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41,288
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7326
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Discharge summary
|
report
|
Admission Date: [**2149-1-28**] Discharge Date: [**2149-2-13**]
Date of Birth: [**2068-5-16**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
1. Appendiceal mucinous neoplasm
2. Pseudomyxoma peritonei
Major Surgical or Invasive Procedure:
[**2149-1-29**]:
1. Appendectomy.
2. Removal of retroperitoneal appendiceal mucocele.
[**2149-2-7**]: Technically successful aspiration and placement of an
8 French [**Last Name (un) 2823**] catheter within a pelvic collection secondary
to sigmoid perforation.
History of Present Illness:
Mr. [**Known lastname **] is a 80-year-old gentleman who is very healthy. He
recently had a left inguinal hernia repair and in analysis of
the hernia sac by the pathologists, a low grade lymphoma was
discovered. A workup for this included a CAT scan of the
abdomen and an incidental finding was evident. Patient had a
large 12 cm cystic type lesion in the right retroperitoneum in
the right lower
quadrant. This apparently was attached to the appendix and
looked most like an appendiceal mucocele than any other
pathology. Patient was evalutated by Dr. [**Last Name (STitle) **] in his office.
Dr. [**Last Name (STitle) **] discussed these findings with the patient and after
consultation with hematology oncology Dr. [**Last Name (STitle) **], surgical
resection was scheduled. All aspects of operation were discussed
with Mr. [**Known lastname **] including risks and benefits. Patient was
scheduled for elective surgical resection.
Past Medical History:
PMH: HTN, BBB, Hyperchol, OSA, Hiatal hernia, RIH, BPH,
low-grade B-cell lymphoma
PSH: B/L IHR, hemorrhoidectomy, ORIF L humerus, "anal fissure
repair"
Social History:
Married with three children and two grandchildren. Denies
smoking, occasional beer.
Family History:
Grandfather-prostate cancer, both parents-cardiac diseases
Physical Exam:
On Discharge:
VS: 97.7, 84, 130/80, 18, 96% RA
GEN: NAD, AAO x 3
CV: RRR, no m/r/g
Lungs: CTAB
Abd: Soft, slightly distended. Midline incision with steri
strips and healing well. Right mid abdomen with [**Last Name (un) 2823**] catheter
to gravity, site with dry dressing and c/i.
Extr: Warm, no c/c/e
Pertinent Results:
[**2149-1-28**] 06:43PM BLOOD WBC-14.1*# RBC-4.31* Hgb-13.4* Hct-38.1*
MCV-88 MCH-31.1 MCHC-35.2* RDW-13.8 Plt Ct-209
[**2149-1-28**] 06:43PM BLOOD Glucose-111* UreaN-12 Creat-0.9 Na-137
K-4.3 Cl-101 HCO3-26 AnGap-14
[**2149-2-11**] 06:07AM BLOOD WBC-12.1* RBC-3.31* Hgb-10.2* Hct-29.1*
MCV-88 MCH-30.7 MCHC-35.0 RDW-14.0 Plt Ct-610*
[**2149-2-12**] 05:23AM BLOOD Glucose-134* UreaN-19 Creat-0.7 Na-136
K-4.4 Cl-105 HCO3-25 AnGap-10
[**2149-2-12**] 05:23AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.2
[**2149-2-7**] 5:27 pm ABSCESS Source: abdomen.
GRAM STAIN (Final [**2149-2-7**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
FLUID CULTURE (Preliminary):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2149-2-11**]):
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
315-8806R
[**2149-2-7**].
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2149-12-2**] EKG: Sinus tachycardia. Right bundle-branch block.
Compared to the previous tracing of [**2149-1-16**] the sinus rate is
faster. The other findings are similar.
[**2149-12-2**] ABD PORTABLE:
IMPRESSION: Multiple air-filled loops of dilated small bowel are
consistent with small-bowel obstruction vs. less likely ileus.
[**2149-12-6**] CT ABD:
IMPRESSION:
1. 3-cm defect in the sigmoid colon opening into a 5.5 x 4 x 6.7
cm abscess.
2. Dilated loops of small bowel with no definite transition
points noted.
This likely represents ileus, although an obstruction cannot be
entirely
excluded. Continued follow-up recommended.
3. Multiple cystic lesions in the pancreas with the largest in
the head of
the pancreas measuring 8 x 7 mm could represent an IPMT. These
may be better evaluated with an MRCP if one has recently not
been obtained.
4. Left adrenal adenoma or myelolipoma. Indeterminate 14 x 13 mm
right
adrenal nodule. A dedicated adrenal CT or MRI may be obtained
for further
characterization.
5. There is a 1.6 cm thin spetated cyst in the left kidney mid
polar region which should be further evaluated with a dedicated
ultrasound.
[**2149-12-12**] ABD CT:
IMPRESSION:
1. Decrease in size of pelvic abscess with percutaneous catheter
coiled
within. While there is no free intraperitoneal air or oral
contrast within
the abdomen or the abscess, a persistent defect in the wall of
the sigmoid
colon cannot be excluded.
2. Multiple cystic lesions within the pancreas are stable and
may represent IPMN.
3. Stable right and left adrenal nodules.
4. Multiple hypodense lesions throughout the liver, unchanged.
5. Moderate-sized hiatal hernia.
6. Calcification within the body of the pancreas measures
approximately 11 mm x 7 mm and may be within the pancreatic duct
as there is upstream dilation of the pancreatic duct up to 6 mm.
However, this is unchanged since [**2148-12-26**].
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 27047**],[**Known firstname 275**] H. [**2068-5-16**] 80 Male [**Numeric Identifier 27048**]
[**Numeric Identifier 27049**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. BUCK, DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mtd
SPECIMEN SUBMITTED: FS r/o pseudo myxoma, peritoneal nodule,
appendix and right lower quadrant mass.
Procedure date Tissue received Report Date Diagnosed
by
[**2149-1-28**] [**2149-1-28**] [**2149-2-4**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rna
Previous biopsies: [**-9/5037**] Paraffin block, 10GS-3226-3A
and 10GS-3226-3C, from [**Doctor First Name **]
[**-8/2392**] GI BIOPSY (1 JAR)
[**-4/2051**] COLONOSCOPY
[**Numeric Identifier 27050**] GI BX'S/hg/ip.
(and more)
************This report contains an addendum***********
DIAGNOSIS:
I. Pelvic mucin (A-B):
A. Mucin with abundant atypical appearing single and small
groups of epithelioid cells, some with cytoplasmic vacuoles
consistent with reactive mesothelial and histiocytic cells; no
carcinoma seen, see note 1.
B. Immunostains for CD68 highlight numerous single and small
groups of histiocytes that coexpress cytokeratin cocktail.
Reactive mesothelial cells present in the specimen demonstrate
reactivity for cytokeratin cocktail, calretinin (patchy staining
pattern), and WT-1. No expression of cytokeratin 20, a marker of
colonic and appendiceal epithelium or LeuM1 is demonstrated in
this sample.
Note 1: Immunostains performed on the permanent sections
demonstrate that the atypical epithelioid cells seen at the time
of intraoperative frozen section diagnosis are mesothelial and
histiocytic in origin, resulting in a discrepancy with the
original frozen section diagnosis of adenocarcinoma. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] was notified of the discrepancy by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7017**]
on [**2149-2-4**] by telephone.
II. Appendix and right lower quadrant mass, resection (C-L,
N-DW):
A. Low grade appendiceal mucinous neoplasm with low grade
cytologic atypia, dissecting mucin, and focal extra-appendiceal
mucin with neoplastic cellular elements (all with low grade
cytologic atypia); see note 2.
B. Five periappendiceal lymph nodes with no carcinoma seen
(0/5); several lymphoid deposits appear to be comprised of
monotonous, small lymphoid cells without well-developed germinal
centers or mantle zones. Immmunohistochemical work-up to
demonstrate involvement by the patient's known chronic
lymphocytic leukemia/small lymphocytic lymphoma is in progress
and will be reported in an addendum to be released by
Hematopathology.
C. No high grade dysplasia is seen in the appendiceal tumor or
extra-appendiceal mucin deposits.
D. Appendiceal proximal margin assessment is limited due to the
extent of the adherent right lower quadrant mass; however, only
a single tissue block (slide C) demonstrates a section of
appendix free of neoplasm. Given fibrous obliteration of one of
the tissue profiles, these sections likely represent the distal
tip of the appendix.
III. Peritoneal nodule, biopsy (M):
Dissecting mucin within fibroadipose tissue with reactive
mesothelial lining consistent with implant from low grade
appendiceal mucinous tumor.
Note 2: The behavior of low grade appendiceal mucinous tumors is
variable with recurrent cases presenting with the clinical
syndrome of pseudomyxoma peritonei and its associated
complications. Studies of patients with such tumors were
associated with 5 and 10-year survival rates of 86 and 45%,
respectively (Misdraji et [**Doctor Last Name **], American Journal of Surgical
Pathology, [**2140**]). Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] has reviewed slides A-M,
AK, CV, and DT (H&E-stained sections), as well as select
immunostains on blocks A and B and concurs with the above
assessment.
ADDENDUM:
Reason for addendum: reviewed by hematopathology
Hematopathology note:
DIAGNOSIS: Involvement by low-grade non-Hodgkin B-cell
lymphoma, favor small lymphocytic lymphoma. See note.
Note: Slides CI, Cx and Cz are reviewed. Sections show multiple
foci of dense lymphoid infiltrate comprised of a monotonous
population of small mature-appearing lymphocytes. A small lymph
node is noted in Section Cz. The architecture of the lymph node
is effaced by a monotonous lymphoid infiltrate with a vaguely
nodular pattern. The lymphocytes are monotonous, round, small to
medium-sized lymphocytes with round to slightly irregular
nuclear contours, condensed chromatin, inconspicuous nucleoli
and scant to moderate amount of cytoplasm. Scattered
residual/overrun lymphoid follicles are noted. There is a focal
collection of histiocytes in the lymph node.
By immunohistochemical stains, the infiltrate is diffusely
immunoreactive for pan-B-cell marker, CD20, with aberrant
co-expression of CD5. They are non-immunoreactive for CD23 as
well as bcl-1, CD10 and BCL-6. CD3 and CD5 highlight scattered
background T-cells. DRC (CD21) highlights rare scattered
residual follicular dendritic reticular meshwork. The
proliferation index by MIB-1 antibody is [**5-6**] % overall.
The overall findings are consistent with involvement by a
low-grade B-cell lymphoma, CD5-positive. Although CD23 is not
expressed, bcl-1 is negative. Overall, the morphologic and
immunophenotypic findings are in keeping with involvement by
small lymphocytic lymphoma/chronic lymphocytic leukemia
(SLL/CLL).
Brief Hospital Course:
The patient diagnosed with cystic abdominal mass was admitted to
the General Surgical Service for elective surgical resection. On
[**2149-1-28**], the patient underwent appendectomy and removal of
retroperitoneal appendiceal mucocele, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO, on IV fluids, with a foley
catheter, and Dilaudid PCA for pain control. The patient was
hemodynamically stable.
Neuro: The patient received Dilaudid PCA and SC Toradol with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications
with minimal requirements.
CV: The patient remained stable from a cardiovascular
standpoint, he had several episodes of sinus tachycardia
postoperatively; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint postoperatively, supplemental O2 was weaned off. On
POD # 5, patient developed acute respiratory distress s/t food
aspiration and was transferred into ICU. Chest x-ray
demonstrated right lund opacification which correlates with
large scale aspiration. In ICU patient was started on BiPAP. On
POD # 6, patient O2 sats were WNL on 2L n/c, antibiotics
treatment was not indicated. Patient was transferred on the
floor on POD # 7. Good pulmonary toilet, early ambulation and
incentive spirrometry were encouraged throughout
hospitalization. Patient remained stable from pulmonary
standpoint until his discharge home.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced to clears on POD # 4, patient
aspirated on POD # 5. Abdominal x-ray revealed small bowel
obstruction. Diet was changed to NPO, NG tube was placed and IV
fluid was restarted. NG tube was removed on POD # 7, patient was
advanced to sips. Diet was advanced to clears with supplements
on POD # 8. On POD # 10, patient's abdomen was found to be
distended and abdominal CT scan was obtained. CT demonstrated
sigmoid colon perforation with intraabdominal abscess. Patient
was started on IV Flagyl and Cipro, IR placed [**Last Name (un) 2823**] catheter
to drain abscess, cultures were sent for microbiology. PICC line
was placed and TPN was started. Cultures back positive for
Pseudomonas Aeruginosa sensitive to Cipro. Diet was advanced to
clears on POD # 12 and was well tolerated. On POD # 15, repeat
abdominal CT demonstrated decrease size of intraabdominal
abscess and no contrast leak. Patient was discharged home on
TPN, clear liquid diet and PO antibiotics on POD # 16.
Electrolytes were routinely followed, and repleted when
necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Patient's intraabdominal
abscess was treated with IV/PO Cipro and Flagyl. Wound was
examined routinely, no signs or symptoms of infection were
noticed. Staples were removed prior discharge and steri strips
were applied.
Endocrine: The patient's blood sugar was monitored throughout
his stay; no insulin administration was indicated.
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:
ASA 81', Acebutolol 200', Lovastatin 80', Nexium EC 40',
Allopurinol 300', Dutasteride 0.5', Tamsulosin SR 0.4'', Flonase
50 nasal prn, Ibuprofen 400 prn, Omega-3 acid ethyl esters 1g'',
Glucosamine-chondroitin 1500-1200'
Discharge Medications:
1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
2. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO once a
day.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. acebutolol 200 mg Capsule Sig: One (1) Capsule PO once a day.
6. allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
7. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal prn as needed for allergy symptoms.
8. 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.
9. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 16 days.
Disp:*32 Tablet(s)* Refills:*0*
10. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 16 days.
Disp:*48 Tablet(s)* Refills:*0*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
12. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day
as needed for constipation.
Disp:*30 suppository* Refills:*0*
13. Outpatient Lab Work
Please check Chem10 (electrolytes, Magnesium, Calcium,
Phosphate, glucose), triglycerides, transferrin, TIBC, albumin,
ALT, AST, T.bili, ALP, amylase, lipase, and ferritin weekly. Fax
results to [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 18971**], RD/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 519**], MD at ([**Telephone/Fax (1) 18972**].
Call ([**Telephone/Fax (1) 18973**] with questions. Thank you.
14. One Touch Ultra System Kit Kit Sig: One (1) kit
Miscellaneous qam.
Disp:*1 kit* Refills:*0*
15. lancets Misc Sig: One (1) lancet Miscellaneous qam.
Disp:*1 box* Refills:*0*
16. One Touch Ultra Test Strip Sig: One (1) strip
Miscellaneous qam.
Disp:*1 box* Refills:*0*
17. Alcohol Prep Pads Pads, Medicated Sig: One (1) swab
Topical once a day.
Disp:*1 box* Refills:*0*
18. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Telephone/Fax (1) 269**] Assoc. of [**Hospital3 **]
Discharge Diagnosis:
1. Appendiceal mucocele.
2. Pseudomyxoma peritonei
3. Respiratory distress s/p aspiration
4. Sigmoid colon perforation with abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-6**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
8 French [**Last Name (un) 2823**] catheter:
*Flush with 10 cc of Normal Saline three times per day.
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or [**Last Name (un) 269**] nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Please call [**Telephone/Fax (1) 27051**] to schedule a follow up appointment
with [**Name6 (MD) **] [**Name8 (MD) **], MD ([**Hospital1 **]) in [**1-30**] weeks after discharge.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2149-2-28**] 11:45 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-2-28**] 10:30
Radiology Department
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2149-7-10**] 12:45
Completed by:[**2149-2-18**]
|
[
"786.09",
"728.85",
"197.6",
"543.9",
"153.5",
"560.9",
"E849.7",
"788.5",
"569.83",
"507.0",
"560.1",
"567.22",
"401.9",
"272.0",
"202.80",
"E878.6",
"997.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"47.09",
"96.07",
"54.91",
"54.4",
"99.15",
"93.90",
"54.23",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
18194, 18279
|
11886, 15625
|
361, 626
|
18455, 18455
|
2282, 3159
|
21353, 22081
|
1885, 1945
|
15898, 18171
|
18300, 18434
|
15651, 15875
|
18606, 19184
|
19199, 21330
|
1960, 1960
|
4218, 11863
|
1974, 2263
|
263, 323
|
654, 1591
|
18470, 18582
|
1613, 1768
|
1784, 1869
|
3194, 4185
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,574
| 129,616
|
22091
|
Discharge summary
|
report
|
Admission Date: [**2159-2-17**] Discharge Date: [**2159-2-28**]
Date of Birth: [**2088-6-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD secondary to glomerulonephritis admitted for cadaveric
renal transplant
Major Surgical or Invasive Procedure:
[**2159-2-17**]: cadaveric renal transplant
[**2159-2-18**]: ECHO
[**2159-2-18**]: Kidney ultrasound
[**2159-2-22**]: Kidney ultrasound
[**2159-2-23**]: Nuclear medicine scan of transplant kidney
History of Present Illness:
70 who presents for renal transplant admission.
The patient has ESRD due to glomerulonephritis, currently on PD
with history of HD, with a working AV Fistula in his LUE. He
reports no recent infections. He denies recent fevers or chills,
or cough. He also denies recent urinary tract infections. No
recent infections are reported of his PD cath
site.
His only current complaints are a transient issue with reflux
disease, for which antiacids are of assistance. He also reports
a
transient complaint of RLQ pain at his hernia repair site.
Last dialysis PD dialysis was tonight.
He denies any chest pain or shortness of breath. His activity
is limited by spinal stenosis but he is able to walk on flat
surfaces and is able to climb two flights of stairs without
problems.
The patient reports making only a few mls of urine per day. No
symptoms of claudication are reported.
Prior abdominal operations include a remote history of an an
appendectomy, a recent prostatectomy in [**2155**], PD cath placement,
bilateral hernia repairs likely with mesh. Of note, the patient
has been declared free of prostate cancer as of [**7-2**], with
undetectable PSA levels.
Past Medical History:
1. ESRD (?etiology but had episode of glomerulonephritis in
[**2127**]; Renal:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) s/p PD cath placement. now treated
with hemodialysis.
2. Anemia of chronic dz
3. Gout
prostate CA ([**Doctor Last Name **] 3+4) s/p radical prostatectomy
4. Spinal stenosis
5. HTN
6. GERD s/p bx with chronic inactive duodenitis with Brunner
gland hyperplasia and foveolar cell metaplasia.
7. s/p appendectomy
Social History:
Pt emmigrated to US from [**Country 5142**] in [**2125**].
Worked at [**Company 2318**] but now retired.
Lives with wife, has two grown children.
Denies EtOH or tobacco use.
Family History:
Non-contributory, although his father may have died from a
cardiac event in his 80s.
Physical Exam:
weight 53 kg, 5'6"
98.1 60 126/68 97%RA
NAD, NC/AT
RRR, no M/R/G
Lungs clear all lung fields
abdom soft, non-tender, PD cath site without erythema, dressing
clean dry, intact
extremities well perfused, DP/PT/femoral pulses palpable and 2+
in both extremities
Pertinent Results:
On Admission: [**2159-2-17**]
WBC-8.6 RBC-3.63* Hgb-12.1* Hct-33.7* MCV-93 MCH-33.2*
MCHC-35.8* RDW-17.1* Plt Ct-334
PT-11.4 PTT-25.0 INR(PT)-0.9
UreaN-66* Creat-16.2*# Na-134 K-3.8 Cl-93* HCO3-24 AnGap-21*
ALT-42* AST-41*
Albumin-4.4 Calcium-10.3* Phos-5.8* Mg-2.4
At Discharge: [**2159-2-28**]
WBC-8.8# RBC-2.81* Hgb-9.2* Hct-26.4* MCV-94 MCH-32.9* MCHC-35.0
RDW-16.7* Plt Ct-290
Glucose-85 UreaN-46* Creat-3.6* Na-139 K-3.6 Cl-109* HCO3-22
AnGap-12
ALT-14 AST-35 AlkPhos-47 TotBili-0.7
Calcium-8.6 Phos-2.3* Mg-1.7
tacroFK-10.8
Brief Hospital Course:
70 y/o male currently on PD who underwent cadaveric kidney
transplant with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. On induction he becamce
hypotensive with SBP of 60-70 and EKG changes. He was started
on pressors X 2 and given 2 liters of fluid. An emergent
cardiology consult was called, they thought the patient had
ischenia secondary to hypovolemia and hypotension. EKG changes
resolved, BP returned to baseline and after consulttion with
cardiology, renal and the family it was decided to proceed with
the transplant.
He received routine induction immunosuppression to include
cellcept, solumedrol with post op taper and ATG (2 doses due to
age of recipient) The kidney was reported to pink up
immediately. The bladder was extremely difficult to find. It
was small and shrunken at time of transplant.
He remained intubated and was transferred to the SICU for post
op care. He received 3 units of RBCs on POD1.
He was extubated on POD 2 and transferred to the surgical unit
POD 3. Urine output had been around 100 cc/hour but was noted to
drop to around 25/ hour and he received a bolus. In addition an
U/S was performed showing good arterial and venous flow. A
moderate sized peritransplant fluid collection was noted. This
was not drained.
The patient did have bruising/hematoma along the right flank in
addition to massive swelling of the scrotum. The Foley was d/c'd
on POD 4, and he was able to void. However it was felt that he
was having retention which was corroborated by bladder scan so a
Foley was reinserted.
He had a nuclear scan on [**2-23**] which showed No evidence of urine
leak on initial images. Normal perfusion and tracer
concentration in the transplanted kidney. Excretion of the
tracer into the bladder by 4 minutes.
The creatinine slowly declined to 3.6 by day of discharge. (Slow
graft function) he was never dialyzed.
His right flank and scrotum remianed bruised although this
improved slightly each day.
He was seen by PT and was deemed able to discharge to home. He
was tolerating diet and had return of bowel function. He
demonstrated good understanding of his meds.
He is to discharge to home with the Foley in place. This will be
re-evaluated in clinic.
Medications on Admission:
Lopressor 25 mg qd, allopurinol 100 mg qd, Calcitriol 0.50 mcg
T-Th-S, 0.25 mcg every other days, [**Month/Year (2) **] 800 mg 3 caps TID,
and
Nephrocaps, epogen 10,000, colace.
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-30**]
hours as needed for pain: Do not take more than 6 in one day.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
8. Tacrolimus 1 mg Capsule Sig: Five (5) Capsule PO twice a day.
9. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
10. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(TU,FR).
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD now s/p cadaveric kidney transplant
Slow graft function
Discharge Condition:
Stable
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, diarrhea, increased abdominal
pain, pain over the kidney transplant.
Monitor incision for redness, draiange or bleeding. Report
increased drainage, you may keep a dressing over the incision
for small amounts of drainage
You may shower, pat incision dry and cover as necessary
No driving if taking narcotic pain medications
Call if the swelling in your scrotum does not continue to get
better
Labs every Monday and Thursday as directed by the transplant
clinic
Take all medications as directed
Foley will remain in place for now. Empty bag and record outout.
Bring record with you to the transplant clinic
[**Telephone/Fax (1) **] Instructions:
[**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2159-3-1**] 10:00
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-3-1**] 10:30
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-3-9**] 10:00
Completed by:[**2159-3-1**]
|
[
"458.29",
"V45.89",
"276.6",
"V45.11",
"585.6",
"724.00",
"V10.46",
"787.91",
"276.2",
"582.9",
"564.00",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.93",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
7082, 7088
|
3406, 5630
|
391, 589
|
7192, 7201
|
2851, 2851
|
2470, 2556
|
5859, 7059
|
7109, 7171
|
5656, 5836
|
7225, 8392
|
2571, 2832
|
3131, 3383
|
275, 353
|
617, 1777
|
2865, 3117
|
1799, 2262
|
2278, 2454
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,420
| 163,980
|
40428+58370
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-6-13**] Discharge Date: [**2159-6-20**]
Date of Birth: [**2085-6-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2159-6-15**] Coronary artery bypass graft x 4 (Left internal mammary
artery to left anterior descending, saphenous vein graft to
diagonal, saphenous vein graft to ramus, saphenous vein graft to
obtuse marginal)
History of Present Illness:
73 year old male who developed exertional chest discomfort over
the last year. His symptoms have increased over the last month
and was referred for evaluation that included echocardiogram
that revealed inferolateral and anterolateral hypokinesis. He
underwent stress test and developed ches tpain with diffuse ST
depressions. He was referred for cardiac catheterization that
revealed significant cornary artery disease and is transferred
for surgical evaluation.
Past Medical History:
Hypertension
Social History:
Race: Caucasian
Last Dental Exam: 4 months
Lives with: spouse
Occupation: retired, used to service medical equipment
Tobacco: denies
ETOH: denies
Family History:
non contributory
Physical Exam:
Pulse: 57 Resp: 18 O2 sat: 95% RA
B/P 135/99
Height: 5'[**58**]" Weight: 90.7 kg
General: no acute distress
Skin: Dry [x] intact [x] right wrist with TR Band from cath
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: alert and oriented x3 non focal
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: band Left: +2
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2159-6-13**] Carotid U/S: Right ICA <40% stenosis. Left ICA <40%
stenosis.
[**2159-6-15**] Echo: PREBYPASS: No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. Trace aortic regurgitation is seen. Mild (1+)
mitral regurgitation is seen. The systolic BP was raised from
100 to 150 and the patient was placed in the tredelengerg
position and the MR remained mild.
POSTBYPASS: There is preserved biventricular systolic function.
The MR is now trace. The study is otherwise unchanged from the
prebypass study.
[**2159-6-19**] 04:25AM BLOOD WBC-8.1 RBC-2.94* Hgb-9.9* Hct-27.8*
MCV-95 MCH-33.5* MCHC-35.4* RDW-12.9 Plt Ct-171
[**2159-6-19**] 04:25AM BLOOD Glucose-127* UreaN-28* Creat-1.2 Na-139
K-4.0 Cl-102 HCO3-29 AnGap-12
[**2159-6-13**] 04:16PM BLOOD ALT-21 AST-27 LD(LDH)-186 CK(CPK)-97
AlkPhos-59 Amylase-85 TotBili-1.0
[**2159-6-19**] 04:25AM BLOOD Mg-2.3
[**2159-6-13**] 04:16PM BLOOD %HbA1c-5.6 eAG-114
Brief Hospital Course:
Mr. [**Known lastname 88607**] was transferred from outside hospital after
cardiac cath revealed severe three vessel coronary artery
disease. Upon admission, he was medically managed and underwent
pre-operative work-up. He was brought to the operating room on
[**6-15**] where he underwent a coronary artery bypass graft x 4.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours he was weaned from
sedation, awoke neurologically intact and extubated. Within 24
hours he was weaned from sedation, awoke neurologically intact
and extubated. On post-op day one he had an episode of
hypotension and was started on Neo-Synephrine. His blood
pressure stabilized and was eventually started on beta-blockers.
On post-op day two his chest tubes were removed and diuresed
towards his pre-op weight. On post-op day three his epicardial
pacing wires were removed and he was transferred to the
step-down floor for further care. During his post-op course he
worked with physical therapy for strength and mobility. He
continued to make good progress without complications and was
discharged home with VNA services on post-op day five.
Appropriate medications and follow-up appointments were made.
Medications on Admission:
Aspirin 325 mg daily started [**6-12**]
Lopressor 25 mg [**Hospital1 **] started [**6-12**]
Diovan 160 mg daily
Allopurinol 150 mg daily
Vitamins
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*45 Tablet(s)* Refills:*2*
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 7 days.
Disp:*7 Tablet, ER Particles/Crystals(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 4
Past medical history:
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**7-12**] at [**Hospital1 **] 9:00 AM
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31888**] on [**7-23**] at 9:30 AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 391**] [**Name (STitle) **] in [**5-8**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2159-6-20**] Name: [**Known lastname 14065**],[**Known firstname 14066**] Unit No: [**Numeric Identifier 14067**]
Admission Date: [**2159-6-13**] Discharge Date: [**2159-6-20**]
Date of Birth: [**2085-6-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 741**]
Addendum:
Pt also given a rx for lipitor 20 mg daily at time of discharge.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 437**] VNA
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2159-6-20**]
|
[
"401.9",
"414.01",
"458.29",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
8268, 8449
|
3325, 4616
|
332, 547
|
6065, 6298
|
2026, 3302
|
7221, 8245
|
1254, 1272
|
4812, 5844
|
5947, 6008
|
4642, 4789
|
6322, 7198
|
1287, 2007
|
271, 294
|
575, 1039
|
6030, 6044
|
1091, 1238
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,265
| 111,925
|
53502
|
Discharge summary
|
report
|
Admission Date: [**2194-5-15**] Discharge Date: [**2194-5-20**]
Date of Birth: [**2123-6-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
[**2194-5-15**]: Rigid bronch, debridement, balloon dilation, bronchial
washing, and #8 tracheostomy tube placement.
History of Present Illness:
70M with O2-dependent COPD who was admitted to [**Hospital **] Hospital
in [**Month (only) 404**] of this year for COPD flare & pneumonia. He had a
prolonged hospital course that
included a month-long ICU stay requiring mechanical ventillation
[**1-4**] and tracheostomy [**1-22**]. Eventually he was discharged to a
vent rehab and was decannulated 3-4 weeks ago. His O2
requirement has diminished to only needing 2-3L at night.
.
For the past 5 days, however, he noted the development of
difficulty clearing his secretions, which at times can be quite
tenacious. He and his family report intermittent periods of what
might be interpreted as stridor. He was seen at [**Hospital **] Hospital
where chest CT demonstrated a, "...4mm sub-glottic stenosis..."
after which he was transferred to [**Hospital1 18**] for further management.
.
Patient has not had any fever, chills, night sweats. His cough
is productive of a thick, non-purulent sputum. He recently
finished a 3 day course of azithromycin for a question of
bronchitis.
.
Past Medical History:
# COPD on O2 x 6yr, underwent trach at [**Hospital **] Hospital in [**1-14**]
that was later decannulated [**4-14**].
# CAD s/p CABG x3/tissue AVR'[**88**] ([**Hospital1 112**])
# PAF s/p multiple DCCV on coumadin
# HTN
# back surgery '[**61**]
# RLE osteo '[**61**]
# spinal decompression '[**86**]
# EtOH abuse (sober x 6 mos)
Social History:
Married, was living at home x 1 month with wife, prior to this
was at [**Hospital1 **] rehab.
Cigarettes [x] ex-smoker Pack-yrs: 100+
quit: [**2188**]
ETOH: [x] No (sober 6 months) previously 4 drinks/day
Family History:
Mother smoker died of lung cancer
Father smoker died of lung cancer
.
Physical Exam:
Exam on Transfer to Medicine Service:
VS: 97.6 128/57 67 22 99TM 97.5kg
GENERAL: NAD, trach mask in place,comfortable, appropriate.
Mouthing words given failure to speak.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Trach. Supple, no JVD.
HEART: distant, difficult to hear over breath sounds
LUNGS: diffusely rhonchorous, but good airmovement. No
appreciable rales.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: Chronic venous changes. Otherwise. WWP, no c/c/e,
2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact
.
Exam on discharge:
AVSS, NAD, trach mask in place,comfortable, appropriate.
Communicating by mouthing words.
HEART: II/VI systolic ejection murmur, heard across precordium
LUNGS: diffusely rhonchorous, but good airmovement, breathing
unlabored. No appreciable rales or wheezes. Moderate secretions.
Ext: trace pedal edema. Skin changes c/w chronic venous stasis,
1+ TP bilat
Neuro- A and O x3, CN 2-12 grossly intact excepted for noted
surgical pupil on L. transfers from bed to chair with some
assistance.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2194-5-19**] 13:00 8.1 3.59* 11.1* 32.1* 89 30.9 34.6 14.4 219
[**2194-5-18**] 06:10 7.9 3.61* 11.2* 32.9* 91 31.0 33.9 14.7 242
[**2194-5-17**] 06:30 7.7 3.34* 10.5* 30.6* 91 31.5 34.5 14.5 228
[**2194-5-16**] 07:00 8.4 3.15* 10.1* 28.2* 90 32.1* 35.9* 14.4
217
[**2194-5-15**] 21:46 8.2 3.14* 9.7* 28.0* 89 30.9 34.7 14.7 213
[**2194-5-15**] 15:05 11.6* 3.73* 11.3* 33.3* 89 30.4 34.1 14.8
274
.
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2194-5-15**] 21:46 89.2* 9.8* 0.9* 0.1 0
[**2194-5-15**] 15:05 86.0* 9.5* 1.9* 2.5 0.2
.
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2194-5-19**] 13:00 219
[**2194-5-19**] 13:00 16.1* 27.1 1.4*
[**2194-5-18**] 09:00 15.9* 1.4*
[**2194-5-18**] 06:10 242
[**2194-5-17**] 06:30 228
[**2194-5-17**] 06:30 17.9* 27.5 1.6*
[**2194-5-16**] 07:00 217
[**2194-5-16**] 07:00 18.8* 1.7*
[**2194-5-15**] 21:46 213
[**2194-5-15**] 21:46 19.5* 29.6 1.8*
[**2194-5-15**] 15:05 274
[**2194-5-15**] 15:05 29.2* 30.1 2.8*
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2194-5-19**] 13:00 125*1 15 0.6 135 4.3 97 31 11
[**2194-5-18**] 06:10 103*1 17 0.7 131* 3.8 95* 30 10
[**2194-5-17**] 06:30 981 16 0.7 133 3.8 97 30 10
[**2194-5-16**] 07:00 135*1 13 0.7 128* 4.9 88* 35* 10
[**2194-5-15**] 21:46 171*1 11 0.6 128* 4.4 89* 33* 10
[**2194-5-15**] 15:05 [**Telephone/Fax (2) 109989**]* 5.0 87* 32 11
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2194-5-17**] 06:30 8.8 3.2 2.1
[**2194-5-16**] 07:00 8.8 3.7 2.2
[**2194-5-15**] 21:46 8.6 3.3 1.6
LAB USE ONLY LtGrnHD GreenHd
[**2194-5-15**] 15:05 HOLD
[**2194-5-15**] 15:05 HOLD1
.
Urine Hematology
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2194-5-15**] 15:35 Straw Hazy 1.005
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln [**2194-5-15**] 15:35 TR POS NEG NEG NEG NEG NEG 5.0 LG
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2194-5-15**] 15:35 2 >182* FEW NONE 0
Chemistry
[**2194-5-15**] 09:45 RANDOM 65 25 83
OTHER URINE CHEMISTRY Osmolal
[**2194-5-15**] 09:45 253
Admission Labs:
[**2194-5-15**] 03:05PM WBC-11.6*# RBC-3.73* HGB-11.3* HCT-33.3*
MCV-89# MCH-30.4 MCHC-34.1 RDW-14.8
[**2194-5-15**] 03:05PM NEUTS-86.0* LYMPHS-9.5* MONOS-1.9* EOS-2.5
BASOS-0.2
[**2194-5-15**] 03:05PM PLT COUNT-274#
[**2194-5-15**] 09:45AM URINE HOURS-RANDOM SODIUM-65 POTASSIUM-25
CHLORIDE-83
[**2194-5-15**] 09:45AM URINE HOURS-RANDOM SODIUM-65 POTASSIUM-25
CHLORIDE-83
.
[**2194-5-17**] 10:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
.
[**2194-5-15**] 7:30 pm BRONCHIAL WASHINGS RIGHT LOWER LOBE.
GRAM STAIN (Final [**2194-5-15**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2194-5-17**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 8 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2194-5-16**]):
SPECIMEN NOT PROCESSED DUE TO: INAPPROPRIATE SAMPLE FOR
ANAEROBIC
CULTURE.
