-image, with CT guided
biopsy when Tbili <6. Had worsening of cavitary lesions and
increased sputum production following 10 day course of
steroidss, and rapid evolution was concern ing for active TB,
and patient was ruled out again, with pulmonology and ID
following. Also considered other causes of cavitary lung lesions
including klebsiella, staph, fungal, etc, but sputum cultures
were unrevealing.
- Patient treated with vancomycin and zosyn to cover pneumonia
and peritonitis.
- F/u quantiferon, HIV, fungal markers pending at discharge
- Discharged off of antibiotics except SBP prophylaxis as
discussed above
# Septic shock: [**1-11**] SIRS criteria + lactic acidosis and elevated
creatinine, hypotension with multiple potential sources,
including cavitary HCAP and peritonitis as discussed below. Had
brief MICU admission for stabilization, did not require pressors
or intubation.
# Hepatorenal syndrome: patient with acute kidney injury late in
hospital course, low urine sodium, bland sediment and no
response to albumin challenge consistent with hepatorenal
syndrome type 1, possibly triggered or exacerbated by restarting
of diuretics when he had stabilized from acute infections.
Midodrine/octreotide did not improve renal function and were
withdrawn when goals of care transitioned to CMO.
# Malnutrition: Severely malnourished. Reported poor diet at
home. Given 500mg IV thiamine x3 days and then started on PO
thiamine. Started on tube feeds while in hospital following
nutrition consult, but this was discontinued when patient
decided to stop aggressive treatment.
CHRONIC ISSUES:
# Alcohol Abuse: Long history of heavy drinking. Last drink 1
month ago so he did not require a CIWA. Social work was
consulted. Patient not candidate for transplant as actively
drinking up until this acute illness.
#HTN: Home metoprolol was held for low blood pressures.
# COPD: Continued on spiriva
# Tobacco abuse: nicotine patch
TRANSITIONAL ISSUES:
======================
Unlikely to affect future management, but of note:
- Liver hypodensity on CT not further characterized on MRI with
gado as renal function not stable, but AFP and CA [**55**]-9 were
normal
- Fungal markers, Tb quantiferon pending at discharge, will not
need to be follow up as patient transitioned to CMO
- Final cultures from peritoneal fluid were pending at time of
discharge
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule inhaled once a day Disp #*14 Capsule Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb(s) inhaled
every 4 (four) hours Disp #*30 Box Refills:*0
3. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
4. Simethicone 80 mg PO QID:PRN gas
RX *simethicone 80 mg 1 tablet by mouth four times a day Disp
#*30 Tablet Refills:*0
5. traZODONE 50 mg PO HS:PRN sleep
RX *trazodone 50 mg 1 tablet(s) by mouth at night Disp #*14
Tablet Refills:*0
6. Nicotine Patch 14 mg TD DAILY
prn patient preferance
RX *nicotine 14 mg/24 hour 1 patch to arm replace daily Disp
#*14 Transdermal Patch Refills:*0
7. Lactulose 15 mL PO TID
Titrate to [**2-9**] BMs daily.
RX *lactulose 10 gram/15 mL (15 mL) 15-30 mL(s) by mouth three
times day Disp #*1 Bottle Refills:*2
8. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB, wheezing
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neg inhaled every
6 (six) hours Disp #*30 Box Refills:*0
9. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
10. Morphine Sulfate (Concentrated Oral Soln) 5-20 mg PO Q2H:PRN
pain or SOB
(0-1mL)
11. Hyoscyamine 0.125 mg SL Q4H:PRN upper respiratory congestion
12. Lorazepam 0.5-2 mg PO Q4H:PRN anxiety/nausea/insomnia
13. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth once a day Disp
#*14 Tablet Refills:*0
14. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
15. Lidocaine 5% Patch 1 PTCH TD DAILY
lower back
16. Lidocaine 5% Patch 1 PTCH TD DAILY low back pain
12 hours on/ 12 hours off
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) Apply to lower back
q24 hours Disp #*1 Box Refills:*2
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Primary Diagnosis:
Alcoholic hepatitis, alcoholic cirrhosis, cavitary hospital
acquired pneumonia (organism unidentified; polymicrobial
peritonitis, hepatorenal syndrome, malnutrition
Secondary diagnosis:
hypertension, COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 111966**],
It was a pleasure caring for you at [**Hospital1 18**]. You were admitted
because your sodium was very low, and you had increased fluid in
your abdomen due to damage to your liver caused by long-term
alcohol use. You were also malnourished, and your diet was
supported by tube feeds through your nose. During this admission
you were also found to have very serious lung and abdominal
fluid infections, as well as damage to your kidneys. You were
given aggressive treatment for these problems, but did not
improve significantly. You were not a candidate for liver
transplant because of your recent alcohol use, and would have to
be involved in relapse recovery for a while before being
considered for transplant. Given your poor prognosis, you made
the decision to stop aggressive treatments. You were stable to
be discharged to hospice according to these wishes.
Followup Instructions:
none
Completed by:[**2149-8-20**]
|
[
"995.92",
"401.9",
"572.4",
"571.2",
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"486",
"572.2",
"041.85",
"427.31",
"452",
"041.49",
"261",
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"54.91",
"96.6",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
19303, 19361
|
11530, 16350
|
288, 342
|
19630, 19630
|
3322, 3322
|
20706, 20742
|
1863, 1966
|
17352, 19280
|
19382, 19382
|
17151, 17329
|
19781, 20683
|
3768, 4255
|
1981, 2758
|
2774, 3303
|
16723, 17125
|
235, 250
|
370, 1675
|
19588, 19609
|
3338, 3752
|
19401, 19567
|
19645, 19757
|
4271, 11507
|
16366, 16702
|
1697, 1738
|
1754, 1847
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,796
| 182,046
|
16066
|
Discharge summary
|
report
|
Admission Date: [**2161-2-21**] Discharge Date: [**2161-3-7**]
Date of Birth: [**2103-6-4**] Sex: F
Service: [**Hospital1 212**] AND MICU
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: This is a 57-year-old woman with
a history of anxiety, congestive heart failure, congestive
obstructive pulmonary disease, and a question of interstitial
lung disease who presented to the [**Hospital3 45967**] on
[**2161-2-12**] with complaints of shortness of breath and
anxiety. The patient states that she has had increasing
agoraphobia and panic attacks since [**Holiday 1451**] of [**2160**].
Patient states her shortness of breath episodes were getting
progressively worse one week prior to admission at the
outside hospital.
Patient returned to the Emergency Department, and had a chest
x-ray demonstrating congestive heart failure. Was given
aspirin, nitroglycerin, and Lasix. At that time,
echocardiogram revealed moderate AS with peak gradient of 44.
RV dilatation and P.A. pressures in the range of 70-75. The
patient's O2 saturation was in the mid 80s on room air which
increased to 96% on 100% nonrebreather. Electrocardiogram
was significant for anterolateral T-wave changes and a
troponin of 2.6. CK was 64. Transaminases were also noted
to be elevated, hematocrit of 28.8.
Arterial blood gas was performed in the Emergency Department
demonstrating 7.39/21/34. BUN was 46 and creatinine was 3.1
up from her baseline of 2.0. Patient was admitted to the
Intensive Care Unit.
A high resolution CT scan was performed which demonstrated
upper mediastinal lymphadenopathy in the pretracheal and
precarinal region, cardiomegaly, no pericardial effusion was
noted, prominent interstitial densities and emphysematous
changes were noted.
Renal ultrasound was performed which demonstrated
hydronephrosis.
Chest x-ray on [**2-13**] demonstrated worsening interstitial and
alveolar process and nondiffuse consolidation of both lung
fields noted on chest x-ray.
Patient received empiric IV antibiotics and diuresed with IV
Lasix with subjective improvement in her shortness of breath.
Cultures were reportedly negative. Cardiology was consulted
and the Intensive Care Unit for the troponin leak which
peaked at 5.8, and she was started on Plavix and Imdur for a
non-Q-wave myocardial infarction. Renal was consulted and
vasculitis workup was performed with rheumatoid factor, [**Doctor First Name **],
P-ANCA, C-ANCA, C3 and C4 all of which returned negative.
Hematocrit evaluation was performed which revealed an iron
deficiency anemia. She was transfused 1 unit of packed red
blood cells and had an appropriate increase in her
hematocrit. Plan for a biopsy of her lung was encouraged,
but the patient refused. She wanted a second opinion in
[**Location (un) 86**], and was transferred to the [**Hospital1 190**].
It appears that the patient was doing well until five years
ago with minimal exertion. She was seen four years ago and
diagnosed with bronchitis. She saw Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 45968**] at
Costal [**Last Name (un) **] in [**Hospital1 789**], and was told she had probable
sarcoid base on imaging. In [**2158-7-13**], she had a
bronchoscopy with nondiagnostic biopsies followed by
mediastinoscopy with nondiagnostic biopsy. That was
performed which demonstrated scarring, but no sarcoid and no
cancer. Underwent three month trial with prednisone 40 mg po
q day without response.
Since that time, she has noted gradual decline. Began to
develop panic attacks in [**2160-11-11**], and had not left
her home since [**Holiday 1451**] of [**2160**]. She also did not see
doctor due to this problem. In [**2161-1-11**], she was
diagnosed with pneumonia based on chest x-ray and
examination. Initiate prednisone and some type of
antibiotic. Her dyspnea continued to worsen at which point,
she referred to [**Hospital3 45967**].