TEST CANCELLED, PATIENT CREDITED.
.
[**2194-5-15**] 3:35 pm URINE Site: CLEAN CATCH
URINE CULTURE (Final [**2194-5-17**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
Radiology Report PICC LINE PLACMENT SCH Study Date of [**2194-5-19**]
10:28 AM
PICC LINE PLACED [**2194-5-19**]
Official report pending, per written report PICC line OK to use.
.
CHEST XRAY [**2194-5-16**]
COMPARISON: [**2194-5-15**].
BEDSIDE FRONTAL RADIOGRAPH OF THE CHEST: A tracheostomy tube is
unchanged,
ending 5.3 cm above the carina. Multiple median sternotomy wires
are intact and note is again made of an aortic valve prosthesis.
Enlargement of the cardiac silhouette is unchanged. Mediastinal
and hilar contours are normal. Note is made of bibasilar
opacities atelectasis. In addition, there are bilateral right
greater than left pleural effusions which are unchanged.
Finally, pulmonary edema appears unchanged.
.
CHEST XRAY [**2194-5-15**]
SINGLE BEDSIDE FRONTAL RADIOGRAPH OF THE CHEST: A tracheostomy
catheter is
visualized terminating 4 cm above the carina. There is no
pneumothorax.
Though the right costophrenic angle is beyond the field of view,
there are
likely bilateral pleural effusions. Note is made of enlargement
of the
cardiac silhouette. Mediastinal and hilar contours are normal.
There is a
background of moderate pulmonary edema with more focal opacities
at both lung bases which may be atelectatic. Multiple median
sternotomy wires are intact and note is made of an aortic valve
replacement.
.
Notably, review of an OSH Chest CT dated [**0-0-0**] for
comparison purposes
reveals extensive plugging of the bronchus intermedius of
uncertain etiology. Would recommend comparison to bronchoscopy.
.
Brief Hospital Course:
TSICU COURSE:
Mr. [**Known firstname **] [**Known lastname 8389**] is a 70 year old male admitted to Thoracic
Surgery service on the evening of [**2194-5-15**] for cough. He was
taken to the operating room with rigid bronchoscopy revealing
well organized granulation tissue in the subglottic area with
malacia, extending for 0.6 cm. A large amount of purulent
secretions were suctioned and sent for micro. He underwent
balloon dilatation to 18mm and stenosis recurred immediately.
Size #8 [**Last Name (un) 295**] TTS fixed phalange tracheostomy tube was placed.
The patient recovered in PACU where he was successfully
extubated. Broad spectrum antibiotics started: [**5-15**]- vanc,
cipro, cefepime. The patient underwent swallow eval on [**5-16**]
which he passed. PT/OT consults were obtained for dispo planning
to ([**Hospital1 **]) rehab. [**Known lastname 8389**] was dc'd. IVFluids stopped.
He received diamox 500mg IV once. He was stabilized on the
surgical service and given multiple medical issues: PNA, PAF,
hyponatremia, Thoracic surgery requested medicine transfer which
occured on [**5-19**].
Coumadin 5mg resumed for Paroxysmal AF on [**5-16**] (lower dose due
to antibiotics)
MEDICINE SERVICE HOSPITAL COURSE: [**5-19**] - [**5-20**]
70M COPD, CAD s/p CABG x3 and Porcine AVR, PAF on coumadin,
hospital day and POD #5 for trach recannulation that was
transferred to the medicine service found to have [**Hospital 89618**]
hospital-acquired pneumonia, E. Coli UTI and exacerbation of CHF
(unclear is systolic of disastolic).
# Pseudomonal HAP: Pt initially with leukocytosis. Following
transfer the pt remained afebrile without leukocytosis.
Breathing comfortably on 50% trach mask. Continues to have
secretions, but now improving with addition of mucomyst. Pt was
initially treated broadly with Vanc, Cefepime, and Cipro which
was narrowed to Cefepime on [**5-17**] for a planned total 14 day
course to end [**2194-5-28**]. A PICC Line was placed on [**5-19**] and the pt
was dischared to rehab with 8 additional doses of Cefepime.
# Subglottal Stensosis - now POD #5 from trach-recannulation
with #8 trach. Thoracics/ IP following. Breathing comfotably.
The pt will follow-up with both thoracics and IP on [**6-10**],
these appointments have been made. Passy- Muir valve was fitted
to help pt to cough up secretions prn just prior to transfer.
# Acute CHF: Unclear if systolic vs diastolic. No evidence of S3
or S4 on exam. Pt initially had 2+ LE edema, whic has been
decreasing, likely secondary to diuresis with lasix. Per records
pt is on lasix 40mg PO and has been receiving 20 ml IV in
hospital. Pt stated that his baseline weight is 215lbs. On [**5-18**]
was 207.4lbs, 206.5 on [**5-19**], and 205.9 on [**5-20**]. Weight at
transfer to LTACH was 205.9. He will continue on Lasix 20mg IV
on transfer although on exam he seems to be approaching
euvolemic. Please assess daily need for further diuresis.
# E. Coli UTI: Clinically stable, patient asymptomatic. Cefepime
should cover due to end [**2194-5-28**].
# Paroxysmal AFib: Pt remained rate controlled on medicine
service without nodal agents. Coumadin was initially held but
restarted [**2194-5-16**]. INR was found low [**2194-5-19**] at 1.4; increased
coumadin to 6 mg (from 5mg) QD [**5-19**].
# Porcine AVR: Clinically stable. No additional reason to bridge
with heparin.
TRANSITIONAL ISSUES
- Blood cultures drawn [**5-17**] still pending (no growth to date)
- Wife and HCP: [**Name (NI) **] @ [**Telephone/Fax (1) 109990**]; HCP paperwork in chart here
-pt confirmed full code here
Medications on Admission:
mucinex 600mg po BID
aldactone 50mg po BID
lasix 40mg po daily
coumadin 7-8mg po daily
flomax 0.4mg po daily
advair 1 puff inh [**Hospital1 **]
spiriva inh daily
zpac [**Date range (1) 109991**]
ativan 1mg prn po
Discharge Medications:
1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for sob/wheeze.
3. acetylcysteine 20 % (200 mg/mL) Solution Sig: 3-5 MLs
Miscellaneous TID (3 times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation QID (4 times a day):
Please give 10 min prior to acetylcysteine administration.
5. CefePIME 2 g IV Q8H
6. furosemide Sig: Twenty (20) mg Intravenous once a day:
titrate according to fluid status and Cr.
7. heparin Sig: 5000 (5000) units Subcutaneous three times a
day: Until INR therapeutic.
8. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
9. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
10. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Subglottic stenosis.
Pseudomonal Pneumonia.
Urinary Tract Infection due to e coli.
Anemia of chronic disease
CAD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
****Activity Status: OOB to chair as tolerated. Pt needs full PT
assessment on arrival to rehab
Discharge Instructions:
You were admitted for shortness of breath thought secondary to
narrowing of your airway; you subsequently received a new
tracheostomy tube. You were found to have pneumonia and a
urinary tract infection and are currently receiving antibiotics.
.
Call Dr.[**Name (NI) 5070**] office at [**Telephone/Fax (1) 2348**] if you have fevers
greater than 101.5, chills, shakes, increasingly productive
cough, worsening shortness of breath.
.
Trach: suction as needed. Keep trach secured at all times. If
this falls out patient will require emergent intubation.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**0-0-**] Date/Time:[**2194-6-10**]
2:30pm
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**]
(interventional pulmonology)
.
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2194-6-10**] 3:00pm to follow. (thoracic surgery)
.
Please obtain CHEST XRAY on Clinical center [**Location (un) 861**] Radiology
at 2pm on [**2194-6-10**]
Completed by:[**2194-5-20**]
|
[
"041.4",
"414.00",
"496",
"428.41",
"478.74",
"V42.2",
"V46.2",
"428.0",
"427.31",
"482.1",
"041.7",
"V45.81",
"599.0",
"401.9",
"305.03",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
"33.91",
"38.97",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
14491, 14563
|
9641, 10852
|
310, 429
|
14720, 14720
|
3374, 5707
|
15501, 16042
|
2109, 2180
|
13481, 14468
|
14584, 14699
|
13244, 13458
|
10869, 13218
|
14924, 15478
|
2195, 2845
|
6178, 9618
|
265, 272
|
457, 1486
|
2864, 3355
|
5723, 6144
|
14735, 14900
|
1508, 1839
|
1855, 2093
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,181
| 198,174
|
11991+56314
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-8-29**] Discharge Date: [**2173-9-27**]
Date of Birth: [**2152-3-29**] Sex: M
Service: [**Hospital Ward Name **] ICU/MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 21 year old
gentleman with a history of [**Hospital Ward Name 37702**] syndrome who initially
presented to [**Hospital3 2358**] on [**2173-8-12**], with altered mental
status. The patient was in his usual state of health until
five days prior to admission when he noticed that his eyes
were blurry and he was bumping into things. He called his
psychiatrist on the day prior to admission and was started on
Risperdal 1 mg p.o. q3hours with instructions to titrate up.
On the night of admission, the patient's blood sugar also
increased to 390 and he called his endocrinologist who
recommended increasing his Humalog. One hour later, the
patient took another six units of Humalog for a blood sugar
of 236. The patient subsequently began snorting and having
difficulty swallowing and acting "quite dazed" per his
mother's report. He was mumbling and EMS was called. The
patient was intubated in the field for airway protection
during witnessed grand mal seizure with jaw clenching, head
turning and unresponsiveness. Upon arrival to the Emergency
Department, the patient was intubated and found to have a
blood sugar of 58. The patient was hemodynamically stable
and started on a Versed drip for persistent seizure activity.
Briefly, the [**Hospital 228**] hospital course at [**Hospital3 2358**]
included Oxacillin sensitive Staphylococcus aureus pneumonia
treated with Oxacillin. The patient was stabilized from a
neurologic standpoint on Dilantin without further seizure
activity (there was concern that initial seizure activity was
due to hypoglycemia as the patient has no known seizure
disorder). He had a neurologic evaluation with
electroencephalogram revealing just generalized
encephalopathy without focal seizure activity. The patient
also had an EMG, which revealed no neuromuscular weakness as
a cause for failure to wean from ventilator. The patient had
recurrent difficulty weaning from ventilator despite
treatment of his pneumonia. He was originally intubated for
airway protection, however, a trial of extubation was done on
[**2173-8-16**], and the patient developed respiratory distress
within four hours of extubation and was reintubated. The
patient subsequently self extubated on [**2173-8-24**], with an
episode of agitation, was placed on a nonrebreather, however,
desaturated into the 50s and required reintubation.
Physicians at [**Hospital3 2358**] recommended tracheostomy, however,
the patient's family requested transfer to [**Hospital1 346**] for a second opinion by pulmonology,
which is how the patient arrived at our facility.
PAST MEDICAL HISTORY:
1. [**Hospital1 37702**] syndrome with a combination of central diabetes
mellitus insipidus, optic atrophy, high frequency hearing
loss, insulin dependent diabetes mellitus, anxiety and
depression. The patient is treated at the [**Last Name (un) **] Diabetes
Center and is currently legally blind.
2. The patient's developed Hashimoto's thyroiditis at age 11
and has been subsequently on thyroid hormone repletion.
3. Depression and anxiety with recurrent suicidal ideation.
4. Pilonidal cyst [**2165**], [**2167**], and [**2169**].
MEDICATIONS ON ADMISSION:
1. Oxacillin times thirteen days.
2. Levaquin times five days.
3. Dilantin 200 mg p.o. twice a day.
4. Propofol drip.
5. Insulin drip at 4 units per hour.
6. Klonopin 1 mg p.o. twice a day.
7. Combivent.
8. DDAVP p.r.n.
9. Cardura 4 mg p.o. once daily.
10. Levothyroxine 200 mcg p.o. once daily.
11. Prozac 40 mg p.o. once daily.
12. Colace.
13. Heparin.
14. Prevacid.
15. Robitussin.
16. Calcium Carbonate 750 mg p.o. three times a day.
SOCIAL HISTORY: The patient is single and lived
independently prior to admission. He is relatively close to
his grandmother who helps him with his cooking. His parents
are very involved and supportive and live in the area. He
works at [**Company 10414**] and denies tobacco or alcohol use.
FAMILY HISTORY: Grandmother with type 2 diabetes mellitus
and Alzheimer's. Maternal grandfather with cancer of the
bones in his 60s. No other relatives with [**Name (NI) 37702**] syndrome.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: Upon admission on [**2173-8-29**],
temperature is 97, heart rate 72, normal sinus rhythm, blood
pressure 104/57, vent setting SIMV with pressure support
500cc by 10 breaths per minute, PEEP 5, FIO2 40%, saturating
94 to 100%. In general, the patient is a diaphoretic male in
no acute distress. Head, eyes, ears, nose and throat -
Mucous membranes are moist. The oropharynx is clear. The
pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact.
Cardiovascular is regular rate and rhythm, no murmurs, rubs
or gallops. Lung examination is clear to auscultation
bilaterally. Abdomen is soft, nontender, nondistended,
positive bowel sounds. Extremities - no cyanosis, clubbing
or edema, 2+ distal pulses. Skin - no rash or petechiae.
Neurologic examination - The patient is alert and seemingly
oriented, following commands and moving all extremities with
2+ deep tendon reflexes.
LABORATORY DATA: Pertinent laboratory studies included white
blood cell count 10.9 with normal differential, hematocrit
37.0. Potassium 4.3, sodium 145, creatinine 0.5. Normal
liver function tests.
Radiologic studies at outside hospital showed on [**2173-8-19**],
head MR [**First Name (Titles) 151**] [**Last Name (Titles) 4493**] consistent with atrophy of the brain
stem into the upper cervical cord with probable mild
cerebellar atrophy. Left sphenoid and frontal sinus
opacification.
A normal EMG was performed on [**2173-8-26**].
HOSPITAL COURSE:
1. Pulmonary - The patient without known pulmonary
dysfunction at baseline, however, there is a question of
brain stem atrophy and dysfunction, also baseline paCO2 in
the high 40s low 50s, these [**Date Range 4493**] concerning for probable
hypoventilation. Chronicity of mild hypercarbia is unknown.
However, since intubation for airway protection during
seizure, the patient has failed extubation times four. The
patient underwent trial of extubation on [**2173-9-3**], at [**Hospital1 1444**] and subsequently developed
acute respiratory distress with inspiratory stridor. The
patient had emergent reintubation which was very difficult
requiring placement of endotracheal tube over a bougie
catheter. A grade II view was obtained and a 6.5 French
endotracheal tube was placed. There was felt to be a
significant component of airway edema and collapse at that
time. The patient had multiple respiratory mechanic trials
while intubated which revealed a negative inspiratory force
of negative 20 mmHg which is significantly impaired. This
was at a time when the patient had defervesced and was doing
well on pressure support. Thus, a repeat EMG and
neuromuscular consultation was obtained to rule out
neuromuscular etiologies of hypoventilation. An EMG was
essentially normal except for hyperexcitable axones which is
a nonspecific yet abnormal finding. Interpretation of this
is unclear. However, there is no acute axonal loss or
myopathy which could have caused his hypoventilation. CKs
are normal and there is no evidence of myositis. A muscle
biopsy was not performed.
The patient developed severe bilateral Methicillin resistant
Staphylococcus aureus pneumonia while he was admitted at [**Hospital1 1444**]. The patient had significant
hypoxemia and required maximal ventilatory support for
approximately ten days. The patient had multiple episodes of
lobar collapse bilaterally requiring emergent bronchoscopy
due to paO2 in the 40s and 50s and acute desaturation. The
patient had copious thick secretions which prevented weaning
from ventilator for approximately two weeks. He was treated
with Vancomycin 1 gram p.o. q12hours for ten days and
continued to clinically deteriorate from his Methicillin
resistant Staphylococcus aureus pneumonia and consolidations.
Thus, infectious disease consultation was obtained and the
patient's Vancomycin was increased to 1 gram p.o. four times
a day and the patient subsequently defervesced and started to
require less ventilatory support. At the time of discharge,
the patient is breathing on pressure support 10 and 10 with
multiple hours of spontaneous breathing trials without
desaturation. He continues to have mild to moderate
secretions and is at risk for lobar collapse due to failure
to handle secretions. However, he has shown significant
improvement from a pulmonary standpoint and resolution of his
Methicillin resistant Staphylococcus aureus pneumonia. He
underwent tracheostomy on [**2173-9-9**], without complication. He
currently uses a Passy-Muir valve intermittently but requires
further training with this.
2. Infectious disease - As noted, the patient originally had
Oxacillin sensitive Staphylococcus aureus pneumonia at
outside hospital and subsequently developed severe bilateral
Methicillin resistant Staphylococcus aureus pneumonia at [**Hospital1 1444**]. He required high dose
Vancomycin to clear this infection. The patient will need
approximately ten more days of Vancomycin 1 gram
intravenously q8hours to complete course approximately
[**2173-10-6**]. His leukocytosis has resolved, as well as his
fevers.
3. Central diabetes mellitus insipidus - This is part of the
patient's [**Month/Day/Year 37702**] syndrome. He has been placed on DDAVP
intravenous q12hours. We have yet to find a stable dose for
him, originally started at 1 mcg intravenously twice a day
and has subsequently been decreased to 0.5 mcg intravenously
twice a day to maintain normal sodium level and manage urine
output. He is doing well at this dose currently but will
require close monitoring of his sodium and urine output to
insure that he is not excessively diuresing or becoming
hyponatremic or hypernatremic.
4. Diabetes mellitus - The patient's insulin had been
difficult to manage but has shown improvement since
resolution of his infection. He is currently on Glargine 38
units q.p.m. with Humalog insulin sliding scale. Of note,
the patient takes twice a day NPH at home because it is
easier to self administer. Upon discharge, he may need to be
transitioned from Glargine back to NPH for ease of use. Will
need close monitoring of his fingerstick blood sugar four
times a day as he tends to run high.
5. Hypothyroidism - The patient is on 250 mcg p.o. once
daily of Levoxyl with last TSH of 31 trending down. For a
brief period, he was on Levoxyl intravenously due to poor
absorption through gastrostomy tube with tube feeds and
inability to get hypothyroidism under control. Will need
follow-up TSH drawn and possible titration up of his
Levothyroxine dose. It is important to make sure he is
euthyroid to maximize his chance to wean from ventilator.
6. Neurologic - The patient with no known prior seizure
disorders and it is possible that this original seizure was
from hypoglycemia. He is maintained on Dilantin 300 mg p.o.
three times a day, however, it is not clear that he will need
long term seizure prophylaxis. This should be discussed with
the patient's neurologist's, Dr. [**First Name8 (NamePattern2) 915**] [**Last Name (NamePattern1) 2523**]. We have been
checking Dilantin levels but adjusting for hypoalbuminemia
and he is currently therapeutic on 300 mg p.o. three times a
day. He has had two electroencephalograms which reveal no
focal seizure activity and he has had no recurrence of
seizure activity since admission. He has had two EMGs which
have revealed no significant axonal or neuronal loss. EMG
here did have hyperexcitable neurons which is a nonspecific
finding with unclear consequence. It is not clear if there
is a component of brain stem atrophy which has led to
hypoventilation, however, this must be considered if the
patient is having difficulty weaning from ventilator.
7. Psychiatry - The patient with a known history of
depression and suicidal ideation which is also consistent
with his [**Last Name (NamePattern1) 37702**] syndrome. The patient has expressed his
desire to diet multiple times during his admission and at the
outside hospital and was actually deemed incompetent to make
his own medical decisions by psychiatry at this outside
hospital. He was followed by psychiatrist, Dr. [**First Name8 (NamePattern2) 36972**]
[**Last Name (NamePattern1) **], during his hospitalization at [**Hospital1 190**]. He did not express suicidal ideation here
and, in fact, stated that he wished to live, was afraid to
die and wanted to recover and become independent once again.
He was continued on Prozac and Klonopin with p.r.n. Ativan
for increased anxiety. For a while, he was maintained on
Haldol for agitation, but this was discontinued approximately
one week prior to discharge and the patient showed no
psychotic features.
8. Access - The patient has right peripheral PICC line for
intravenous antibiotics. There is no evidence of erythema or
purulence at the PICC line site.
9. FEN - The patient is NPO and has a gastrostomy tube
placed and is receiving tube feeds at 75cc per hour without
any residuals or difficulties. He is eager to eat, however,
a Passy-Muir valve was just instituted and the patient will
need more pulmonary rehabilitation and training before
consideration of speech and swallow for p.o. intake. Will
defer to pulmonary rehabilitation for this, pending his
advancement and weaning from ventilator.
DISCHARGE DIAGNOSES:
1. Ventilatory failure, multifactorial due to recurrent
severe Methicillin resistant Staphylococcus aureus pneumonia
and hypoventilation.
2. [**Hospital1 37702**] syndrome including diabetes mellitus, diabetes
insipidus, cerebellar atrophy, optic atrophy, hearing loss.
3. Depression with suicidal ideation and anxiety.
4. Hypothyroidism.
5. History of urinary retention.
MEDICATIONS ON DISCHARGE:
1. Prozac 40 mg p.o. once daily.
2. Heparin 5000 units subcutaneous three times a day.
3. Colace 100 mg p.o. twice a day.
4. Combivent MDI four puffs four times a day.
5. Vancomycin 1 gram intravenously q8hours until [**2173-10-6**].
6. DDAVP 0.5 mcg intravenously q12hours.
7. Dilantin 300 mg p.o. three times a day.
8. Levoxyl 250 mcg p.o. once daily.
9. Klonopin 1 mg p.o. twice a day.
10. Ativan 0.5 to 1.0 mg p.o. q4-6hours p.r.n. anxiety.
11. Glargine 38 units subcutaneously q.p.m.
12. Humalog insulin sliding scale.
13. Senna p.r.n.
14. Tylenol p.r.n.
DISCHARGE DISPOSITION: At the time of dictation, the patient
is awaiting transfer to [**Doctor Last Name **] Pulmonary Rehabilitation
in [**Hospital1 3597**] for ventilator management and weaning. He will need
a room with Methicillin resistant Staphylococcus aureus
precautions.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8037**], M.D. [**MD Number(2) 8038**]
Dictated By:[**Name8 (MD) 10996**]
MEDQUIST36
D: [**2173-9-26**] 13:50
T: [**2173-9-26**] 14:35
JOB#: [**Job Number 37703**]
Name: [**Known lastname 6805**], [**Known firstname **] Unit No: [**Numeric Identifier 6806**]
Admission Date: [**2173-8-29**] Discharge Date: [**2173-9-28**]
Date of Birth: [**2152-3-29**] Sex: M
Service:
The patient was scheduled to be discharged on [**2173-9-27**], however, on the morning of [**9-27**], patient had
two isolated episodes of respiratory distress. During this
time was found his oxygen saturations had fallen to the mid
80s. The patient was removed from the ventilator, was
suctioned aggressively, and given supplemental oxygen. With
these maneuvers, the patient's oxygen levels increased
appropriately. Patient was monitored over the course of the
day to ensure that he had no more repeat episodes. Patient
had a CBC drawn which demonstrated an elevated white blood
cell count and repeat chest x-ray showed likely left lower
lobe pneumonia.
Patient was thus placed on ceftazidime to cover for
gram-negative rods including Pseudomonas given his extended
length of time on a ventilator. The patient did not have any
more episodes of respiratory distress and tolerated the
antibiotics very well.
DISCHARGE MEDICATIONS: As per his original dictation. In
addition to this, ceftazidime, which he would continue on for
a course of 14 days with the first day being [**10-7**].
DR.[**Last Name (STitle) 3731**],[**First Name3 (LF) **] 12-AEW
Dictated By:[**Last Name (NamePattern4) 6807**]
MEDQUIST36
D: [**2173-9-29**] 17:14
T: [**2173-9-30**] 04:53
JOB#: [**Job Number 6808**]
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icd9cm
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icd9pcs
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14687, 14945
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16434, 16825
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|
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|
14970, 16410
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,692
| 197,909
|
4937
|
Discharge summary
|
report
|
Admission Date: [**2198-12-19**] Discharge Date: [**2198-12-27**]
Date of Birth: [**2137-3-18**] Sex: F
Service: Urology
HISTORY OF PRESENT ILLNESS: Ms [**Known lastname 8389**] is a 61 year old female
who in [**2198-10-14**] presented with atypical chest pain,
tightness in the neck. She was evaluated by Cardiology at
the time with stent placement. On follow up the patient had
an abdominal computerized axial tomography scan performed
which revealed the presence of a left kidney mass. On
questioning, the patient admitted to occasional back pain,
numerous urinary tract infections and a 5 pound weight loss
over the past three months. The patient denied any
hematuria. The patient also reported intense fatigue and
exhaustion over the same period of time. The patient was
evaluated by the Urology Service and was admitted for a
possible surgical intervention.
PAST MEDICAL HISTORY: 1. Systemic lupus erythematosus since
[**2183**]; 2. History of pulmonary embolism times two; 3.
History of deep vein thrombosis in [**2182**]; 4. History of
angioplasty times two in [**2198**] with stent placement; 5.
Hypertension times five years.
PAST SURGICAL HISTORY: 1. Status post appendectomy; 2.
Status post hysterectomy in [**2182**]; 3. Status post removal of
a benign soft tissue tumor in the shoulder in [**2190**] and breast
in [**2182**].
ALLERGIES: 1. Plavix; 2. Penicillin causes rash; 3. Sulfur
drugs cause rash; 4. Intravenous contrast
MEDICATIONS ON ADMISSION: 1. Coumadin 7 mg p.o. Monday
through Friday followed by 8 mg p.o. q. day on Saturday and
Sunday; 2. Aspirin; 3. Atenolol 50 mg p.o. b.i.d.; 4.
Prilosec; 5. Fosamax; 6. Prednisone 2 mg p.o. q. day; 7.
TUMS.
PAST FAMILY HISTORY: No history of renal cancer or any other
cancers.
SOCIAL HISTORY: The patient lives at home with husband. She
is active.
REVIEW OF SYSTEMS: Notable for increased fatigue and
exhaustion for approximately three months as described above.
The patient denied any flank pain. The patient denied any
fevers.
PHYSICAL EXAMINATION: Temperature 97.5, heartrate 48, blood
pressure 160/78, respiratory rate 16, 100% on 2 liters.
Head, eyes, ears, nose and throat examination, within normal
limits, no neck masses, no thyromegaly, no palpable lymph
nodes. Respiratory examination, clear to auscultation
bilaterally. Cardiac examination, bradycardiac, but normal
rhythm, no murmurs, rubs or gallops. No carotid bruits.
Abdomen, soft, mildly tender over the left abdomen and flank
(the patient was status embolization procedure of the left
kidney. Neurological examination, alert and oriented times
three, grossly intact.
LABORATORY DATA: White blood cell count 13.4, hematocrit 27.
Interventions: 1. The patient underwent kidney embolization
procedure by Interventional Radiology on [**2198-12-19**] to
limit perioperative bleeding; 2. The patient also has a
history of inferior vena cava filter placement by
interventional radiology.
HOSPITAL COURSE: The patient underwent left kidney
embolization by Interventional Radiology as described above.
There were no complications. The patient was then admitted
to the Urology Service. The patient was placed on Ancef. On
[**2198-12-20**], given the diagnosis of left renal mass by
the computerized axial tomography scan, the patient underwent
left radical nephrectomy and left adrenalectomy and excision
of the para-aortic lymph nodes. The procedure was performed
by Dr. [**Last Name (STitle) 9125**]. There were no complications. The estimated
blood loss was 200 cubic cm. The patient tolerated the
procedure well. The patient was extubated without
difficulty. The epidural was placed for pain control
postoperatively. The nasogastric tube remained in place.
Postoperatively the patient was producing adequate urine but
some intravenous fluid was administered. The patient was
also transfused with 1 unit of packed red blood cells
postoperatively. The patient was transferred to the
Intensive Care Unit. She was extubated. Of note is that the
patient developed a rash after receiving Ancef and
intravenous contrast. It is unclear what the etiology of the
rash was. [**Known lastname 8389**] catheter remained in place, draining clear
yellow urine. The incision remained clean, dry and intact.
The patient was then transferred to the Regular Floor. She
was started on sips. Additional transfusion was given. The
epidural was capped on postoperative day #3. Oral
medications such as Percocet and Dilaudid were started but
the patient became very nauseous. Consequently the epidural
was restarted. The patient continued to make good urine
output. Her heartrate was stable. She had a low grade fever
which eventually resolved. However, her systolic blood
pressures were noted to be in 160s to 190s. The patient was
gently diuresed with small decrease in the systolic blood
pressure. The patient was started on Lisinopril in addition
to the standing dose of Atenolol 50 mg b.i.d. The Geriatric
Service was consulted regarding her blood pressure issues and
they followed the patient throughout the hospitalization and
agreed with the management. The patient's pain was now
better controlled with demerol and Tylenol #3. The epidural
was removed. The incision remained clean, dry and intact.
There was noted to be a small area of redness inferior to the
incision. Clindamycin p.o. was given for two days and then
discontinued. The redness improved and then disappeared.
The patient was ambulating without difficulty. She was given
an enema given some abdominal pain which resolved with a
bowel movement. The patient was discharged to home on
[**2198-12-27**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with [**Hospital6 407**]
services.
DISCHARGE DIAGNOSIS:
1. Left renal mass, status post radical left nephrectomy
2. Hypertension
3. Inferior vena cava filter placement
4. Systemic lupus erythematosus
DISCHARGE MEDICATIONS:
1. Tylenol #3 one to two tablets p.o. q. 4-6 hours prn pain
2. Atenolol 50 mg p.o. b.i.d.
3. Lisinopril 5 mg p.o. q. day
4. Prednisone taper, the patient was instructed to continue
her taper by taking 3 mg on the day after discharge and then
taking 2 mg p.o. q. day as a standing dose
5. Prilosec 40 mg p.o. q. day
6. Lipitor 10 mg p.o. q. day
7. Colace 100 mg p.o. q. day
8. Coumadin 7 mg Monday through Friday and 8 mg Saturday
through Sunday (spoke to the patient's primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who will follow the patient's
Coumadin levels, the patient was instructed not to take any
Coumadin on the day of discharge, given the INR of 3.0)
9. Ibuprofen 400 mg p.o. q. 6 hours prn pain
10. Zofran 8 mg p.o. q. 8 hours prn nausea
DISCHARGE INSTRUCTIONS:
1. The patient is to have her INR levels drawn by the
visiting nurse which are to be sent to her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] who will determine the Coumadin
dose.
2. The patient is to see Dr. [**Last Name (STitle) 9125**] in approximately one to
two weeks.
3. The patient is to be visited by a nurse daily for blood
pressure check, to supervise Prednisone taper, and for wound
check.
4. The patient's staples are to be removed on [**2198-12-31**] by the visiting nurse.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2198-12-29**] 12:12
T: [**2198-12-29**] 13:08
JOB#: [**Job Number 20516**]
|
[
"V45.82",
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] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
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icd9pcs
|
[
[
[]
]
] |
5741, 5782
|
1744, 1794
|
5975, 6771
|
5803, 5952
|
1510, 1727
|
3001, 5685
|
6795, 7630
|
1194, 1483
|
2075, 2983
|
1888, 2052
|
171, 893
|
916, 1170
|
1811, 1868
|
5710, 5717
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,779
| 182,198
|
34207
|
Discharge summary
|
report
|
Admission Date: [**2103-6-19**] Discharge Date: [**2103-7-11**]
Date of Birth: [**2042-8-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
bilious cough w/ chest pain
Major Surgical or Invasive Procedure:
bronch/EGD with dilation/Y-stent placement for TEF
BMS placement x 2 (Y-stent removal)
Y stent placement (BMS's removed due to migration)
conduit exclusion, G tube, J tube, xiphiodectomy
History of Present Illness:
60M (general surgeon from [**Hospital1 112**]) 12 years s/p multi-modality Rx
for
stage III esophageal CA. Admitted to [**Last Name (un) 883**] with dense RLL PNA
and hypoxemia. Barium swallow demonstrates obstructed conduit
at
diaphragm (s/p 3 hole esophagectomy). Dr. [**Last Name (STitle) **] is a 60 year
old man (general surgeon at [**Hospital1 112**]) who initially presented to OSH
with a 5 day history of cough, shortness of breath and anorexia
that was not responding to PO antibiotics prescribed by his PCP.
[**Name10 (NameIs) **] pt was in his usual state of health intil 7 weeks ago when
he
was in [**Country 32814**] and suffered smoke inhalation from fires in the
reigon. Pt also reports dust inhalation in his home from a wall
that was torn down.
Past Medical History:
Esophageal Cancer s/p Esophagectomy at [**Hospital1 112**] [**2091**] c/b stricture
requiring 2 dilatation procedures, left vocal cord paralysis,
Depression s/p ECT (following [**2091**] surgery), Anxiety disorder,
Social History:
general surgeon, lives w/ wife and 2 small children ages 5 and
7.
non-smoker
Family History:
non-contributory
Physical Exam:
general: well appearing but pale 60 YO male in DAD
[**Name (NI) 4459**]: bronchial Y stent overlying TEF
Chest: coarse breath sounds on right greater than left. cough
strong and productive of thin white secretions.
COR: RRR S1, S2
abd: Gastric tube to gravity and J-tube for feeds.
abd incision intact. staples removed and steri strips placed. G
and J- tubes secured.
extrem: no edema
neuro: intact
Pertinent Results:
[**6-20**] CT Torso: Bibasilar barium aspiration, Contrast in mid and
distal neoesophagus from prior barium swallow. Distal SB looks
ok with contrast to TI. Distal esophagus dilated to 3cm with
air/contrast level. No perforation, masses, abscess, or
adenopathy.
[**6-21**] CXR:mild improvement in bibasilar aeration with b/l medial
basal atelectases, opacities in R mid lung c/w barium
aspiration, no PTX or effusion. Low lung volumes. Increasing
proximal dilation of neo esophagus with air-fluid level.
[**6-25**] RUQ u/s: Sludge and small gallstones with no cholecystitis.
No biliary dilatation. 1.5-cm hemangioma in L lateral lobe,
echogenic lesion in R lobe (? hemangioma).
Brief Hospital Course:
The patient was admitted on [**2103-6-19**] from an outside hospital to
the thoracic surgery service. He was continued on clinda, levo,
and prepared for the OR for a bronchoscopy and EGD. He was kept
NPO with IVF for hydration.
[**6-20**]: The patient underwent a bronchoscopy, EGD and Y stent
placement for a tracheo-esophageal fistula. He remained
intubated following the procedure and was transferred to the ICU
with an NG tube and foley catheter in place. Abx included
clinda/levo/fluc
[**6-21**]: bronchoscopy revealed stent in place, remained intubated,
started TPN, cont abx
[**6-22**]: bronchoscopy revealed incomplete coverage of fistula,
returned to the OR for replacement of stent with covered metal
stent. Cont TPN, abx
[**6-23**]: bronchoscopy and adjustment of ETT
[**6-24**]: weaned FiO2 as tolerated, cont TPN, abx
[**6-25**]: bronchoscopy revealed proximal migration of stent, rigid
bronch for metal stent replacement, placement of silicone y
stent
[**6-26**]: bronchoscopy revealed stent in good position, patient
extubated in the afternoon.
[**6-27**]: remained in the ICU for aggressive pulm toilet, cont TPN,
cont abx
[**6-28**] - [**7-1**]: started beta blocker for tachycardia, BiPAP
initiated, foley discontinued, cont TPN, abx, transferred to
[**Hospital Ward Name 121**] 7 for continued monitoring
[**7-2**]: Patient was taken to the OR for exploratory laparotomy, G
tube, J tube placement and exclusion of conduit, continued TPN,
abx. The patient tolerated the procedure and was transferred to
[**Hospital Ward Name 121**] 7 for continued monitoring.
[**7-3**] - [**7-5**]: started trophic tube feeds and advanced slowly to
goal of 90cc/hr, continued abx, foley removed, TPN discontinued
when tube feeds at goal
[**7-6**]: PICC line placed for antibiotics
[**7-7**]: Tube feeds at goal, TPN discontinued, continued abx,
aggressive chest PT
[**7-8**]: Patient developed rapid a fib and transferred to the unit
treated initially with lopressor and then amiodarone and
converted to sinus rhythm.
[**7-9**]: transferred back to [**Hospital Ward Name 121**] 7 for continued monitoring,
bronchoscopy revealed stent in proper place, cont TF at goal,
vanc discontinued, continued levo
[**7-10**]: d/c PCA, po pain medications started
[**7-11**]: tube feeds cycled over 18hrs and [**Last Name (un) 1815**] well. amb indep w/
cane. RA sats >95%. pain well controlled w/ roxicet. teaching
done re: j-tube care and feeds.
Medications on Admission:
Roxicet before meals, Ativan PRN sleep, MVI
Discharge Medications:
1. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation q6h ().
Disp:*360 ML(s)* Refills:*2*
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) ml
Inhalation Q6H (every 6 hours).
Disp:*120 ml* Refills:*2*
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mls PO BID (2
times a day).
Disp:*600 mls* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: crush into fine powder and completely
dissolve in water and give via j-tube.
Disp:*20 Tablet(s)* Refills:*0*
5. Roxicet 5-325 mg/5 mL Solution Sig: 5-10 mls PO every four
(4) hours as needed for pain.
Disp:*500 cc* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
on [**7-16**] start 400mg x7days. 0n [**7-23**] 200mg daily ongoing
crush finely and dissolve completely.
Disp:*60 Tablet(s)* Refills:*2*
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous Q6H (every 6 hours) for 120 doses.
Disp:*360 ML(s)* Refills:*4*
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-17**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*1 vial* Refills:*3*
9. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mls PO Q4H (every
4 hours) as needed for breakthrough pain.
Disp:*100 mls* Refills:*0*
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mls Inhalation Q6H (every 6 hours)
as needed.
Disp:*120 doses* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Esophageal Cancer s/p Esophagectomy at [**Hospital1 112**] [**2091**] c/b stricture
requiring 2 dilatation procedures, left vocal cord paralysis,
Depression s/p ECT (following [**2091**] surgery), Anxiety disorder,
TEF s/p Y stent
G and J-tube placement; conduit exclusion and xiphoidectomy
PICC placement and removal
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) **] office [**Telephone/Fax (1) 170**] if you develop chest pain,
shortness of breath, increasing cough, fever, chills, abd pain,
inability to [**Last Name (un) 1815**] tube feeds, nausea, vomiting, diarrhea or any
symptoms that concern you.
You may shower. No tub bathing or swimming.
No driving while taking narcotic pain medication.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] on [**2103-7-26**] at
9:30am on th [**Hospital 78799**] campus clinical center [**Location (un) **]. Please
arrive 45 minutes prior to your appointment and report to the
[**Location (un) **] radiology for a chest XRAY.
Completed by:[**2103-7-11**]
|
[
"568.0",
"112.84",
"530.84",
"427.31",
"530.87",
"507.0",
"V10.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"33.24",
"46.39",
"96.05",
"42.92",
"33.23",
"38.93",
"96.72",
"54.59",
"33.78",
"45.16",
"45.51",
"96.6",
"96.04",
"43.19"
] |
icd9pcs
|
[
[
[]
]
] |
6831, 6875
|
2835, 5296
|
348, 537
|
7239, 7246
|
2132, 2812
|
7651, 7969
|
1680, 1698
|
5390, 6808
|
6897, 7218
|
5322, 5367
|
7270, 7628
|
1713, 2113
|
281, 310
|
565, 1331
|
1353, 1570
|
1586, 1664
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,199
| 100,793
|
17924
|
Discharge summary
|
report
|
Admission Date: [**2196-4-20**] Discharge Date: [**2196-5-1**]
Date of Birth: [**2137-7-10**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 58-year-old
male with underlying coronary artery disease who was admitted
after an episode of VF arrest after a stress test. The
patient had a cardiac catheterization at an outside hospital
in [**2193**] which reportedly showed moderate three vessel
disease. He had exertional angina for one year prior and had
been medically managed. Over the past two months, he had an
increasing frequency of exertional chest pain lasting five to
ten minutes, relieved by sublingual nitroglycerin and rest.
No radiation. No diaphoresis, palpitations, or shortness of
breath.
The patient was seen in his cardiologist's office and
underwent ETT and a standard [**Doctor First Name **] protocol. After 28
minutes, developed ST depression and chest pain, treated with
sublingual nitroglycerin, felt dizzy, went into VF arrest,
cardioverted times one with 300 joules and 100 of lidocaine,
reversed to normal sinus rhythm and was transferred to [**Hospital6 1760**].
In the Emergency Department, he was found to have a blood
pressure of 200/100 and was started on a nitroglycerin drip,
heparin drip, and Integrelin. He was given 5 mg of IV
Lopressor and magnesium. The patient was scheduled for
catheterization.
PAST MEDICAL HISTORY:
1. CAD.
2. Hypertension.
3. Renal artery stenosis.
4. Diabetes mellitus.
5. Hypercholesterolemia.
6. Chronic renal insufficiency.
ADMISSION MEDICATIONS:
1. Catapres 2 patch q. week.
2. Isordil 60 mg t.i.d.
3. Atenolol .................... 100/25 q.d.
4. Diovan 320 mg q.d.
5. Lipitor 20 mg q.d.
6. Minoxidil 10 mg q.d.
7. Norvasc 10 mg q.d.
8. Folate.
9. Amaril 1 mg q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a nonsmoker and uses only
social alcohol.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: On
admission, the patient was afebrile with vital signs stable
by the time he arrived on the floor and had a regular rate
and rhythm. Lungs: Clear to auscultation bilaterally.
LABORATORY DATA: White count 3, hematocrit 42, platelets
242,000. The electrolytes were within normal limits. CK
146, troponin less than 0.3.
HOSPITAL COURSE: The patient underwent cardiac
catheterization which showed a LVEF of 60%, LMCA 70% ostial
left main, LAD moderate diffuse distal 70%, moderate OM at
the LCX, RCA with probable ostial disease. Renal angio with
50% right renal proximal lesion, moderate aortic disease,
patent common iliacs, bilateral internal iliacs severe
disease, patent external iliacs, known SFA disease from prior
limited study.
The patient underwent a CABG times four on [**2196-4-22**] with LIMA
to LAD, SVG to OM1 and OM2, SVG to the distal RCA. The
patient tolerated the procedure without complications.
The patient was extubated on postoperative day number one.
The patient had a temperature spike to 102 on postoperative
day number two. The patient was started on antibiotics.
The patient was transferred to the floor on postoperative day
number three and continued to have a temperature spike.
Infectious Disease was consulted and opted for discontinuing
antibiotics as it was felt that it would be a probable source
of medication fever. The patient was also noted to have very
elevated LFTs with amylase and lipase which were believed to
be secondary to a pancreatitis episode which resolved by
placing the patient on n.p.o. and then enzymes improved as
time progressed. The patient was able to tolerate a regular
diet at the time of discharge.
The patient continued to have temperature spikes of
undetermined etiology until postoperative day number eight
when the patient's left lower extremity began to look
erythematous. The patient was started on ciprofloxacin and
improved symptom wise and with his temperatures.
By postoperative day number nine, he was felt to be ready for
discharge as he was tolerating a regular diet, ambulating
well, cleared by physical therapy and with good p.o. pain
control and much improved left lower extremity. The patient
is to follow-up with Dr. [**Last Name (STitle) 70**] in six weeks, Dr. [**Last Name (STitle) 11139**],
his primary care provider in one to two weeks, and his
cardiologist in two to three weeks.
DISCHARGE MEDICATIONS:
1. Ciprofloxacin 500 mg p.o. q. 12 hours for ten days.
2. Clonidine 2 patch q. week.
3. Isordil 60 mg t.i.d.
4. Diovan 320 mg q.d.
5. Atenolol 100 mg q.d.
6. Protonix 40 mg q.d.
7. Amaril 1 mg q.d.
8. Percocet one to two tablets q. 4-6 hours p.r.n.
9. Tylenol 650 mg q. four hours p.r.n.
10. Lasix 20 mg q.d. times five days.
11. Colace 100 mg q.d. times five days.
12. Potassium chloride 20 mEq q.d. times five days.
13. The patient is to follow a sliding scale until sugars are
adjusted.
The patient is to follow with his primary care provider in
the first week to follow electrolytes and also to come to
[**Hospital Ward Name 121**] II for a wound check of his left lower extremity to
assure improvement.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft times four.
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2196-5-1**] 12:03
T: [**2196-5-1**] 12:30
JOB#: [**Job Number 49648**]
cc:[**Last Name (NamePattern4) 49649**]
|
[
"411.1",
"401.9",
"998.59",
"682.6",
"593.9",
"250.00",
"414.01",
"458.2",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"39.61",
"89.68",
"88.42",
"88.47",
"88.56",
"39.64",
"36.13",
"36.15",
"88.45"
] |
icd9pcs
|
[
[
[]
]
] |
4403, 5122
|
5205, 5573
|
2339, 4380
|
1588, 1871
|
1982, 2321
|
1428, 1565
|
1888, 1967
|
5147, 5183
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,942
| 163,179
|
37338
|
Discharge summary
|
report
|
Admission Date: [**2148-12-25**] Discharge Date: [**2148-12-30**]
Date of Birth: [**2082-1-3**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
neck and back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66F trauma transfer, s/p MVC, +LOC, unrestrained driver, unknown
airbag, found minimally responsive and slumped over steering
wheel. Taken by EMS to OSH, where she was neurologically intact
but CT scans revealed multiple cervical spine fractures. She was
transferred to [**Hospital1 18**] for further management and found to be GCS
15 upon arrival. L trans foraminal fx at C1, C3, C4, C6, C7, R
transverse foraminal fractures at C1, C2, R vertebral artery
dissection on CT and MRI. Per patient, no neurological defects
w\she is able to move all extremities and notes no sensory
defects. Mentation WNL. Denies history of rectal or UGIB.
Past Medical History:
PMH
1. Hypertension
2. IDDM
3. Restless leg syndrom
4. Hypothyroidism
5. OSA, uses CPAP mask at home
PSH
1. Hysterectomy
2. Bilateral tennis elbow repair
Social History:
Lives alone
ETOH none
Tobacco remote
Family History:
non contributory
Physical Exam:
O: T: 97.4 BP: 102/55 HR: 92 R 22 97% O2Sats 60% FM
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: unable to open eyes due to ecchymosis
Neck: [**Location (un) 2848**] J collar in place
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, Obese, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: unable to open eyes
III, IV, VI: unable to open eyes
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: B/L scapular fracture (unable to examine)
XII: Tongue midline without fasciculations.
Motor: limited by pain, [**6-4**] handgrip B/L
Sensation: Intact to light touch, proprioception.
Pertinent Results:
[**2148-12-25**] 05:50PM WBC-25.7* RBC-3.60* HGB-9.9* HCT-30.9* MCV-86
MCH-27.6 MCHC-32.2 RDW-14.4
[**2148-12-25**] 05:50PM NEUTS-77* BANDS-12* LYMPHS-5* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2148-12-25**] 05:50PM PLT COUNT-282
[**2148-12-25**] 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2148-12-25**] 05:50PM GLUCOSE-157* UREA N-34* CREAT-1.2* SODIUM-138
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-14
[**2148-12-25**] 06:10PM PT-12.8 PTT-24.2 INR(PT)-1.1
[**2148-12-25**] CT Chest/Abd/Pelvis : . Small left-sided pneumothorax
located in the lower anterior pleural space.
2. Multiple rib fractures as detailed above.
3. Bilateral scapular fractures, right distal clavicle fracture.
4. Acute fracture involving the T2 vertebra along the anterior
aspect of the superior endplate. No malalignment.
[**2148-12-25**] Head CT :
1. No acute intracranial hemorrhage.
2. Degloving injury of the left frontoparietal scalp without
fracture.
3. Please refer to the concurrent CT c-spine report for cervical
spine
assessment.
[**2148-12-25**] CT C Spine : There is a linear lucency involving the
right lateral mass of C2, best seen on series 4 image 29 likely
representing a non-displaced fracture. At C3 there is a chip
fracture involving the left transverse process not extending to
the foramen transversarium. At C4 there is also a chip fracture
involving the left transverse process not extending into the
transverse foramen. At C5 and C6 there are fractures of the left
transverse process which do extend to the transverse foramen
with the fractured lateral fragments slightly laterally and
inferior displaced, clearly depicted on the coronal
reformations. There is a fracture involving the C7 right
transverse process best seen on series 4 image 73 involving the
transverse foramina. There is also a fracture involving the C1
right transverse process best seen on series 4 image 24 as well
as series 9 image 53 which does not clearly extend to the
transverse foramina. Irregularity at the superior endplate of C7
is likely related to motion artifact. However, given the lucent
line seen on series 4 image 71 involving the superior endplate
of C7 a fracture cannot be entirely
excluded.
Bilateral rib fractures involving the posterior arch of the
first ribs is
seen. The left posterior second rib is also fractured. On the
lateral view
there is maintenance of cervical alignment. Small amount of
degenerative
disease is noted in the mid cervical spine with loss of disc
space and small spurring. A posterior disc-osteophyte complex is
seen at C4-5 and C5-6. There is no prevertebral soft tissue
swelling. IMPRESSION: Multiple fractures involving the cervical
spine as detailed above
with involvement of the transverse process and several fractures
involving the transverse foramina. Correlate with CTA to assess
for associated vertebral artery injury. No malalignment or
evidence of unstable fracture. An MRI spine to further assess as
clinically warranted.
[**2148-12-25**] CTA Head and Neck :
Segmental non-visualization of the right vertebral artery
predominantly more proximally. This is likely more due to
atherosclerotic disease than
trauma/dissection , but further evaluation can be obtained with
gadolinium- enhanced MRA and fat- suppressed axial images of the
neck if clinically
indicated. Otherwise, no vascular occlusion or stenosis seen in
the carotid or vertebral arteries. Intracranial CTA appears
unremarkable except for vascular calcifications. This report is
provided without the availability of 3D reformatted images. When
additional images are available, and if there is additional
information obtained, an addendum will be given to this report.
[**2148-12-26**] MRI C Spine : 1. Large prevertebral hematoma in the
cervical region from craniocervical junction to C5 level.
2. Increased interspinous signal at C5-6 level indicating injury
to the
interspinous ligament but no evidence of disruption of the
anterior, posterior longitudinal ligaments of ligamentum flavum
identified.
3. Moderate spinal stenosis due to degenerative change from C3-4
to C5-6 with extrinsic indentation on the spinal cord.
4. No evidence of abnormal signal within the spinal cord.
[**2148-12-27**] Cardiac echo : Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.9 m/s
Left Atrium - Peak Pulm Vein D: 0.6 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.6 cm <= 5.0 cm
Left Ventricle - Lateral Peak E': 0.11 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 13 < 15
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Ascending: *3.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - A Wave: 1.2 m/sec
Mitral Valve - E/A ratio: 1.08
Mitral Valve - E Wave deceleration time: 141 ms 140-250 ms
TR Gradient (+ RA = PASP): *>= 27 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 1.3 m/sec <= 1.5 m/sec
Findings
suboptimal images pt supine with neck brace on.
LEFT ATRIUM: Normal LA and RA cavity sizes.
LEFT VENTRICLE: LV not well seen. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion. RV
not well seen.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
MITRAL VALVE: Mild mitral annular calcification. Normal LV
inflow pattern for age.
TRICUSPID VALVE: Tricuspid valve not well visualized. Moderate
[2+] TR. Mild PA systolic hypertension.
GENERAL COMMENTS: Suboptimal image quality as the patient was
difficult to position. Suboptimal image quality - body habitus.
Conclusions
The left atrium and right atrium are normal in cavity size. The
left ventricle is not well seen. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. Moderate [2+] tricuspid regurgitation is seen. There is
mild pulmonary artery systolic hypertension.
IMPRESSION: Extremely poor technical quality due to patient's
body habitus. Left ventricular function cannot be determined.
The right ventricle is not well seen but is likely normal. No
pathologic valvular abnormality seen although the valves are
poorly visualized.
Brief Hospital Course:
Mrs. [**Known lastname **] was involved in a high speed rollover down a 15 ft.
embankment. She was the unrestrained driver. Extrication was
prolonged but she was eventually taken to [**Hospital **] Hospital. Due
to multiple injuries including C spine she was transferred to
[**Hospital1 18**] for further evaluation. She was seen in the Emergency
Room, outside scans were reviewed and her vital signs remained
stable. She was admitted to the Trauma ICU for management.
Her airway was monitored closely as she had a prevertebral
hematoma presumed secondary to her multiple cervical fractures.
This proved to be [**Last Name **] problem, her oxygen saturations were stable
and she was able to cough up her secretions. Her hematocrit was
also followed and she was transfused with 2 units of packed red
blood cells for a hematocrit of 21. Subsequently she maintained
a hematocrit in the 25-26 range. Her neurologic status remained
intact. There was no evidence of any decreased sensation or
paresthesias in her extremities.
During her ICU stay the Vascular and Neurosurgery services were
consulted as her CTA of the neck was concerning for a right
vertebral dissection vs. atherosclerotic changes. She was
briefly placed on heparin however at discharge she will be
placed on aspirin and Plavix and will have a repeat CTA of the
neck in 2 weeks. At that time further recommendations for
anticoagulation will be given. She was asymptomatic from that
standpoint.
Her blood sugars were out of control on admission requiring an
insulin drip for the first 3 days however she was transitioned
to part of her pre admission Levemir dose and this has gradually
been adjusted to attempt to keep her sugars between 60 and 120.
Due to her multiple issues a PICC line was placed for
medications and phlebotomy however this may be for the short
term. Her diet was advanced to a diabetic diet and she was able
to eat without any difficulty. Her foley catheter is scheduled
to be removed at midnight tonight.
Following transfer to the Trauma floor she was evaluated by
Physical Therapy and Occupational Therapy as she was quite
limited in her ability to move with her multiple fractures and
orthotics. She will require acute rehabilitation with the hopes
of maintaining her independence at home.
Medications on Admission:
Novalog SS
Metformin 2grams qd
Levamir 52U in AM 36 U qHS,
Clonopin 1mg qhs
Synthroid 88 mcg qd
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
9. Indapamide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
12. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
17. Insulin Glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous once a day: Every AM.
18. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous at bedtime.
19. Regular insulin sliding scale qid See scale attached
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary Diagnosis
S/P MVC
1. small non displaced T 2 fracture
2. Multiple C Spine fractures, paravertebral hematome
3. Bilateral 1st rib fractures posterior
4. Left [**3-6**] rib fractures anterior and posterior
5. Periorbital ecchymosis
6. 10 cm scalp laceration
7. Bilateral small pneumothoracies
8. Left scapular fracture
9. Comminuted right scapular fracture
10. Right vertebral artery dissection
11. Right distal clavicle fracture
Secondary diagnoses
1. Hypertension
2. IDDM
3. Restless leg syndrome
4. Hypothyroidism
Discharge Condition:
Stable, pain better controlled
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR DOCTOR IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy 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.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-1-14**] 11:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3243**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2149-1-14**] 1:15
Call [**Telephone/Fax (1) 1228**] for an appointment in 1 month at the
[**Hospital **] Clinic. You will need an Xray of your right clavicle
before this appointment.
Call [**Telephone/Fax (1) 1228**] for an appointment with Dr. [**Last Name (STitle) 1352**] in 4 weeks
Completed by:[**2148-12-30**]
|
[
"811.00",
"807.04",
"401.9",
"V58.67",
"333.94",
"860.0",
"244.9",
"805.08",
"443.24",
"780.09",
"805.2",
"E816.0",
"873.0",
"810.02",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
12747, 12819
|
8674, 10970
|
286, 293
|
13386, 13419
|
2175, 8651
|
14389, 14947
|
1210, 1228
|
11117, 12724
|
12840, 13365
|
10996, 11094
|
13443, 14366
|
1243, 1540
|
228, 248
|
321, 963
|
1741, 2156
|
1555, 1725
|
985, 1140
|
1156, 1194
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,740
| 107,188
|
28139
|
Discharge summary
|
report
|
Admission Date: [**2164-9-19**] Discharge Date: [**2164-10-16**]
Date of Birth: [**2087-5-7**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Headache, visual difficulties
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 77 yo woman who was recently dx'ed with HTN and
started on lisinopril 2 wks ago, who presents after severe R
temporal HA that woke her from sleep at 3AM - HA sharp, constant
and throbbing component, which worsens with coughing. She has
also had nausea (no vomiting), and when she tried to walk felt
unsteady on feet. She took [**First Name3 (LF) **] 81mg x 4 tabs, and called 911 -
she was brought to [**Hospital 1474**] Hosp where card [**Last Name (un) **] were neg, gluc
128, INR 1.0, nl hct/ptt/plt; head CT revealed ICH (we do not
have report here), and she was transferred to [**Hospital1 18**] for further
w/u and care. She denies visual changes, but felt that when her
vision was tested in hospital she realized she couldn't see well
to the left. No c/o recent visual changes, hearing changes,
trouble with speech or swallowing, problems with memory or
language, no dizziness, no weakness, numbness, tingling, or
falls; no head trauma. She had a cold 2 months ago, but no
recent f/c/sob/cp/palp/gi/msk c/o.
ROS:
+ dysuria/burning x days
+ leg swelling, on bumex
+ dry cough since starting lisinopril
+ L shoulder pain "chronic"
Past Medical History:
1. HTN - recent dx, on lisinopril. Has developed dry cough
since starting lisinopril
2. AAA s/p percutaneous stent placement [**2163**]
3. Diverticulitis s/p colostomy/reversal 20 yrs ago
4. s/p hernia repairs x 3
5. s/p Appy as child
6. s/p cataract [**Doctor First Name **] bilat
7. pedal edema
Social History:
Lives alone since husband died; former nursing assistant.
Smokes [**3-3**] cig/day, on/off since age 24. Drinks 6 etoh
beverages/wk (all on weekend). No drugs. Has living will,
daughter [**Name (NI) 7346**] [**Last Name (NamePattern1) 68406**] is [**Name (NI) 68407**] - pt says she is full code,
unless underlying process "irreversible."
Family History:
Mother d. MI age 54, siblings with cad. No strokes or aneurysms
in family.
Physical Exam:
T 98.2 149/117 77 23 97%4L
General appearance: white female, nad
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues
Mental Status: The patient is alert and attentive, +DOW
backwards, registered three objects at 30 seconds and recalled 2
out of 3 items at 3 minutes plus one with prompt. Good knowledge
for events leading to hospitalization. Language is intact with
no errors. Naming intact; only reads R [**1-2**] of words ("fifty"
for "fifty-fifty"). There is no apraxia or agnosia.
Cranial Nerves: Dense L homonomous hemianopsia, does not spare
macula. The optic discs are very difficult to visualize due to
pupil size/lighting. Eye movements are normal, with no
nystagmus. Pupils react equally to light, both directly and
consensually 3->2. Sensation on the face is intact to light
touch, pin prick. Facial movements are normal and symmetrical.
Hearing is intact to finger rub. The palate elevates in the
midline. The tongue protrudes in the midline and is of normal
appearance.
Motor System: There is pain and giveway weakness of L deltoid;
decreased bulk bilat edb's and very mild toe ext weakness. Mild
weakness of R apb with decr bulk of thenar mm as well.
Elsewhere, normal appearance, tone, and full strength elsewhere
in limbs, including shoulder abductors, and extensors and
flexors of the arms, wrists, fingers, hips, knees, feet and
toes. There is no
tremor, drift, or abnormal movements.
Reflexes: The tendon reflexes are 1+ at [**Hospital1 **], [**Last Name (un) **], tri,
patellar, absent at achilles; symmetric. The plantar reflexes
are flexor. No grasp, nl jaw jerk.
Sensory: Diminished vibration at toes; elsewhere, sensation is
intact to pin prick, light touch, and position sense in all
extremities and trunk.
Coordination: There is no ataxia. The finger/nose test and
finger and foot tapping are performed normally, as are rapid
alternating hand movements.
Gait: could not be assessed
Pertinent Results:
145 111 28 99
-------------<
4.5 26 1.1
Phenytoin: 1.0
MCV 88
WBC 11.0 H/H 13.3/ 37.8 PLT 212
N:77.4 L:16.8 M:4.9 E:0.7 Bas:0.1
PT: 12.1 PTT: 25.3 INR: 1.0
SpecGr 1.009
Leuk Mod
Bld Lg
Nitr Pos
RBC [**11-19**] WBC>50 Bact Many
Imaging:
CT head appears to have large R ICH - area of R occipital
(occip-pariet jxn) intraparenchymal blood with associated IVH in
R lateral vent, small amount of blood in L lat vent, with blood
in 3rd, no blood in 4th. Some edema on R, minimal shift.
EKG is NSR with occ PACs, TW flat in III
MRI: 1. There is no definite increase in size of the large right
parietooccipital hemorrhage compared to the study of twelve
hours previously. There is extensive hemorrhage into the right
lateral ventricle with slightly more extension of blood
breakdown products into the third ventricle and left lateral
ventricle.
2. The mass effect on the right ventricular system and cerebral
hemisphere is stable. There is no shift of normally midline
structures, and the basal cisterns are patent.
3. There are mild microvascular changes elsewhere in the
cerebral white matter without evidence of microhemorrhages to
suggest underlying amyloid angiopathy. No enhancing lesion is
seen. There is focal linear enhancement near the lesion, of
uncertain significance, as discussed in the wet [**Location (un) 1131**].
CT Chest/Abd: 1. 6-mm nodules within the lung parenchyma for
which one year interval followup is recommended to assess for
stability.
2. Indeterminate left adrenal lesion for which further
characterization with either dedicated MRI or CT scan of the
adrenal is recommended.
3. Surgical clips in the left upper abdomen, correlate with
prior history of surgery.
4. Infrarenal intraluminal endograft within the aorta.
Surrounding thrombus and no evidence for endoleak seen. Aorta
measures approximately 4.7 x 4.5 in maximal transverse and AP
dimensions. Recommend correlation with prior CT scans to assess
for interval growth of aneurysm site.
5. No evidence for fluid collection within the abdomen and
pelvis.
EEG: Initially showed focal epileptiform discharges, then
generally encephalopathic. 3rd EEG again showed focal
discharges but less frequent.
Brief Hospital Course:
77 yo woman who was recently dx'ed with HTN and started on
lisinopril 2 wks ago, who presents after severe R temporal HA
that woke her from sleep at 3AM, found on exam to have dense L
homonomous hemianopsia, and on CT appears to have R ICH
occipital lobe with extension into ventricular system (blood in
lateral vents R>>L, and blood in 3rd). She has been evaluated
by neurosurgery, who feels that due to her current exam/clinical
picture, a vent drain may currently pose more risks than
benefits, and she should be monitored conservatively for now, in
the ICU. She also has UTI on labs. With normal coags, proplex
is not indicated.
Rec:
-Admit to neurology ICU/Attg: [**Doctor Last Name **]
-Dilantin load 1g, then start 100mg tid
-Q1h neuro checks
-Goal sbp<140s
-Check AM head CT next (or sooner if acute change in exam)
-AM labs including cbc, coags, lytes, a1c, flp, cardiac enzymes
-Tight ISS
-Temp control (goal <100)
-No antiplatelet or anticoag
-Tylenol for pain
-Treat UTI with ceftriaxone; await cultures
-Full code (discussed with patient); [**Doctor Last Name 68407**] is daughter [**Name (NI) 7346**]
[**Name (NI) 68406**]
-MRI/A to evaluate for underlying vascular lesion, or for
presence of microbleeds to suggest underlying etiology (ie,
amyloid, vs hypertensive)
Went to ICU for several days where she was noted to improve.
Transferred to the floor [**9-21**] and noted to be lethargic with
headache am of [**9-22**]. Stat CT done for concern of new
hemorrhage, but no progression seen. Again on [**9-23**] am patient
noted to be lethargic, and stat head CT showed no changes.
Percocets were d/c'd and thought to be contributing. Left
homonymous hemianopsia improved but still present.
Neuro:Neurologically, had encephalopathic exam for majority of
stay with etiology thought to initially be seizures vs.
infection and then narrowed down to infection. Had EEG which
showed focal spikes and was loaded with dilantin. Subsequent
reads of EEG showed diffuse encephalopathy but no focality. Was
continued on Dilantin and then transitioned to Keppra [**10-3**].
Keppra increased to 1500 [**Hospital1 **] on [**2164-10-10**] after repeat EEG showed
few focal sharp/slow wave discharges.
Patient's mentation and level of function gradually improved
over stay.
CVS: Aspirin held for duration of stay and will be restarted
out patient. Low dose antihypertensives started [**9-24**] with
lisinopril 10mg daily and Metoprolol 12.5mg [**Hospital1 **].
ID: Had low grade fevers off and on [**9-23**] and [**9-24**] with 3 blood
cultures/urine cultures from [**9-22**] [**9-23**] and [**9-24**]. No clear
source seen, bu PNA suspected and started on levo and flagyl.
Continued to have low grade fevers second week. Was pan
cultured several times with no growth. Elevated white count but
no left shift. ID was consulted and recommended withdrawing
antibiotics to see if infection would declare itself.
Antibiotics (levo/flagyl) taken off on [**9-28**] and continued to
have low grade fevers. Cultures were continued almost daily but
there was no growth. Transthoracic echo done to rule out
endocarditis and was negative. Transesophageal echo attempted
twice but failed secondary to poor cooperation from patient.
Serial chest xrays showed no clear infiltrate. There was no
skin breakdown and no diarrhea. A torso CT with contrast was
done to rule out any chest cavity fluid collections. LP
performed on [**10-3**] with findings as listed above. Started
Acyclovir, Vancomycin and Ceftriaxone all at meningitic doses.
Cultures were negative, but fever and white count responded to
ABX so finished a one week course. Acyclovir d/c'd after 6 days
when HSV PCR negative. No clear source of infection found after
multiple cultures/work-up. One urine culture with 10-100K
Enterococcus thought to be contamination, but received high dose
vanc for three days regardless.
RESP: no issues
GI: On PPI. Wasn't taking good PO and was eventually on tube
feeds by NG. Transitioned back to ground PO on [**10-11**] with NG
supplement. Multiple samples sent for CDIFF and negative.
DERM: consulted derm regarding vesicles and bed sore. Sent for
studies and negative for HSV.
Follow up CXR or CT should be done as out-patient for follow up
of 6mm pulmonary nodule.
Medications on Admission:
Bumex (for leg swelling)
[**Month/Year (2) **] 81mg
Lisinopril (unknown dose) - x 2 wks
PRN [**Last Name (LF) **], [**First Name3 (LF) **]
Discharge Medications:
1. Zinc Oxide-Cod Liver Oil 40 % Ointment [**First Name3 (LF) **]: One (1) Appl
Topical PRN (as needed).
Disp:*30 1* Refills:*2*
2. Docusate Sodium 150 mg/15 mL Liquid [**First Name3 (LF) **]: One (1) PO BID (2
times a day).
Disp:*60 tab* Refills:*2*
3. Senna 8.6 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Miconazole Nitrate 2 % Powder [**First Name3 (LF) **]: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*30 1* Refills:*0*
5. Lisinopril 5 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO DAILY (Daily):
hold for SBP <100.
Disp:*30 Tablet(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever >101.0.
Disp:*30 Tablet(s)* Refills:*0*
7. Thiamine HCl 100 mg Tablet [**First Name3 (LF) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO TID
(3 times a day) as needed.
Disp:*30 ML(s)* Refills:*0*
12. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED): per regular insulin sliding
scale.
Disp:*1 1* Refills:*2*
13. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: 1500mg PO BID (2
times a day).
Disp:*30 days* Refills:*2*
14. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
Disp:*0 0* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Right Occipital Intracranial Hemorrhage
Discharge Condition:
Good
Discharge Instructions:
Return to the ED or call EMS if you experience any new changes
in your vision or severe headache, nausea or vomitting. Follow
up with your appointments as listed below. You will need to
have a follow up CXR in 6 months to monitor a pulmonary nodule.
After discharge, call [**Telephone/Fax (1) 6713**] to schedule your CXR (it is
currently set for [**2165-3-31**] but you may wish to change the date for
convenience).
Followup Instructions:
Stroke: Dr. [**First Name (STitle) **] [**11-12**] at 4:30pm, [**Hospital Ward Name 23**] 8th, [**Telephone/Fax (1) 1694**].
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 29983**], [**2163-11-20**] at 9am, fax:
[**Hospital1 68408**], [**Last Name (un) 33487**], MA. [**Telephone/Fax (1) 39942**]
(phone)
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
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"782.1",
"729.81",
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"401.9",
"780.6",
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"368.46",
"431",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"03.31",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
13167, 13264
|
6720, 11010
|
312, 318
|
13347, 13353
|
4499, 6697
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|
2195, 2272
|
11200, 13144
|
13285, 13326
|
11036, 11177
|
13377, 13797
|
2287, 2673
|
243, 274
|
346, 1498
|
3061, 4480
|
2688, 3045
|
1520, 1819
|
1835, 2179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,877
| 134,731
|
49507
|
Discharge summary
|
report
|
Admission Date: [**2145-5-21**] Discharge Date: [**2145-6-2**]
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is an 84 year old
male with a history of dementia, hypertension, thoracic
aortic aneurysm who was admitted on the 7th from his nursing
home with septic shock and biliary sepsis. The patient was
started on the MUST protocol and admitted to the Intensive
Care Unit.
The patient was started on Vancomycin and Zosyn for empiric
coverage of biliary organisms. A CT scan on admission showed
a distended gallbladder filled with large stones and sludge.
There was a small amount of pericolic fluid. The common bile
duct was dilated up to 1.4 cm. There were no definite common
bile duct stones identified. There was minimal stranding
around the head of the pancreas with no peripancreatic fluid
collection. In addition, a thoracic aortic aneurysm was
noted to be 6.9 cm in its greatest diameter and there was a
left internal iliac aneurysm which was 3.4 x 4.6 cm. On [**5-22**] the patient was intubated for increasing metabolic and
respiratory acidosis with respiratory distress. The patient
was diagnosed with gallstone pancreatitis and enterococcal
sepsis. The patient was started on Neo-Synephrine for
hypotension which was quickly weaned off. The patient
underwent an endoscopic retrograde cholangiopancreatography
on [**5-22**] with placement of a biliary stent. The endoscopic
retrograde cholangiopancreatography showed multiple erosions
and ulcers in the stomach. There was a single nonbleeding
diverticulum with small opening in the major papilla.
Cannulation of the biliary duct was successful with a
sphincterotome and contrast medium was injected resulting in
complete opacification. Multiple filling defects were seen
in the common bile duct. The proximal cystic duct filled
with contrast but the gallbladder was not visualized. There
was no dilatation of the intrahepatic duct. A 10 x 10
biliary stent was placed successfully in the common bile duct
and purulent bile exuded from the duct. Repeat right upper
quadrant ultrasound showed no evidence for cholecystitis and
therefore no percutaneous drain was placed. During the
patient's Intensive Care Unit course he developed atrial
fibrillation which resolved. The patient was started on
total parenteral nutrition on [**5-24**]. The Intensive Care
Unit course was also complicated by acute renal failure with
an admission creatinine of 3.3 which had improved to the
patient's baseline of 0.9 by transfer to the floor. A
peripherally inserted central catheter was placed on [**5-24**].