PAST MEDICAL HISTORY:
1. Pulmonary history as above.
2. Diabetes mellitus type 2 x20 years.
3. Proteinuria.
4. Retinopathy.
5. Status post laser coagulation.
6. Chronic renal failure.
7. Hypothyroidism.
8. Severe anxiety.
9. Congestive obstructive pulmonary disease.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Rocephin 1 gram IV.
2. Xanax 1 mg q4h prn.
3. Albuterol/Atrovent nebulizers qid.
4. NPH 16 units q am, 10 units q pm.
5. Lasix 60 mg po q am.
6. Imdur 30 mg po q day.
7. Plavix 75 mg po q day.
8. Actos 45 mg po q day.
9. Paxil 25 mg po q day.
10. BuSpar 15 mg po q day.
11. Flovent 220 mcg two puffs [**Hospital1 **].
12. Synthroid 75 mcg po q day.
13. Klonopin 0.5 mg po bid.
FAMILY HISTORY: Father died at age 70 of a myocardial
infarction. Mother had emphysema.
SOCIAL HISTORY: Patient was a former smoker, but quit 11
years ago. Lives with her husband. Formally worked in
retail as a hair dresser. No known exposure to birds, pets,
mold, dust, asbestos.
PHYSICAL EXAM ON ADMISSION: Vital signs: 96.7, 102/74, 84,
32, 92% on 4 liters. In general, she is alert, cooperative,
obese woman in mild distress, speaking in complete sentences.
HEENT is normocephalic, atraumatic. Sclerae are anicteric.
Mucous membranes moist. Conjunctivae: Pale. Pupils are
equal, round, and reactive to light and accommodation
extraocular muscles are intact. Neck: No jugular venous
distention appreciated, supple. Chest: Fine rales
throughout the lung fields, anterior and posteriorly.
Cardiovascular: Regular, rate, and rhythm, normal S1, S2, no
S3, S4, III/VI systolic ejection murmur. Abdomen is obese,
soft, nontender, nondistended, no hepatosplenomegaly, no
masses. Extremities: 1+ edema bilaterally with left
slightly greater than right. Neurologic: Alert and oriented
times three. Cranial nerves II through XII intact. Strength
5/5 in upper and lower extremities bilaterally. Deep tendon
reflexes 2+ at biceps and quadriceps.
HOSPITAL COURSE: The patient was admitted and had CT scan of
the chest without contrast performed which demonstrated
diffuse ground-glass opacification with underlying fibrotic
lung disease and extensive mediastinal lymphadenopathy
consistent with sarcoid. However, multiple other etiologies
were possible. Biopsy was thought to be needed for
definitive diagnosis.
Pulmonary and the Medical team consulted throughout her
surgery for VATS. Throughout her surgery, agreed that biopsy
was needed for medical management and discussed with the team
and the patient. Postprocedure ventilation would most likely
be required due to the patient's worsening shortness of
breath and poor functional status.
The patient was brought to the operating room and had a
procedure done which demonstrated extremely inflated, effused
lung with friable tissue and bleeding. In the PACU, she had
hypoxia, severe pulmonary hypertension, and shock. Pulmonary
artery pressures in the 100s/50s, systemic pressures of
90s/40s. Patient required initially Neo-Synephrine which was
changed to dobutamine, which was then titrated off. As
oxygenation improved, pulmonary artery pressure decreased to
the 60s/65.
Arterial blood gas at one point was 7.12/75/118. Patient was
transferred to the MICU for further management. Of note, the
patient's procedure initially was thoracoscopy which had to
be converted to open lung biopsy due to bleeding. Nitrous
oxide was also started in the PACU which helped to bring the
patient's pulmonary pressures down as well.
As the patient was in the MICU, her nitrous oxide was slowly
weaned off. The patient had several hypotensive episodes
which were treated with intravenous fluids with fair
improvement. Patient's biopsy returned as acute organizing
pneumonitis with marked type II pneumocyte hyperplasia in the
background of interstitial fibrosis consistent with
organizing stage of ARDS. Patient's chest tubes remained on
persistent suction due to an air leak which was not unusual
given her high pulmonary pressures and significant pulmonary
fibrosis.
Patient's ventilatory support was attempted to wean with
decreasing levels of PEEP. Patient's sedation was titrated
down, however, the patient could not tolerate ventilatory
setting with decreased sedation. She also became very
desynchronous with the vent with her saturations of oxygen
decreased significantly. Multiple attempts at weaning the
patient off the ventilator were attempted with no
improvement.
The patient was unable to be awoken. P.A. catheter was
placed demonstrating increased cardiac output with low SVR
consistent with a distributive physiology. The patient was
started on vasopressin and was pancultured. The patient was
started on Vancomycin and ceftazidime to cover for
vent-associated pneumonia. Blood cultures then grew out
gram-positive cocci in pairs and clusters with probable line
infection, also increased secretions from her nose were noted
with the question of sinusitis.
A long family meeting was undertaken. The patient's family
expressed the patient would not want prolonged ventilatory
support. Family consents given the patient's end stage
interstitial lung disease and would not be able to come off
the ventilator, they had decided to make her DNR/DNI, and
ultimately made her comfort measures. The patient was
started on a Morphine drip, and the patient passed away with
the family present.
2. Cardiovascular: The patient had non-ST elevation
myocardial infarction at outside hospital. She was
maintained on her anticoagulants during her admission. No
additional CK or troponin leaks were noted during her
admission. Her hypotensive episodes were likely due to cor
pulmonale. These did respond with fluid boluses and
eventually vasopressins.
3. Infectious Disease: The patient did not have any signs of
infection on admission to the hospital. During her hospital
course, she had distributive physiology on her P.A. line.
Following extensive workup, eventually blood cultures did
reveal 3/8 bottles with gram-positive cocci. Obvious source
was never discovered, however, infected line or vent
associated pneumonia were the most likely etiologies. The
patient was treated with antibiotics until her passing.
4. Heme: The patient's hematocrit declined slightly during
her admission. HIT antibody was checked which was negative
most likely due to hemodilution and iron deficiency.
5. Endocrine: Hypoglycemia. The patient had multiple
episodes of hypoglycemia. The patient had insulin drip
during most of her hospital stay which was titrated down
during these episodes.
6. Renal failure: The patient had elevated BUN and
creatinine on admission which slightly improved during her
course. The patient did, however, did have worsening
acidosis that was nongap. Renal was consulted for this, and
this was felt likely to be due to her poor lung function and
poor ventilation. Attempts to correct this were made with
minimal improvement. The patient also had decreasing urine
output which was helped by the addition of vasopressin.
CONDITION ON DISCHARGE: Expired.
DISCHARGE DIAGNOSES:
1. End stage interstitial lung disease with diffuse alveolar
damage.
2. Non-anion gap metabolic acidosis.
3. Staphylococcus bacteremia.
4. Iron deficiency anemia.
5. Diabetes mellitus complicated by hypoglycemia.
6. Status post thoracotomy.
7. Pulmonary artery hypertension.
8. Chronic renal failure.
9. Coronary artery disease.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Name8 (MD) 17420**]
MEDQUIST36
D: [**2161-5-25**] 18:09
T: [**2161-5-26**] 08:05
JOB#: [**Job Number 45969**]
|
[
"112.2",
"584.9",
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"998.2",
"410.71",
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] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
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"32.29",
"96.04",
"96.72",
"33.39",
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] |
icd9pcs
|
[
[
[]
]
] |
4666, 4740
|
11048, 11621
|
4268, 4649
|
5933, 10992
|
173, 195
|
224, 3936
|
4967, 5915
|
3958, 4242
|
4757, 4952
|
11017, 11027
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,009
| 141,790
|
53880
|
Discharge summary
|
report
|
Admission Date: [**2136-5-1**] Discharge Date: [**2136-5-5**]
Date of Birth: [**2057-3-9**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3021**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
[**2136-5-1**]: EGD
History of Present Illness:
79yo F with multiple myeloma c/b ESRD on HD recently discharged
from [**Hospital1 **] [**2136-4-28**] where she was found to have 3 gastric ulcers
that were cauterized as the source of an upper [**Hospital1 **] bleed who
re-presented to [**Hospital1 **] the evening of [**2136-4-30**] with 1 hour acute
onset severe nausea, vomiting x 1, bright red blood. In the
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], she denied abdominal pain, melena, BRBPR, dyspnea,
and chest pain. She further denied any dizziness or
lightheadedness. EMS noted large puddle of BRB @ scene. Pt was
noted to be tachycardic but normotensive during transport.
Patient is currently undergoing therapy for multiple myeloma
with high dose steroids. She denies any significant hx of NSAID
use. It is unclear if she has been previously evaluated for H
pylori infection.
In the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], initial VS were: 98.8 F (37.1 C). Pulse: 101.
Respiratory Rate: 20. Blood-pressure: 121/67. Oxygen Saturation:
98%.
At [**Hospital1 **], she got 2L NS, HR improved to 80. Started on
pantoprazole gtt. She was admitted to the [**Hospital1 **]-[**Hospital1 **] ICU, but is
now being transferred here for further care, particularly
anticipated difficultly in crossmatching her for transfusions.
Vitals prior to transfer (midnight): T 98.5, HR 89, RR 20, BP
114/57, weight 66.42kg
On arrival to the MICU, patient's VS were 98.4 114/71 97 99% RA.
The patient reported fatigue but denied any abdominal pain or
further episodes of vomiting. She further denied chest pain or
shortness of breath
Review of systems:
(+) Per HPI, patient also notes 10 lb wt loss over the past few
months
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- type 2 diabetes, diet controlled
- hypertension
- total abdominal hysterectomy
- appendectomy
- benign colonic polyps and
- degenerative arthritis of the spine
Social History:
Originally from [**Country 2784**]. Moved to the US with husband in the
50's. Lives independently with her husband in [**Name (NI) 60542**]. 3 grown
children who live in the area. Smokes 1/2 per day for many
years. Occ EtOH but 'lost the taste for it' suddenly in [**Month (only) 1096**]
[**2134**]. Denies illicit drugs.