The patient's course was further complicated by congestive
heart failure and significant peripheral edema thought to be
due to fluid overload as the patient had received 20 liters
of fluid by the middle of his Intensive Care Unit stay. The
patient was therefore diuresed aggressively and by the time
he was transferred to the floor was thought to be euvolemic.
The patient's blood cultures grew out enterococcus which was
pansensitive. Therefore, his antibiotics were changed to
ampicillin [**5-26**]. On [**5-27**] the patient developed
increasing sputum production and a decreased O2 saturation.
The sputum was sent and came back with rare coagulase
positive staph. Repeat cultures were negative. Therefore,
the patient's antibiotic regimen was not changed. The
patient remained afebrile. The patient was started on tube
feeds. The patient was extubated on [**2145-5-31**] to room
air. No further blood cultures were positive. The while
blood cell count resolved. The liver function tests were
coming down. The patient was not requiring any oxygen. The
patient was transferred to the medical [**Hospital1 **] in stable
condition on [**5-31**].
PAST MEDICAL HISTORY:
1. Dementia with delirium.
2. Hypertension.
3. Bronchitis.
4. Sleep apnea.
5. Thoracic aortic aneurysm of 7 cm.
6. Pulmonary nodules.
7. Benign prostatic hypertrophy status post transurethral
resection of the prostate.
8. Hydrocele.
9. Glaucoma.
10. Hyperlipidemia.
11. Severe aortic insufficiency seen on echocardiogram
in [**2144**]. Normal ejection fraction at that time.
12. Recurrent urinary tract infections.
13. MRSA bacteremia with MRSA urinary tract infection
and pneumonia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER TO THE MEDICAL [**Hospital1 **]:
1. Haldol 2 mg intravenous q 4 hours p.r.n.
2. Miconazole powder.
3. Ampicillin 1 gram intravenous q 6.
4. Fentanyl p.r.n.
5. Midazolam p.r.n.
6. Insulin sliding scale.
7. Protonix.
8. dorzolamide/Timolol eye drops.
9. Pilocarpine eye drops.
10. Colace.
11. Heparin.
SOCIAL HISTORY: The patient lives at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. His
health care proxy is his sister, [**Name (NI) **] [**Name (NI) 103575**]. Her phone
number is [**Telephone/Fax (1) 103576**] or [**Telephone/Fax (1) 103577**].
MEDICATIONS ON ADMISSION TO THE HOSPITAL:
1. Isordil 10 mg P.O. q.d.
2. Enteric coated aspirin 81 mg P.O. q.d.
3. Multivitamin.
4. Protonix 40 mg P.O. q.d.
5. Terazosin 1 q.h.s.
6. Lisinopril 10 mg P.O. q.d.
7. Lopressor 25 mg .o. B.I.D
8. Colace, Senna and Cosopt and Pilocarpine eye drops.
PHYSICAL EXAMINATION: On transfer to the medical floor the
patient on [**6-1**]. He was disoriented to date and place.
Temperature was 98.3, heart rate 85 to 95, blood pressure
114/60 with a range of 96/34 to 114/68. Respiratory rate 14
to 30, oxygen saturation 98 to 99 percent on room air. The
patient had been 11 liters negative, his length of stay in
the Intensive Care Unit. Head, eyes, ears, nose and throat:
Pupils were minimally reactive to light. Sclerae were
anicteric. Left pupil was cloudy. Extraocular muscles were
intact. Oropharynx was without erythema or edema. In
general the patient was an elderly thin male in no acute
distress. Neck showed no lymphopathy, no jugular venous
distension, no thyromegaly. Lungs: There were decreased
breath sounds bilaterally. Otherwise clear. Cardiovascular
regular with an S3 and an apical III/VI murmur, laterally
displaced point of maximal impulse. Abdomen soft, nontender,
nondistended with bowel sounds, no hepatosplenomegaly and no
masses. Extremities: 1+ edema in the lower extremities
bilaterally with no rash. Neurologic examination: Patient
was oriented times one. He was alert. Cranial nerves 2 to
12 were intact and symmetric.
LABORATORY DATA: On transfer to the medical [**Hospital1 **] white blood
cell count was 12.8, hematocrit 27.6, platelets 246. Sodium
144, potassium 3.8, chloride 107, bicarbonate 30, BUN 23,
creatinine 0.9, glucose 71, calcium 8.2, magnesium 2.2,
phosphorus 4.2, total bilirubin was 1.5, alkaline phosphatase
was 257. Review of the patient's microbiology showed stool
that was negative for C difficile, positive blood cultures
for enterococcus on the 7th and 8th with negative blood
cultures on the 11th and 13th. An MRSA screen was positive
twice. Sputum culture showed staphylococcus aureus and
repeat cultures were negative.
The patient was admitted to the medical [**Hospital1 **] for further
treatment.
1. Enterococcal sepsis: The patient has had repeat blood
cultures which were negative for any growth. He is
receiving 14 days of ampicillin and is currently on day
12. His blood pressure has been stable though somewhat
low. His white blood cell count has normalized. He is
afebrile.
1. Cholangitis and gallstone pancreatitis: Patient is being
treated with ampicillin for a 14 day course. He is status
post biliary stent placed via endoscopic retrograde
cholangiopancreatography. Gastrointestinal recommendation
for cholecystectomy in one month and if the patient is not
found to be a surgical candidate then recommend
sphincterotomy with stent exchange. Patient's liver
function tests are clearly improving.
1. Pulmonary: The patient was intubated for hypercarbic
respiratory failure. However, he is now extubated with no
evidence of pulmonary compromise.
1. Anemia of unclear etiology. The patient's stools were
guaiaced. He was transfused one unit of blood for
decreasing hematocrit slowly over the past week.
1. Renal: The patient presented with renal insufficiency
likely due to hypotension and hypovolemia which returned
to his baseline with creatinine of 0.9 with fluid
hydration.
1. Endocrine: The patient underwent a cortisol stimulation
test in the unit which was normal. His fingersticks have
all been normal. He has not needed any insulin sliding
scale.
1. Fluid, electrolytes and nutrition. The patient did fail a
speech and swallow evaluation at the bedside. No video
swallow was performed. The family who is the health care
proxy refuses the PEG tube or an nasogastric tube.
Therefore the patient will be fed with strict aspiration
precautions. He can eat thick liquids and soft solids.
He was requiring potassium and calcium repletion while in
the hospital.
1. Prophylaxis: The patient received subcutaneous heparin
injections and proton pump inhibitor.
1. Access: A peripherally inserted central catheter was
placed on [**5-24**].
1. Communication: Is with the patient's sister and health
care proxy, [**Name (NI) **] [**Name (NI) 39685**].
1. Code status: The patient is Do Not Resuscitate, Do Not
Intubate.
DISCHARGE STATUS: Back to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] Nursing Home.
DISCHARGE CONDITION: Stable with decreased white blood cell
count, afebrile, all the cultures negative, no abdominal
pain, decreasing liver function tests, tolerating an oral
diet.
DISCHARGE DIAGNOSIS: Enterococcal sepsis.
Cholangitis with gallstone pancreatitis.
Respiratory failure with intubation.
Acute renal failure.
Congestive heart failure.
Endoscopic retrograde cholangiopancreatography, status post
stent.
MAJOR SURGICAL/INVASIVE PROCEDURES: Endoscopic retrograde
cholangiopancreatography with biliary stent on [**5-22**].
Peripherally inserted central catheter line placement on [**5-24**].
DISCHARGE MEDICATIONS: Acetaminophen 325 mg 1 to 2 tablets
P.O. 4 to 6 hours p.r.n., heparin sodium 5,000 units 1
injection q 8 hours, Docusate sodium 150 mg per his VML
liquid 1 P.O. B.I.D, Pilocarpine 2 percent eye drops, 1 q 6
hours to the right eye, dorzolamide/Timolol eye drops 1 B.I.D
to the right eye, miconazole nitrate powder 1 application
B.I.D as needed, calcium carbonate 500 mg 1 P.O. B.I.D,
heparin flush, Protonix 40 mg 1 P.O. q.d., ampicillin sodium
1 gram q 6 hours for two days.
FOLLOW UP: The patient is to follow up with primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. He is also to follow up with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 103578**] in gastroenterology in the [**Hospital Ward Name 23**] Center
Medical Specialties on [**2145-7-13**] at 2 P.M.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Dictated By:[**Last Name (NamePattern1) 103579**]
MEDQUIST36
D: [**2145-6-2**] 15:36:03
T: [**2145-6-2**] 16:59:49
Job#: [**Job Number **]
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79,427
| 174,326
|
42122+58492
|
Discharge summary
|
report+addendum
|
Admission Date: [**2154-1-15**] Discharge Date: [**2154-1-19**]
Date of Birth: [**2121-6-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
chest pain, arm pain
Major Surgical or Invasive Procedure:
[**2154-1-15**] - Catheter placement, coronary thrombectomy, coronary
artery infusion of eptifibatide, Intravascular ultrasound,
Coronary Angiography
[**2154-1-18**] Coronary catheterization with placement of 2 bare metal
stents to mid LAD.
History of Present Illness:
This is a 32 year-old with a PMH significant for HTN,
insulin-dependent diabetes mellitus who presents with a 3-day
history of chest and arm pain that developed with exertion with
some exertional dyspnea and fatigue.
.
The patient awoke Sunday ([**2154-1-13**]) feeling well and went to the
laundry mat walking 1-block with bags full of laundry and
developed some exertional dyspnea and left arm pain that
radiated in a pulsatile fashion to his fingers; without frank
chest pain, but with some diaphoresis. When he returned home,
his dyspnea improved with rest. However, his left arm pain
progressed to right arm pain even while resting. This pain
continued through Monday and early Tuesday morning he noted the
left arm pain was [**9-5**] in intensity and was sharp in character,
radiating to the left shoulder and back with some chest
discomfort that was constant. He presented to the BU Student
Health Center Tuesday PM and they gave him Aspirin 325 mg PO x 2
and called EMS. He was BIBA to the [**Hospital1 18**] ED for further
management.
.
In the ED, initial VS 102 114/85 20 99% 2LNC. An EKG showed
sinus tachycardia @ 119, NA/NI, 2-[**Street Address(2) 2051**]-elevations in lead
V2-6, 1-mm ST-elevations in leads aVL, I and inferior lead
reciprocal changes. He received Metoprolol 5 mg IV x 1, Heparin
bolus of 4000 units IV and Ativan 2 mg PO x 1. He was emergently
rushed to the cardiac cath [**Street Address(2) **] where the patient was noted to
have an abrupt cut-off at the mid-LAD with visible vessel
thrombus of the mid-LAD and distal reconstitution with
distal-LAD disease; underwent aspiration and ballooning of LAD
via RFA access (closed with angioseal). In the [**Street Address(2) **], he was given
Plavix 300 mg loading dose. Integrillin gtt was started and
heparin gtt was continued. In the cath [**Street Address(2) **] he was also
diaphoretic with a blood glucose of 390 mg/dL. He remained chest
pain free, but had on-going arm pain following the procedure.
.
On arrival in the CCU, the patient has some on-going left arm
pain while resting flat, but no chest pain, diaphoresis,
palpitations or nausea.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or pre-syncope.
.
ROS: The patient denies a history of prior stroke/TIA, deep
venous thrombosis or pulmonary embolus. They deny bleeding at
the time of prior procedures or surgeries. Denies headaches or
vision changes. No cough or upper respiratory symptoms. Denies
dizziness or lightheadedness; no palpitations. No nausea or
vomiting, denies abdominal pain. No dysuria or hematuria. No
change in bowel movements or bloody stools. Denies muscle
weakness, myalgias or neurologic complaints. No exertional
buttock or calf pain.
Past Medical History:
1. Insulin-dependent diabetes mellitus (diagnosed at age 19
year-old - blood glucose runs in the 150-200 mg/dL range; takes
Lantus and Humalog)
2. Hypertension
Social History:
Patient lives at home with his wife, who is 9-weeks pregnant. He
denies any smoking history. He stopped drinking 8-years ago for
spiritual reasons. He is a BU graduate student who just moved
here from [**Location (un) 58091**], VA/DC for graduate school studying
practical theology. He notes significant stress related to
semester deadlines. He denies recreational substance use.
Family History:
Denies family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death. Strong family history of diabetes,
hypertension and stroke.
Physical Exam:
ADMISSION EXAM
VITALS: 98.6 / 98.6 138/87 112 23 100% 2LNC
GENERAL: Appears in no acute distress. Alert and interactive
African American male.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD difficult to assess
given body habitus.
CVS: PMI located in the 5th intercostal space, mid-clavicular
line. Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal. No S3 or S4.
RESP: Respirations unlabored, no accessory muscle use. Clear to
auscultation bilaterally without adventitious sounds. No
wheezing, rhonchi or crackles. Stable inspiratory effort.
ABD: soft and obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
DERM: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
PULSE EXAM:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
.
[**2154-1-15**] 11:40AM BLOOD WBC-7.5 RBC-6.16 Hgb-14.6 Hct-46.1
MCV-75* MCH-23.7* MCHC-31.7 RDW-12.9 Plt Ct-244
[**2154-1-15**] 11:40AM BLOOD PT-11.5 PTT-27.3 INR(PT)-1.1
[**2154-1-15**] 11:40AM BLOOD Fibrino-572*
[**2154-1-15**] 08:00PM BLOOD UreaN-10 Creat-0.8 Na-130* K-4.1 Cl-97
[**2154-1-16**] 05:00AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.0
.
PERTINENT LABS AND STUDIES:
[**2154-1-15**] 08:00PM BLOOD CK(CPK)-387*
[**2154-1-16**] 05:00AM BLOOD CK(CPK)-275
[**2154-1-16**] 12:36PM BLOOD CK(CPK)-218
[**2154-1-15**] 08:00PM BLOOD CK-MB-7
[**2154-1-16**] 05:00AM BLOOD CK-MB-6 cTropnT-0.32*
[**2154-1-16**] 12:36PM BLOOD CK-MB-4 cTropnT-0.28*
[**2154-1-15**] 11:40AM BLOOD Lipase-35
[**2154-1-16**] 05:00AM BLOOD %HbA1c-11.5* eAG-283*
[**2154-1-16**] 05:00AM BLOOD Triglyc-180* HDL-35 CHOL/HD-3.4
LDLcalc-48 Cholest-119
.
[**2154-1-15**] CARDIAC CATH - French XBLAD3.5 guide provided good
support. Crossed with Prowater very easily into the distal LAD.
This did not restore flow in the apical LAD and visible
thrombus was seen to occlude
the vessel there. Administered intracoronary Integrilin (180
mcg/kg x 2) and performed catheter based thrombectomy using the
Export catheter with significant clot removal/dissolution.
Administered intracoronary vasodilators. Perfomed intravascular
ultrasound using the Atlantis catheter and this revealed mild
diffuse atherosclerosis throughout the LAD and residual
subocclusive thrombus in the proximal LAD. A ChoICE PT XS [**Name (NI) **]
was redirected into various branches of the distal LAD and an
uninflated 2.0 mm balloon was used to "Dotter" across the apical
vessel clot, but this did not restore flow. It was decided that
we would administer 18 hours of integrilin and IV heparin for at
least 48 hours rather than cause distal embolization with stent,
balloon or rheolytic thrombectomy. Final angiography revealed
normal flow to the apical LAD where there was TIMI 0 flow and
filling via faint collaterals. There was 20-40% residual
thrombus in the proximal LAD. He left the laboratory in stable
condition with no chest pain.
.
[**2154-1-15**] CXR - The cardiomediastinal and hilar contours are
normal. The lungs are essentially clear. There is no pleural
effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process. [**2154-1-15**]
ECHOCARDIOGRAM The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Suboptimal image
quality. Mild symmetric left ventricular hypertrophy. Normal
global and regional biventricular function. No evidence of
intracardiac shunt with agitated saline administration.
.
[**2154-1-16**] 2D-ECHO - The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic arch is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Suboptimal image
quality. Mild symmetric left ventricular hypertrophy. Normal
global and regional biventricular function. No evidence of
intracardiac shunt with agitated saline administration.
.
[**2154-1-18**] CARDIAC CATH:
Findings:
ESTIMATED blood loss: <100 cc
Hemodynamics (see above):
Coronary angiography: left dominant
LMCA: No angiographically-apparent CAD.
LAD: Unchanged 60-80% subocclusive thrombus proximal LAD.
Visible thrombus in apical LAD with "train track" appearance
with
some flow in apex.
LCX: No angiographically-apparent CAD.
RCA: Not injected. Known nondominant and free of disease.
.
Interventional details
XB3 guide. Crossed with Prowater wire and performed IVUS
interrogation using the InfraredX catheter. This demonstrated
significant thrombus in the proximal LAD with a RVD of 5.1 cm.
There was very little atheroma. The decision was made to
proceed with direct stenting. A 4.0 x 22 mm Integriti stent was
deployed and postdilated with a 5.0 mm balloon and residual
thrombus was visible distal to this stent and thought to be due
to uncovered (rather than due to prolapse or "toothpasting")
thrombus. A distal overlapping 4.0 x 15 mm Integriti stent was
deployed and postdilated to 5.0 mm. Final angiography revealed
normal flow, no dissection and 0% residual stenosis in the
stent,
no thrombus in the LAD up to the apex and no change in the
apical
LAD appearance.
.
Assessment & Recommendations
1. Secondary prevention CAD, CHF.
2. Plavix (clopidogrel) 75 mg daily X 12 months.
3. Heparin at 1700 U/hr as bridge to therapeutic warfarin.
4. Suggest warfarin INR [**3-1**].
5. ASA 81 mg QD.
6. Consider Cardiac MRI.
.
[**2154-1-19**] 2D-ECHO - The left atrium is mildly dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. Compared with the prior study (images
reviewed) of three days ago, [**2154-1-16**], the findings are
similar.
Brief Hospital Course:
32M with a PMH significant for HTN, insulin-dependent diabetes
mellitus who presents with a 3-day history of chest and arm pain
that developed with exertion with some exertional dyspnea and
fatigue found to have an anterolateral STEMI.
.
# ACUTE CORONARY SYNDROME, ST-SEGMENT ELEVATION MYOCARDIAL
INFARCTION - patient presented with acute coronary syndrome; no
prior history of chronic, stable angina but he has notable risk
factors including obesity, HTN, diabetes history and family
history. No prior cardiac catheterizations or known coronary
disease. EKG consistent with anterolateral ST-elevations with
cardiac catheterization showing abrupt cut-off at the mid-LAD
with visible vessel thrombus of the mid-LAD and distal
reconstitution with some distal-LAD disease; underwent
aspiration and balloon dottering of LAD via RFA access but given
the need to avoid distal embolization, anti-platelet therapy was
planned for 48-hours with a re-look planned. Received Aspirin
325 mg, Plavix 300 mg load, heparin IV 4000 unit bolus prior to
cath [**Year (4 digits) **] transfer. Integrillin and heparin gtt continued
following cardiac cath. Some on-going left arm pain and
persistent ST-elevations and TWI in the inferior leads following
the procedure resulted in starting Nitroglycerin gtt (evening of
[**1-15**]), which was discontinued. His re-look cardiac
catheterization procedure was performed on [**2154-1-18**] and showed
unchanged 60-80% sub-occlusive thrombus in the proximal LAD.
Visible thrombus in the apical LAD with "train track" appearance
with some flow in the apex was also noted. A 4.0 x 22 mm
Integrity stent was deployed and post-dilated with a 5.0 mm
balloon and residual thrombus was visible distal to this stent
and thought to be due to uncovered (rather than due to prolapse
or "toothpasting") thrombus. A distal overlapping 4.0 x 15 mm
Integrity stent was deployed and post-dilated to 5.0 mm. Final
angiography revealed normal flow, no dissection and 0% residual
stenosis in the stent, no thrombus in the LAD up to the apex and
no change in the apical
LAD appearance. Heparin gtt was continued until Lovenox was
utilized and then the patient was bridged to Coumadin. He was
continued on Plavix (for 12-months), Aspirin, Metoprolol,
Atorvastatin for medical management of his coronary disease, as
an outpatient. He was also treated with Ibuprofen for suspected
pericarditis, given a pleuritic component of his chest pain.
.
# DIASTOLIC HEART DYSFUNCTION - No historical evidence of
systolic or diastolic dysfunction; no prior 2D-Echo reports and
no physical evidence of heart failure noted. Remains on an ACEI
given diabetes for renal protection as an outpatient. His
echocardiogram demonstrated no PFO or atrial septal defects and
his left ventricular function was read as normal with no global
systolic dysfunction (LVEF 55%). He did have evidence of
diastolic dysfunction (grade 2) and for this we continued his
ACEI therapy and he was maintained on a beta-blocker. A repeat
2D-Echo on [**1-19**] was unchanged. He had no indication for
diuresis and his weight was stable this admission.
.
# INSULIN-DEPENDENT DIABETES MELLITUS - He has a history of
insulin-dependent diabetes mellitus diagnosed at age 19-years
when he presented unresponsive and was hospitalized. Has been on
insulin since and has blood glucose levels in the 150-200 mg/dL
range at home, per patient. No history HbA1c, but found to be an
HbA1c of 11.5% here. The patient required aggressive uptitration
of insulin given persistent hyperglycemia in the 400 mg/dL
range. At time of discharge, his blood glucose had improved
control with use of 18U Lantus and 20U short-acting insulin
prior to meals, resulting in blood glucoses of 150-170 mg/dL. He
will follow-up with [**Hospital **] [**Hospital 982**] clinic as an outpatient.
.
# HYPERTENSION - patient's home regimen included HCTZ and ACEI
therapy given his diabetes. We resumed his ACEI during this
hospitalization.
.
TRANSITION OF CARE ISSUES:
1. At the time of discharge, the following laboratory data,
microbiologic data and radiologic studies were pending.
2. Scheduled follow-up with his primary care physician and with
[**Name9 (PRE) **] [**Hospital 982**] clinic regarding the management of his
insulin-dependent diabetes.
3. Will require cardiac MR imaging and follow-up
echocardiography as an outpatient.
4. Will continue Lovenox bridge to Coumadin as an outpatient.
5. We started iron supplementation given his anemia.
Medications on Admission:
1. Lantus 16 units SC at nighttime
2. Humalog 20 units SC prior to meals
3. Metformin 1000 mg PO BID
4. HCTZ 12.5 mg PO daily
5. Lisinopril 10 mg PO daily
Discharge Medications:
1. insulin glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
2. insulin lispro 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous three times a day, prior to meals.
3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
4. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
5. 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:*0*
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Outpatient Physical Therapy
Outpatient physical therapy for mechanical left shoulder pain.
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may repeat every 5 minutes for a maximmum of 3 doses (15 minutes
of treatment).
Disp:*30 Tablet, Sublingual(s)* Refills:*1*
10. warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day:
You labs will have to be drawn while on this medication.
Disp:*30 Tablet(s)* Refills:*0*
11. enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): Continue until Dr. [**Last Name (STitle) 4427**]
tells you to stop.
Disp:*14 syringe* Refills:*0*
12. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Outpatient Radiology
Cardiac MRI one month from discharge.
16. Outpatient Radiology
Outpatient Echo within the next month.
17. Outpatient [**Name (NI) **] Work
PT/INR on Wednesday [**2154-1-23**]. Please fax results to Dr. [**Last Name (STitle) 4427**]
at [**Hospital 18**] [**Hospital6 733**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. Acute anterolateral ST-segment elevation myocardial
infarction
2. Grade II, diastolic heart dysfunction
.
Secndary Diagnoses:
1. Insulin-dependent diabetes mellitus
2. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Coronary Care Unit (CCU) at [**Hospital1 771**] on [**Hospital Ward Name 121**] 6 regarding management of your
chest pain and shortness of breath. You were found to have an
anterolateral ST-segment elevation myocardial infarction (heart
attack) and went to the cardiac catheterization [**Hospital Ward Name **] urgently
where we attempted to remove the thrombus or clot in your heart
artery. You were medically managed with anti-platelet therapy
and anticoagulants following your first procedure and a second
catheterization was planned. This showed persistent clot in your
heart artery and required 2 bare metal stents be placed in that
artery. You chest pain resolved and you were monitored without
any additional events.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED:
Aspirin 325mg by mouth daily for one month. Following this, you
should take 81mg by mouth daily.
Plavix (Clopidogrel) 75mg by mouth daily for 1 year
Metoprolol extended release 200mg by mouth daily
Nitroglycerin sublingually 0.4 as needed for chest pain
Atorvastatin 80mg by mouth daily
Lovenox 120mg injection twice daily until our primary care
doctor tells you to stop.
Warfarin 7.5mg by mouth daily at 4pm
Iron 300mg by mouth twice daily.
.
* The following medications were CHANGED on admission:
TAKE Lisinopril 20mg daily (you were previously on 10mg daily)
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.
You will need a follow up Cardiac MRI and echo.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) **] office to schedule a follow up
cardiology appointment. You should be seen by Dr. [**Last Name (STitle) 911**] in the
next 7-10days. His office can be reached at: ([**Telephone/Fax (1) 7283**].
Name: He, [**Name8 (MD) 91372**] MD
Location: [**Last Name (un) **] Diabetes Center
Address: [**Last Name (un) 3911**] [**Location (un) 86**], [**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 2384**]
Appointment: Wednesday [**2154-1-23**] 2:00pm
*Your appointment will be about 2-3 hours long. You will be
meeting with an educator as well as the doctor.
.
Primary Care:
Department: [**Hospital3 249**]
When: THURSDAY [**2154-1-24**] at 8:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15398**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Cardiology:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2154-2-20**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname 14369**],[**Known firstname 14370**] Unit No: [**Numeric Identifier 14371**]
Admission Date: [**2154-1-15**] Discharge Date: [**2154-1-19**]
Date of Birth: [**2121-6-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3373**]
Addendum:
ADDENDUM TO THE DISCHARGE SUMMARY FROM [**2154-1-19**]:
.
Per Dr. [**Last Name (STitle) 677**] (Interventional cardiologist), the patient should
continue on Lovenox with a bridge to Coumadin (INR goal [**3-1**]).
The anticoagulation should continue for a duration determined by
his cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Dr. [**Last Name (STitle) 677**] will also see this
patient in clinic. Coumadin was started given the concern for a
thromboembolic source as the precursor to his thrombus formation
in the coronary arteries (however, no shunt or patent foramen
ovale was noted on 2D-Echo). Dr. [**Last Name (STitle) 677**] should be contact[**Name (NI) **]
regarding the need for bridging anticoagulation prior to
procedures. The patient was also given Lovenox teaching while
hospitalized and felt comfortable with the brigding strategy.
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1547**], MD
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) 947**] [**Last Name (NamePattern4) 3374**] MD [**MD Number(2) 3375**]
Completed by:[**2154-1-19**]
|
[
"423.9",
"V17.1",
"V17.49",
"414.01",
"429.9",
"V58.67",
"401.9",
"250.01",
"410.01",
"278.00",
"V18.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"00.66",
"00.46",
"36.06",
"99.20",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
24442, 24608
|
12089, 16564
|
324, 567
|
19139, 19139
|
5297, 5297
|
21804, 24419
|
3979, 4130
|
16769, 18863
|
18913, 19118
|
16590, 16746
|
19322, 21547
|
4145, 5278
|
264, 286
|
595, 3382
|
5313, 12066
|
21561, 21781
|
19154, 19266
|
3404, 3565
|
3581, 3963
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,210
| 114,274
|
4088
|
Discharge summary
|
report
|
Admission Date: [**2154-6-8**] Discharge Date: [**2154-6-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Fatigue, n/v
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 3175**] is an 85 yo female with history of atrial
fibrillation, hypertension, chronic kidney disease, who presents
with one week of progressive fatigue. She was feeling like her
usual self until [**5-31**] when she sustained a mechanical fall.
She was walking downstairs backwards carrying a meal tray and
slipped and fell when she miscalculated the number of steps. She
hit her head, R shoulder, and R hip. No loss of consciousness,
no LH or dizziness, no incontinence of stool or urine associated
with the fall. She was able to walk the next few days, but had
some pain in shoulder and hip that progressively worsened to
generalized pain all over. Starting on [**6-3**] she began to develop
progressive general fatigue and malaise. This progressed to the
point that yesterday pt was too tired to move out of bed. She
has also had decreased PO intake over this same time period.
This morning, after eating a bowl of cereal she developed nausea
and vomitted x1. She also notes some SOB and mild non-productive
cough that started today. Her husband and son were worried about
her and so brought her to the ED for further evaluation.
In the ED, initial vitals were: T 101.7, P 92, BP 134/60, RR 20,
O2 sat 88% on RA-->93% on 5L. Her blood pressure dropped as low
as the 80s systolic and she received a total of 2L NS with good
response. Labs were notable for WBC of 11.4 with 96%
neutrophils, lactate of 2.7 (improved to 1.2 after IVF), BNP of
2284, Hct of 26 (baseline low-mid 30s), Na of 128, and Cr 4.3
(from baseline 1.9). CXR showed a new right pleural effusion
along with a right-sided infiltrate. Xrays of the right shoulder
and bilateral hips were negative for fracture. CT head was
negative. Patient was given levofloxacin 750mg PO x 1 and
tylenol 650mg PO x 1. She is being admitted to the ICU for close
monitoring.
On arrival to the [**Hospital Unit Name 153**], she notes feeling a bit shaky and has a
mild non-productive cough. She denies feeling short of breath.
Past Medical History:
Atrial fibrillation (not on anticoagulation)
Hypertension
Congestive Heart Failure
Renal cell carcinoma s/p nephrectomy and radiotherapy
Chronic kidney disease, baseline Cr 1.6-1.7
Rectal ca s/p low ant resection and colostomy
Deaf
Partial R CN III palsy
Osteoarthritis of the hips
s/p Hysterectomy
Social History:
Lives at home with her husband and her son. [**Name (NI) 6419**] the patient and
her husband are deaf, but she is able to read lips. Her son is
able to speak sign language. At baseline, she is independent of
all ADLs and overall high functioning. She formerly worked as a
seamstress for the original Filene's store. No history of
smoking but did have extensive secondhand smoke exposure due to
her husband being a heavy smoker for many years. Very rare EtOH
intake. No history of illicit drug use.
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: T: 99.3, BP: 114/47, P: 81, R: 15, O2: 95% on 4L
General: Alert, oriented, elderly deaf female in no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds at the right base, no wheezes,
rales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
+colostomy bag, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 1+ LE edema, large echymoses at R
shoulder and hip, FROM in both joints, 2+ pulses, no clubbing,
cyanosis
Discharge:
Afebrile 97.5 155/78 76 20 93% RA
GEN: pleasant, non-toxic, well appearing.
HEENT: eomi, mmm
CV: RRR. no mrg.
RESP: Some mild rales R Lung fields, good AE and insp effort.
Abd: soft, nt/nd. Ostomy in place, pink, brown stool in bag.
Ext: 1+ edema LE B.
Neuro: deaf. otherwise CN2-12 grossly intact. Moves all 4. No
focal defecits.
Pertinent Results:
[**2154-6-8**] WBC-11.4* RBC-2.97* Hgb-9.1* Hct-26.9* MCV-91 MCH-30.6
MCHC-33.8 RDW-13.8 Plt Ct-326
Neuts-96.2* Lymphs-1.9* Monos-1.5* Eos-0.4 Baso-0.1
Iron-12* calTIBC-183 Hapto-565* Ferritn-605* TRF-141* Ret
Man-1.2LD(LDH)-287* TotBili-0.8 CK(CPK)-348*
[**2154-6-8**] 10:20AM BLOOD Glucose-139* UreaN-56* Creat-4.3* Na-128*
K-3.9 Cl-93* HCO3-22 AnGap-17
[**2154-6-8**] 10:20AM BLOOD proBNP-2284*
[**2154-6-8**] 09:46AM Lactate-2.7*
[**2154-6-8**] 01:52PM Lactate-1.2
[**2154-6-8**] 12:18PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2154-6-13**] 06:30AM BLOOD WBC-5.6 RBC-3.17* Hgb-9.5* Hct-28.4*
MCV-90 MCH-30.0 MCHC-33.5 RDW-15.1 Plt Ct-299
[**2154-6-11**] 03:52PM BLOOD Glucose-130* UreaN-80* Creat-5.3* Na-132*
K-3.8 Cl-99 HCO3-18* AnGap-19
[**2154-6-12**] 05:39AM BLOOD Glucose-97 UreaN-81* Creat-5.2* Na-132*
K-3.3 Cl-96 HCO3-23 AnGap-16
[**2154-6-13**] 06:30AM BLOOD Glucose-114* UreaN-80* Creat-4.8* Na-134
K-3.6 Cl-98 HCO3-24 AnGap-16
[**2154-6-14**] 05:40AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2154-6-11**] 04:24AM BLOOD ALT-54* AST-65* AlkPhos-132* TotBili-0.4
[**2154-6-8**] 10:20AM BLOOD cTropnT-0.07*
[**2154-6-9**] 02:00AM BLOOD CK-MB-6 cTropnT-0.06*
[**2154-6-9**] 10:03AM BLOOD CK-MB-5 cTropnT-0.06*
[**2154-6-13**] 06:30AM BLOOD Phos-3.9 Mg-1.8
[**2154-6-14**] 05:40AM BLOOD Phos-PND Mg-PND
[**2154-6-8**] 05:48PM BLOOD calTIBC-183 Hapto-565* Ferritn-605*
TRF-141*
Urine legionella antigen: Positive
Culture data
Urine culture ([**2154-6-8**]): no growth
Blood culture: pending x5
Imaging:
Renal U/S of right kidney:
1. No hydronephrosis in the right kidney.
2. Evidence of RFA treated lesion within the right kidney, as
seen on prior MRI. Several small simple renal cysts in the right
kidney, as seen on prior MRI.
Echo ([**2154-6-10**]): The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The ascending aorta is mildly dilated. The aortic arch
is mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
AP portable CXR ([**2154-6-10**]): Bilateral pleural effusion, large on
the right and moderate on the left, has increased since [**6-8**].
Lung bases are largely obscured but pneumonia could be present.
Heart is at least mildly enlarged. Left upper lobe is clear.
Right upper lobe vasculature is engorged suggesting a
substantial component of cardiac decompensation.
Chest CT ([**2154-6-10**]): IMPRESSION: Extensive right lower lobe
consolidation and opacity, strongly suggesting pneumonia, with
an accompanying moderate reactive pleural effusion. Minimal
effusion on the left, with adjacent area of atelectasis.
No evidence of hilar or mediastinal lymphadenopathy, the
other parts of the lung are unremarkable, taking the multiple
motion artifacts into
consideration. No evidence of lymphadenopathy, coronary
calcifications, clips in the left upper abdomen.
U/S of lung to assess for diagnostic purposes: Small area of
fluid in left pleural cavity, not enough to tap.
B LENI:
1. No evidence of deep venous thrombosis in either lower
extremity.
2) Cystic lesion in the right groin, likely representing a
lymphocele, which appears stable from the prior CT scan
performed in [**2147**].
Cardiac Echo:
Conclusions
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is a trivial/physiologic pericardial
effusion.
Brief Hospital Course:
85 year-old female with CHF, afib, HTN, CKD, recent fall,
presenteed with malaise, cough, hypoxia, new bilateral
effusions, anemia, and acute renal failure. Pt was subsequently
diagnosed with Legionella pneumonia and acute renal failure due
to ATN.
# RLL pneumonia with bilateral pleural effusions: Most likely
etiology of pt??????s leukocytosis and fever. Urine legionella
antigen was positive, so likely cause of pneumonia. CXR showed
pleural effusion on the R with a consolidation in the R lower
lobe. CT scan showed bilateral pleural effusions and R-sided
consolidation in lower lobe. Sputum Cx canceled by lab because
of contamination w/ upper resp. secretions. On Levofloxaxin 250
mg PO daily for treatment of Legionella PNA, suggest continue to
treat for a total of 14 days.
.
# Hypotension: Pt was fluid responsive, however relatively
hypotensive given she carries a history of hypertension on
multiple anti-hypertensive meds as an outpatient. Pt did not
require pressors in the ICU and was treated with fluid boluses
and 1 U PRBCs. LE dopplers ordered w/ no DVT found. On the
medical floor, her blood pressure slowly rose, and her
amlodipine was added back on the evening of [**6-13**] for SBP 196/86.
Multiple other cardiac medications remain held at the time of
discharge.
.
# Bilateral pleural effusions: New compared to CXR from one
year ago. Likely secondary to pneumonia. As of [**6-10**], pt was
planned to undergo thorocentesis to evaluate effusions but on
U/S too little fluid was seen for a succesful tap.
.
# Acute anemia: Concern for blood loss secondary to fall one
week ago, possible hematomas at shoulder and right hip. Hct
dropped from 34.6 one month ago to 28.2 today, but currently
trending up. Hemolysis labs were negative, iron studies
suggestive of anemia of chronic disease. She was transfused 2 U
in the [**Hospital Unit Name 153**] and aspirin and heparin were held. On the medical
floor H/H remained stable, and aspirin as added back at the time
of discharge.
.
# Acute on chronic renal failure: Initially thought to be
pre-renal in setting of hypovolemia and FeNa<1. Seen by renal
who concluded that pt most likely initially had pre-renal but
now has ATN, as a result of her pre-renal azotemia. Pt was
treated with IV fluid with intermittent bicarb and potassium
repletion. At time of discharge, renal function was continuing
to improve significantly, and pt was maintaining good UOP.
# Hyponatremia: Likely secondary to hypovolemia and HCTZ.
Improved with volume repletion and holding of HCTZ.
HCTZ remains held at the time of discharge.
.
# s/p Fall: History consistent with mechanical fall. No
evidence of fracture or ICH. No e/o bleed.
.
# Atrial fibrillation: patient remained in NSR throughout the
hospitalization. At the time of discharge, pt's propafenone was
held, and we suggest adding back as tolerated in the near
future.
.
# Hypertension: All home anti-hypertensives were held in the
ICU given her hypotension; amlodipine was added back as pt's BP
started to rise. HCTZ remains held d/t ARF and hyponatremia.
Lisinopril remains held d/t ARF.
# [**Last Name (LF) 9215**], [**First Name3 (LF) **] >55%: no evidence of decompensation during this
admission. Please add back cardiac medications, particularly
Rythmol 150 mg po TID, as tolerated.
DISPO: pt discharged to LTAC for ongoing medical care and rehab.
Medications on Admission:
ASA 81mg PO daily
Digoxin 125mcg PO 3x/week
HCTZ 25mg PO daily
Norvasc 5mg PO daily
Rythmol 150mg PO TID
Lisinopril 20mg PO daily
Zocor 20mg PO qHS
MVI 1 tab PO daily
SLN prn
Caltrate 600mg PLUS Vit D 200mg PO BID
Cyanocobalamin 1000mcg PO daily
Dairy digestive 9000 units 1-2 tabs PO prior to eating lactose
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days: Please monitor renal function and increase
dose to 500 mg if her renal function significantly improves.
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as dir as needed for chest pain: Take 1 tab q5 min
prn chest pains, up to 3 tabs. Seek medical attention.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Dairy Digestive 9,000 unit Tablet Sig: 1-2 Tablets PO prn as
needed for prior to consuming dairy (lactose).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection [**Hospital1 **] (2 times a day): discontinue when pt ambulating
frequently.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
# Legionella pneumonia
# Acute on chronic renal failure, acute tubular necrosis
# Hyponatremia
# Hypertension, benign
# Acute anemia, without bleeding
# Hx [**Last Name (LF) 9215**], [**First Name3 (LF) **] >55%
# Hx Paroxysmal afib
# Deafness, communicates via sign language
Discharge Condition:
stable
Discharge Instructions:
You were admitted with legionella pneumonia, and were also found
to have renal failure. You were treated with antibiotics for
your pneumonia, and provided IV fluids while your kidney is
healing. Please take your medications as prescribed. Please
seek medical attention if you develop fevers, chills, shortness
of breath, decreased urine output, or any other concerns.
Followup Instructions:
Please follow up with your primary care provider in late
[**Name9 (PRE) 205**]/early [**Month (only) 216**].
Please follow up with Dr. [**Last Name (STitle) **], Nephrology in mid-late [**Month (only) 216**].
Please call [**Telephone/Fax (1) 60**] if you have not been contact[**Name (NI) **] with an
appointment.
Please follow renal function and electrolytes closely after
discharge while at LTAC and thereafter.
Several of the patient's cardiac medications have been held in
the setting of acute illness. Please add medications back as
tolerated. Pt's cardiac medications currently not being
provided:
Digoxin 125 mcg po 3x/wk (hold until renal function improved)
Rythmol 150 mg po TID (propafenone)
Lisinopril 20 mg po qday
|
[
"V10.06",
"276.1",
"585.9",
"584.5",
"428.32",
"428.0",
"389.9",
"403.90",
"482.84",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14022, 14101
|
8819, 12209
|
274, 280
|
14421, 14430
|
4203, 8796
|
14848, 15588
|
3163, 3181
|
12569, 13999
|
14122, 14400
|
12235, 12546
|
14454, 14825
|
3221, 4184
|
222, 236
|
308, 2309
|
2331, 2632
|
2648, 3147
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,126
| 174,067
|
36488
|
Discharge summary
|
report
|
Admission Date: [**2183-4-7**] Discharge Date: [**2183-4-17**]
Date of Birth: [**2119-11-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
[**2183-4-11**] MV repair ( 26mm [**Company 1543**] 3D ring)/ CABG x 2 (LIMA to
LAD, SVG to PDA)
History of Present Illness:
63 yo female was in good health until 3 weeks ago when she
thought she had the flu. Treated with abx and eventually
developed severe SOB. Admitted to [**Hospital1 **] on [**3-27**]. She had
NSTEMI with ST depression and a + troponin. Treated with heparin
and admitted to the CCU. Cardiac cath there [**3-28**] revealed severe
3VD and [**1-29**]+ MR. On [**3-31**] she had 3 DES placed in the CX. Loaded
with plavix and has had a continued daily dose. Treated with
ACE-I and beta blocker, but did not tolerate them well.
Transferred here for MVR/CABG.
Past Medical History:
coronary artery disease s/p CX stents [**3-31**]
mitral regurgitation
hypertension
GI ulceration
renal calculi
gastroesophageal reflux disease
Social History:
one ppd for 50 years, quit 3 weeks ago
lives alone
ETOH rare
school cafeteria worker
last dental exam 2 weeks ago
Family History:
non-contrib
Physical Exam:
HR 88 RR 18 99% RA sat
103/69 5'3" 53.5 kg
skin dry and intact
PERRLA, EOMI, neck supple, full ROM
CTAB
RRR
soft, NT, ND, + BS
warm, well-perfused, no edema or varicosities
neuro grossly intact
2+ bil. fem/DP/PT/radials
no carotid bruits
Pertinent Results:
Conclusions
PRE-BYPASS:
The left atrium is elongated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No spontaneous echo contrast or thrombus is seen in
the body of the right atrium or the right atrial appendage.
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
regional left ventricular systolic dysfunction with focalities
in the basal, m id and apical lateral walls. Overall left
ventricular systolic function is moderately depressed (LVEF= 40
%).
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications 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. The mitral
regurgitation vena contracta is >=0.7cm. Severe (4+) mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results on [**Known firstname **] [**Known lastname 76883**]
at 8AM before surgical incision.
Post_Bypass:
Normal RV systolic function.
Intact thoracic aorta.
Post repair, there is a mitral annular prosthesis which is
stable and functioning well. There is a mild residual mitral
regurgitation and at worst a mild to moderate degree with the
vitals at 110/70. This was conveyed to DR.[**Last Name (STitle) **].
Trivial TR. No AI.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2183-4-11**] 11:31
[**2183-4-15**] 06:10AM BLOOD WBC-11.5* RBC-3.48* Hgb-10.8* Hct-32.7*
MCV-94 MCH-31.1 MCHC-33.1 RDW-15.3 Plt Ct-155
[**2183-4-13**] 04:21AM BLOOD PT-13.7* PTT-27.2 INR(PT)-1.2*
[**2183-4-15**] 06:10AM BLOOD Glucose-75 UreaN-16 Creat-0.7 Na-140
K-4.3 Cl-106 HCO3-25 AnGap-13
[**2183-4-8**] 12:30AM BLOOD ALT-15 AST-15 LD(LDH)-250 AlkPhos-101
TotBili-0.6
Brief Hospital Course:
Ms. [**Known lastname 76883**] was admitted on [**4-7**] and completed a pre-operative
workup. A pre-operative echo and CT of chest to evaluate aorta
were completed. Dental clearance was obtained. A carotid
ultrasoun showed 40-59% [**Doctor First Name 3098**] and 60-69% [**Country **] stenoses. She
underwent surgery with Dr. [**Last Name (STitle) **] on [**4-11**]. She tolerated the
surgery well and was transferred to the CVICU in stable
condition on titrated phenylephrine, epinephrine, and propofol
drips. Ms. [**Known lastname 76883**] was extubated later that day. Her chest
tubes were removed. Her beta-blockade was titrated as tolerated.
She was transferred to the floor on POD #3 to begin increasing
her activity level. Her pacing wires were removed and her
diuresis was continued. By post operative day six she was ready
for discharge to home.
Medications on Admission:
plavix 75 mg daily ( received ?600 mg on [**3-31**])
lisinopril 10 mg daily
zantac 150 mg [**Hospital1 **]
proventil IH ( recently)
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for
7 days.
Disp:*14 Tablet(s)* Refills:*0*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease
mitral regurgitation s/p MVrepair/CABG x2
NSTEMI
hypertension
GI ulceration
renal calculi
gastroesophageal reflux disease
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
no driving for one month and off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
Followup Instructions:
see Dr. [**First Name (STitle) **] in [**11-29**] weeks ([**Telephone/Fax (1) 82655**]
see Dr. [**Last Name (STitle) 32255**] in [**12-31**] weeks [**Telephone/Fax (1) 6256**]
see Dr. [**Last Name (STitle) **] in 4 weeks at [**Hospital1 **] [**Telephone/Fax (1) 6256**]
please call for appts.
Completed by:[**2183-4-17**]
|
[
"791.9",
"433.30",
"530.81",
"458.29",
"V45.82",
"492.8",
"414.01",
"599.0",
"401.9",
"424.2",
"433.10",
"V13.01",
"424.0",
"531.90",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"35.12",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
5811, 5870
|
3831, 4691
|
282, 381
|
6060, 6067
|
1564, 3808
|
6404, 6728
|
1275, 1288
|
4874, 5788
|
5891, 6039
|
4717, 4851
|
6091, 6381
|
1303, 1545
|
239, 244
|
409, 961
|
983, 1128
|
1144, 1259
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,274
| 130,914
|
37481
|
Discharge summary
|
report
|
Admission Date: [**2191-1-30**] Discharge Date: [**2191-1-31**]
Date of Birth: [**2155-8-10**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
LUQ pain
Major Surgical or Invasive Procedure:
No major surgical/invasive procedures while at [**Hospital3 **].
History of Present Illness:
35F with history of IVDU, initially admitted to OSH on [**2191-1-21**],
now transferred to [**Hospital1 18**] MICU for further management of her
septic shock, endocarditis, and GI bleeding.
.
She initially fell on [**1-18**] or [**1-19**]. With this fall started to
develop LUQ and mid back pain. She apparently presented to OSH
and had CTA for rule out PE. This was negative, but she was
called back to the hospital when CT read to have possible
splenic hematoma. She has since had a very complicated OSH
course with diagnosis of 3 valve endocarditis, septic shock, and
more recent GI bleeding.
.
OSH course:
[**Date range (1) 31762**] overnight - Admitted. Received Levofloxacin, Dilaudid.
Neurosurgery was consulted for back pain; Surgical consult was
obtained following abdominal/pelvic CT.
[**1-23**] - Obtain MRI of the lumbar spine.
[**1-24**] - Levofloxacin was changed to Zosyn.
[**Date range (1) 53013**] - Decompensated and transferred to ICU. Neo,
vasopressin, norepi started; Patient received 3 units PRBCs, 2
FFP, hydrocortisone. Repeat abdominal/pelvic CT obtained.
Patient was started on Vancomycin, Clindamycin and Zosyn. First
set of blood cultures were drawn on [**1-25**]. TTE showed
endocarditis. WBCs to 40K. L fem line placed. R fem a-line
placed. Venous pH 6.87.
[**1-26**] - PICC line. 2 FFP, 1 6pk platelets, 4FFP and then 12pk
platelets. Patient went to OR for ex-lap and bowel resection.
Her lactate 14; LFTs peaked at 14K LDH, 9K AST, 4K ALT.
[**1-27**] - 1 unit pRBCs; Hematology and Vascular surgery were
consulted.
[**1-28**] - Patient underwent bronchoscopy and started on IV
acyclovir. HIT negative.
[**1-29**] - CT head. 1x6pk platelets, 2 units PRBCs.
[**1-30**] - Overnight, patient was transfused [**1-22**] units FFP, vitamin
K, protonix and then received 4 more FFP and total 8 units
pRBCs, 12pk platelets, and 1 unit cryop. Patient subsequently
transferred to [**Hospital1 18**].
Past Medical History:
- Intravenous drug use - heroin, ?others
- Lumbar disc disease with protrusion
- Congenital single kidney
Social History:
- Tobacco: ~[**1-22**] PPD per patient at presentation.
- Alcohol: Denied at presentation
- Illicits: IVDU per family though patient initially denied
this.
Family History:
- IVDU in multiple family members
Physical Exam:
Patient expired;
Pertinent Results:
Labs:
Last known OSH labs:
WBC 20.6 (last man diff 75N, 13B, 9L, 2M, 1 meta)
Hct 18.9 (1600 today); 25 (730 today)
PRBCs at 2200 yest, 200, 400x2, 1000, 1200, 1740x2 (times).
Plt 101 (1600 today); 13 (730 today)
INR 2 (1600) - s/p 5 FFP
vanco 15 (1600 today)
Na 147, K 3, Cl 106, bicarb 28, creat 1.8, BUN 78, iCa 0.92,
Phos 5.3
Tbili 14, AST 122, ALT 170, AP 133, albumin 2.1, LD 772, CK 182
MB 4
lactate 4.7
troponin I 5.6 (today)
ABG 7.49/36/137 on AC 0.40, 650 x 10, PEEP 5
HIT Ab [**1-28**]: negative (though borderline)
.
Micro:
MRSA nares [**1-25**]: negative.
sputum cx [**1-28**]: no growth.
blood cx [**1-25**]: negative
blood cx [**1-26**], [**1-28**], [**1-28**]: NGTD
BAL [**1-28**]: AFB smear neg. culture neg.
blister [**1-28**]: negative.
urine [**1-25**]: negative.
.
Images:
MRI L spine without contrast: limited by motion artifact.
Possible R lateral disc herniation L4-5 with disc bulging and
protrusion.
.
TTE [**2191-1-25**]: slight LV dilation, normal LV function EF 50-55%.
RV systolic function mod-severely reduced, RVSP 43. Severe AI.
Vegetation on aortic valve, prolapses into LVOT. MV mod
thickened. can't exclude vegetation. ?perforated mitral
leaflet. Severe MR. Echodensity in the RV appears attached to
RV chordae. Mild-mod TR.
.
TEE [**2191-1-25**]: aortic valve cusps have been essentially destroyed.
Large vegetation, prolapses into aortic root and into LVOT,
severe AI. Apparent perforation of anterior mitral leaflet iwth
?vegetation and severe MR. TV appears intact. ?small vegetation
vs. redudant chordae. moderate TR. No abscess seen.
.
CT abd/pelvis [**2191-1-22**]: large multi locular lesion in spleen
10x0.6x0.8. 14 mm round low denisty L adrenal mass. Trace free
fluid in pelvis. Small to mod bilateral effusions.
.
CT abd/pelvis [**2191-1-25**]: new decreased enhancement throughout liver
- ?acute hepatic failure. edema surrounding proximal pancreas.
Increased free fluid in Abd/pelvis, appears simple. splenic
lesion unchanged (dictated at 10 x 9.2). increased wall
thickening in small bowel and colon. appendix not seen.
tubular fluid filled structure in RLQ measuring 3.3 cm - ?R
hydrosalpinx.
.
CT head [**2191-1-29**]: presence of air fluid levels in paranasal
sinuses. otherwise no intracranial process.
.
CXR [**2191-1-30**]: L sided PICC line, ET and OGT, midl central
congestion, L hemidiaphragm obscured from atelectasis and/or
infiltrate plus small effusion. Mild atelectasis and/or
infiltrate at R base medially.
.
CXR (here): L sided PICC, ET and OGT all in good position.
Cardiomegaly. R sided atelectasis. Bilateral R>L effusions.
.
Bronch report [**2190-1-28**]: moderate amount of blood in R and L
mainstem bronchi, seemed to be coming from RLL and LLL. mucosa
filled up with whitish thick plaques particularly at R mainstem
bronchus (concern for herpetic infection).
.
EKG: sinus tach at 114, NANI, low voltage, poor RWP, nonspecific
T wave flattening diffusely.
.
Brief Hospital Course:
35F with IVDU, congenital single kidney, presenting to OSH s/p
fall with subsequent development of septic shock, endocarditis,
multiple sites of bleeding, with transfer to [**Hospital1 18**] MICU for
further management.
.
Patient PEA arrested on [**2191-1-31**] in the afternoon; family was
present at the code. Code was called after 30 minutes of ACLS.
.
# Septic shock. Source thought to be endocarditis, question of
other ongoing infection. Likely with multiple sites of embolic
burden - splenic abscess, ?vertebral osteo per our radiologists,
? intraabdominal abscess collection (though per descriptions
more c/w endometriosis). Replaced central access from OSH.
Replaced arterial line and d/c'd femoral line. Continued on
pressors. Continued broad spectrum antibiotics with coverage as
detailed below (vancomycin, cefepime, flagyl, acyclovir).
.
# BRBPR/anemia. Required massive transfusion of PRBCs in
addition to cryo, platelets, and FFP. Multiple services
involved and ultimately planned for IR intervention, but coded
prior to procedure.
.
# Respiratory failure. Intubated for unclear reasons at OSH,
but remained intubated for multiple reasons (mental status in
particular). With significant AI and MR, at risk of acute CHF
once positive pressure removed.
.
# Endocarditis. No organism ever isolated as above. Received
levofloxacin and zosyn doses prior to blood cultures. 4 sets
done at OSH all NGTD (on multiple days of antibiotics). Known
high vegetation burden with significant valvular compromise. No
known abscesses.
.
# Altered mental status. Unclear how much she was given for
sedation at OSH, but did not wake up here. Nonresponsive to
painful stimuli of extremities, but does seem to react to
suctioning.
.
# ARF. No known baseline insufficiency. Likely ATN in setting
of septic shock.
.
# Coagulopathy. Likely DIC plus some bone marrow suppression
from severe sepsis, plus synthetic dysfunction in setting of
shock liver.
.
# Hyperbilirubinemia/transaminitis. History of shock liver from
profound hypotension at OSH.
.
# Splenic abscess. Collection stable on imaging at OSH.
.
# ? Vertebral osteomyelitis. OSH read of MRI benign (though
limited), some question of osteo by our radiologists on very
prelim read.
.
# NSTEMI. Likely demand in setting of all the above.
Medications on Admission:
Medications on transfer:
- Acyclovir 475 mg IV Q12 hours
- Fluconazole 200 mg IV daily
- Imipenem 500 mg IV Q12H
- Vancomycin 1000 mg IV daily
- Furosemide 80 mg IV BID
- Hydrocortisone 25 mg IV Q8H
- Fentanyl gtt
- Insulin lispro per sliding scale
- Pantoprazole 40 mg IV daily
- Combivent 8 puffs Q4H
.
Medications at home:
- Ibuprofen 800 mg Q5 hours prn
- Diazepam 5 mg 1-2 tabs TID prn spasm
- Naprosyn 500 mg Q12H prn
- Percocet 1-2 tabs Q4-6H prn
Discharge Medications:
Patient expired;
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired;
Discharge Condition:
Expired;
Discharge Instructions:
Expired;
Followup Instructions:
Expired;
Completed by:[**2191-2-15**]
|
[
"449",
"421.9",
"557.9",
"584.5",
"289.59",
"305.50",
"285.1",
"730.28",
"995.92",
"286.6",
"570",
"410.71",
"038.9",
"444.22",
"276.0",
"753.0",
"518.81",
"287.5",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"96.71",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
8565, 8574
|
5713, 8020
|
305, 371
|
8626, 8636
|
2735, 5690
|
8693, 8732
|
2648, 2683
|
8524, 8542
|
8595, 8605
|
8046, 8046
|
8660, 8670
|
8372, 8501
|
2698, 2716
|
257, 267
|
399, 2330
|
8071, 8351
|
2352, 2459
|
2475, 2632
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,815
| 133,558
|
54008
|
Discharge summary
|
report
|
Admission Date: [**2173-10-18**] Discharge Date: [**2173-10-22**]
Date of Birth: [**2101-10-24**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Pepcid / Penicillins / Aspirin
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
GIB and Hypotension
Major Surgical or Invasive Procedure:
Attempted IR embolization
History of Present Illness:
71 Year old female with history of recent colonoscopy with polyp
removal (5mm transverse colon polyp on [**10-8**]), GERD, and
diverticulosis who presented from the ED via EMS with abd pain
and hypotension.
.
Patient was at physical therapy this AM, when she finished her
workout she complained [**5-28**] abd pain radiating to her throat.
Has had loose stools for the last few days.
.
In the ED, initial VS were: HR 88 bp 147/84 RR 93 100% room air.
Patient diaphoretic and panicking. Also complaining of back pain
and abdominal pain. No chest pain or SOB. Her blood pressure
dropped to systolic blood pressure in 80s, but she responded to
IVF bolus. In the ED she was given 2L NS, 80 MG protonix, 8 /hr
ggt, and lorazepam 2mg for anxiety. Had episodes of BPBPR in the
ED. Had a CTA Chest ruling out aortic dissection, aneurysm,
intramural hematoma and pulmonary embolus. Lungs were clear.
.
CT Abd/Pelvis showed findings concerning for active GI Bleeding
from sigmoid colon. Diverticulosis, no diverticulitis. No free
fluid or free air. Urinary bladder appears thickened and
collapsed. ED labs were notable for lactate of 3.9, LDH of 415,
Hct of 23, WBCs of 14.4 (82% neutros), INR of 0.9 Na of 147 and
Cr of 1.2.
.
Surgery and GI were consulted who advised IR for embolization.
GI would consider colonoscopy if GI bleed recurs after
embolization. On transfer vitals were 76, 127/66, 14, 100% on
RA.
.
On arrival to the MICU, patient is feeling slightly better. Her
abdominal pain is slightly improved. She has not had any further
bowel movements.
.
Review of systems:
Denies any: fevers, chills, sore throat, dysphagia, chest pain,
cough, wheeze, hematuria, dysuria, rashes, dry skin, polyuria or
polydypsia. Remainder of review of systems otherwise negative
except for what is mentioned in the HPI
Past Medical History:
GERD
Diverticulosis
Gastroapresis
Bipolar d/o
Arthritis
Osteopenia
Social History:
Denies any smoking, etoh or IVDU, married lives
with husband -[**Telephone/Fax (1) 110721**] - husband's cell Dr. [**Known lastname 46087**]
Family History:
maternal uncle with gastric cancer
Physical Exam:
Vitals: T 96.1 BP: 142/66 P: 92 R: 16 O2: 100% RA
General: Elderly woman, alert, oriented, no acute distress
HEENT: Sclera anicteric, slightly dry mucus membranes,
oropharynx clear, EOMI
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, mild epigastric tenderness and lower abdominal
tenderness to palpation, bowel sounds present, no rebound, no
guarding
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: CNII-XII grossly intact, 5/5 strength upper/lower
extremities
Pertinent Results:
CBC:
[**2173-10-18**] 01:00PM BLOOD WBC-14.4*# RBC-4.14* Hgb-12.5 Hct-37.8
MCV-91 MCH-30.2 MCHC-33.0 RDW-12.3 Plt Ct-302
[**2173-10-18**] 08:37PM BLOOD WBC-9.2 RBC-4.11* Hgb-12.3 Hct-37.1
MCV-90 MCH-29.8 MCHC-33.0 RDW-12.4 Plt Ct-183
HCT:
[**2173-10-18**] 01:00PM Hct-37.8
[**2173-10-18**] 08:37PM Hct-37.1
[**2173-10-19**] 02:42AM Hct-33.5*
[**2173-10-19**] 07:20AM Hct-33.9*
[**2173-10-19**] 02:44PM Hct-32.5*
CHEM-7:
[**2173-10-18**] 12:05PM BLOOD Glucose-271* UreaN-16 Creat-1.2* Na-143
K-5.2* Cl-105 HCO3-23 AnGap-20
[**2173-10-19**] 02:42AM BLOOD Glucose-150* UreaN-13 Creat-0.8 Na-148*
K-3.4 Cl-109* HCO3-27 AnGap-15
LFTs:
[**2173-10-18**] 12:05PM ALT(SGPT)-22 AST(SGOT)-47* LD(LDH)-415* ALK
PHOS-80 TOT BILI-0.3
LACTATE:
[**2173-10-18**] 12:23PM Lactate-4.3*
[**2173-10-18**] 01:35PM Lactate-3.9*
[**2173-10-18**] 09:19PM Lactate-1.7
IMAGING:
CTA CHEST/ABDOMEN/PELVIS [**2173-10-18**]:
CTA: Non-contrast imaging through the chest demonstrates no
evidence of
aortic intramural hematoma. No significant atherosclerotic
calcification
along the aorta. Mild left coronary circulation atherosclerotic
calcification is noted. Following the administration of IV
contrast, the thoracic aorta enhances normally without
dissection or aneurysm. The aortic arch vessels have a normal
configuration without evidence of dissection, aneurysm, or
significant atherosclerotic disease. The descending aorta is
mildly tortuous. There is marked tortuosity of the abdominal
aorta, though of normal caliber and with widely patent major
branches. The pulmonary arterial tree is widely patent without
filling defects.
CHEST: The imaged portion of the thyroid gland is unremarkable.
There is no lymphadenopathy. The heart size is normal. There is
mild pericardial fluid versus thickening. The airway is patent.
No pleural effusion. No
pneumothorax. Within the right lower lobe on series 5, image 82,
there is a 3-mm nodule which was seen on [**2168**] CT. There is no
worrisome nodule, mass, or consolidation.
ABDOMEN: There is an elongated right hepatic lobe which could be
on the basis of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13070**] lobe. No focal liver lesions. The
spleen is normal. The adrenal glands appear grossly
unremarkable. The pancreas appears unremarkable. The kidneys
enhance symmetrically. There is left renal hypodensity measuring
approximately 12 mm, stable, likely a simple cyst, better
assessed on priors. There is no retroperitoneal
lymphadenopathy. No free air or free fluid is seen.
The stomach and duodenum appear normal.
PELVIS: Loops of small bowel demonstrate no signs of ileus or
bstruction.
The cecum is moderately distended with fecaloid material. The
appendix is not clearly visualized. Extensive colonic
diverticulosis is noted without
definite signs of diverticulitis. No pneumatosis or definite
sign of bowel
wall thickening. On series 5, image 216 and 217, there is
hyperdense material within the lumen of the sigmoid colon which
is concerning for active arterial extravasation in the setting
of active GI bleeding. There is no pelvic or inguinal
lymphadenopathy.
BONES: S-shaped scoliosis is noted with a levoscoliosis of the
thoracic spine and a compensatory dextroscoliosis of the lumbar
spine. Severe degenerative disease in the lumbar spine at L2-3
level with significant loss of disc space, vacuum disc
phenomenon, endplate sclerosis, and osteophyte formation.
IMPRESSION:
1. Findings concerning for active GI bleeding in the sigmoid
colon.
2. No evidence of aortic dissection or aneurysm.
3. No PE.
4. Diverticulosis without evidence of diverticulitis.
5. Distended cecum containing a large volume of fecaloid
material.
6. Elongated liver, possibly due to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13070**] lobe, though
correlation with LFTs is advised.
Brief Hospital Course:
71F with history of GERD, know diverticula, gastroparesis,
presenting from rehab with abdominal pain, hypotension, and
several episodes of BRBPR.
.
#Lower GI bleed: Patient had several episodes of BRBPR in the
ED. Combined with the h/o diverticulosis, recent polypectomy and
CT findings (sigmoid blush) suggested lower GI bleed. She
underwent IR embolization, however no active extravasation was
noted during procedure and nothing was embolized. Pt received
100 - 200 cc of contrast during procedure, and was given
post-contrast hydration with 150 mEq bicarb, D5. Lactate trended
down from 3.9 to 1.7 and the HCT remained stable. Very small
amount of melena x2 was noted in the night after the procedure
but the pt remained hemodynamically stable. On [**10-19**],HCT dropped
from 37.1 to 33.5. Repeat Hct remained stable at 32.5, and she
was called out to the floor.
.
After the patient was called out, she continued to remain
hemodynamically stable. However she had a repeat bloody bowel
movement. Surgery initially recommended colectomy for
diverticular bleeding, however the patient opted for a less
invasive approach and she underwent a colonoscopy for further
diagnosis. This demonstrated evidence of ischemic colitis. The
patient's hematocrits remained stable and she was discharged
without surgical intervension.
.
#Hypotension: Patients sbps were initially in the 80s-90s, but
responded well to 1L fluid bolus.
.
# Urinary tract infection - the patient was found to have a
urinary tract infection during her admission. She was placed on
ciprofloxacin for this problem.
.
#Leukocytosis: On admission WBC count was elevated (14.4). This
was thought likely reactive given no s/sx infection (no fevers,
abdominal pain or any localizing sign of infection, nl UA and CT
chest). By HD#2 leukocytosis had resolved.
# Acute Renal Failure: Creatinine 1.2, on admission, returned to
baseline by HD#2 with IV fluids, suggesting pre-renal etiology.
.
#Bipolar disorder: Patient with history of bipolar d/o, required
lorazepam in the ED for agitation/distress. She was continued on
her home dose of lithium.
.
#GERD: Stable. Continued home pantoprazole and ranitidine.
.
# Hyperlipidemia: Stable. Continued home simvastatin 20 mg qHS
Medications on Admission:
-Lithium 600 mg daily
-Pantoprazole 120mg daily
-Zyprexa prn
-Domperidone 10 mg [**Hospital1 **]
-Bethanecol 25mg tid
-Alprazolam 0.25mg qhs prn
-Simvastatin 20mg qhs
-Valacyclovir 500mg prn
-Colace 100mg daily
-Ranitidine 300mg [**Hospital1 **]
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
2. lithium carbonate 300 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
3. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*14 Tablet(s)* Refills:*0*
6. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
7. bethanechol chloride 25 mg Tablet Sig: One (1) Tablet PO
three times a day.
8. domperidone (bulk) Powder Sig: Ten (10) mg Miscellaneous
twice a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic colitis
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 46087**],
You were admitted to the hospital because you had bleeding from
your colon. You were given a blood transfusion, and underwent a
colonoscopy. This showed that you had a condition called
ischemic colitis, which happens when your colon does not get
enough blood. This resolved and your blood counts were stable.
You were also found to have a urinary tract infection. You were
given a prescription for ciprofloxacin to treat this.
The following changes have been made to your medications:
START ciprofloxacin and take for 7 days.
You should continue to take all your other medications as
before.
Followup Instructions:
You should make a followup appointment with your primary care
doctor within the next week.
You have the following other appointments:
Department: DERMATOLOGY AND LASER
When: THURSDAY [**2174-10-13**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16424**], MD [**Telephone/Fax (1) 3965**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2173-10-26**]
|
[
"530.81",
"599.0",
"272.4",
"557.0",
"733.90",
"276.0",
"285.1",
"584.9",
"296.80",
"562.10",
"536.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.25",
"88.47"
] |
icd9pcs
|
[
[
[]
]
] |
10373, 10379
|
7022, 9260
|
323, 350
|
10464, 10464
|
3160, 6999
|
11278, 11909
|
2449, 2486
|
9556, 10350
|
10400, 10443
|
9286, 9533
|
10615, 11255
|
2501, 3141
|
1950, 2183
|
263, 285
|
378, 1931
|
10479, 10591
|
2205, 2274
|
2290, 2433
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,676
| 102,761
|
4245
|
Discharge summary
|
report
|
Admission Date: [**2200-5-13**] Discharge Date: [**2200-5-29**]
Date of Birth: [**2121-7-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lansoprazole
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt is a 78 yo male with p-ANCA vasculitis, history of
interstitial lung disease, recent d/c from [**Hospital1 **] at the end of
[**Month (only) 547**] who presents with frank hemoptysis, transfer from an OSH.
Pt was admitted to [**Hospital1 **] from [**Date range (3) 18455**] when he presented
with chills, wt loss, muscle cramps, night sweats. He was found
to be in ARF with creatinine of 2.7, CRP 113, ESR >100, mildly
elevated transaminases in the lower 100s, CK 785. He was found
to have a positive p anca (mpo specificity, negative pr3). Renal
biopsy had "evidence of fibrinoid necrosis of the small/medium
vessels. This was consistent with a pauci-immune vasculitis of
the medium vessels. "(per d/c summary. No report in computer).
Pt was started on prednisone (60mg qday) and received one dose
of cytoxan. This admission was also complicated by anemia and
hematuria.
Patient was seen in both rhematology and renal clinic yesterday
and looked and felt well per report. Today, he presented to
[**Hospital1 **] Hospiatl by EMS from home when he had a sudden
onset of difficulty breathing and frothy hemoptysis (per NW
note). He was only able to answer in one word answers,
tachycardic in the 140s, and hypertensive to 190/110. SaO2 was
50s per report (ambulance tx) and pt was having frank hemoptysis
or BRB (150-200 cc) and pt was emergently intubated. He was
given 5 mg versed, 20 etomidate, 120 mg succinylcholine prior to
intubation. ABG at NWH was 7.34/37/180 on an FiO2 of 100%. Labs
were notable for potassium 5.5, BUN/cr of 86/3.8, lactate of
3.6, wbc of 28.2. He was also give protonix 40 mg IV and 1 gram
of IV solumedrol. He received 3.375 mg IV zosyn, 1 gram of IV
vancomycin. Patient was then transferred to [**Hospital1 18**].
In the ED at [**Hospital1 **], VS on arrival were: T: 99.0 HR: 80, BP:
146/83; RR 18; O2: 94-97%RA.
Past Medical History:
1. Interstitial lung disease- diagnosed four years ago with
restrictive pattern on PFTs.
2. Bladder cancer-transitional cell, low grade
3. HTN
4. GERD
5. Hyperlipidemia
6. 4 mm subpleural chest nodule
7. p-anca vaculitis as above.
Social History:
Per last d/c summary (cannot obtain info from pt now as he is
intubated). No smoking. 6 drinks/week. No drugs. Retired stock
broker.
Family History:
Sister with crohns
Physical Exam:
VS: T: 97.5; HR: 72; BP: 125/73; RR: 17; O2: 98 on AC
500/16/80/13
Gen: Intubated, sedated though can follow commands. Does not
open eyes.
HEENT: Pupils reactive 3-->2. ETT in place.
Neck: No LAD
CV: RRR S1S2. No M/R/G
Lungs: posteriorly: bronchial breath sounds throughout though
good aeration. There are dry crackles scattered bilaterally.