Import Social History
Family History:
Her father died of metastatic gastric cancer. Her sistert died
of unknown cancer. Her mother may have had renal failure.
Physical Exam:
Physical Exam on admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, + pallor of the mucous membranes,
oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 1-2/6 SEM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, mild tenderness to palpation, no rebound or
guarding
GU: no foley
Ext: Warm, well perfused, 1+ pulses 2+ edema to the mid shin
bilaterally
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.
Physical Exam on discharge:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, 1-2/6 SEM
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: no foley
Ext: Warm, well perfused, 1+ pulses 2+ edema to the mid shin
bilaterally
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
Admission labs:
[**2136-5-1**] 06:30PM HCT-24.1*
[**2136-5-1**] 05:57AM GLUCOSE-123* UREA N-32* CREAT-1.0# SODIUM-144
POTASSIUM-4.4 CHLORIDE-112* TOTAL CO2-25 ANION GAP-11
[**2136-5-1**] 05:57AM estGFR-Using this
[**2136-5-1**] 05:57AM cTropnT-<0.01
[**2136-5-1**] 05:57AM CALCIUM-7.7* PHOSPHATE-4.0 MAGNESIUM-1.6
[**2136-5-1**] 05:57AM WBC-10.0 RBC-2.08* HGB-6.1*# HCT-19.3*#
MCV-93 MCH-29.3 MCHC-31.6 RDW-15.4
[**2136-5-1**] 05:57AM NEUTS-81.9* LYMPHS-12.0* MONOS-4.4 EOS-1.3
BASOS-0.3
[**2136-5-1**] 05:57AM PLT COUNT-327
[**2136-5-1**] 05:57AM PT-11.5 PTT-25.9 INR(PT)-1.1
Discharge Labs:
[**2136-5-5**] 06:45AM BLOOD WBC-5.7 RBC-2.99* Hgb-9.2* Hct-27.2*
MCV-91 MCH-30.6 MCHC-33.7 RDW-14.7 Plt Ct-285
[**2136-5-5**] 06:45AM BLOOD Neuts-72.5* Lymphs-17.4* Monos-7.3
Eos-2.2 Baso-0.6
[**2136-5-5**] 09:46AM BLOOD PT-10.6 PTT-28.3 INR(PT)-1.0
[**2136-5-5**] 06:45AM BLOOD Glucose-90 UreaN-20 Creat-1.0 Na-144
K-3.4 Cl-108 HCO3-29 AnGap-10
[**2136-5-5**] 06:45AM BLOOD ALT-12 AST-10 LD(LDH)-198 AlkPhos-70
TotBili-0.3
[**2136-5-5**] 06:45AM BLOOD Calcium-8.7 Phos-4.3 Mg-1.7
EGD: [**2136-5-1**]
Impression: Normal mucosa in the esophagus
Erythema and congestion in the duodenal bulb compatible with
duodenitis
Ulcers in the stomach (endoclip)
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue ppi infusion for the next 48 hours.
Can then transition to 40mg pantoprazole [**Hospital1 **] po
Repeat endoscopy in 12 weeks
Liquid diet today
If no further bleeding can transition to regular diet tomorrow.
Check serum Hpylori and treat if positive
Avoid all nsaids and etoh.
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSIS are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology.
L-spine [**2136-5-4**]:
There are five non-rib-bearing lumbar-type vertebral bodies.
There is
scoliosis with convexity to the right side which is mild. There
are no
definite compression deformities. There are again seen severe
degenerative changes, worst at L1-L2 and L2-L3, with disc space
narrowing, endplate sclerosis, and vacuum gas phenomenon. This
is unchanged since the [**2136-4-2**] skeletal survey. There are
extensive abdominal aortic calcifications. The evaluation of
sacroiliac joints is limited by the bowel gas pattern.
Bilateral hip joints are relatively preserved.
Multiple myeloma labs:
[**2136-5-2**] 02:35PM BLOOD PEP-HYPOGAMMAG b2micro-3.4* IgG-404*
IgA-56* IgM-19* IFE-TRACE MONO
FREE KAPPA, SERUM 935.6 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 16.7 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 56.02 H 0.26-1.65
Brief Hospital Course:
79 yo female with multiple myeloma c/b ESRD (previously on
dialysis) and recent upper GI bleed from gastric ulcers s/p
cautery [**2136-4-24**] who presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] the evening of [**4-30**]
with nausea and hematemesis, transferred here for ongoing care
in the setting of being a difficult crossmatch for blood, s/p
EGD with clips applied x 2.
Active Issues:
# Hematemasis: On admission, hct was 19, but pt remained
hemodynamically stable in the ICU. Pt has known gastric ulcers
that have bled in the past. On HD2 she went for EGD that
revealed duodenitis and one non-bleeding gastric ulcer in the
antrum that was clipped with endoclips achieving hemostasis.
Post procedure and s/p 3 units of [**Name (NI) 110533**], pt's Hct remained
stable at 26-27. She was continued on pantoprazole drip for 48
hrs post procedure and then transitioned to PO pantoprazole. Pt
did not have any additional episodes of melena or hematemesis
and her hematocrit remained stable. H pylori returned negative.
# Multiple Myeloma: Was referred to Oncologist in [**Hospital1 392**] ([**First Name8 (NamePattern2) **]
[**Location (un) 4223**]) after d/c from BMT service in [**Month (only) 116**]. She is currently on
her second cycle of velcade dex, last treatment was 2 weeks
prior to admission. She is due for another round of velcade and
dex that will be performed on [**Last Name (LF) 766**], [**5-7**]. This was
discussed with Dr. [**First Name (STitle) 4223**] during admission. Labs showed a
much improved free kappa to lambda light chain ratio.
# Back pain: Pt complained of lumbar back pain. L-spine x-ray
was negative for lytic lesions or compression fractures. Her
pain regimen was transtioned to oxycodone 2.5-5 mg q6h prn and
oxycontin 10 mg qam, given concern over tylenol dosing with
vicodin.
# Urinary tract infection: Pt's urine grew 10-100K of
enterococcus, pansensative. Pt was discharged on amoxacillin
500 mg tid x 7 days after confirmed that she had received this
medication in the past without complication.
Inactive Issues:
# ESRD: Patient previously required hemodialysis. Last treatment
was prior to d/c from [**Hospital1 **]. Dialysis was held throughout this
hospitalization and her creatinine remained at 1.0 with no
significant electrolyte abnormalities. She continued to urinate
normally after removal of foley catheter.
# HTN: IN setting of GIB, her home antihypertensives were held
while in the ICU. Amlodipine was restarted before transfer to
the floor
# DM: Diet-controlled, placed on sliding scale insulin as an
inpatient.
Medications on Admission:
[**First Name8 (NamePattern2) **] [**Hospital1 **] d/c summary [**2136-4-28**] - Gets meds from [**Company 25795**] in
[**Name (NI) **], husband was unable to confirm doses at [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 110534**] patch
Norvasc 5 mg daily
Colace 100 mg b.i.d.
Protonix 40 mg daily
Percocet p.r.n. pain.
Per Pharmacy [**Company 25795**] in [**Location (un) **]
Renvala 800 mg two tablets TID
Zofran 8 mg Q8h
Omeprazole 40 mg daily
Dexamthasone with chemo
[**Location (un) **] patch one daily
Vicodin 5/500 Q6h
Nephrocaps daily
Acyclovir 200 mg Q12h (PT STATES NO LONGER TAKING)
Amlodipine 10 mg daily
Fluconazole 200 mg daily (15 with no refills)
Discharge Medications:
1. Renvela 800 mg Tablet Sig: Two (2) Tablet PO three times a
day.
2. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 30 days.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. dexamethasone with chemotherapy
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
7. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day
for 15 doses.
8. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every six (6)
hours as needed for pain for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
10. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO QAM (once a day (in the
morning)) for 14 doses.
Disp:*14 Tablet Extended Release 12 hr(s)* Refills:*0*
11. amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours) for 7 days.
Disp:*42 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Primary:
Upper gastrointestinal bleed
Secondary:
Multiple Myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 94806**],
It was sincere pleasure taking care of you during your
hospitalization at [**Hospital1 69**]. You
were transferred with a recurrence of gastrointestinal bleeding.
We performed a procedure to place a few "clips" on an ulcer in
your stomach. You blood counts remained stable after this
procedure. You are now safe to be discharged home.
You will have your next round of chemotherapy with Dr.
[**First Name (STitle) 4223**] on [**First Name (STitle) 766**].
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) 4223**] on [**5-7**] at 1pm for your
next round of chemotherapy
|
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icd9cm
|
[
[
[]
]
] |
[
"44.43"
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icd9pcs
|
[
[
[]
]
] |
11717, 11775
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7222, 7628
|
281, 303
|
11886, 11886
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4420, 4420
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5032, 7199
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3155, 3169
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1976, 2455
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230, 243
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7644, 9308
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331, 1957
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9326, 9843
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4436, 5016
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3183, 3795
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11901, 12013
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2477, 2640
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2656, 3002
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,354
| 108,001
|
47167
|
Discharge summary
|
report
|
Admission Date: [**2168-7-19**] Discharge Date: [**2168-7-26**]
Date of Birth: [**2115-11-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Bactrim Ds / Sandostatin Lar / Sulfa
(Sulfonamides)
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy, mediastinoscopy, thoracotomy for RUL & RML
lobectomy
History of Present Illness:
53 yo F w/ history of sigmoid colectomy in 11/00 for colon
cancer since, s/p resection of liver metastases in [**2-3**], who
presents w/ hemoptysis in [**2-6**]. CT scan reveals 2 pulmonary
nodules: in R upper lobe and in R middle lobe. Biopsy
demoanstrated adenocarcinoma consistent w/ past colon ca.