Abd: Soft, nondistended. No grimaces to palpation
Back: No lesions.
Ext: trace edema pitting b/l. DP 1+ b/l.
Neuro: intubated, sedated though arousable. Can squeeze hands,
wiggle toes. Dorsiflexion strength is intact. biceps, brachio,
patellar [**1-6**] reflexes.
Pertinent Results:
EKG: Sinus rhythm at 85. Normal axis. Normal intervas. No acute
ST=t wave changes. Upsloping of St in V2, v3, nonspecific.
.
Radiology:
CXR AP [**2200-5-13**]-Marked progression to diffuse parenchymal
opacities. Differential includes severe infectious etiology
including PCP in immunocompromised patient, pulmonary hemorrhage
with asymmetric diffuse alveolar edema felt less likely. Mild
over distention of endotracheal tube balloon cuff.
Labs on admission:
[**2200-5-13**] 08:19PM BLOOD freeCa-1.04*
[**2200-5-13**] 03:13PM BLOOD Lactate-2.5*
[**2200-5-14**] 12:31AM BLOOD Type-ART Temp-36.2 Rates-/4 Tidal V-500
PEEP-13 FiO2-50 pO2-129* pCO2-36 pH-7.46* calTCO2-26 Base XS-2
Intubat-INTUBATED Vent-CONTROLLED
[**2200-5-12**] 02:45PM BLOOD CRP-29.1*
[**2200-5-12**] 02:45PM BLOOD WBC-16.5* RBC-3.97* Hgb-11.7* Hct-37.3*#
MCV-94 MCH-29.4 MCHC-31.3 RDW-17.8* Plt Ct-204
[**2200-5-12**] 02:45PM BLOOD Neuts-95.4* Bands-0 Lymphs-2.1* Monos-2.1
Eos-0.4 Baso-0
Echo
The left atrium is mildly dilated. The estimated right atrial
pressure is [**5-15**] mmHg. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 50-55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are mildly thickened. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a fat
pad.
CXR [**2200-5-13**] There has been interval progression of diffuse
parenchymal opacities involving majority of the lung fields
bilaterally with scattered air bronchograms and without evidence
of overt cardiac enlargement or pleural effusions. Endotracheal
tube is approximately 6 cm from the carina and there is mild
over distention of the balloon cuff. Orogastric true terminates
within the stomach fundus. There is no evidence of a
pneumothorax and the hemidiaphragms are well visualized.
CXR [**2200-5-28**]
Endotracheal tube terminates approximately 3.9 cm above the
carina. A right subclavian line terminates at the level of the
mid superior vena cava. A Dobbhoff tube courses below the
diaphragm and out of view of the film.
Right lung opacity may demonstrate more confluence today with
persistent left retrocardiac and perihilar opacity with air
bronchograms. Low lung volumes are noted bilaterally and there
is no evidence of pneumothorax. Left costophrenic angle is cut
off on this film; however, a right-sided effusion likely
persists. Cardiomediastinal silhouette is unchanged. Compared
with the prior there is massive increase in the amount of air
within the stomach.
Brief Hospital Course:
Pt is a 78 yo male with a history of interstitial lung disease,
newly diagnosed P-ANCA vasculitis presented with respiratory
failure from hemoptysis. He received plasmapheresis, pulse dose
steroids, and cytoxan. Now s/p extubation, episode of AFlutter
s/p cardioversion.
1. Respiratory failure- Patient intubated with likely pulmonary
hemorrhage secondary to vasculitis (capillary alveoli leak) on
admission. He was bronched on HD 3 which did not show active
bleeding. He was treated broadly for possible infection with
vancomycin, levaquin, and flagyl (14 day course) as well as the
fact that blood is a nidus of infection. He had pressure support
trial on HD2 and was extubated on HD3, failing extubation and
had to be reintubated 8 hours later. His ABG showed good
ventilation and it was purely hypoxic failure and tiring out.
Based on BNP >assay, CXR, and physical exam, it was thought that
fluid overload played a large part in the failed extubation. He
was diuresed aggressively. A repeat echo did not show any wall
motion abnormalities and enzymes checked showed an elevated
troponin but not thought to be ischemia. Rebronch on HD 7 showed
no active hemorrhage and patient was successfully extubated on
HD 8. He continued to need aggressive suctioning (including
nasally) as he was having large mucus plugs. On [**5-27**] he became
neutorpenic with increased secretions. He was started on
vancomycin and aztreonam. On [**5-28**] during a change in his central
line developed respiratory distress with profound hypoxia. Was
intubated. Bronchoscopy showed coupious secretions throughout.
After meeting with family, given overall poor prognosis and
patients prior voiced wishes, care was withdrawn. Patient was
extubated and expired within in minutes.
2. Anca positive non-eosinphilic vasculitis with hemoptysis-
microangiopathic vasculitis vs. wegeners vs. other. He had
respiratory failure as above. He was treated with three courses
of plasmapheresis (HD1, HD3, HD4) and with pulse dose steroids
on admission (1 gram of solumedrol x 3 days). The solumedrol was
tapered down and PO prednisone was started on HD 13. ANCA levels
per [**Hospital1 2025**] lab were decreased from last admission;
antimyeloperoxidase ab on [**2200-4-25**] 76--> [**2200-5-13**] values of 14. Pt
received his second dose of cytoxan on [**2200-5-23**] (560 mg/m2 -1000
mg) with mesna and prehydration. Secondary to steroids, bactrim
prophylaxis was started which was changed to atovaquine when pt
had thrombocytopenia (see below).
Renal, rheumatology,and transfusion medicine were all heavily
involved in patients care of above.
3. Aflutter- History of aflutter on last admission. Patient had
his Toprol XL changed to metoprolol tid. On HD 8 he had aflutter
to the 170s, hemodynamically stable treated with a diltiazem
drip. He was cadioverted on HD 10 and was in sinus from then. He
was initially dig loaded but this was stopped
post-cardioversion.
He was started on amiodarone gtt at the time of cardioversion
and was on an amiodarone taper.
4. Renal failure- followed by renal. Creatinine remained
relatively stable, though BUN increased. Medications were
renally dosed for creatinine clearance of 15-20. Pholo and
epogen were started. BUN rose steadily to mid 140s.
5. Hypertension. patient with known hypertension. His
metoprolol was uptitrated to 75 tid and amlodipine and
hydralazine were started.
6. Hypernatremia- intermittent hypernatremia to upper 140s
likely from decreased PO intake when failed S&S. He got free
water boluses via Dobhoff and D5W IVF as needed.
7. [**Name (NI) 18456**] Pt with overall weakness post extubation. Overall
normal neurological exam though with decreased strength. CPK was
checked and normal. Head CT was negative for an acute event
(evidence of encephalomalcia from trauma from boating accident
20 years ago).
8. Thrombocytopenia- nadir 65 on HD 7. Pt's bactrim was switched
to atovaquine. HIT ab was sent and negative. Platelets improved.
However dropped again secondary to cytoxan and was low at the
time of death.
9. F/E/[**Name (NI) **] Pt failed a S&S study on HD 10 and a dubhoff was
placed the next day.
Medications on Admission:
Prednisone 60 mg po qday
Cyanocobalamin 500 mcg po qday
Chlorphenirmaine 4 mg po qday
Citalopram 10 mg po qday
Bactrim DS qMonday, Wednesday, Friday
Protonix 40 mg po qday
Epoetin 10,000 qweek
Ferrous sulfate 325 po qday
Toprol XL 75 mg po qday
ASA 325 mg po qday
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
pneumonia
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2200-5-29**]
|
[
"515",
"518.81",
"401.9",
"584.9",
"272.4",
"276.0",
"447.6",
"284.8",
"787.2",
"486",
"933.1",
"428.0",
"V10.51",
"786.3",
"E933.1",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"99.04",
"96.72",
"99.71",
"96.6",
"33.23",
"96.04",
"96.71",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
10630, 10639
|
6138, 10287
|
297, 309
|
10693, 10703
|
3271, 3717
|
10756, 10791
|
2610, 2630
|
10601, 10607
|
10660, 10672
|
10313, 10578
|
10727, 10733
|
2645, 3252
|
247, 259
|
337, 2189
|
3732, 6115
|
2211, 2443
|
2459, 2594
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,835
| 150,478
|
37434
|
Discharge summary
|
report
|
Admission Date: [**2197-2-15**] Discharge Date: [**2197-2-22**]
Date of Birth: [**2129-4-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
abdominal pain, suprapubic pain
Major Surgical or Invasive Procedure:
Incision and drainage of left buttock abscess.
Stent graft repair of ruptured abdominal aortic aneurysm,
coiling of left hypogastric artery.
Flex sigmoidoscopy
History of Present Illness:
67M with multiple medical problems with recent admissions
for bleeding duodenal ulcer p/w vague complaints of lower
abdominal and suprapubic pain. On work-up, found to have an
enlarged AAA. He is taken emergently to the operating room for
repair.
He was recently admitted for Fournier's gangrene to his scrotum
and perineum on [**2197-1-10**] requiring operative debridement by
[**Date Range 159**]. Per family, reports indurated area increasing past
several days with erythema. On examination, noticed purulent
drainage on dressing.
Past Medical History:
- large infrarenal AAA with b/l large common iliac aneurysms
- Urethral abscess
- DM
- HTN
- CAD s/p PCI
- R hypogastric coiled embolization on [**2197-1-17**]
- suprapubic urinary catheter placement [**2197-1-10**]
- per pt has Hx of "stenting" of vessel after left arm pain, but
does not believe stent in heart, thinks in arm.
Social History:
Lives at home with wife and is retired. Quit smoking two months
ago; previously 1 ppd x 50 years. No drugs.
Family History:
Colon cancer in father
Physical Exam:
PHYSICAL EXAM:
VS: 37.2, 87, 88/44, 19, 96% (30% face mask)
General: pleasant, nad
HEENT:PERRL, EOEMI, sclerae anicteric
OP: MMM, no ulcers/lesions/thrush
Neck: supple, no LAD, no thyromegaly
Cardiovascular: RRR, normal S1, S2, + 2/6 M at RUSB
Respiratory: CTA bilat w/o wheezes/rhonchi/rales
Back: no focal tenderness, no CVAT; L. gluteus abscess with
clean
base and borders
Gastrointestinal: +bs, soft, non-tender, non-distended;
suprapubic cath with no surrounding drainage
Musculoskeletal: moving all extremities
Ext: Warm and well perfused, no edema. 2+ DP pulses palpable
bilaterally
Skin: no rashes, no jaundice
Neurological: aaox3, cn 2-12
Pertinent Results:
[**2197-2-21**] 06:12AM BLOOD
WBC-5.5 RBC-3.33* Hgb-9.2* Hct-28.4* MCV-85 MCH-27.5 MCHC-32.2
RDW-15.5 Plt Ct-202
[**2197-2-21**] 06:12AM BLOOD
Plt Ct-202
[**2197-2-22**] 05:36AM BLOOD
PT-12.6 PTT-27.5 INR(PT)-1.1
[**2197-2-21**] 06:12AM BLOOD
Glucose-99 UreaN-17 Creat-1.4* Na-139 K-4.1 Cl-101 HCO3-31
AnGap-11
[**2197-2-16**] 06:20PM BLOOD
ALT-9 AST-12 LD(LDH)-169 AlkPhos-61 Amylase-18 TotBili-1.5
[**2197-2-21**] 06:12AM BLOOD
Calcium-8.1* Phos-3.4 Mg-2.1
[**2197-2-15**] 01:05PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
URINE Blood-LG Nitrite-NEG Protein-150 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-4* pH-6.5 Leuks-MOD
URINE RBC-[**12-9**]* WBC-[**12-9**]* Bacteri-MOD Yeast-FEW Epi-0
WOUND CULTURE (Final [**2197-2-19**]):
Due to mixed bacterial types (>=3) an abbreviated workup is
performed; P.aeruginosa, S.aureus and beta strep. are reported
if
present. Susceptibility will be performed on P.aeruginosa and
S.aureus if sparse growth or greater..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. SECOND
STRAIN.
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ <=0.5 S
CTA:
Status post endovascular repair with stent extending from the
infrarenal
aorta into bilateral common iliac arteries. There is no evidence
of endoleak at this time. The caliber of the aortic aneurysm and
right greater than left iliac artery aneurysms are stable.
2. Small bilateral low-density pleural effusions, left greater
than right
with mild compressive atelectasis. Two pulmonary nodules in the
right lower lobe are stable.
3. Status post incision and drainage of a left gluteal
subcutaneous fluid
collection.
Brief Hospital Course:
Pt admitted, emergently taken to the OR.
CTA showed ruptured AAA and Buttock abcess.
Stent graft repair of ruptured abdominal aortic aneurysm,
coiling of left hypogastric artery.
Buttuck abcess, this was also I/D by Dr [**Last Name (STitle) 12352**] team.
Tolerated the procedure. No complications, Transfered to the VCU
for further care.
Pt did have BM post repair. Taken for flex sig for possible
bowel ischemia
There were no obvious luminal masses but a careful examination
of all folds was not performed. The mucosa appeared slightly
pale, but there were multiple visible vessels in the bowel wall.
The mucosal folds were not thickened and there was no
evidence of mucosal edema. There was no evidence of ulceration
or mucosal sloughing.
Pt pan cx'd, blood cx's are negative.
ID consult because of stranding on CT, Forniers gangrene and
buttock abcess.
PICC line placed
Recommended vancomycin 4 weeks, Cipro and flagyl x 6 weeks. Pt
on current regime at time of DC.
PT consult, case management. Pt stable for home with PICC and IV
AB.
Medications on Admission:
Toprol xl 25mg daily, ASA 81mg daily, simvastatin 20mg
daily, glyburide 2.5mg daily, lisinopril 5mg daily, hyoscyamine
0.125mg qid PRN
Discharge Medications:
1. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 1 months: Check trough
twice weekly.
Disp:*90 Recon Soln(s)* Refills:*0*
2. Normal Saline Flush 0.9 % Syringe Sig: One (1) Injection
three times a day for 1 months: flush after each use and prn,
then with heparin flush.
Disp:*90 Normal Saline Flush (Injection) 0.9 % Syringe*
Refills:*0*
3. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous three
times a day for 1 months: follow NS flush.
Disp:*90 Heparin Flush (Intravenous) 10 unit/mL Kit* Refills:*0*
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 6
weeks.
Disp:*84 Tablet(s)* Refills:*0*
10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 6 weeks.
Disp:*126 Tablet(s)* Refills:*0*
11. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Ruptured abdominal aortic aneurysm
Left buttock abcess
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Discharge Instructions
Medications:
?????? If instructed, Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, do not stop Aspirin unless your Vascular
Surgeon instructs you to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-22**]
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
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and [**Month/Day (3) **] dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**4-25**] weeks for
post procedure check and CTA
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name12 (NameIs) **] ID WEST (SB) Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2197-3-13**] 3:50
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2197-3-15**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2197-3-15**] 1:00
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] on [**3-24**], at 1115. [**Location (un) **]
[**Location (un) 470**] [**Hospital Ward Name 23**] Building. She I/D your abcess.
([**Telephone/Fax (1) 6347**]
Completed by:[**2197-2-22**]
|
[
"442.2",
"403.90",
"V45.82",
"250.00",
"414.01",
"585.9",
"682.5",
"441.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"86.04",
"39.71",
"39.79",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6809, 6867
|
4227, 5278
|
347, 511
|
6966, 6966
|
2279, 4204
|
9709, 10405
|
1571, 1595
|
5465, 6786
|
6888, 6945
|
5304, 5442
|
7111, 9130
|
9156, 9686
|
1625, 2260
|
275, 309
|
539, 1076
|
6980, 7087
|
1098, 1429
|
1445, 1555
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,718
| 176,672
|
4530
|
Discharge summary
|
report
|
Admission Date: [**2196-10-29**] Discharge Date: [**2196-11-2**]
Date of Birth: [**2116-1-19**] Sex: M
Service: MEDICINE
Allergies:
Indocin / Lipitor
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest Discomfort
Major Surgical or Invasive Procedure:
Permanent pacemaker placement
History of Present Illness:
80 y/o male with CKD, HF with preserved EF (EF 55%, [**2194-5-8**]),
AAA, and history of escape junctional bradycardia with
retrograde P-waves that was attributed to excessive AV nodal
blockade (Diltiazem) who presents with intermittent palpitations
for approximately 4 days, each episode lasting approximately one
minute in duration, which the patient describes as a funny
feeling in his chest. He had an episode prior to arrival to the
ED that had resolved prior to arrival. The patient's wife
explicitly stated that he did not complain of chest pain but did
have some back pain. The patient's family called EMS when he
began expressing chest pain. Per EMS, he was bradycardic to the
30s for which he received Atropine once. He further received
Aspirin 81 mg x 4.
.
Upon arrival to the ED, the patient stated that his chest pain
had resolved as above but reported that he felt lightheaded and
overall feeling unwell. His HR was noted to be in the 40s with
SBPs in the 90s initially. No significant EKG findings other
than bradycardia were reported. He was noted to have pulmonary
crackles on exam but no other significant physical exam findings
were reported. Labs were significant for a K of 5.7, BUN of 39,
and serum creatinine 3.4 (up from a recent baseline of 2.0-2.4).
He received Calcium gluconate, insulin and D50 for his
hyperkalemia, which was later followed by an Albuterol nebs. He
received several doses of Atropine (2) as well as Glucagon for
reversal of any excess beta-blockade. His systolics were noted
to be mostly in the 90s with one episode of hypotension to the
high-70s, during which the patient was reportedly asymptomatic.
He was subsequently started on Dopamine at 2.5 mg/min. Transfer
vitals were HR 47, BP 103/60, RR 14, 93% on 2L.
.
Of note, his family noted a deterioration in his mental status
following either administration of either Atropine or Glucagon.
They further stated that he is typically a very organized and
oriented individual though they did state that he has poor
vision and decreased hearing.
.
Upoon arrival to the floor, the patient was noted to be delirius
and unable to answer quetions. History was obtained via his
family. The family believed that he may have been taking older
or
.
Past Medical History:
-distal abdominal aortic aneursym (3.5 cm [**2196-10-7**])
-Gastric ulcer treated with Protonix
-Hyperlipidemia
-Migraine headache
-HTN
-Gout
-Prior Hepatitis B infection (surface Ag negative, surface and
core Ab positive)
-Chronic kidney disease secondary to FSGS
-Hyperthyroidism
-Lactose intolerance
-diastolic CHF with preserved EF
-stage II inflammation and stage II fibrosis of the liver
Social History:
Retired and lives in [**Location 86**] with family. Used chewing
tobacco and smoked a pipe for 30-40yrs but quit 6yrs ago, ETOH:
Quit 12 years ago, Illicit drugs: denies
Family History:
Negative for liver disease, cancer or metabolic syndrome
Physical Exam:
ADMISSION EXAM:
VS: 97.6, 42, 123/57, 21, 98% on 6L
GENERAL: NAD, AAOx1-2, [**Hospital1 1516**] pads in place
HEENT: NCAT, unable to assess EOMI, MMM
NECK: supple with inability to appreciate JVP while patient
lying flat
CARDIAC: bradycardic but regular, normal S1 and S2, no m/r/g
LUNGS: unlabored respirations, lungs CTAB anteriorly with
crackles at the bases bilaterally in the posterior lung fields
ABDOMEN: S/NT/ND, BS+
EXTREMITIES: WWP, 2+ DP/PT pulses, zero to possibly trace edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
.
DISCHARGE EXAM:
Vitals - 98.1 155/90 81 18 94 on RA
GENERAL: NAD
NECK: supple with no JVD
CARDIAC: normal S1 and S2, no m/r/g
LUNGS: Crackles right base only, no wheezes.
ABDOMEN: S/NT/ND, BS+
EXTREMITIES: WWP, 2+ DP/PT pulses, no edema
SKIN: intact
Pertinent Results:
ADMISSION LABS:
[**2196-10-29**] 06:45AM GLUCOSE-107* UREA N-41* CREAT-3.6* SODIUM-140
POTASSIUM-5.7* CHLORIDE-110* TOTAL CO2-22 ANION GAP-14
[**2196-10-29**] 12:45AM WBC-7.7 RBC-4.47* HGB-13.4* HCT-40.7 MCV-91
MCH-30.0 MCHC-32.9 RDW-13.5
[**2196-10-29**] 12:45AM NEUTS-60.1 LYMPHS-29.0 MONOS-5.2 EOS-5.0*
BASOS-0.6
[**2196-10-29**] 12:45AM PLT COUNT-239
[**2196-10-29**] 12:45AM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-2.4
[**2196-10-29**] 12:45AM cTropnT-<0.01
[**2196-10-29**] 12:45AM CK-MB-1
[**2196-10-29**] 03:23AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-600
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG
[**2196-10-29**] 07:03AM LACTATE-1.5
.
DISCHARGE LABS:
[**2196-11-2**] 06:40AM BLOOD WBC-7.7 RBC-4.79 Hgb-14.6 Hct-42.9 MCV-90
MCH-30.4 MCHC-34.0 RDW-13.3 Plt Ct-217
[**2196-11-2**] 06:40AM BLOOD Glucose-122* UreaN-54* Creat-3.4* Na-138
K-4.9 Cl-105 HCO3-24 AnGap-14
.
EKG: [**2196-9-28**]
Junctional rhythm with retrograde V-A conduction. Left
ventricular
hypertrophy. Prolonged Q-T interval. No major change compared to
previous
tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
39 0 122 518/481 0 -13 -3
[**2196-11-2**]
Sinus rhythm. Ventricular ectopy. Left ventricular hypertrophy.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2196-10-31**] ventricular ectopy is new.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 158 92 410/434 36 -29 24
.
CXR [**2196-11-2**]
FINDINGS: A dual-lead left pectoral pacemaker device has its
leads
terminating at expected locations in the right atrium and right
ventricle. No pneumothorax. Bilateral pleural effusions and
bibasal atelectases are mild. Bilateral lungs are remarkable
for mild vascular and interstitial prominence, likely
congestion. Normal heart size, mediastinal and hilar contours
are unchanged in appearance since [**2194-4-10**].
Brief Hospital Course:
80 y/o male with CKD, dCHF, AAA, and h/o bradycardia who
presents with symptomatic bradycardia with junctioanl escape
rhythm.
.
ACTIVE ISSUES:
# Bradycardia: Junctional escape rhythm with retrograde P waves
likely related to initiation of metoprolol on previous
admission. Metoprolol was held and isoproterenol was started. He
returned to [**Location 213**] sinus rhythm shortly after admission. A
permant pacemaker was succesfully placed. A EKG showed NSR above
the set rate of pacemaker, CXR showed good placement of leads.
He did have some episodes of tachycardia on telemetry. He may
benefit from metoprolol to prevent tachycardia.
.
# Acute kidney injury on CKD: Serum creatinine elevated to 3.4,
up from recent baseline of 2.0-2.4 believed to be from
hypotension in the setting of bradycardia. His ACE and [**Last Name (un) **] were
held and his creatinine improved. He will have a follow up visit
with his renal doctor [**First Name (Titles) **] [**Last Name (Titles) 3390**] who will decide on restarting his
ACE/[**Last Name (un) **].
.
# Acute on Chronic Diastolic Heart Failure: Had pulmonary edema
on admission likely from bradycardia on baseline CHF also
possible exacerbated by acute kidney injury. He was diuresed
with IV lasix with resolution of euvolemia.
.
# Hypertension: Was hypotensive on admission but BP increased
after he was in NSR. His BP meds were initially held. Amlodipine
was restarted. ACE and [**Last Name (un) **] were held in setting of [**Last Name (un) **] but may
possibly be restarted as directyed by outpatient [**Last Name (un) 3390**] and
nephrology. Metoprolol was not restarted but may be beneficial
to prevent tachycardia.
TRANSITIONAL ISSUES:
#Outpatient Renal follow-up
#Creatinine check in 1 week
Medications on Admission:
- Gabapentin 300 mg PO TID
- Aspirin 325 mg PO daily
- Metoprolol tartrate 25 mg PO BID
- Amlodipine 5mg PO daily
- Lisinopril 40 mg PO daily
- Losartan 50 mg PO daily
- Febuxostat 40 mg PO daily
- Vitamin D 1,000 unit PO daily
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
3. febuxostat 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO three
times a day as needed for pain or fever for 4 days.
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for pain for 4 days.
Disp:*10 Tablet(s)* Refills:*0*
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
10. ketotifen fumarate 0.025 % Drops Sig: One (1) drop
Ophthalmic twice a day.
11. Outpatient Lab Work
Please check chem-7 and CBC on Friday [**11-4**] with results
to [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**] or fax
[**Telephone/Fax (1) 13238**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Bradycardia s/p pacemaker placement
Acute on Chronic diastolic congestive heart failure
Acute Delerium
Acute on Chronic Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a slow heart rate and needed a pacemaker. It is very
important that you do not lift anything more than 5 pounds with
your left arm or lift your left hand over your head for 6 weeks
to let the pacer site heal and keep the pacer leads in the right
place. We have stopped 2 of your blood pressure medicines
because your kidney function is worse, another blood pressure
medicine has been increased. You will need to get blood drawn on
Friday to check your kidney function. Weigh yourself every
morning, call Dr.[**Name (NI) 3733**] if weight goes up more than 3 lbs
in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. STOP taking lisinopril and losartan for now, Dr. [**Last Name (STitle) **] may
restart these again soon.
2. INCREASE the amlodipine to 10 mg daily
3. START taking clindamycin four times a day for 2 days to
prevent an infection at the pacer site.
4. START tylenol 1000mg (2 extra strength) three times a day to
treat the pain at the pacer site. You can also take one
oxycodone every 6 hours if needed if the tylenol does not work
for the pain. You should expect the pain to get better every day
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2196-11-15**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2196-11-30**] at 11:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: WEDNESDAY [**2196-11-30**] at 11:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: TUESDAY [**2196-11-8**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: CARDIAC SERVICES
When: TUESDAY [**2196-12-6**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2196-11-7**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"780.09",
"441.4",
"V15.82",
"414.01",
"427.81",
"585.9",
"428.33",
"428.0",
"276.7",
"584.9",
"272.4",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
9156, 9213
|
5991, 6119
|
295, 326
|
9391, 9391
|
4106, 4106
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|
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|
3851, 4087
|
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|
239, 257
|
6134, 7659
|
354, 2591
|
4122, 4784
|
9406, 9518
|
2613, 3008
|
3024, 3197
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,667
| 164,861
|
27128+57523
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-12-21**] Discharge Date: [**2159-12-27**]
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y/o male, resident of [**Hospital 100**] Rehab, with aortic mechanical
valve secondary to Listeria endocarditis (on coumadin), Coombs
positive autoimmune hemolytic anemia (warm autoantibody, on
prednisone), CAD s/p NSTEMI [**7-11**], CKD stage III, chronic CHF
(likely diastolic with EF 50%), and history of GIB who presents
from rehab with dropping HCT. HCT today was 21.8 down from 27.3
on [**2159-12-19**]. Vitals prior to transfer to ED were T 97.2 BP
108/64 HR 86 RR24 99% RA.
.
On arrival to the ED vitals were 97 99/56 84 16 99% RA. In the
[**Name (NI) **] pt reported feeling tired and was noted to be pale. HCT was
17.9 (baseline HCT 25-30) and INR was 6.1. BUN was notable to be
elevated to 61 with creatinine at baseline of 1.3. Pt had brown
stool but was strongly guaiac positive with indicator. A right
femoral line was placed and an 18 gauge IV was placed. The pt
was transfused 2 units of packed RBCs, 2 units of FFP, and 2L of
IVF. Vit K was discussed but not given per ED attd recs. He was
seen by heme onc who recommended adding on hemolysis labs. He
received protonix 40 IV x1 and GI recommended against PPI gtt.
They plan for colonoscopy once INR is down. SBP nadired at 95 in
the ED which is low compared to patient's baseline (SBP 120s).
He got tylenol 650mg po x1 for right shoulder pain. His EKG was
unchanged compared to prior.
.
On arrival to the ICU vitals were 97.8 150/67 RR18 96% RA. He
had shoulder pain at the time of transfer from the streatcher.
He then was pain free. He reported being weak. He states he
feels good after his blood transfusions but otherwise often
feels weak. He reports approximately 1 BM per day and denies
blood in the stool or black stool.
Past Medical History:
# Anemia from GI bleed of gastric ulcer vs. hemolytic anemia
# Autoimmune hemolytic anemia (Coomb's +, warm autoantibody),
previously on prednisone [**11-9**]
# Listeria Endocarditis s/p AVR, suppressive amoxicillin stopped
due to hemolytic anemia
# Aortic mechanical valve, recently Coumadin resistant so on
Lovenox bridge
# hx recent GI bleeds: colonoscopy [**9-9**]: noted normal colon,
hemorrhoids
# GERD: EGD [**7-11**] with non-bleeding ulcers in
esophagus and stomach
# H/o presyncope
# CKD Cr 1.6-2.0 Stage III
# CAD s/p NSTEMI [**7-11**]
# Chronic CHF, likely diastolic, on diuretics ([**9-10**] EF=50%)
# Hyperlipidemia
# Hypertension
# Depression vs adjustment disorder after death of brother
# Prostate cancer- s/p radiation
# Bladder/bowel incontinence
# Right lateral malleolus stage 1 pressure ulcer
# Dementia
Social History:
Never smoked, no EtOH or other drugs. Born in NY and has been a
book binder all of his life. Moved to [**Location (un) 86**] to be closer to
his son, who is a Rabbi [**First Name8 (NamePattern2) 151**] [**Last Name (Titles) **] PhD. Currently living at
[**Hospital 100**] Rehab. Uses walker or wheelchair typically. Requires a
significant degree of assistance in all his ADLs and IADLs.
Family History:
No bleeding diatheses. Father had stomach cancer. No other
cancers including colon.
Physical Exam:
Admission PE:
VS: 97.8 150/67 RR18 96% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mm, oropharynx clear
Lungs: CTAB posteriorly
CV: mechanical S1 and S2, no murmurs, rubs, gallops
Abdomen: + ventral hernia, soft, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Stage 1 ulcer on left lateral malleolus
Neuro: A & O x3, surgicsl pupils but reactive, CN II-XII intact,
UE and LE strength 5/5
Pertinent Results:
[**2159-12-21**] 05:14PM GLUCOSE-108* UREA N-61* CREAT-1.3* SODIUM-139
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-24 ANION GAP-11
[**2159-12-21**] 05:14PM ALT(SGPT)-12 AST(SGOT)-15 LD(LDH)-216
CK(CPK)-19* ALK PHOS-34* TOT BILI-0.3
[**2159-12-21**] 05:14PM CK-MB-3 cTropnT-0.02*
[**2159-12-21**] 05:14PM CALCIUM-8.1* PHOSPHATE-3.3 MAGNESIUM-2.0
[**2159-12-21**] 05:14PM HAPTOGLOB-5*
[**2159-12-21**] 05:14PM GLUCOSE-102 LACTATE-1.6
[**2159-12-21**] 05:14PM HGB-6.1* calcHCT-18
[**2159-12-21**] 05:14PM WBC-8.9# RBC-1.74*# HGB-6.2*# HCT-17.9*#
MCV-103* MCH-35.5* MCHC-34.5 RDW-21.3*
[**2159-12-21**] 05:14PM NEUTS-80* BANDS-0 LYMPHS-14* MONOS-6 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
Brief Hospital Course:
[**Age over 90 **] male, resident of [**Hospital 100**] Rehab, with aortic mechanical valve
secondary to Listeria endocarditis (on coumadin), Coombs
positive autoimmune hemolytic anemia (warm autoantibody, on
prednisone), CAD s/p NSTEMI [**7-11**], CKD stage III, chronic CHF
(likely diastolic with EF 50%), and history of GIB who presents
from rehab with low hematocrit.
.
# GI bleed: The patient was noted to have a hematocrit drop from
32 to 17.4 in the setting of supratherapeutic INR of 6.1. He
was h/o chronic anemia with baseline Hct 25-30 secondary to warm
autoimmune hemolytic anemia, Chronic kidney disease, and
myelodysplasia. He had recent admission for HCT drop and upper
endoscopy which showed a non-bleeding duodenal polyp and a small
hiatal hernia. He has history of esophageal erosions/non
bleeding stomach ulcers/gastritis/lymphangiectasias. However, pt
did also have radiation for prostate cancer which could lead to
a lower GI etiology. Given this history we were concerned for GI
bleed. He had a femoral line placed in the ED for access which
was transitioned to a PICC line in the ICU on [**2159-12-23**]. He
received a total of 4 units of packed RBCs and 4 units of FFP.
Subsequently his Hct remained between 24 to 27. GI was consulted
and an EGD was performed. The EGD showed a small hernia but was
otherwise normal with no identifiable source of bleeding. A
capsule endoscopy was then performed and the results were not
available at the time of discharge (plan to be read week of [**12-31**]). He remained hemodynamically stable with stable blood count
on serial hematocrits (HCT of 27 morning of discharge). He was
continued on prednisone 10mg po daily for his autoimmune
hemolytic anemia.
.
# Atrial fibrillation - pt had new onset a fib with RVR to
130s-150s on hospital day number 2. He received IV metoprolol
and IV digoxin with good rate control. He was started on
metoprolol 12.5mg [**Hospital1 **] (carvedilol d/c). We transitioned ot
metoprolol succinate 25mg daily at discharge (not given [**12-27**]).
He is already on anticoagulation for mechanical aortic valve
placed many years ago. Cardiology believed that no intervention
was necessary for the atrial fibrillation acutely and that it
should resolve spontaneously after GI bleed resolves. At
discharge, heart rate noted to be regular with sinus rhythm on
EKG.
.
# Possible Bacteremia - blood cultures on [**12-24**], drawn in
setting of temp to 100.6, with one out of four bottles positive
for Gram + rods and Gram + cocci. He was started on vancomycin
emperically on [**2159-12-25**] pending speciation. Surveillance
cultures are negative to date. These will need to be followed at
[**Hospital 100**] rehab as results may represent contaminant rather than
bacteremia.
.
# CAD s/p NSTEMI: Pt with shoulder pain in ED. During last
admission had left arm pain which was felt to be the result of
demand ischemia in the setting of an acute HCT drop. He did
have a + troponin at the last admission. His EKG was
unremarkable and his troponin plateaued at 0.07. He was
continued home statin, carvedilol held and started on metoprolol
succinate as above.
.
# Aortic mechanical valve: Noted to have supratherapeutic INR
of 6.1 on admission (normally his goal INR is 2.5-3.5). He was
given 4 units of FFp, but no vitamin K. INR trended down and was
1.2 at discharge. He was started on heparin drip after
hematocrit stabalized and INR subtherapeutic. He has been
maintained on heparin for the past 48 hours (PTT of 74 at
discharge) and coumadin has been held during hospitalization.
Plan was to restart coumadin on the day of admission, we will
continue 4mg as we are stopping bactrim, which can elevated INR.
He will need to be on heparin bridge until INR therepeutic (goal
2.5-3.5).
.
# Autoimmune hemolytic anemia: Continued home prednisone and
bactrim for ppx. We discussed at length the risk-benefit of
continuing bactrim given that it can cause supratherapeutic INR,
since pt is on this for Listeria prophylaxis, we decided to
discontinue this. His folic acid was continued.
.
# Stage III CKD: Baseline appears to be 1.2 to 1.3 since [**Month (only) 216**].
Pt at recent creatinine baseline.
.
# Subclinical Hypothyroidism: Continued home levothyroxine 75
mcg daily
.
# Hyperlipidemia: Continued home statin
.