Patient is administered chemotherapy with consequent tumor
shrinkage and patient is admitted on [**2168-7-19**] for surgical
excision of the pulmonary nodules.
Past Medical History:
1. Colon cancer status post sigmoid colectomy in 11/[**2162**]. Lymph
nodes were positive and she received adjuvant 5-FU and
leukovorin. She was found to have a liver metastases in [**2-3**] and
underwent resection of this. Her most recent colonoscopy and EGD
from [**9-5**] were unremarkable. However CT done for hemoptysis in
[**2-6**] revealed 2 pulmonary nodules within the right upper lobe
and right middle lobe. The right upper lobe nodule appears to
abut a subsegmental bronchus. These were biopised and confirmed
to be adenoCA. Patient may begin chemo in near future.
2.HOCM and resultant diastolic dysfunction, hyperdynamic EF of
70%, 3+ MR
3. Hypertension
4. IHSS
5. IDDM
6. PAF
7. OSA not on cpap
8. Anxiety and depression
9. Chronic sinusitis
10. Pituitary tumor resection in [**2144**].
11. Sinus surgery in [**2149**].
12. Abnormal PAP smear in 11/91.
13. Pacemaker DDD
14. obesity
Social History:
Lives alone; SSI since [**2160**]; worked 25 years in the Polaroid
plant.
Smoking: none
OH: none
Family History:
Her father died at 45 from an MI, mother died at 64
from a CVA. She has one sister who is a breast cancer
survivor, another sister who died at 47 from an MI and two of
her
sisters are alive and well.
Physical Exam:
Patient alert and oriented, NAD;
VS: 98.2 / 72 / 122/63 / 22 / 96 RA
Pulm: vesicular bilat.
Cardio: RRR
Wound: dry and clean; no erythema, no drainage, no sign of
infection;
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2168-7-25**] 09:50AM 8.0 3.68* 10.7* 32.3* 88 29.0 33.1 16.4*
176
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT) [**Name (NI) 11951**]
[**2168-7-26**] 05:55AM 13.4* 1.2
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2168-7-26**] 05:55AM 3.4
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2168-7-26**] 05:55AM 9.2 1.5*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2168-7-25**] 8:55 AM
CHEST (PA & LAT)
Reason: ?PTX/interval change
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman s/p RUL/RML lobectomy for metastatic colon CA.
CT now out
REASON FOR THIS EXAMINATION:
?PTX/interval change
TWO VIEW CHEST OF [**2168-7-25**]
COMPARISON: [**2168-7-23**].
INDICATION: Pneumothorax.
Examination is limited by underpenetration and low lung volumes.
A previously reported right lateral pneumothorax has nearly
resolved in the interval, with only a tiny residual lateral
pneumothorax remaining. Cardiac and mediastinal contours are
stable. There is increasing hazy increased opacity within the
lower portion of the right hemithorax. There is also a probable
small right pleural effusion. Allowing for technical factors,
the left lung is grossly clear, and there is no evidence of
significant left pleural effusion.
IMPRESSION:
1. Resolving right pneumothorax.
2. Increasing hazy opacity in lower right hemithorax. In the
appropriate clinical setting, evolving pneumonia should be
considered.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2168-7-25**] 12:34 PM
Brief Hospital Course:
Patient is operated on [**2168-7-19**] under general anesthesia for
felxible bronchoscopy, mediastinoscopy, R upper lobectomy and R
middle wedge lobectomy. Immediate post op period is spent in
PACU. On [**2168-7-20**], CXR reveal R hemothorax. Patient is transfused
with PRBC and thoracotomy is performed on the same day to stop
the bleeding. An epidural cath is placed by anesthesia for pain
control. Chest tubes are withdrawn on [**2168-7-23**].
Cardio: on [**7-25**] AM, patient went into atrial fibrillation; a
cardiology consult is requested and patient is treated with
amiodarone 400mg x4 weeks, then 200mg qd.
Afib recurred at 1800 for 1hour, therefore started on coumadin
upon d/c [**7-26**]- 2mg x3days. To be followed by [**Hospital 197**] clinic at
[**Company 191**]- [**Telephone/Fax (1) **]. Dr.[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2450**], [**Doctor Last Name 665**] and Smentana emailed for
re-referral to clinic. Dose to be managed by appropriate [**Hospital 191**]
clinic.
Patient discharged to home [**7-26**] in company of brother w/ [**Name2 (NI) 269**]
services with f/u appt by [**Doctor Last Name **] in 2 weeks, [**Name8 (MD) **], MD-
Cardiology in 4 weeks. [**Hospital 197**] Clinic draw [**7-29**], with dose f/u
by [**Hospital 191**] clinic.
Medications on Admission:
Amiodorone 200mg', Diovan 160'', Furosemide 80'', ranitidine
150'', atenolol 100'', KCl 10', ASA 325', Traizolam 0.25 qhs,
Lantus 24U qhs, [**Name (NI) 3435**] SS, MOM 2 tab qhs, flonase 50mcg'
Plan: home [**7-25**]
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
begin after you have completed the 4 weeks of 400mg.
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
7. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily).
12. Diovan 160 mg Capsule Sig: One (1) Capsule PO twice a day.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty Four (24)
units Subcutaneous at bedtime.
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
unit Subcutaneous four times a day as needed for for blood
sugar: [**Month/Year (2) 3435**] Insulin- per Blood sugar need 4times/day.
15. Atenolol 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
16. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day for 3
days: at bedtime.
Take 2 pill for [**7-26**], [**7-27**], [**7-28**] then as per Dr.[**Name (NI) 10427**] office
directs.
Disp:*30 Tablet(s)* Refills:*1*
17. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Pulmonary nodules (metastatic colon cancer)
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office for: fever, shortness of breath, chest
pain, drainage from incision site.
You may shower. No tub baths or swimming for 3-4 weeks.
You may change bandaids on chest tube sites as needed.
Do not remove small strips on incision site, let them fall off.
No lifting more than 5 pound for 2 weeks, them as per lung
surgery booklet.
Restart regular medicine as previous.
Take new medication as directed for pain. No driving if taking
narcotic medication. Can transition to tylenol when able
Followup Instructions:
Call for appointment w/ Dr. [**Last Name (STitle) **] in [**9-16**] days. [**Telephone/Fax (1) 170**].
Call for an appointment to see Dr. [**Last Name (STitle) **] in 4 weeks.
[**Telephone/Fax (1) 285**].
Completed by:[**2168-7-26**]
|
[
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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7632, 7690
|
4133, 5425
|
343, 412
|
7778, 7785
|
2385, 3000
|
8359, 8595
|
1974, 2176
|
5692, 7609
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3037, 3113
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|
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2191, 2366
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293, 305
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3142, 4110
|
440, 903
|
926, 1843
|
1859, 1958
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,231
| 172,492
|
40177
|
Discharge summary
|
report
|
Admission Date: [**2116-11-27**] Discharge Date: [**2116-11-30**]
Date of Birth: [**2086-4-29**] Sex: F
Service: MEDICINE
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
seizure/overdose
Major Surgical or Invasive Procedure:
Mechanical Intubation
History of Present Illness:
Pt is a 30 yo f w/ history of depression and opiod dependence
p/w a seizure in setting of intentional overdose on tramadol.
Patient initially presented to the ED with an unclear complaint
but was tearful. She stated that she had had a seizure while in
the taxi cab on the way over to the ED but it was unclear why
she was coming to the hospital in the first place; pt would not
provide a complete history. It was eventually determined that
she had taken 60 pills of Ultram earlier in the evening shortly
after finding out that her boyfriend had cheated on her; pt
endorsed this was an intentional suicide attempt. No other
details of the history were available at that time as the
patient was intubated in ED and no collateral sources were
available.
.
On arrival at the [**Hospital1 18**] ED she was alert and oriented but noted
to be agitated and labile. She was tachycardic to 160s and
hypertensive to 158/105. On exam she was noted to have small but
reactive pupils (3 -> 2 mm) and persistent clonus in her right
lower extremity, as well as 8-10 beats of clonus in her left
lower extremity. She also exhibited hyperreflexia bilaterally in
her lower extremities. She was able to respond to questions. An
EKG showed sinus tach with normal QTc ~430. Ativan was about to
be initiated when the pt had another 30 second tonic clonic
seizure in ED witnessed by ED physicians.Pt had no apnea but
remained post-ictal for 10-15 minutes and was slow to arouse.
.
Toxicology was consulted who felt that her findings overall were
potentially concerning for serotonin syndrome, although it was
more likely that her symptoms were limited to medication-induced
seizures. Treatment with supportive measures initiated, however
given her repeated seizures it was felt that an elective
intubation was warranted. This was discussed with the patient
who agreed, and she was intubated with etomodate and succinate
and started on a propafol gtt for sedation. Her vital signs at
the time of transfer to the unit were 105 118/69 100%/FiO2. She
remained afebrile.
.
In the MICU, pt was stablized and was able to be quickly
extubated w/out difficulty ([**2116-11-27**]). Pt did not have
additional seizures. However, code purple was called for
agitation/hostility towards staff/wanting to leave hospital; pt
pulled out all iv lines, refusing labs. Psych was consulted and
pt was sectioned (Section 12; can't leave AMA). Per toxicology,
needed to monitor for seizures for at least 24 hours; use benzos
not haldol for agitation, and held of restarting cymbalta. On
[**2116-11-28**], Lorazepam 2 mg PO/NG Q4H:PRN agitation ordered, b/c pt
almost code purpled again for smoking and lighting match after a
bowel movement. On [**2116-11-29**] pt called out to the floor . Tox
said to monitor lower extremity clonus. Eventually pt will be
transferred to inpt psych when bed available; currently
sectioned 12 so not ok to leave AMA. psych will continue to
follow her while inpatient.
.
Per most recent Psych note; "Pt. is frustrated by continued stay
in the hospital. She is irritable and vaguely threatening,
suggesting that she could hang herself in the ICU if she wished
but denying active SI or intent. "I think about it all the
time". She is disappointed about missing a job interview
postponed to tommorrow morning. Denies recent stress. Says
taking 12 ultram was "nothing for a heroin addict like me"
Reports sober for 2 years. Seen crying in her rooom before
evaluation. She denies this during evaluation
"Everything is fine". Denies opiate withdrawal symptoms.
Received lorazepam 2 mg twice overnight for anxiety.
Nonerequired during the day per nursing staff."
.
On transfer VS were stable 97.8 afebrile, 132/78 (117-132/68-78)
84 (84-92) 97%RA. When asked about pain pt stated she always has
pain. Wanted to know when she would be leaving.
.
Review of systems:
By report of the patient's family from the toxicology team she
has not endorsed any recent SI or HI. The patient has never been
hospitalized for psychiatric reasons before(according to
family). Review of systems otherwise unable to obtain.
.
Past Medical History:
multiple wrist surgeries (after being pushed down the stairs by
ex-boyfriend)
RSD s/p spinal stimulator
Hepatitis C
reports head trauma from MVA with brief LOC years ago
denies h/o seizures
depression
h/o IVDU
h/o alcoholism
? kidney disease (per boyfriend, unclear details)
chronic pain
Social History:
Lives with boyfriend in [**Name (NI) **].
Recently laid off job in advertising agency. Spent 4 months in
jail for drug possession about 2 years ago. H/o physical abuse
by
boyfriends. Finished high school, no college. Parents divorced,
mother remarried. Did not meet her real dad or discover her step
father was not her real father until the age of 10. Now all 3
parents are actively involved and supportive.
-reports opiate addiction starting after wrist injury and being
prescribed moriphine. Addicted to heroin (IV), morphine and
oxycodone. States she has been sober for 2 years, denies
methadone or suboxone maintenance.
-denies alcohol use
-smokes [**1-18**] ppd
-denies marijuana or cocaine use
-denies benzo use
Family History:
mother's twin has bipolar disorder, brother has depression and
is addicted to heroin. No family h/o suicide attempts.
Physical Exam:
Vitals: hr 101 bp 117/68 rr 16 O2 sat 100%
Vent Settings: CMV FiO2 100% VT 500 Peep 5 f 16
General: nonresponsive
HEENT: MMM
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds bilaterally
CV: RRR no R/G/M appreciated
Abdomen: soft, mildly obese, non-tender, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: +foley, +rash on genitalia
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs
[**2116-11-27**] 09:25PM URINE HOURS-RANDOM
[**2116-11-27**] 09:25PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2116-11-27**] 08:15AM URINE HOURS-RANDOM
[**2116-11-27**] 08:15AM URINE UCG-NEGATIVE
[**2116-11-27**] 08:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-POS
[**2116-11-27**] 08:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2116-11-27**] 06:19AM K+-3.7
[**2116-11-27**] 05:35AM GLUCOSE-71 UREA N-7 CREAT-0.7 SODIUM-138
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-24 ANION GAP-13
[**2116-11-27**] 05:35AM estGFR-Using this
[**2116-11-27**] 05:35AM HCG-<5
[**2116-11-27**] 05:35AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2116-11-27**] 05:35AM WBC-15.4* RBC-4.29 HGB-13.6 HCT-38.0 MCV-89
MCH-31.8 MCHC-35.8* RDW-13.2
[**2116-11-27**] 05:35AM NEUTS-78.5* LYMPHS-16.2* MONOS-3.9 EOS-0.8
BASOS-0.6
[**2116-11-27**] 05:35AM PLT COUNT-221
.
Discharge Labs
.
.
ECG Study Date of [**2116-11-27**] 5:37:04 AM
Artifact is present. Regular supraventricular tachycardia which
is most likely sinus. There are small R waves in the anterior
leads which are most likely due to lead placement. Non-specific
ST-T wave changes. No previous tracing available for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
152 0 90 270/431 0 87 -83
.
CHEST (PORTABLE AP) Study Date of [**2116-11-27**] 6:41 AM
FINDINGS: An endotracheal tube is with tip in standard position
4.4 cm above the level of the carina. A nasogastric tube
terminates within the mid stomach. There is diffuse perihilar
interstitial abnormality. There are no pleural effusions or
pneumothorax. Cardiomediastinal and hilar contours are normal,
with normal heart size.
Hardware overlying the mid trachea, can be confirmed to be
external to the
patient upon discussion with the clinical team.
.
IMPRESSION:
1. Endotracheal tube in standard position 4.4 cm above the
carina.
2. Diffuse interstitial abnormality for which differential
includes pulmonary edema and atypical infections such as viral
pneumonia or PCP.
.
Brief Hospital Course:
Pt is 30F w/PMH of depression (no prior suicide attempts) and
opiod abuse (2yr sobriety per pt) here with seizure in setting
of intentional Ultram overdose after found out boyfriend's
infidelity.
.
# Seizures/Ultram Overdose: Seizures were most likely medication
(ultram)-induced seizures but some concern for complete
serotonin syndrome. No known prior history of seizures.
Toxicology was consulted and followed pt at the time of transfer
to MICU and recommended to monitor lower extremity clonus and to
hold home cymbalta. Serial EKGs were performed to monitor
intervals have been stable. Benzo prn (versed gtt)was used for
seizures and agitation; however no additional seizures occured
after arrival to MICU. Pt was stablized and was able to be
called out to the floor on [**2116-11-29**]
.
# Airway Protection: electively intubated for airway protection
in the setting of seizures in the E.D, was extubated soon after
in the ICU and tolerated room air well.
.
#Depression: unclear history and no previous known SI/HI or
hospitalizations but now with apparent attempt in setting of
social stressor. Psych has seen the patient and sectioned 12 her
after code purple was called for agitation and threatening
behavoir. Currently denies any suicidal thoughts but remains
agitated at times. Needs inpatient psych treatment once stable.
Pt was able to be transferred to the floor for continued
monitoring and management while awaiting psych bed placement. Pt
was also restarted on cymbalta (low dose of 20mg daily) and
gabapentin 300 TID initially when brought to the floor;
medications were titrated per psych recs as needed in inpt
psych. Gabapentin was eventually increased back to the pt's home
dose of 800mg, 800mg and 1600mg (at night).
.
Initially plan was to transfer to inpt psych facility; however,
upon reevaluation by psychiatry after transfer to the floor it
was felt that pt no longer was actively suicidal and that she
agreed to a concrete plan of outpt follow. She no longer met
section 12 criteria. It was felt that the overdose was an act of
impulsivity and not consistent with a suicide attempt.
Therefore, psychiatric hospitalization deemed unnecessary. As
the pt was medically stable and requesting to be discharge home,
she was discharged under own care with planned outpt follow-up
with her PCP, [**Name Initial (NameIs) 2447**]/therapist at [**Location 8391**] Health
Center, as well as the pain specialist at [**Hospital1 2177**]. Pt also agreed to
continue with AA/NA and home group for substance abuse
treatment. She also agreed to call 911 or go to the nearest ED
if she was feeling worse or developing thoughts of harming
herself and was in agreement w/plan to d/c tramadol.
Medications on Admission:
(not able to confirm at time of admission)
celexa
neurontin
ultram
Discharge Medications:
1. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
3. gabapentin 400 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Medication overdose induced seizure
Possible suicide attempt
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 after you had a seizure as a
result of overdosing on tramadol and their was concern that this
was a suicide attempt or gesture of self harm. You required
intubation and admission to the ICU for stabilization of your
condition. You were able to be extubated after your condition
improved. You were seen by psychiatry who felt that you were
initially unsafe to discharge as your overdose was viewed
initially as a suicide attempt or gesture of self harm. For this
reason, after psychiatry's initial evaluation, you were received
a Section 12 meaning that you were not allowed to leave the
hospital setting over concerns that you may harm yourself or
others. However, your condition improved and after additional
evaluation and assessment it was determined that you could be
discharged home with close follow-up and in the care of your
family.
.
The following changes were made to your medications:
- Please START taking cymbalta 20mg. Please discuss this
medication with your [**Hospital1 2447**] and other doctors; adjustments
may may need to be made.
- Please STOP taking tramadol.
- Please continue to take all of your other home medications as
prescribed. DO NOT TAKE MORE THAN THE PRESCRIBE DOSE.
Please be sure to take all medication as prescribed.
.
Please be sure to keep all follow-up appointments with your PCP,
[**Name Initial (NameIs) 2447**]/psychologist, pain doctor and other health care
providers.
Followup Instructions:
Please be sure to keep all follow-up appointments with your PCP,
[**Name Initial (NameIs) 2447**]/psychologist, pain doctor and other health care
providers. Please be sure to contact your main doctor [**First Name (Titles) **] [**Last Name (Titles) 62043**] to make follow-up appointments within the next
week. Please be sure to call their offices tomorrow morning [**12-1**] to arrange follow-up appointments.
.
We have also scheduled a follow-up appointment with your primary
care doctor who can also help to ensure your symptoms resolve
and that you have the appropriate follow-up.
Name: [**Last Name (LF) 88230**],[**First Name3 (LF) 88231**] N.