# Comm: HCP [**Name (NI) **] [**Name (NI) 66590**] [**Telephone/Fax (1) 66592**], [**Telephone/Fax (1) 66591**] (cell)
Medications on Admission:
--Bactrim 400-80 mg 1 tab daily
--clindamycin 600mg po prn
--folic acid 1 mg Four Tablet PO DAILY
--ipratropium bromide 0.02 % Solution 0.5 mg q 4hr prn SOB
--levothyroxine 75 mcg daily
--omeprazole 40 mg po BID
--prednisone 10mg po daily
--simvastatin 40 mg PO DAILY
--warfarin 2 mg, 2 Tablet PO Once Daily
--acetaminophen 325 mg 2 Tablet PO Q6H prn pain
--bisacodyl 5 mg, 2 Tablet, Delayed Release q 2 days prn
--guaifenesin 100mg q4hr prn
--vit b12 2000mcg daily
--senna17.2 mg qhs
--carvedilol 3.125 mg po BID
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
6. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: Two (2)
Tablet PO once a day.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every other day.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
11. warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day.
12. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
13. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Gastrointestinal bleeding
Bacteremia
Atrial fibrillation
Secondary:
Aortic mechanical valve
Autoimmune hemolytic anemia
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted from [**Hospital 100**] Rehab to [**Hospital1 18**] for a drop in your
hematocrit (red blood cell count) and dark stools suggesting
bleeding in your GI tract. You were initially taken to the ICU
but stabilized there after receiving blood. Your INR was high on
admission, which can predispose to bleeding, and your coumadin
was held. The gastroenterologists evaluated you and did an EGD
(upper endoscopy) which showed a small hernia but was otherwise
normal. You undewerwent a video capsule study and will follow up
with gastroenterology as an outpatient for the results. Your
blood counts remained stable and there was no further evidence
of active gastrointestinal bleeding.
You were restarted on heparin after the EGD, which will be
continued until your coumadin level is therapeutic. Before the
procedue, you were found to have an arrhythmia in your heart
called atrial fibrillation. You were given a medication called
metoprolol to control your heart rate from going too fast. This
medication will be continued when you leave the hospital. Your
hear was back in the normal rhythm at discharge.
Blood cultures grew bacteria, for which we started antibiotics.
This will be continued when you return to [**Hospital 100**] Rehab.
You should follow up with your hematologist at the date/time
below.
We have made the following changes to your medications:
- START taking heparin until your coumadin level is therapeutic
- START taking vancomycin for bacteria in the blood
- START TAKING metoprolol succinate for heart rate
- STOP TAKING carvedilol
- STOP TAKING bactrim
Followup Instructions:
Department: HEMATOLOGY/BMT
When: TUESDAY [**2160-1-1**] at 1:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/BMT
When: TUESDAY [**2160-1-1**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please call your gastoenterology physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**],
at ([**Telephone/Fax (1) 2306**] next week to discuss the results of your
capsule endoscopy and schedule a follow up appointment
Completed by:[**2159-12-27**] Name: [**Known lastname 11583**],[**Known firstname 11584**] Unit No: [**Numeric Identifier 11585**]
Admission Date: [**2159-12-21**] Discharge Date: [**2159-12-27**]
Date of Birth: [**2069-10-9**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 11586**]
Addendum:
Heparin drip should be included in the patient's discharge
medications. Rate was at 850cc/hr at discharge.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 609**] for the Aged - MACU
[**First Name11 (Name Pattern1) 2197**] [**Last Name (NamePattern4) 2198**] MD [**MD Number(1) 2199**]
Completed by:[**2159-12-27**]
|
[
"283.0",
"V58.61",
"211.2",
"707.06",
"578.9",
"427.31",
"790.7",
"294.8",
"V10.46",
"V58.65",
"428.0",
"238.75",
"414.01",
"534.90",
"585.3",
"244.9",
"V43.3",
"428.32",
"707.21",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
14301, 14529
|
4646, 9071
|
230, 236
|
11072, 11072
|
3928, 4623
|
12871, 14278
|
3263, 3351
|
9635, 10786
|
10896, 11051
|
9097, 9612
|
11255, 12602
|
3366, 3909
|
12631, 12848
|
182, 192
|
264, 1986
|
11087, 11231
|
2008, 2837
|
2853, 3247
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,074
| 181,147
|
33031
|
Discharge summary
|
report
|
Admission Date: [**2179-12-9**] Discharge Date: [**2179-12-13**]
Date of Birth: [**2106-2-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Tracheal Stent Placement
SVC Stent Placement
History of Present Illness:
Mr. [**Known lastname **] is a 73 year old man with history of laryngeal
cancer s/p external beam radiation, COPD, and diabetes who
presented to an OSH with worsening shortness of breath, hoarse
voice, inability to lie flat, non-productive cough, and
increasing swelling of his bilateral upper extremities and neck.
He notes for the past 3 weeks or so, he has noticed increasing
shortness of breath and orthopnea, with an increasing number of
pillows at night; he now sleeps only in a sitting position. He
has noticed a change in the quality of his voice. In addition,
his neck and face have been "swelling up". He initially
presented to an OSH in [**State 1727**], where a CT neck demonstrated
mediastinal lymphadenopathy, a 4mm trachea likely secondary to
extrinsic compression, and multiple pulmonary nodules (the
largest of which was 1.5cm in diameter). He was transferred to
[**Hospital 1727**] Medical Center for further workup, where compression of
the SVC was revealed. He was seen by ENT, who noted bilateral
immobile vocal cords fixed in the paramedial/medial position, as
well as an 80% subglottic stenosis. He was noted to have
intraperitoneal air, which was deemed non-surgical and benign by
the consulting surgery team. Radiation oncology was also
consulted, and they recommended XRT after treatment of his SVC
syndrome and tracheal compression. He was referred to [**Hospital1 18**] for
tracheal Y-stenting, SVC stenting, and transbronchial biopsy of
the mediastinal lymphadenopathy.
Past Medical History:
- Hypertension
- Baseline chronic kidney disease, unknown creatinine; was 1.4
on admission to OSH
- Diabetes mellitus (HgbA1C 9.8)
- Coronary artery disease (sestamibi in [**2-/2175**] with fixed
inferior segment and small reversible defect at apex, EF 68%)
- COPD (on 20mg prednisone daily)
- Bladder CA
- Laryngeal CA (s/p external beam radiation in [**2172**])
- Cataract surgery
- Laser eye surgery
Social History:
Former smoker, quit 20 years ago, 40 pack-year history.
Family History:
Father died of lung cancer, diabetes; mother with diabetes.
Physical Exam:
VITALS: T 96.2F, BP 128/55, HR 57, RR 19, O2sat 100%4LNC
GENERAL: Older gentleman in mild respiratory distress, sitting
up in bed
HEENT: Marked facial swelling and plethora, OP clear
NECK: thick, unable to appreciate JVD
CARD: RRR no m/r/g
RESP: Audible inspiratory and expiratory stridor, occasional
wheeze; diffuse rhonchi anteriorly
ABD: Tympanic, soft, non-tender, decreased bowel sounds
BACK: Deferred
UPPER EXT: 2+ pitting edema bilaterally, 2+ radial pulses
LOWER EXT: no clubbing, cyanosis, edema
NEURO: A&O x 3
Pertinent Results:
[**2179-12-9**] 01:15PM PT-12.2 PTT-22.8 INR(PT)-1.0
[**2179-12-9**] 01:15PM PLT COUNT-371
[**2179-12-9**] 01:15PM WBC-9.6 RBC-3.65* HGB-10.9* HCT-33.9* MCV-93
MCH-29.9 MCHC-32.2 RDW-13.5
[**2179-12-9**] 01:15PM CALCIUM-9.3 PHOSPHATE-7.2* MAGNESIUM-2.5
[**2179-12-9**] 01:15PM LD(LDH)-229
[**2179-12-9**] 01:15PM estGFR-Using this
[**2179-12-9**] 01:15PM GLUCOSE-357* UREA N-79* CREAT-2.4*
SODIUM-132* POTASSIUM-5.5* CHLORIDE-94* TOTAL CO2-25 ANION
GAP-19
[**2179-12-9**] 05:24PM URINE EOS-NEGATIVE
[**2179-12-9**] 05:24PM URINE OSMOLAL-439
[**2179-12-9**] 05:24PM URINE HOURS-RANDOM UREA N-456 CREAT-95
SODIUM-52 POTASSIUM-44 TOT PROT-32 CALCIUM-2.8 PROT/CREA-0.3*
[**2179-12-9**] 11:09PM GLUCOSE-270* UREA N-91* CREAT-3.1* SODIUM-135
POTASSIUM-5.3* CHLORIDE-95* TOTAL CO2-25 ANION GAP-20
[**2179-12-9**] 11:09PM CALCIUM-9.3 PHOSPHATE-8.0* MAGNESIUM-2.7*
.
[**2179-12-12**]: CXR - FINDINGS:
Compared to the prior study, there is no new consolidation and
the pulmonary vascular markings are within normal limits.
Diminished linear atelectatic changes at left base are noted.
IMPRESSION:
No significant interval change vs. prior.
Brief Hospital Course:
The patient was admitted to the medical ICU on transfer from
[**Hospital 1727**] Medical Center for monitring peri-procedure.
Interventional Pulmonary placed a Y-stent and Interventional
Radiology placed an SVC stent. The procedures went well. The
Y-stent placement was complicated by a small left lower
pneumothorax. A chest tube with a pig-tail catheter was placed.
This was placed on water seal and showed no re-expansion. The
pigtail catheter was removed and there is no residual PTX and no
leak as evidenced by repeat chest film.
The interventional Pulmonary attending is named [**Name (NI) 828**] [**Name (NI) 829**]
When removing the bialteral femoral lines, there was unexpected
bleeding approx 30 minutes after the right SVC-stent introducer
catheter was removed. The line was pulled, and no bleeding was
noted. However, upon sitting up and eating, blood was noticed
oozing from the wound site. Pressure was held and his Hct was
stable. No further complications were noted.
The patient suffered acute renal failure felt secondary to
contrast nephropathy as a result of multiple contrast studies.
His Creatinine stabilized @ 3.2 and he continued to make urine.
Renal was consulted and felt dialysis was not needed and that
his kidneys should continue to improve gradually.
Surgery was notified of the CT finding of marked bowel wall gas
and free air under the diaphragm. He was asymptomatic and
tolerating a diet. They felt this was [**Last Name (un) 17066**] issue without clear
etiology. They felt a diet as tolerated and bowel regemine were
indicated and close monitoring.
The following recommendations are made regarding his ongoing
care:
Oncology input once the pathology of the tumor is identified
regarding treatment
Tapering of his steroids
He is to continue on his Aeroslized N-Acetyl Cysteine and normal
saline nebs
continued monitoring of his abdominal exams
Medications on Admission:
Lantus 35 units QHS
Novalog sliding scale
Glyburide 10mg [**Hospital1 **]
Metformin 1000mg [**Hospital1 **]
Prednisone 20mg daily
HCTZ 25 mg daily
Lisinopril 20mg daily
Metoprolol 50mg TID
Simvastatin 40mg QHS
Precose 100mg TID
ASA 81mg daily
Triamcinolone 100mcg 4 puffs [**Hospital1 **]
Omeprazole 40mg daily
Loratadine 10mg daily
Albulterol 2 puffs q4-6hours
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units Injection TID (3 times a day).
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
[**11-24**] Nebulizers Inhalation Q6H (every 6 hours) as needed.
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet 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. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Ipratropium Bromide 0.02 % Solution Sig: [**11-24**] Nebs Inhalation
Q6H (every 6 hours).
9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please taper as symptoms tolerate.
11. Acetylcysteine 20 % (200 mg/mL) Solution Sig: [**11-24**] Nebs
Miscellaneous Q6H (every 6 hours).
12. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
13. Ciprofloxacin 400 mg IV Q24H
14. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
Units Subcutaneous once a day.
15. Insulin Regular Human 100 unit/mL Solution Sig: 2-10 Units
Injection four times a day: As Directed per Sliding Scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1727**] Medical Center
Discharge Diagnosis:
Primary:
1. Tumor of unknown primary
2. Tracheal Encroachment/Invasion.
3. SVC Syndrome from tumor compression
4. Acute on chronic renal failure.
5. Diabetes mellitus type II.
Secondary:
1. Chronic kidney disease.
2. Hypertension
3. Laryngeal CA (s/p external beam radiation in [**2172**])
4. Coronary Artery Disease
5. COPD
6. History of Bladder Cancer
Discharge Condition:
Tolerating 35% facemask, tolerating oral diet, hemodynamically
stable.
Discharge Instructions:
You were transfered to [**Hospital1 18**] from [**Hospital 1727**] Medical Center for
interventional pulmonary and interventional radiology
procedures. These went well. You are being transfered back to
[**Hospital 1727**] Medical Center for on-going care.
Followup Instructions:
Please follow up with your oncologist and primary care doctors
as directed by the [**Hospital 1727**] Medical Center providers.
|
[
"276.1",
"512.1",
"196.1",
"197.3",
"250.40",
"585.9",
"V10.21",
"V10.51",
"E947.8",
"496",
"584.9",
"403.90",
"459.2",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.05",
"00.40",
"39.50",
"00.45",
"31.5",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
7899, 7960
|
4205, 6091
|
322, 368
|
8359, 8432
|
3029, 4182
|
8737, 8868
|
2412, 2473
|
6504, 7876
|
7981, 8338
|
6117, 6481
|
8456, 8714
|
2488, 3010
|
275, 284
|
396, 1896
|
1918, 2323
|
2339, 2396
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,947
| 153,446
|
9072
|
Discharge summary
|
report
|
Admission Date: [**2107-7-20**] Discharge Date: [**2107-7-22**]
Date of Birth: [**2051-5-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
sigmoidoscopy
History of Present Illness:
56 yo woman with recent colonscopy and resection of rectal
carcinoid who presents post-procedure with BRBPR.
.
On screening [**First Name3 (LF) 2792**] in [**Month (only) **] found to have rectal polyp with
biopsy positive for carcinoid. Yesterday underwent repeat
[**Month (only) 2792**] which revealed a 4mm hypoechoic ovoid mass arising
from deep mucosa/submucosa seen in the mid rectum wihtout
extension into deep muscularis (no bleeding noted). She
underwent Duetta band mucosectomy with snare resection. She
tolerated the procedure well, which was uncomplicated without
bleeding. She went home at 4pm and had two episodes of BRBPR
associated with cramping abdominal pain (last one at 7PM).
Denies dizziness, sycope, or palpitations.
.
In the ED, initial vital signs were: 98.4, 67, 119/80, 16, 100%
on RA. Rectal exam without blood. Had several bowel movements
but no blood. HCT of 39. The patient was transferred to the MICU
for sigmoidoscopy.
Past Medical History:
- Endometrial CA s/p surgery [**2103**]
- Rectal carcinoid
- Hyperlipidemia
Social History:
Ms. [**Known lastname 31330**] has had a long term domestic partner of >30 years,
whom she lives with and has a 16 year old son. She is an art
curator. She denies tobacco use and reports [**3-3**] ETOH drinks per
week.
Family History:
Her mother was recently diagnosed with leukemia and is receiving
treatment at the [**Hospital 4601**] Cancer Center. A maternal aunt had
breast cancer. There is no other family history of cancer.
Physical Exam:
ADMISSION EXAM
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,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs:
[**2107-7-20**] WBC-7.7 RBC-4.05* Hgb-13.4 Hct-39.0 MCV-96 MCH-33.0*
MCHC-34.3 RDW-14.4 Plt Ct-228
[**2107-7-20**] PT-14.8* PTT-34.0 INR(PT)-1.3*
[**2107-7-20**] Glucose-92 UreaN-6 Creat-0.5 Na-145 K-2.5* Cl-119*
HCO3-19*
[**2107-7-20**] Calcium-5.7* Phos-1.7* Mg-1.6
.
[**2107-7-22**] WBC-6.1 RBC-3.60* Hgb-11.9* Hct-34.6* MCV-96 MCH-33.0*
MCHC-34.2 RDW-14.0 Plt Ct-177
[**2107-7-22**] Glucose-96 UreaN-5* Creat-0.7 Na-139 K-3.5 Cl-105
HCO3-26 [**2107-7-22**] Calcium-8.6 Phos-3.6 Mg-2.2
.
Sigmoidoscopy ([**2107-7-20**]):
A single deep oblong 6 mm ulcer was found in the rectum. Few
pigmented red spots were noted. No active bleeding was noted.
This was vigorously irrigated. No bleeding was noted. Since the
ulcer was non-bleeding, large and deep, decision was made not to
clip or cauterize it.
Brief Hospital Course:
56F with BRBPR after [**Month/Day/Year 2792**] and polyp resection today,
found to have ulcer on repeat sigmoidoscopy. Please see
admission H&P for details. Brief hospital course by problem:
.
BRBPR: Sigmoidoscopy performed in the MICU revealed a rectal
ulcer but no active bleeding. HCT drop from baseline of
41.5->39->31, but has been uptrending and was 34.6 upon
discharge. She has been hemodynamically stable. No further
rectal bleeding.
- Started colace 50mg [**Hospital1 **]
- She will schedule an OP appointment with Dr. [**Last Name (STitle) **] (GI)
within the next [**1-1**] wks
.
Fever: She experienced a fever in the MICU, but no further
fevers after being transferred to the floor. Possibly due to
transient bacteremia from gut in setting of recent
procedurization. Blood cultures from [**7-21**] are pending.
- I will f/u blood culture results to make sure they are
negative
.
Hyperlipidemia:
- Continue lovastatin
Medications on Admission:
- Albuterol
- Lovastatin
- Calcium
- Vitamin D
- Fish Oil
- MVI
Discharge Medications:
1. Albuterol Sulfate Inhalation
2. Lovastatin Oral
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding rectal ulcer
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 rectal bleeding. The GI
doctors did [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2792**] and found an ulcer from your previous
biopsy. The ulcer has stopped bleeding and you have not
experienced any more bleeding from your rectum.
.
Please continue to take your home medications. In addition, we
have STARTED the following medication:
Colace (docusate sodium) 50mg 1 pill by mouth twice daily
.
Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) within the
next 1-2 weeks.
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **] (gastroenterology)
within 1-2 weeks. ([**Telephone/Fax (1) 31331**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2107-7-23**]
|
[
"275.41",
"998.11",
"458.9",
"569.41",
"285.1",
"272.0",
"780.60",
"E878.8",
"209.57"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.23"
] |
icd9pcs
|
[
[
[]
]
] |
4759, 4765
|
3233, 3396
|
342, 357
|
4831, 4831
|
2404, 3210
|
5552, 5808
|
1689, 1887
|
4279, 4736
|
4786, 4810
|
4190, 4256
|
4982, 5529
|
1902, 2385
|
275, 304
|
3424, 4164
|
385, 1338
|
4846, 4958
|
1360, 1437
|
1453, 1673
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,849
| 131,581
|
44566
|
Discharge summary
|
report
|
Admission Date: [**2131-1-18**] Discharge Date: [**2131-1-25**]
Date of Birth: [**2079-6-5**] Sex: M
Service: SURGERY
Allergies:
Bactrim DS / Stavudine
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2131-1-19**]: Cadaveric renal transplant
History of Present Illness:
Mr. [**Known lastname **] is a 51-year-old
gentleman with end-stage renal disease who was on the kidney
transplant list. A kidney became available. The risks and
benefits of this particular kidney were explained in detail
to the patient and he elected to receive the kidney.
Past Medical History:
Past Medical History: HIV, HTN, latent TB, cryptococcal
meningitis
Past Surgical History: multiple access procedures on the LUE
Social History:
He is married with three children. His wife will be around
after the transplant.
Family History:
His father died approximately 25 years ago of causes that he
does not know. His mother died of stroke.
Physical Exam:
Vitals-WNL
Gen-AxOx3, NAD
CV-RRR, No MRG
Pulm-CTA BL
Abd-soft, NT, ND, incision CDI
Ext-No peripheral edema
Pertinent Results:
[**2131-1-18**] 09:07PM GLUCOSE-95 UREA N-58* CREAT-9.0*# SODIUM-138
POTASSIUM-5.4* CHLORIDE-93* TOTAL CO2-29 ANION GAP-21*
[**2131-1-18**] 09:07PM estGFR-Using this
[**2131-1-18**] 09:07PM ALT(SGPT)-13 AST(SGOT)-19
[**2131-1-18**] 09:07PM ALBUMIN-4.6 CALCIUM-9.7 PHOSPHATE-8.9*#
MAGNESIUM-2.4
[**2131-1-18**] 09:07PM WBC-8.6 RBC-3.87* HGB-13.0* HCT-37.3* MCV-96
MCH-33.6* MCHC-35.0 RDW-16.5*
[**2131-1-18**] 09:07PM PLT COUNT-259
[**2131-1-18**] 09:07PM PT-13.0 PTT-20.3* INR(PT)-1.1
Brief Hospital Course:
Pt was admitted [**2131-1-18**] for renal transplanatation. The
procedure went well and pt was transferred to the floor
post-operatively in stable condition. His pain was well
controlled with IV pain medication initially and then was
transitioned to oral pain medications. He was started on
immunosupressive medication immediately post-operatively and
this regimen was monitored closely post-operatively. He was
started on his home medications for blood pressure and his home
regimen of HIV medications. He began tolerating a regular diet
and was making urine. A kidney biopsy done on [**2131-1-24**] showed no
acute rejection. At the time of discharge pt was tolerating a
regular diet,his vital signs were within the normal limits, he
had normal bowel funtion and his pain was well controlled. He
had teaching for all of his transplant medications and he was
discharged in stable condition on [**2131-1-25**].
Medications on Admission:
atazanavir 300', lamivudine 150' following
HD, lisinopril 20', nevirapine 200", pravastatin 20', ritonavir
100', sevelamer 800''', asa 81'
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO Q72H (every 72 hours).
9. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(MO): MAC prevention.
Disp:*16 Tablet(s)* Refills:*2*
13. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
14. FreeStyle Lite Strips Strip Sig: One (1) Miscellaneous
four times a day.
Disp:*1 box* Refills:*2*
15. FreeStyle Lite Meter Kit Sig: One (1) kit Miscellaneous
twice a day.
Disp:*1 kit* Refills:*0*
16. FreeStyle Lancets Misc Sig: One (1) Miscellaneous twice
a day: check blood sugar prior to breakfast and supper.
Disp:*1 box* Refills:*2*
17. tacrolimus 5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
18. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
20. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*120 Tablet(s)* Refills:*2*
21. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
HIV nephropathy/HTN s/p kidney transplant
Delayed renal function
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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, incisional
redness, drainage or bleeding, pain over the graft kidney,
increased leg edema, decreasing urine output or any other
concerning symptoms.
Labwork to be drawn every Monday and Thursday at the [**Hospital **]
Medical Building lab [**Location (un) 448**]
Your anti-retrovirals have been changed, please use only the
newly prscribed medications
No heavy lifting
No driving if taking narcotic pain medication
You may shower, no tub baths or swimming until noified you may
do so.
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2131-1-29**] 9:30
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2131-2-9**] 9:40
[**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2131-2-9**] 10:00
|
[
"042",
"V45.11",
"403.91",
"996.81",
"585.6",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"00.93",
"55.69",
"55.23"
] |
icd9pcs
|
[
[
[]
]
] |
4654, 4712
|
1680, 2592
|
286, 332
|
4821, 4821
|
1157, 1657
|
5668, 6026
|
908, 1014
|
2782, 4631
|
4733, 4800
|
2618, 2759
|
4972, 5645
|
752, 792
|
1029, 1138
|
242, 248
|
360, 637
|
4836, 4948
|
682, 728
|
808, 892
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,631
| 123,075
|
37981
|
Discharge summary
|
report
|
Admission Date: [**2108-8-1**] Discharge Date: [**2108-8-12**]
Date of Birth: [**2052-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Norvasc / Beta-Blockers
(Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Epigastric burning and shortness of breath with exertion
Major Surgical or Invasive Procedure:
[**2108-8-1**] Cardiac Catheterization
[**2108-8-7**] Coronary Artery Bypass Grafting time four: left internal
mammary artery grafted to left anterior descending, reverse
saphenous vein graft to the posterior descending artery,
marginal branch, diagonal branch.
History of Present Illness:
This is a 56 yo male with history of hypertension,
hyperlipidemia, and strong family history of CAD who reports
shortness of breath and abdominal discomfort for the past six
month. The patient underwent abdominal ultrasound and CT to
workup his abdominal discomfort. This revealed a right renal
mass, which is likely cancerous. The patient was schedule to
have this resected at [**Hospital 794**] Hospital in [**Month (only) 359**]. He was
referred for cardiac catheterization as part of preoperative
surgical clearance.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Type II Diabetes Mellitus
- Right renal mass 3cm, presumed cancerous-schedule for surgical
resection at [**Hospital 794**] Hospital on [**2108-9-3**]
- History of kidney stones
- Anxiety/Depression/Panic attacks for past 6 months
- History of Duodenal ulcer as child
- Chronic back pain d/t pinched nerve- R leg goes numb with
prolonged standing
- Benign Prostatic Hypertrophy
- History of Testicular Cancer
- s/p surgery for undescended testicle age 10
- s/p removal of testicle [**2084**]
Social History:
Pt is single, lives alone in CT. Works as mail carrier. Prior
heavy ETOH, none in 25 years. Occasional cigars 3-4x/ week
Family History:
Mother with MI at age 42. Brother with cardiac stent age 45
Physical Exam:
Pulse:93 Resp: 18 O2 sat: 97% RA
B/P Right:195/94 Left:213/100
Height:5'6" Weight:300 lbs
General: Obese male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]thick neck
Chest: Lungs clear bilaterally anteriorly[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 1+ LE
Varicosities: None [x]
Neuro: Grossly intact[x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit: none
Pertinent Results:
[**2108-8-1**] WBC-11.0 RBC-4.47* Hgb-12.8* Hct-38.5* RDW-14.6 Plt
Ct-230
[**2108-8-1**] PT-11.7 PTT-25.2 INR(PT)-1.0
[**2108-8-1**] Glucose-186* UreaN-19 Creat-0.6 Na-141 K-4.1 Cl-105
HCO3-25
[**2108-8-1**] ALT-20 AST-11 AlkPhos-76 Amylase-37 TotBili-0.2
[**2108-8-1**] %HbA1c-8.1*
[**2108-8-1**] Triglyc-178* HDL-40 CHOL/HD-5.4 LDLcalc-138*
[**2108-8-1**] Cardiac Catheterization:
1. Selective coronary angiography in this right dominant system
demonstrated three vessel disease. The LMCA had an 80% stenosis
in the distal portion of the vessel. The LAD had a 80% proximal
stenosis, a 70 mid vessel stenosis and a 80% distal vessel
stenosis. The Cx had a 70% stenosis in the proximal portion of
the vessel. The RCA had an 80% stenosis in the distal portion of
the vessel and there was diffuse plaquing all throughout the
RCA. 2. Limited resting hemodynamics reveal elevated left sided
filling pressures with an LVEDP of 20 mmHg. There was no
transaortic valve gradient on pullback from the LV to the aorta.
The central aortic pressure was 153/85 mmHg.
[**2108-8-2**] Echocardiogram:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Transmitral Doppler and tissue velocity imaging are
consistent with Grade I (mild) LV diastolic dysfunction. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. There is an anterior space
which most likely represents a fat pad. IMPRESSION: Mild
symmetric left ventricular hypertrophy with preserved global
biventricular systolic function. Mild diastolic LV dysfunction.
No significant valvular disease seen
[**2108-8-2**] Chest CT Scan:
In the left lobe of the thyroid, a 2.5 cm nodule is seen. This
nodule should be further worked up with ultrasonography.
Otherwise, there are no abnormalities in the upper mediastinum.
Generally, in the mediastinum, no enlarged lymph nodes are seen.
Extensive coronary calcifications. There is no evidence of
pleural effusions or other pleural pathology. In the lung
parenchyma, in the right apex (3, 9), a 3-4 mm nodule is seen.
Otherwise, there is no evidence of nodular lung lesions, notably
no evidence of lesions suspicious for metastasis. The airways
are patent. No evidence for airway lesions. At the left lateral
margin of the spleen (2, 58) a small calcification is seen.
Small gallbladder stone (2, 62). 2-mm right renal calculus (2,
68). The bone windows show moderate degenerative
vertebraldisease, but no evidence of bone destruction.
[**2108-8-3**] Carotid Ultrasound:
There is antegrade right vertebral artery flow. There is
antegrade left vertebral artery flow. Right ICA stenosis <40%.
Left ICA stenosis <40%.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent cardiac catheterization
which revealed severe three vessel coronary artery including
left main lesion - see result section for further details.
Cardiac surgery was consulted and further preoperative
evaluation was performed. This was highlighted by an
echocardiogram, chest CT scan and carotid ultrasound - see
result section for additional details. The echocardiogram showed
only mild symmetric left ventricular hypertrophy with preserved
global biventricular systolic function, mild diastolic LV
dysfunction, and no significant valvular disease. Carotid
ultrasound showed minimal disease of both internal carotid
arteries. Chest CT scan revealed a thyroid nodule and right
upper lobe nodule, but there was no evidence of lesions
suspicious for metastasis. He remained pain free on medical
therapy and was eventually cleared for surgery. On [**8-7**], Dr. [**Last Name (STitle) **] performed coronary artery bypass grafting
surgery. Please see operative note for details.
Following surgery, he was brought to the CVICU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated without incident. He maintained stable
hemodynamics and weaned from pressor support without difficulty.
On postoperative day one, he transferred to postop floor to
begin increasing his activity level. Chest tubes and pacing
wires removed per protocol. His calcium channel blockers were
uptitrated (beta blockade was not started as her is allergic to
this class of drugs). He was started on Kefzol for
serosanguinous sternal drainage without erythema or a sternal
click. He was cleared for discharge to home on POD #5 with ten
days of Keflex and strict sternal precautions. His lantus dose
was increased to 45 units at bedtime in response to elevated
blood sugars and an admission Hemoglobin A1C of 8.1.
Dr. [**Last Name (STitle) **] has recommended to Mr. [**Known lastname **] and his urologist
that he not undergo his renal mass surgery for six weeks after
his bypass surgery. He was requested to make all followup appts
as per discharge instructions.
Medications on Admission:
Metformin 1000mg [**Hospital1 **]
Diltiazem SR 180mg daily
Asprin 81mg daily (on hold for renal surgery)
Lantus 40units at bedtime
Benicar Hct 40- 12.5mg, 1 tab daily
Glipizide 20mg daily
Flomax .4mg daily
Cymbalta 90mg daily
Percocet 7.5-325mg PRN back pain (takes daily)
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. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 14
days.
Disp:*14 Tablet(s)* Refills:*2*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 14
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Forty Five (45)
units Subcutaneous at bedtime.
Disp:*qs * Refills:*2*
13. Glipizide 10 mg Tablet Extended Rel 24 hr (b) Sig: Two (2)
Tablet Extended Rel 24 hr (b) PO once a day.
Disp:*60 Tablet Extended Rel 24 hr (b)(s)* Refills:*2*
14. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 10 days: sternal drainage.
Disp:*40 Capsule(s)* Refills:*2*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Coronary artery disease, s/p CABG
Hyperlipidemia
Hypertension
Diabetes Mellitus Type II
Obesity
Right Renal Mass, most like malignant
Thyroid Nodule
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**2-19**] weeks, call for appt [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) 24717**] in [**12-20**] weeks, call for appt
Dr. [**Last Name (STitle) 84864**] in [**12-20**] weeks, call for appt
[**Hospital Ward Name 121**] 6 wound check next Friday [**8-17**], make appt prior to
discharge
f/u with your kidney surgeon- NO SURGERY FOR 6 WEEKS
Completed by:[**2108-8-12**]
|
[
"428.0",
"189.0",
"401.9",
"278.01",
"272.4",
"241.0",
"414.01",
"411.1",
"600.00",
"428.32",
"250.60",
"300.4",
"357.2",
"V10.47"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.55",
"36.15",
"37.22",
"88.52",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10356, 10375
|
5879, 8002
|
417, 681
|
10568, 10575
|
2701, 5856
|
11119, 11534
|
1935, 1996
|
8325, 10333
|
10396, 10547
|
8028, 8302
|
10599, 11096
|
2011, 2682
|
321, 379
|
709, 1232
|
1254, 1781
|
1797, 1919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,669
| 141,796
|
54039
|
Discharge summary
|
report
|
Admission Date: [**2108-9-27**] Discharge Date: [**2108-10-25**]
Date of Birth: [**2069-2-12**] Sex: F
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old
woman who presented with mental status changes. The patient
is status post cadaveric renal transplant on [**2107-12-18**]
and a pancreas transplant on [**2108-4-17**]. The patient was
found to be confused with decreased oral intake, and
lethargic, and slurred speech. Therefore, the patient was
brought in for information.
PAST MEDICAL HISTORY: (Her past medical history is
significant for)
1. Type 1 diabetes mellitus (with retinopathy).
2. End-stage renal disease.
3. Gastroparesis.
4. Status post pancreas-renal transplant (as above).
6. Hypertension.
7. Depression.
8. High cholesterol.
MEDICATIONS ON ADMISSION: (Her medications on admission
included)
1. CellCept [**Pager number **] mg by mouth twice per day.
2. Prednisone 5 mg by mouth once per day.
3. Protonix 40 mg by mouth once per day.
4. Prograf 3 mg by mouth in the morning and 4 mg by mouth
at night.
5. Reglan 10 mg by mouth four times per day (with meals).
6. Megace 80 mg by mouth in the morning.
7. Lopressor 200 mg by mouth twice per day.
8. Norvasc 5 mg by mouth once per day.
9. Prozac 40 mg by mouth once per day.
10. Aspirin 81 mg by mouth once per day.
11. Periactin 4 mg by mouth as needed.
12. Ativan 4 mg by mouth as needed.
13. Trazodone 50 mg by mouth as needed.
14. Zofran 4 mg by mouth as needed.
ALLERGIES: (Allergies are significant including)
1. COMPAZINE.
2. CIPROFLOXACIN.
3. DIFLUCAN.
4. KEFLEX.
5. SULFA.
6. TETRACYCLINE.
7. COZAAR.
8. BACTRIM.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient was afebrile. Her vital signs were
stable. In general, the patient was very sleepy. Sclerae
were anicteric. The mucous membranes were moist. Her lungs
were clear. Heart was regular. The abdomen was soft,
nontender, and nondistended. Extremities were warm and well
perfused. The patient was lethargic and arousable to voice
only.
PERTINENT RADIOLOGY/IMAGING: The patient had a full
evaluation including a head computed tomography which was
relatively normal.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
to the hospital for further evaluation. Cultures were taken,
and the patient was noted to have a witnessed seizure.
The Neurology Service was consulted at that time. After
evaluation, it was found upon culture that the patient had a
diffuse disseminated cytomegalovirus infection, including a
neurologic infection. The patient was taken to the Intensive
Care Unit and monitored closely.
Over the next couple of days, her mental status slowly
started to improve. She was started on ganciclovir 250 mg
intravenously twice per day, and her cytomegalovirus loads
were sent. Her first two sets of cytomegalovirus loads were
greater than 10,000 which helped to indicate a significant
cytomegalovirus infection.
The patient stabilized on ganciclovir treatment and slowly
started to improve. She was transferred to the floor and
began tolerating a regular diet. Her blood pressure was
significantly labile, and she required increases in her
Lopressor to 200 mg by mouth three times per day as well as
an increase of her Norvasc to 10 mg. However, the patient
began having episodes of hypotension and was ultimately
scaled back on her antihypertensive medications back to her
baseline medications which she was able to tolerate.
The patient was put back on her home regimen of
antihypertensive medications; however, again, she had higher
blood pressures with this. It was ultimately decided that
her Norvasc would be stopped and she would just be continued
on Lopressor 100 mg by mouth twice per day.