Address: 409 [**Location (un) 61346**], [**Location **],[**Numeric Identifier 46146**]
Phone: [**Telephone/Fax (1) 6511**]
Appointment: [**12-2**] at 1:30PM
.
As agreed to prior to discharge, please call 911 immediately if
you have any suicidal thoughts or feelings or other concerns
about your safety.
Completed by:[**2116-12-2**]
|
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icd9cm
|
[
[
[]
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[
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[
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346, 4171
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11618, 11729
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,831
| 160,008
|
41667
|
Discharge summary
|
report
|
Admission Date: [**2194-11-4**] Discharge Date: [**2194-11-11**]
Date of Birth: [**2151-4-30**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
LEFT renal mass in a horseshoe kidney
Major Surgical or Invasive Procedure:
1. Open partial nephrectomy (of left renal mass) of a horseshoe
kidney.
2. Umbilical hernia repair.
3. Retroperitoneal lymph node sampling.
History of Present Illness:
43yM who underwent an annual physical exam over the summer with
slightly increased LFTs leading to an abdominal ultrasound. The
ultrasound revealed a horseshoe kidney and a 6 cm renal mass,
which was situated in the isthmus of the kidney, slightly to the
left.
Past Medical History:
Diabetes type 2 x1 year, hepatic steatosis, and small umbilical
hernia.
Social History:
He works as a leasing consultant for an apartment complex in
[**Location (un) 3786**]. No tobacco, occasional alcohol, no drug use. He walks
his greyhound 5-20 minutes per day without shortness of breath.
Family History:
Positive for kidney tumor in his father, which was apparently
benign.
Physical Exam:
EXAM ON DISCHARGE DATE:
WdWn male, NAD, AVSS
Interactive, cooperative
Abdomen soft, appropriately tender along incisions
Incisions c/d/i w/out evidence hematoma, infection
SIX surgical skin clips remain in place but all other abdominal
incision clips have been removed. Incision site reinforced with
steri-strips.
Extremities w/out edema or pitting and no report of calf pain
Pertinent Results:
[**2194-11-9**] 06:00AM BLOOD WBC-12.1* RBC-3.26* Hgb-9.7* Hct-29.7*
MCV-91 MCH-29.8 MCHC-32.7 RDW-14.7 Plt Ct-270
[**2194-11-8**] 06:12AM BLOOD WBC-15.1* RBC-3.52* Hgb-10.4* Hct-31.9*
MCV-91 MCH-29.4 MCHC-32.4 RDW-14.8 Plt Ct-277
[**2194-11-5**] 01:37AM BLOOD PT-13.7* PTT-27.0 INR(PT)-1.2*
[**2194-11-10**] 07:55AM BLOOD Glucose-136* UreaN-12 Creat-1.1 Na-139
K-4.2 Cl-104 HCO3-28 AnGap-11
[**2194-11-9**] 06:00AM BLOOD Glucose-106* UreaN-18 Creat-1.0 Na-134
K-3.7 Cl-101 HCO3-25 AnGap-12
[**2194-11-4**] 04:01PM BLOOD Glucose-218* UreaN-16 Creat-1.3* Na-137
K-5.4* Cl-107 HCO3-23 AnGap-12
[**2194-11-11**] 05:47AM BLOOD ALT-40 AST-23 AlkPhos-173* Amylase-261*
TotBili-0.9
[**2194-11-10**] 07:55AM BLOOD Amylase-224*
[**2194-11-11**] 05:47AM BLOOD Albumin-2.9* Cholest-167
[**2194-11-10**] 07:55AM BLOOD Calcium-8.0* Mg-2.0
[**2194-11-9**] 06:00AM BLOOD Calcium-7.7* Phos-2.8 Mg-2.1
Brief Hospital Course:
ICU course:
.
# Hypotension/tachycardia
In the setting of blood loss (3L) during surgery. Patient has
received significant fluid resuscitation and had required
pressor support in the PACU (phenylephrine for a few hours). He
was bolused in the [**Hospital Unit Name 153**] as needed o maintain BP. His Hct was
stable.
.
# Left partial nephrectomy
As per urology. Will continue with post op pain management with
bupivicaine epidural and dilaudid pca. Was kept on maintenance
IVF's.
.
# Diabetes
Pt reported on metformin as per records. Will hold oral meds
and places on RISS while on sliding scale.
.
# GERD
- c/w prilosec
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Mr. [**Known lastname 77775**] was admitted to Urology after undergoing open left
partial nephrectomy. Although there were no adverse
intraoperative events; the dissection was described as tough,
the mass was large and there was high blood loss and fluid
resuscitation due to size of resection bed. Please see dictated
operative note for details. The patient received perioperative
antibiotic prophylaxis. The patient was transferred to the unit
floor from the PACU in stable condition. On POD1 he was
transferred to the general surgical floor where he remained with
good pain control coverage with his epidural. He was hydrated
for urine output >30cc/hour, and provided with pneumoboots and
incentive spirometry for prophylaxis. His post operative course
was complicated by post-operative ileus. Over the course of
several days he was gradually weaned from oxygen support,
transitioned to PCA from epidural and then to oral pain
medications once he reported flatus. It was on [**11-7**], POD3, that
his epidural was discontinued and while his PCA was maintained.
He was weened from Ox support and kept on telemetry. Awaiting
bowel functions as no flatus on morning rounds. He was
ambulating regularly. No n/v. His foley was also d/c'd on POD3.
He was monitored daily with cbc and basic metabolic panel. With
the passage of flatus his diet was advanced to a clears/toast
and crackers diet cautiously. His JP output was fairly high as
well and this was checked for creatinine levels x two and was
normal. The remainder of the hospital course was relatively
unremarkable. The patient was discharged in stable condition,
eating well, ambulating independently, voiding without
difficulty, and with pain control on oral analgesics.
On exam, incision was clean, dry, and intact, with no evidence
of hematoma collection or infection. The patient was given
explicit instructions to follow-up in clinic in one week with
Dr. [**Last Name (STitle) 3748**] for staple removal (six remaining). He was given
instructions to follow-up with his primary care doctor as well.
Medications on Admission:
NKDA
Meds: Metformin 500' and omeprazole 20'.
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain >[**5-4**].
Disp:*50 Tablet(s)* Refills:*0*
4. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day): hold for sys<100, HR<60
.
Disp:*120 Tablet(s)* Refills:*2*
5. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
7. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Outpatient Lab Work
Please monitor your blood pressure regularly and keep a log of
your values to present to your PCP. [**Name10 (NameIs) **] up with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], within the next 1-2 weeks time to reveiw your post
operative course and medications.
Discharge Disposition:
Home
Discharge Diagnosis:
PREOPERATIVE DIAGNOSIS: Tumor, suspicious for renal cell
carcinoma.
POSTOPERATIVE DIAGNOSIS: Tumor, suspicious for renal cell
carcinoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Please also refer to the provided written instructions on
post-operative care, instructions and expectations made
available from Dr. [**Last Name (STitle) 3748**]??????s office.
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-You have been started on NEW MEDICATION to help control your
blood pressure/heart rate. You should follow up with your PCP,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within the next 1-2 weeks time to reveiw your post
operative course and medications.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-Resume all of your pre-admission/home medications except as
noted.
-Call your Urologist's office today to schedule/confirm your
follow-up appointment in 2 weeks AND if you have any questions.
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-If you have been prescribed IBUPROFEN (the ingredient of Advil,
Motrin, etc.) , you may take this and Tylenol together
(alternating) for additional pain control---please try TYLENOL
FIRST and take the narcotic pain medication as prescribed if
additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark tarry stools)
-You may shower normally but do NOT immerse your incisions or
bathe
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool-softener, NOT a laxative
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
-NOT all of your surgical skin clips were removed... SIX REMAIN.
PLEASE CALL TO RE-SCHEDULE your Dr. [**Last Name (STitle) 3748**] f/u APPOINTMENT and
to have these 'staples' removed.
-Call Dr.[**Name (NI) 11306**] office at ([**Telephone/Fax (1) 8791**] for follow-up AND if
you have any urological questions. Dr. [**Last Name (STitle) 3748**]??????s Nurse
Practitioner [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22714**] may be reached at the same number.
You must follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within the next [**1-26**]
weeks time to reveiw your post operative course and medications.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 31372**]
Completed by:[**2194-11-14**]
|
[
"753.3",
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"560.1",
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icd9cm
|
[
[
[]
]
] |
[
"40.29",
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icd9pcs
|
[
[
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6562, 6568
|
2506, 5303
|
343, 485
|
6752, 6752
|
1597, 2483
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9317, 10096
|
1113, 1185
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266, 305
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513, 776
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798, 872
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888, 1097
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,138
| 173,662
|
26594
|
Discharge summary
|
report
|
Admission Date: [**2168-7-15**] Discharge Date: [**2168-8-2**]
Date of Birth: [**2099-2-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Intrathecal methotrexate therapy x2 via lumbar puncture
History of Present Illness:
HPI: 69 yo man with NHL with CNS involvement (lymphomatous
meningitis) s/p intrathecal MTX, Rituxan, Velcade and steroids.
Patient presented to ER on [**2168-7-15**] with progressive weakness of
both arms and legs for the last 2-3 weeks. He reports that his
weakness (b/l arms and legs, R>L) has been ongoing over the past
few months worsening over the past few weeks, mainly over the
past 5 days. He walks with a cane at baseline, but has noted
that walking up stairs with his left leg leading has become
increasingly more difficult due to his weakness. He denies
symptoms of bowel/bladder incontinence.
.
On arrival to ED was found to be tachycardic and hypotensive to
systolic near 70s. EKG c/w SVT. He was given adenosine 6 mg then
12, had a 30 sec break, but reverted to SVT. After 1 g
procainamide load, he converted to NSR.
.
Additionally in the ED, CTA was performed which did not show
evidence of PE (h/o DVT on coumadin; INR therapeutic) but with
new LUL infiltrate. He was seen by Neuro in the ED; weakness
thought secondary to patient's underlying disease vs. use of
velcade. He underwent MRI of entire spine which has not yest
been read.
.
He was transferred to the [**Hospital Unit Name 153**] for monitoring. During his 24 h
stay patient has remained in NSR. He was started on levofloxacin
for possible PNA given LUL consolidation on imaging although not
c/o symptoms of pneumonia.
.
ROS: Pt denies fever or chills. No night sweats or recent weight
loss or gain. No headache, rhinorrhea or cough,or congestion.
Denied cough, shortness of breath (except transiently in the
setting of SVT). Denied chest pain or tightness, palpitations.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No melena or BRBPR. No dysuria. Denied arthralgias or
myalgias. No rash.
Past Medical History:
NHL (see below) complicated by lymphomatous meningitis
RLE weakness secondary to plexopathy
Bilateral upper extremity weakness
RLE DVT
Hives intermittently over last couple years
Raynaud's phenomena
LUL lesion in [**2129**] s/p INH x1yr
S/p appendectomy
.
Onc Hx: Initially presented with palpable lymph node in the
groin in [**2167-3-4**]. Biopsy revealed diffuse large cell
lymphoma. S/p R-CHOP x 6 cycles, completed in [**2167-7-2**]. Patient
was well until [**Month (only) **]-[**2167-11-1**] when he developed right
lower extremity paralysis. LP at that time was negative for
malignant cells but repeat LP on [**2168-2-17**] revealed malignant
cells with MRI showing increased uptake in the sacral plexus.
The patient was evaluated by neurology and thought to have a
right lumbosacral plexopathy. The patient underwent IVIg therapy
without relief. Around mid [**2168-2-1**] the patient began
radiation therapy x9-12 treatments to the sacrum with
improvement in pain complaints. He was also initiated on
decadron. Since [**2168-3-4**] the patient receives intrathecal
methotrexate every 1-2 weeks. He has regained some use of his
right lower extremity.
Social History:
He is retired and worked as a marine engineer. He is married and
never smoked. he has approximately 3 alcholic beverages a night.
He has never used any illegal drugs.
Family History:
His mother died at 93 of old age. His father died at 75 of heart
failure. His sister is 65 and has diabetes and hypertension. He
has two healthy daughters.
Physical Exam:
Vitals: T: 99.2 BP: 119/71 P: 86 RR: 20 SpO2: 95% 2L
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI, sclera anicteric. MMM, OP without
lesions
Neck: supple, no JVD or carotid bruits appreciated
Pulm: fine crackles left lung base, no rhonchi nor wheezes
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, NT/ND, + BS, no masses or hepatomegaly noted.
Ext: Right lower extremity 1+ edema.
Neurologic: CN 2-12 intact, LUE with 4/5 biceps and triceps
strength, 2-3/5 right biceps strength, Right hip flexor [**2-5**], [**6-4**]
left hip flexor, [**5-5**] right plantar flexion, [**3-7**] right
dorsiflexion, sensation to soft touch decreased slightly
anterior right lower extremity to distal shin.
.
Pertinent Results:
B-glucan= >500
[**2168-7-16**] CXR: Comparison is made with prior examination performed
one day ago. There is persistent ill-defined airspace disease
involving left upper lobe likely related to pneumonia. There is
increasing density at the right base with blunting of the right
costophrenic angle. Findings are suggestive of right basilar
atelectasis and small right pleural effusion. Cardiomediastinal
silhouette is stable. Central venous catheter is present with
tip in the right atrium.
.
[**2168-7-15**] MRI spine: Compared to the previous study of [**2168-4-2**],
there are now new focal signal abnormalities identified from L1
to L5 level. The previously noted subtle lesions in some of
these vertebral bodies have increased in size. Findings are
indicative of lymphoma deposits or metastatic disease. There is
increased signal seen on T1- and T2-weighted images in the
remaining portions of the lumbar vertebral bodies and sacrum
indicative of fatty marrow changes from radiation. Focal signal
abnormality in the upper sacrum is also identified on the right
side, indicative of metastasis or bony involvement by lymphoma.
This has also increased since the previous study. There is no
epidural mass seen or thecal sac compression identified.
IMPRESSION: New bony metastatic lesions involving the lumbar
vertebral body with increase in size of previously noted lesion.
No evidence of pathologic fracture or intraspinal mass.
.
[**2168-7-15**] CTA chest:
1. No evidence of pulmonary embolus.
2. Patchy ground-glass opacity within the left upper lobe,
which is new since [**2168-4-1**] and likely represent an infectious
process.
3. Stable 12 mm prevascular lymph node within the mediastinum.
4. Multiple low density lesions within the liver, which given
history of lymphoma may represent metastates, or given pulmonary
findings could represent infection.
[**2168-7-21**]:MRI spine, interval increase in size and # of enhancing
metastatic foci in LS spine, no involvment of exiting nerve
roots or thecal sac.
[**2168-7-21**] MRI brachial plexus: Normal examination of the right and
left brachial plexus, without abnormal
enhancement. Mild degenerative changes of the cervical spine and
focus of signal abnormality in the T6 vertebral body.
Parenchymal abnormalities of the left lung apex.
[**2168-7-24**]: CXR:progressive L.apical consolidation, ?radiation
pneumonitis, r/o TB
[**2168-7-15**] 10:49PM GLUCOSE-165* UREA N-19 CREAT-0.6 SODIUM-139
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
[**2168-7-15**] 10:49PM CALCIUM-8.5 PHOSPHATE-3.3 MAGNESIUM-2.0
[**2168-7-15**] 10:49PM WBC-5.3 RBC-4.01* HGB-12.2* HCT-35.5* MCV-89
MCH-30.4 MCHC-34.3 RDW-17.2*
[**2168-7-15**] 10:49PM PLT COUNT-149*
[**2168-7-15**] 10:49PM PT-28.8* PTT-27.2 INR(PT)-3.0*
[**2168-7-15**] 09:00PM CK(CPK)-40
[**2168-7-15**] 09:00PM cTropnT-0.06*
[**2168-7-15**] 09:00PM CK-MB-NotDone
[**2168-7-15**] 01:18PM COMMENTS-GREEN TOP
[**2168-7-15**] 01:18PM GLUCOSE-133* LACTATE-2.7* NA+-137 K+-4.1
CL--101 TCO2-25
[**2168-7-15**] 01:10PM GLUCOSE-137* UREA N-25* CREAT-0.6 SODIUM-140
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
[**2168-7-15**] 01:10PM estGFR-Using this
[**2168-7-15**] 01:10PM CK(CPK)-57
[**2168-7-15**] 01:10PM cTropnT-0.05*
[**2168-7-15**] 01:10PM CK-MB-NotDone
[**2168-7-15**] 01:10PM CALCIUM-9.2 MAGNESIUM-2.4
[**2168-7-15**] 01:10PM WBC-8.1 RBC-4.53* HGB-13.9* HCT-39.8* MCV-88
MCH-30.8 MCHC-35.1* RDW-17.5*
[**2168-7-15**] 01:10PM NEUTS-94* BANDS-3 LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2168-7-15**] 01:10PM PLT COUNT-212#
[**2168-7-15**] 01:10PM PT-26.8* PTT-28.8 INR(PT)-2.8*
Brief Hospital Course:
Assessment and Plan: 69yoM with history of NHL with CNS
involvement presented to the ED with worsening b/l UE and LE
weakness, found in the ED to be tachycardic to the 180s and
hypotensive to the 70s systolic now in NSR and normotensive.
.
1.Weakness: Patient was evaulated by neurology and it was
thought that patients weakness was either due to CNS lymphatous
involvement vs. velade. MRI perforemd showed new focal signal
abnormalities from L1-L5 and sacral bony involvement looks
worse. However, there was no epidural or thecal
compression/involvement found. Treatment was discussed by Dr.
[**Last Name (STitle) 724**]. Patient was given decadron, and received intrathecal
methotrexate and high dose intravenous methotrexate. Patient has
been working with physical therapy. He continues to regain
strenght by the day but still needs to work on his strength
with physical therapy as an outpatient. He will follow up with
Dr. [**First Name (STitle) 1557**] on tuesday at 10:00 for examination followed by
admission of his next methotrexate treatment.
2. LUL infiltrate: Consolidation was visualized on CXR and CT
chest.
Patient had been on decadron and was on bactrim DS qMWF at the
beginning of admission. Several attempts were made to induce
sputum unsuccessfully, the patient was continued on levofloxacin
for 14 days. A chest x-rday on [**7-23**] showed proessive left apical
consolidation. Eventually the patient underwent bronchoscopy
which showed PCP. [**Name10 (NameIs) 2772**], there was some question originally as
to whether this was radiation pneumonitis. The patient had
already been started on atovaquone 750mg [**Hospital1 **] by the time of
bronchoscopy. The patient is clinically improving.
3. Hypoxia: Very mild, on 2L while in the [**Hospital Unit Name 153**] without O2
requirement previously at home. The etiology was thought to be
due to PCPor LUL infiltrate. The patient eventually was weaned
off O2, and is sating well while sitting. He will go home with
O2 at bedtime and when active.
.
4. SVT: In NSR with normal BPs. CTA performed in the ED was
negative for PE. Resolved after procainamide. Troponin up to
0.07 max in this setting. Case discussed with cards in the [**Hospital Unit Name 153**]
and no additional meds/treatments necessary at this time.
Patient remained in normal sinus rhythm for the rest of the
admission.
.
5. Elevated troponin: CK-MBI normal, troponin was elevated to
max 0.08 likely in the setting of his SVT which is now resolved.
Patient continued to be asymptomatic.
.
6. NHL: Followed by Dr. [**First Name (STitle) 1557**]. Neuropathy thought secondary
to velcade, now stopped. Patient had recieved rituxan q2 weeks
(has received 3 out of planned 4 doses, last [**2168-7-5**]). Plan
discussed with Dr. [**Last Name (STitle) 724**]. On [**2168-7-23**] methotrexate and leucovorin
were started and methotrexate levels and labs were followed.
Patient was given decadron, and urine pH kept above 7 during
treatment. Patient tolerated the treatment well.
.
7. RLE swelling: Patient has history of RLE DVT diagnosed in
[**3-/2168**] for which he has been on coumadin. A repeat U/S has been
ordered which showed improved clot burden since [**Month (only) **]. Patient's
coumadin was held and he was started on lovenox. Patient will be
transitioned back to coumadin for discharge.
.
8.increased LFT's thought to be due to either methotrexate or
bactrim. Bactrim d/cd, methotrexate ended, LFT's are decreased.
RUQ ultrasound was performed.
.
Medications on Admission:
Medications on admission:
Oxycodone 60 mg Sustained Release PO Q12H
Pregabalin 100 mg 3 times a day
Senna 8.6mg Two (2) Tablet PO 2 times a day as needed.
Zantac 150 mg PO twice a day
Oxycodone 5 mg PO Q4-6H as needed for Breakthrough pain
Warfarin 5 mg QHS
Decadron 3 mg qam - 2 mg qpm
.
Meds on transfer:
Bactrim DS qMWF
Oxycodone 5-10mg q4-6h prn breakthrough pain
Levofloxacin 500mg PO q24h
Dexamethasone 2mg PO qpm
Dexamethasone 3mg PO qam
Ranitidine 150mg PO bid
Oxycodone SR 40mg q12h
Zolpidem 5mg PO hs prn
Acetaminophen 325-650mg PO q4-6hprn
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO BID (2
times a day).
Disp:*60 * Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
Disp:*60 Tablet(s)* Refills:*2*
6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
7. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Care
Discharge Diagnosis:
Primary:
NHL with CNS involvment
hypoxia
superventricular tachycardia
Seconday:
DVT [**3-/2168**]
RLE weakness
Discharge Condition:
Stable without further decline in weakness, respiratory status
improved.
Discharge Instructions:
You were admitted for worsening weakness. You underwent
intrathecal methotrexate therapy x2 with no further decline in
your weakness. Additionally, you were given systemic
methotrexate with leucovorin rescue.
.
Please call your doctor or return to the emergency room if you
develop worsening weakness, fevers/chills, trouble breathing,
bleeding or any other symptoms that concern you.
.
Please be sure to follow up as outlined below.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 1557**] on Tuesday [**8-9**] at 10:00am
with an admission to follow for methotrexate treatment.
.
Please follow up with your appointments as scheduled prior to
this admission:
|
[
"799.02",
"453.41",
"518.0",
"486",
"285.9",
"453.40",
"427.89",
"202.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.92",
"99.15",
"99.04",
"99.25",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
13188, 13249
|
8189, 11701
|
323, 381
|
13404, 13479
|
4497, 8166
|
13964, 14192
|
3588, 3745
|
12302, 13165
|
13270, 13383
|
11753, 12016
|
13503, 13941
|
3760, 4478
|
275, 285
|
409, 2206
|
2228, 3387
|
3403, 3572
|
12034, 12279
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,447
| 106,027
|
39206
|
Discharge summary
|
report
|
Admission Date: [**2201-5-12**] Discharge Date: [**2201-5-18**]
Date of Birth: [**2148-9-15**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Right Craniotomy for Tumor
History of Present Illness:
This is a 52 year old female Haitian Creole speaking female
transferred from OSH after head CT showed a 3 cm x 3 cm R
parietooccipital brain mass with rim of calcification and
associated vasogenic edema. The patient has had headaches for
one month involving her whole head. Recently, they have
increased in intensity and prevent her from sleeping. As a
result of these symptoms, she was referred to an OSH ED where CT
scan showed the above findings.
Past Medical History:
Fibroids, s/p TAH
Social History:
Emigrated from [**Country 2045**] 7 years ago. She works and
[**Last Name (un) 1445**] [**Doctor Last Name **] and KFC. She lives with her husband. She had two
adult children.
Family History:
mother deceased from [**Name (NI) 3685**]
Physical Exam:
EXAM ON ADMISSION:
Vitals: T 97.7; BP 144/80; P 70; RR 18; O2 sat 100%
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple
Extremities: no c/c/e.
Neurological Exam:
Mental status: awake, alert, per family relays coherent history
with no paraphasic errors. Follows simple and multi-step
commands.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light. VF appear full though she
continues to saccade towards finger movements in periphery even
when instructed not to do so.
III, IV, VI: EOMI.
V, VII: facial sensation intact, facial symmetric.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**6-10**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. Full
strength.
Sensation: intact to light touch.
Reflexes: Bic T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally.
Coordination: FNF intact.
On discharge:
Oriented x 3. PERRL, EOMs intact.
She has a persistent left visual field.
Face symmetric, tongue midline.
No drift.
Full strength throughout.
Sensation intact.
Incision: clean, dry, intact. Sutures in place.
Pertinent Results:
ADMISSION LABS:
[**2201-5-12**] 08:40PM WBC-8.6 RBC-5.02 HGB-12.5 HCT-37.2 MCV-74*
MCH-24.8* MCHC-33.5 RDW-13.4
[**2201-5-12**] 08:40PM GLUCOSE-91 UREA N-11 CREAT-0.6 SODIUM-141
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-29 ANION GAP-11
[**2201-5-12**] 08:40PM PT-11.7 PTT-24.0 INR(PT)-1.0
DISCHARGE LABS:
[**2201-5-18**] 05:35AM BLOOD WBC-17.3* RBC-4.52 Hgb-10.9* Hct-32.7*
MCV-72* MCH-24.1* MCHC-33.3 RDW-13.6 Plt Ct-223
[**2201-5-18**] 05:35AM BLOOD PT-11.4 PTT-22.8 INR(PT)-0.9
[**2201-5-18**] 05:35AM BLOOD Glucose-105* UreaN-12 Creat-0.5 Na-138
K-4.1 Cl-101 HCO3-29 AnGap-12
IMAGING:
CT Head from OSH [**5-12**]:
3 cm x 3 cm R pariet-occipital mass with calcified rim and
associated vasogenic edema.
CT CHEST [**5-13**]:
Limited evaluation of the pulmonary parenchyma due to image
acquisition during the expiratory phase of respiration. However,
no
intra-thoracic malignancy is identified
MRI Brain [**5-14**]:
Large extra-axial mass lesion identified at the right occipital
region, causing mass effect, associated with vasogenic edema and
adjacent and contacting the right transverse sinus as described
above, more likely
consistent with a meningioma.
Head CT [**5-15**]:
Expected post-op changes.
Residual edema in the right temporo-occipital region causing
mass effect on the occipital [**Doctor Last Name 534**] of the right lateral ventricle
and approximately 6 mm of right-to-left midline shift.
MRI Brain [**5-16**]:
There is increased DWI signal surrounding the resection cavity.
Infarct cannot be ruled out at this time but this is likely due
to retraction during the surgery though infarct cannot be
excluded. There is gross total resection.
Brief Hospital Course:
The patient was admitted to the NSurg service for Q 4 hour
neurochecks and for further work up of the CT findings. She was
given a load of Dexamethasone, and maintained on 4 Q 6. A chest
CT was obtained, which revealed no pulmonary lesions or other
areas of tumor. MR head showed large extra-axial mass lesion at
the right occipital region, causing mass effect, more likely
consistent with a meningioma.
She proceeded to the OR on [**5-15**] with Dr. [**First Name (STitle) **] for a craniotomy.
Frozen section was consistent with a meningioma with no atypical
features. The procedure went well without complications. The
patient was in the ICU overnight for Q1 hour neuro checks. She
was transferred to the neurosurgical floor the following night
since she was neurologically stable.
Physical therapy and occupational therapy evaluated the patient
over the weekend and recommended rehab. She was re-evaluated on
[**5-18**] and was still quite unsteady and required significant
assistance. She was screened for rehab and and was sent to an
appropriate facility on [**2201-5-18**].
Medications on Admission:
HCTZ 25 mg daily, Celexa 20 mg daily, Omeprazole 20
mg q day, Simvastatin 20 mg daily.
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain .
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
12. Dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 6 doses.
13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 6 doses: Start after 3 mg tapered dose.
14. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day) for 6 doses: Start after 2 mg tapered dose.
15. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Right parietooccipital mass
Discharge Condition:
Neurologically stable
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance.
Discharge Instructions:
General Instructions/Information
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed. You will not require blood work
monitoring.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2201-6-15**]
at 9:30 am. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2201-5-18**]
|
[
"225.2",
"401.9",
"530.81",
"348.5",
"434.91",
"E878.8",
"272.4",
"311",
"997.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"01.51"
] |
icd9pcs
|
[
[
[]
]
] |
6644, 6714
|
4017, 5103
|
328, 357
|
6786, 6808
|
2328, 2328
|
8864, 9342
|
1093, 1136
|
5241, 6621
|
6735, 6765
|
5129, 5218
|
6961, 8841
|
2635, 3994
|
1151, 1156
|
2100, 2309
|
1342, 1342
|
280, 290
|
385, 839
|
1491, 2086
|
2344, 2619
|
1171, 1323
|
6823, 6937
|
861, 880
|
896, 1077
|
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