The Dermatology Service was also consulted for
darkening/tanning of her skin. It was felt that this was
also caused by her cytomegalovirus infection.
Renal Transplant (Dr. [**Last Name (STitle) **] followed her throughout her
entire hospital stay. Infectious Disease also followed her
care closely throughout her entire stay. Physical Therapy
was consulted to help with ambulation and to assess for needs
at home or therapy. The patient did well with physical
therapy, and it was felt that she could ultimately go home.
The patient had a temperature spike in the Intensive Care
Unit. She was cultured earlier and was ultimately found to
have a urinary tract infection with Morganella. Therefore,
she was started on aztreonam. The patient tolerated a 5-day
course of aztreonam, and her urine was screened. This was
stopped in the hospital.
She continued to improve from her cytomegalovirus interferon.
Her repeat cytomegalovirus load prior to discharge had
decreased to 4000. Therefore, it was felt both by the Renal
Service, Infectious Disease Service, and the Transplant
Surgery Service that she could be kept on 250 mg of
ganciclovir intravenously once per day for treatment of her
disseminated cytomegalovirus infection.
The patient had a right-sided peripherally inserted central
catheter line for long-term intravenous ganciclovir
treatment, and she did well. The patient continued to
improve. Her electrolytes were originally mildly abnormal
and began to normalize. Her sodium was slightly low at 132
upon discharge; however, all other electrolytes were within
normal limits. Her white blood cell count was 5.3, and her
hematocrit was stable at 29. The patient continued to do
well.
It was decided on [**2108-10-25**] that the patient could be
in stable condition. The patient was to have outpatient
intravenous ganciclovir and to be followed by Infectious
Disease Service, Transplant Surgery Service, and Renal
Service with follow-up cultures; sensitivities to be done as
an outpatient for determining the length of course for the
ganciclovir treatment. The patient aztreonam was stopped in
the hospital prior to discharge with successful treatment of
her urinary tract infection.
DISCHARGE STATUS: The patient was discharged to home with
plans for outpatient [**Hospital6 407**].
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Ganciclovir 250 mg intravenously once per day.
2. Seroquel (which was started in the hospital by the
Psychiatric Service for sleep).
3. Protonix 40 mg by mouth once per day.
4. Colace.
5. Tums.
6. Megace 40 mg by mouth once per day.
7. Norvasc (discontinued).
8. Multivitamin one tablet by mouth once per day.
9. Tylenol.
10. Regular insulin sliding-scale as needed.
11. Zofran.
12. Nystatin swish-and-swallow.
13. Prozac.
14. Lopressor 200 mg by mouth twice per day.
15. Prograf 1.5 mg by mouth twice per day.
16. Prednisone 5 mg by mouth once per day.
17. CellCept [**Pager number **] mg by mouth twice per day (levels to be
checked and followed by the Transplant Center).
DISCHARGE DISPOSITION: The patient was discharged to home in
stable condition.
DISCHARGE DIAGNOSES:
1. Disseminated cytomegalovirus infection; now being
treated with ganciclovir intravenously.
2. Status post cadaveric renal transplant in [**2108-10-6**].
3. Pancreas transplant in [**2108-4-5**].
4. Type 1 diabetes mellitus.
5. High cholesterol.
6. Osteoporosis.
7. Hypertension.
8. Depression.
9. Gastroparesis.
10. Coronary artery disease; status post cardiac
catheterization times four.
11. Status post left arteriovenous fistula.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with the
Transplant Center.
2. The patient was instructed to follow up with Transplant
Infectious Disease Center (Dr. [**Last Name (STitle) 724**]. She was to see Dr.
[**Last Name (STitle) 724**] in one week's time in the Infectious Disease Transplant
Center.
3. The patient was instructed to follow up with Renal
Service(Dr. [**Last Name (STitle) **] as scheduled time as scheduled.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Dictator Info 98693**]
MEDQUIST36
D: [**2108-10-25**] 13:59
T: [**2108-10-25**] 14:38
JOB#: [**Job Number 110776**]
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70,110
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43218
|
Discharge summary
|
report
|
Admission Date: [**2116-4-1**] Discharge Date: [**2116-4-7**]
Date of Birth: [**2031-9-11**] Sex: M
Service: MEDICINE
Allergies:
Dicloxacillin / Penicillins / Ampicillin
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 84 yo M with h/o pulmonary fibrosis, pulmonary
hypertension, CHF, s/p bioprothesic AVR, afib on coumadin who
presented to his [**Hospital 6435**] clinic with shortness of breath. He was
seen today in [**Location (un) **] (note in OMR) with weakness, weakness,
shortness of breath and cough productive of blood-tinged sputum.
He had been seen recently in clinic and lasix was increased with
good result. His oxygen satuiration in clinic was 88% and he was
referred to the ED.
In ED, initial vitals 99.4 88 107/60 18 95% 10L. His BNP and
trop were elevated. He was given vanc, levofloxacin,
azithromycin and aspirin. He was placed on a non-rebreather. CXR
showed evidence of CHF.
Vitals on transfer: 98.7 63 111/54 sat 97% on NRB.
He states that he has had hemoptysis for the past 2 weeks. the
worsened shortness of breath he noticed this morning. He had to
sit down and rest when he went outside to get his paper. He
denies chest pain or pressure. He denies fever or nightsweats.
Past Medical History:
Afib- on coumadin, prosthetic valve.
Interstitial lung disease/Pulmonary fibrosis- with chronic mild
exertional dyspnea
Type 2 DM
Gout
Obstr Sleep Apnea
Neuropathy
Carotid artery Stenosis
CAD
CHF
Social History:
Smoked cigarettes 1ppd x 20 years. Quit 40 years ago, then
smoked pipe but quit that several years ago. Drinks 1-2 beers
qweek. Lives alone and does all cooking/cleaning. Has 2
daughters who look after him. He worked as an engineer before
retirement. Was exposed to asbestos in his early 20s when he
worked in a factory producing heating boilers.
Family History:
Family history is significant for coronary artery disease and
diabetes. His mother died of TB in [**2051**]
Physical Exam:
On admission:
Tmax: 35.9 ??????C (96.7 ??????F)
Tcurrent: 35.9 ??????C (96.7 ??????F)
HR: 62 (62 - 75) bpm
BP: 111/66(77) {107/55(67) - 111/66(77)} mmHg
RR: 31 (21 - 35) insp/min
SpO2: 93%
Heart rhythm: SR (Sinus Rhythm)
General Appearance: Well nourished, No acute distress, No(t)
Diaphoretic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : inspiratory bilateral, No(t) Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+, No(t) Cyanosis, No(t) Clubbing
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, No(t) Sedated, Tone: Normal
.
On discharge:
Tm 96.7 118/60 58 26 99% CPAP; O = 650 since 12am
General Appearance: AOx3, in no acute distress
HEENT/neck: PERRL, EOMI, no cervical LAD
Cardiovascular: nl S1/S2, RRR, no m/r/g
Peripheral Vascular: 1+ distal pulses
Respiratory / Chest: coarse breath sounds at bases with rhonchi,
no wheezing or rales
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: 1+ pedal edema L>R, grafting scar in LLE
Skin: rash
Neurologic: AOx3, [**4-16**] motor strength, no sensory deficits.
Pertinent Results:
On Admission:
=============
[**2116-4-1**] 01:15PM BLOOD WBC-8.7 RBC-3.73* Hgb-10.0* Hct-30.0*
MCV-80* MCH-26.7* MCHC-33.2 RDW-16.6* Plt Ct-316
[**2116-4-1**] 01:15PM BLOOD Neuts-80* Bands-0 Lymphs-11* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2116-4-1**] 01:15PM BLOOD Glucose-108* UreaN-48* Creat-2.2* Na-138
K-5.2* Cl-101 HCO3-23 AnGap-19
[**2116-4-1**] 01:15PM BLOOD proBNP-2799*
[**2116-4-1**] 01:15PM BLOOD cTropnT-0.17*
[**2116-4-1**] 01:15PM BLOOD CK(CPK)-64
[**2116-4-1**] 01:15PM BLOOD PT-33.0* PTT-29.6 INR(PT)-3.3*
.
Microbiology:
Respiratory Viral Antigen Screen (Final [**2116-4-2**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
.
On Discharge:
=============
[**2116-4-6**] 06:40AM BLOOD WBC-10.6 RBC-3.86* Hgb-10.1* Hct-31.2*
MCV-81* MCH-26.1* MCHC-32.3 RDW-16.0* Plt Ct-331
[**2116-4-6**] 06:40AM BLOOD Glucose-203* UreaN-55* Creat-1.4* Na-138
K-4.4 Cl-103 HCO3-28 AnGap-11
[**2116-4-6**] 06:40AM BLOOD ALT-58* AST-28 AlkPhos-63 TotBili-0.3
[**2116-4-1**] 01:15PM BLOOD proBNP-2799*
[**2116-4-1**] 01:15PM BLOOD cTropnT-0.17*
[**2116-4-1**] 08:50PM BLOOD CK-MB-4 cTropnT-0.25*
[**2116-4-2**] 03:48AM BLOOD CK-MB-3 cTropnT-0.18*
[**2116-4-3**] 04:14AM BLOOD CK-MB-2 cTropnT-0.07*
[**2116-4-6**] 06:40AM BLOOD Albumin-3.2*
[**2116-4-5**] 04:42AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.6
[**2116-4-2**] 03:09PM BLOOD calTIBC-360 VitB12-1054* Folate-GREATER
TH Ferritn-208 TRF-277
.
Imaging:
Chest X-ray [**2116-4-1**] - New diffuse alveolar opacities throughout
both lungs and perihilar haziness are findings consistent with
moderate-to-severe
pulmonary edema. Probable moderate layering pleural effusions
also exist.
Opacification of the bases is greater than the upper lung zones,
likely de to underlying chronic interstitial lung disease seen
on prior chest radiographs and CT. Median sternotomy wires are
intact. Mediastinal and hilar contours are within normal limits.
Evaluation of the cardiac silhouette is limited due to pleural
fluid. There is no pneumothorax or definite focal consolidation.
IMPRESSION: 1. New moderate-to-severe pulmonary edema
superimposed upon known chronic interstial lung disease.
2. Possible new bilateral pleural effusions.
.
CT scan [**2116-4-3**]:
Known fibrotic changes, likely to reflect mild-to-moderate UIP.
Newly appeared ground-glass opacities in both lungs and in
diffuse
distribution, suggesting either acute exacerbation or
superinfection, for
example with PCP. [**Name10 (NameIs) 227**] the distribution of the changes, acute
allergic
alveolitis is less likely.
.
ECHO [**2116-4-2**]: Compared with the findings of the prior study
(images reviewed) of [**2116-2-20**], the posterior wall is now
severely hypokinetic/akinetic
.
Brief Hospital Course:
84 yo M with h/o CHF, pulmonary fibrosis and pulmonary
hypertension presenting with dyspnea, hypoxemia, elevated BNP
and bilateral infiltrates on chest xray. Likely had CAP and CHF
exacerbation with underlying IPF, improved with antibiotics,
prednisone course and diuresis.
.
ACTIVE ISSUES:
==============
# Hypoxemia: Initial differential included CHF, pneumonia or
worsening UIP/IPF. Ruled out for flu. He was started on
non-rebreather and did not require intubation. He was diuresed
with IV lasix, started on high dose IV steroids and covered for
CAP with Azithromycin and Ceftriaxone. He continued to require
100% NRB on hospital day 2. High dose steroids were stopped for
one day as unclear whether IPF flare but re-started once CT
chest findings more consistent with IPF and overlying pulmonary
edema. He was weaned to 5 L nasal cannula with high-dose
steroids, aggressive diuresis (-4L) and antibiotics. He was
stable after coming to the floor and was maintaining sats on 4L
O2 nasal cannula. He completed a 5-day course of azithromycin
and will have a total of 7-days of ceftriaxone/cefpodoxime. He
was restarted on his home lasix dose for continued diuresis and
was largely euvolemic on exam. Pulmonology evaluated patient and
recommended a taper of prednisone from 60mg over 2 weeks until
follow up with Dr. [**Last Name (STitle) **]. He was started on bactrim prophylaxis
while on steroids. Patient's initial hypoxemia was likely in the
setting of CHF exacerbation and community acquired pneumonia
causing severe symptoms given underlying structural disease due
to IPF. Patient was discharged to rehab on 3-4L O2 and will
likely need temporary home O2 after going home.
.
# NSTEMI: Had elevated troponin which peaked at 0.25 with normal
CK and CK-MB, no new ECG changes. TTE showed a posterior wall
motion abnormality which per Dr. [**First Name (STitle) **] was seen on previous
studies, though the official read said this was new since [**Month (only) 958**].
Patient had no chest pain or other symptoms. He was continued on
ASA 81mg, simvastatin 40mg, and on atenolol and lisinopril upon
discharge. He should follow up with his cardiologist as
outpatient.
.
# Hemoptysis: patient had 2-week history of bloody sputum
starting 2 weeks prior to admission which gradually imprvoed
throughout hospitalization. His INR was supratherapeutic on
admission and coumadin was held as below. Small amounts of
hemoptysis were likely due to infection or CHF with underlying
IPF and supratherapeutic INR. At time of discharge, he did not
have any more blood tinged sputum and HCT remained stable.
.
# CHF: patient was slightly volume overloaded on admission with
CT chest demonstrating ground glass opacities consistent with
IPF and/or pulmonary edema. He was diuresed aggresively in the
MICU with net negative output of 4L and improvement in
oxygenation. He was restarted on his home diuretic regimen at
time of discharge.
.
# Anemia - iron studies consistent with iron deficiency anemia,
likely mixed picture with anemia of chronic inflammation.
Patient was started on ferrous sulfate supplementation with
bowel regimen of senna, colace, and miralax. HCT remained stable
at 32 throughout admission and should be trended as outpatient.
.
INACTIVE ISSUES:
================
# Atrial fib: On coumadin as outpatient, held in setting of
supratherapeutic INR and restarted at decreased dose on
discharge given azithromycin use. His INR at time of discharge
was 3.4 and coumadin dose was 4mg 4x/week and 2mg on the other 3
days. He will have his INR rechecked at rehab.
.
# Gout: Held colchicine on admission in setting of mildly
elevated renal insufficiency and aggressive diuresis. This was
restarted after renal function normalized. No symptoms of gout
flare throughout hospitalization.
.
# Obstructive Sleep Apnea: continued on cpap at night during
hospital stay.
.
# GERD: Continued xantac
.
TRANSITION OF CARE:
===================
# INR check - in 2 days for goal INR [**1-16**]. Coumadin dose at time
of discharge was 4mg 4x/week and 2mg the other 3 days, INR was
3.4.
.
# Anemia - should have HCT trended as outpatient and consider
further work-up. Discharged on iron supplementation.
.
# Home oxygen - discharged to rehab on 3-4L O2 which should be
tapered as tolerated. [**Month (only) 116**] need temporary course of home O2.
.
# Follow-up with pulmonology on [**2116-4-20**] to possibly stop steroid
taper which was inititated for IPF on this hospitalization. Will
also have repeat PFTs at that time.
.
# Follow-up with cardiology regarding NSTEMI - discharged on
ASA, statin, atenolol, and lisinopril.
Medications on Admission:
ATENOLOL - 25 mg Tablet - one Tablet(s) by mouth once a day
CALCITRIOL - 0.25 mcg Capsule - 1 Capsule(s) by mouth Daily
COLCHICINE - 0.6 mg Tablet - [**12-17**] Tablet(s) by mouth once a day
DISOPYRAMIDE [NORPACE CR] - 100 mg Capsule, Extended Release - 1
Capsule, Sustained Release(s) by mouth twice a day
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 20 mg
Tablet - 2 (Two) Tablet(s) by mouth twice a day - lasix 40, 20
po
LISINOPRIL - 5 mg Tablet - one Tablet(s) by mouth once a day
METFORMIN - 850 mg Tablet - 1 Tablet(s) by mouth twice a day new
dose
RANITIDINE HCL - 150 mg Capsule - one Capsule(s) by mouth twice
a
day
SIMVASTATIN - 40 mg Tablet - one Tablet(s) by mouth once a day
WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth daily as needed
for
warfarin dose As directed by Coumadin provider
[**Name Initial (PRE) **] - 2 mg Tablet - [**12-15**] Tablet(s) by mouth daily As
directed
by Coumadin provider
[**Name Initial (PRE) **] - 5 mg Tablet - 1 Tablet(s) by mouth four times weekly
Medications - OTC
ASCORBIC ACID [VITAMIN C] - (update omr) - 500 mg Tablet - 1
Tablet(s) by mouth daily
ASPIRIN [ASPIRIN LOW DOSE] - (update omr) - 81 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth daily
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - 1,000 mcg Tablet
-
1 Tablet(s) by mouth once a day
MULTIVITAMIN WITH IRON-MINERAL - (OTC) - Tablet - 1 (One)
Tablet(s) by mouth once a day
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. disopyramide 100 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO Q12H (every 12 hours).
6. ranitidine HCl 150 mg Capsule Sig: One (1) Tablet PO twice a
day.
7. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
8. colchicine 0.6 mg Tablet Sig: 1-4 Tablets PO DAILY (Daily).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
14. warfarin 4 mg Tablet Sig: One (1) Tablet PO MON, WED, FRI,
SUN.
15. warfarin 2 mg Tablet Sig: One (1) Tablet PO TUE, [**Last Name (un) **], SAT.
16. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
17. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
18. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
19. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
20. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): ***PLEASE TAPER AS FOLLOWS: take 60mg daily for two
more days (last day = [**4-9**]), then take 50mg from [**Date range (1) 40693**], then
take 40mg from [**Date range (1) 58651**], then take 30mg from [**Date range (1) 58652**], then take
20mg from [**Date range (1) 16935**], take 10mg daily after that.
22. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
23. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 days: last day = [**4-8**].
24. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Primary:
Community acquired pneumonia
Acute on chronic systolic heart failure
Idiopathic pulmonary fibrosis
NSTEMI
Secondary:
Atrial fibrillation
Type 2 DM
Gout
CAD
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 40102**],
You were admitted to [**Hospital1 18**] with difficulty berathing and went to
the ICU. We treated you for an infection in your lungs and fluid
overload, as well as a possible flare of your IPF. Your
breathing improved and you were transferred to the regular
medical floor. You have underlying abnormalities in your lungs
due to the fibrosis and infection or heart failure exacerbation
can cause you difficulty with breathing. You will be going to a
rehab facility on some oxygen and this will be weaned down over
time. You have 1 more day of antibiotics for your infection and
you will also be completing a course of steroids for your IPF,
as described below.
You should follow up with your Dr. [**Last Name (STitle) **] at the date/time below
and call Dr. [**Last Name (STitle) 93118**] to make a follow up appointment after you
leave the rehab.
We have made the following changes to your medications:
- TAKE cefpodoxime 200mg twice daily for 1 more day after
leaving the hospital (last day = [**2116-4-8**]) for your lung
infection
- TAKE prednisone 60mg daily for two more days (last day =
[**4-9**]), then take 50mg from [**Date range (1) 40693**], then take 40mg from
[**Date range (1) 58651**], then take 30mg from [**Date range (1) 58652**], then take 20mg from
[**Date range (1) 16935**]. You will have a follow up appointment on [**4-20**] with Dr.
[**Last Name (STitle) **] at which point he may discontinue your steroids
- START bactrim 1 double strength tab daily while you are on the
steroids
- START ferrous sulfate (iron supplement) for your anemia
- START senna, colace, miralax and dulcolax as needed daily to
help move your bowels
- DECREASE your coumadin to 4mg four times a week and 2mg on the
other 3 days; please have your INR re-checked in 2 days at rehab
for a goal INR of [**1-16**]
- CONTINUE your oxygen therapy, you may need to go home with
this temporarily after discharge
Followup Instructions:
The following appointments have already been scheduled for you:
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2116-4-20**] at 3:25 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2116-4-20**] at 3:45 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2116-5-7**] at 11:30 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: THURSDAY [**2116-5-7**] at 11:45 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: THURSDAY [**2116-5-7**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2116-4-7**]
|
[
"274.9",
"V15.84",
"288.60",
"280.9",
"515",
"410.71",
"433.10",
"427.31",
"482.9",
"250.60",
"327.23",
"V58.61",
"428.0",
"564.09",
"416.8",
"357.2",
"799.02",
"V42.2",
"V58.65",
"414.01",
"428.23",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14717, 14789
|
6372, 6648
|
307, 314
|
14999, 14999
|
3545, 3545
|
17148, 18538
|
1939, 2049
|
12441, 14694
|
14810, 14978
|
11006, 12418
|
15182, 16096
|
2064, 2064
|
4326, 6349
|
16125, 17125
|
260, 269
|
6663, 9609
|
342, 1338
|
9626, 10980
|
3559, 4312
|
15014, 15158
|
1360, 1558
|
1574, 1923
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,708
| 108,513
|
52317
|
Discharge summary
|
report
|
Admission Date: [**2179-4-27**] Discharge Date: [**2179-4-30**]
Date of Birth: [**2120-6-4**] Sex: M
CHIEF COMPLAINT: Mental status changes.
HISTORY OF PRESENT ILLNESS: This is a 57-year-old male with
multiple medical problems including cardiomyopathy, heart
Staphylococcus aureus, acquired immunodeficiency syndrome,
chronic obstructive pulmonary disease, and pulmonary embolism
who was admitted via the Emergency Department for hypercarbic
and anoxic respiratory distress.
In the Emergency Department, he was found to have a blood gas
of 7/121/115, and for this he admitted to the Medical
REVIEW OF SYSTEMS: Positive headache, lightheadedness,
shortness of breath, abdominal pain, constipation. No visual
changes, sore throat, dysphagia, chest pain, fevers, or
chills.
PAST MEDICAL HISTORY:
1. Right-sided heart failure.
2. Acquired immunodeficiency syndrome complicated by
candidal esophagitis; on antiretroviral therapy.
3. Intravenous drug use; the patient is on methadone.
4. Chronic lung disease and hypoventilation syndrome with
oxygen saturation on room air typically in the low 80s. He
is on chronic oxygen therapy.
5. Pulmonary embolism and deep venous thrombosis; the
patient on Coumadin.
6. Hepatitis C.
7. Central and peripheral sleep apnea.
8. Renal failure; on dialysis.
9. Hemorrhoidal bleeding.
10. Splenomegaly.
11. Multiple episodes of pneumonia with respiratory
failure and intubation.
12. Benign prostatic hyperplasia.
13. Anemia.
14. Depression.
15. Chronic pancreatitis of unclear etiology.
16. Hepatitis B.
FAMILY HISTORY: Father died of unknown causes. Mother died
of a myocardial infarction at the age of 75. Brother died in
[**Country 3992**]. His sister is alive and well with three children.
SOCIAL HISTORY: He lives with his wife and has a
100-pack-year history of smoking; he quit in [**2166**]. He has a
long history of alcohol and heroin use and has been on
methadone since [**2162**]. For the past several years prior to
admission, he has been on dialysis. His physical condition
has markedly deteriorated, and he is unable to ambulate
without assistance.
ALLERGIES: HALDOL, STELAZINE, THORAZINE, CODEINE, H2
BLOCKERS, CLINDAMYCIN.
MEDICATIONS ON ADMISSION: Albuterol meter-dosed inhaler
2 puffs q.i.d. p.r.n., Atrovent meter-dosed inhaler 2 puffs
q.8h. p.r.n., methadone 50 mg p.o. q.d., zinc sulfate 220 mg
p.o. q.d., Coumadin 2.5 mg p.o. q.h.s., stavudine 20 mg p.o.
q.d., Zoloft 50 mg p.o. q.d., Protonix 40 mg p.o. q.d.,
lamivudine 25 mg p.o. q.d., vitamin C 500 mg p.o. b.i.d.,
amiodarone 200 mg p.o. q.d., Colace 100 mg p.o. b.i.d.,
Bactrim-DS one tablet p.o. three times per week (Tuesday,
Thursday, and Saturday), Renagel 1600 mg p.o. t.i.d.,
levothyroxine 25 mcg p.o. q.d., Nephrocaps 1 mg p.o. q.d.,
Roxicet one to two tablets p.o. q.i.d. p.r.n. for pain, and
Bicitra.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
temperature of 98.8, heart rate of 80, blood pressure of
98/52, respiratory rate of 16, oxygen saturation of 94% on 3
liters nasal cannula. In general, cachectic. Head, eyes,
ears, nose, and throat revealed mucous membranes were moist.
Pupils were equal, round and reactive to light. Extraocular
movements were intact. Neck revealed no jugular venous
distention appreciated. Chest revealed coarse fibrotic
breath sounds bilaterally with occasional expiratory wheezes.
In addition, there were also some wet crackles. Heart had a
regular rate and rhythm laterally and downward, displaced
point of maximal impulse with a murmur heard at the base of
the heart without radiation to the carotids. Abdomen revealed
positive bowel sounds, scaphoid. Extremities revealed
toenails with evidence of superficial infection.
RADIOLOGY/IMAGING: Electrocardiogram revealed sinus at 73
with left and right atrial abnormalities, left axis
deviation, supraventricular conduction delay.
A chest x-ray revealed no consolidations, no effusions, no
congestive heart failure. Positive interstitial markings.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count of 4.6, hematocrit of 43.5, platelets of 101, mean cell
volume of 120. INR of 1.7. Sodium of 138, potassium of 4.9,
chloride of 100, bicarbonate of 29, blood urea nitrogen
of 25, creatinine of 8.4, blood glucose of 53. Albumin
of 3.1, calcium of 8.5, phosphate of 6, magnesium of 2.
Blood gas revealed 7/121/115, sputum with 4+ gram-negative rods
and o/p flora.
HOSPITAL COURSE: The patient was admitted for hypercarbic
respiratory failure.
1. CARDIOVASCULAR: The patient was maintained on
amiodarone for a history of ventricular tachycardia. He did
not require pressor support. He did not require diuresis.
2. PULMONARY: The patient required oxygen at baseline, and
he was kept on nasal cannula oxygen throughout his stay. To
correct his hypercarbia and hypoxia, he was initially placed
on noninvasive mask ventilation which resulted in marked
improvement of his respiratory status. A repeat arterial
blood gas was shown to be 7.18/80/64 with a lactate of 0.4.
He was initially given steroids, but then these were
discontinued because it was felt that he was not having a
chronic obstructive pulmonary disease exacerbation. He was
started on levofloxacin and will continue a 10-day course,
finishing on [**2179-5-8**]. He was to be discharged on home
oxygen, and his primary care provider planned to give him a
BiPAP machine at home, hopefully to avoid need for
readmission.
3. RENAL: The patient was maintained on hemodialysis
during his course. He was changed from sodium bicarbonate to
baking soda, and he was given Nephrocaps instead of folate
and multivitamin. He was followed in consultation by the
Renal Service while he was here.
4. INFECTIOUS DISEASE: The patient was treated with
Levaquin 250 mg p.o. q.o.d. beginning on [**2179-4-28**]; to
continue until [**2179-5-8**]. He was also maintained on
lamivudine and stavudine in addition to prophylactic Bactrim.
5. GASTROINTESTINAL: The patient was maintained on
Protonix, and he did not have any liver function tests
abnormalities.
6. HEMATOLOGY: The patient was maintained on Coumadin for
his history of pulmonary embolism. He was therapeutic during
his hospital stay.
7. FLUIDS/ELECTROLYTES/NUTRITION: The patient was
encouraged to take p.o.
8. NEUROLOGY: The patient maintained his mental status
without any changes once he was put on BiPAP. He was
maintained on Zoloft and maintenance methadone.
9. LINES: The patient had a dialysis cathether and a
central line.
10. CODE STATUS: The patient is full code.
MEDICATIONS ON DISCHARGE:
1. Albuterol meter-dosed inhaler 2 puffs q.i.d. p.r.n.
2. Atrovent meter-dosed inhaler 2 puffs q.8h. p.r.n.
3. Methadone 50 mg p.o. q.d.
4. Zinc sulfate 220 mg p.o. q.d.
5. Coumadin 2.5 mg p.o. q.h.s. (titrate to INR 2 to 3).
6. stavudine 20 mg p.o. q.d.
7. Zoloft 50 mg p.o. q.d.
8. Protonix 40 mg p.o. q.d.
9. Lamivudine 25 mg p.o. q.d.
10. Vitamin C 500 mg p.o. b.i.d.
11. Amiodarone 200 mg p.o. q.d.
12. Colace 100 mg p.o. b.i.d.
13. Bactrim-DS one tablet p.o. three times per week
(Tuesday, Thursday, and Saturday).
14. Renagel 1600 mg p.o. t.i.d.
15. Levofloxacin 250 mg p.o. q.o.d. (from [**2179-4-28**] to
[**2179-5-8**]).
16. Levothyroxine 25 mcg p.o. q.d.
17. Nephrocaps 1 capsule p.o. q.d.
18. Roxicet one to two tablets p.o. q.i.d. p.r.n. for pain.
19. Baking soda 0.5 teaspoon in 8 ounces of water p.o.
b.i.d.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE FOLLOWUP: The patient was to follow up with
Dr. [**Last Name (STitle) **] (who is his primary care doctor).
DISCHARGE DIAGNOSES:
1. Human immunodeficiency virus.
2. Cardiomyopathy.
3. End-stage renal disease.
4. Hepatitis B.
5. Hepatitis C.
6. Hypoventilation syndrome.
7. Intravenous drug use.
8. Chronic pancreatitis.
9. Depression.
10. Anemia.
11. Ventricular tachycardia.
12. Pneumonia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 9336**]
MEDQUIST36
D: [**2179-4-30**] 20:35
T: [**2179-5-4**] 09:34
JOB#: [**Job Number 35105**]
|
[
"070.32",
"496",
"425.4",
"428.0",
"518.81",
"585",
"042",
"070.54",
"V45.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
1600, 1778
|
7713, 8267
|
6659, 7520
|
2257, 4472
|
4490, 6632
|
7535, 7571
|
632, 795
|
135, 159
|
7592, 7691
|
188, 612
|
818, 1583
|
1795, 2230
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,948
| 130,018
|
44870
|
Discharge summary
|
report
|
Admission Date: [**2140-11-22**] Discharge Date: [**2140-12-23**]
Date of Birth: [**2088-10-25**] Sex: F
Service: MEDICINE
Allergies:
Oxycodone / Ciprofloxacin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Reason for ICU Admission: Hypernatremia, hypotension, acute
renal failure, failure to thrive
Major Surgical or Invasive Procedure:
PEG tube placement by surgical service on [**2140-11-30**]
femoral line placement
History of Present Illness:
Patient is a 52 year old female with history of Down's Syndrome,
dementia, and atrial fibrillation on coumadin, who presents to
the emergency room after a visit with her physician. [**Name10 (NameIs) 95980**] of
her group home brought her to the physician office as they were
concerned about her safety in the group home due to lack of oral
intake, difficulty walking (per report was newly in a wheelchair
for last two week). The ED physicians spoke with her brother,
who is also her HCP, who per report told them that she had had
very poor PO intake for "a while" at the group home, and the
family had been discussing moving her to a facility with a
higher-level of care.
Per report, her caregiver stated that her mental status appeared
at baseline, which was not very communicative. A copy of her PCP
visit note accompanies her paperwork and describes that she has
lost about 35 lbs, and possibly has been vomiting. Her INR was 7
recently and she received vitamin K for that.
Based on a speech and swallow evaluation note from [**2140-10-25**] in
OMR, at that time staff in the group home were concerned about
the patient's lack of PO intake. It was described at that time
that the patient was refusing former favorite foods, and would
eat about [**2-26**] spoonfulls prior to spitting out solid foods at
meals; there was also concern about choking on pills. It was
also noted that the patient appeared to regurgitate food after
meals (ongoing behavoir for 20 years). It was noted that she had
lost about 15 pounds due to this behavoir. The evaluation by the
speech and swallow team determined that her inadequate PO intake
was possibly secondary to dementia and behavoiral changes,
although further studies were recommended given inability to
fully evaluate.
Also of note, patient was admitted in [**Month (only) **] for failure to
thrive and decreased PO intake. It was found that she was
constipated, and she was tolerating a regular diet prior to
discharge.
In the ED, initially it was difficult to measure the patient's
blood pressure. Her heart rate was 90, respiratory rate of 14,
with difficulty measuring oxygen saturation. First recorded
blood pressure was 92/palp, with oxygen saturation of 100%.
Patient was lethargic but responsive with moaning and crying out
to verbal stimuli. She was given 2L of NS initially when her SBP
dropped to 70's and 80's. She was guaiac negative, and a chest
x-ray was unremarkable. Labs were notable for renal
insufficiency, hypernatremia (166), hyperchloremia (124),
lactate of 9.2, INR of 9.6 (then >11), and leukocytosis of 14.
A femoral line was placed and patient was given 4L of IVF with
improvement to systolics in 100's. However, then patient fell
asleep and systolic dropped to 70's, so she received an
additional 2 liters and levophed was started. She was given
vancomycin and zosyn, and cultures were drawn. She was also
given 5 mg of IV vitamin K for elevated INR. EKG was without
concering changes. FAST was negative (no free fluid, bedside
echo looked ok).
Upon arrival to the floor, patient was crying out. She would
make eye contact occasionally and stated "I love you" once,
otherwise was incomprehensible.
Past Medical History:
- Down's syndrome
- Alzheimers Dementia
- Mitral valve regurgitation, followed by Dr. [**Last Name (STitle) **]
- Hypothyroidism
- Status-post right mastectomy for breast cancer, last mammogram
[**7-/2139**] WNL
- Atrial fibrillation
- History of bacterial endocarditis in [**2126**]
- Status-post appendectomy (laproscopic [**12/2136**])
- Esophageal reflux and H. Pylori infection ([**6-/2137**])
- Status-post cholecystectomy
- Status-post laparoscopic umbilical hernia repair
- Status-post gangrenous cholecystitis, lap chole [**10-26**]
Social History:
Patient lives in group home. She recently has stopped walking
and has been in a wheelchair. No alcohol, drug, or tobacco use.
She enjoys playing with beads (per office note).
Brother [**Name (NI) **] [**Name (NI) 54135**] is HCP [**Telephone/Fax (1) 95981**]; work [**Telephone/Fax (1) 95982**] (?
home)
Per ED discussion with family, she is full code.
Family History:
Not known
Physical Exam:
ADMISSION PHYSICAL EXAM:
Temperature 95.7, HR 99, BP 111/57, RR 13, Oxygenation 100% on
RA
General: Thin, slightly catchetic female, moving around in bed
when name is called, crying out and alternatively curling up
HEENT: Very dry mucous membranes with fissuring of the lipds and
tongue. PERRL, no scleral icterus or conjunctival pallor.
Neck: Supple, no JVD
Cardiac: RR, III/VI holosystolic murmur, no rubs or gallops
Lungs: CTAB, although examination limited by effort, no apparent
wheezes, raltes
Abd: Soft, +BS, ND, cannot assess for tenderness, but no
guarding
Extr: Very dry, cracked skin over dorsum of hands, feet. Few
small ecchymoses over right thigh, no discrete rashes or other
lesions.
Neuro: Awake, agitated, difficult to understand when makes
attempts at speaking, CNs appear symmteric, moving all
extremities equally.
Pertinent Results:
ADMISSION LABS:
[**2140-11-22**] 05:40PM BLOOD WBC-14.1*# RBC-3.77* Hgb-14.2 Hct-44.3
MCV-117*# MCH-37.6*# MCHC-32.0 RDW-15.2 Plt Ct-528*#
[**2140-11-22**] 05:40PM BLOOD Neuts-83.3* Lymphs-14.0* Monos-2.4
Eos-0.1 Baso-0.2
[**2140-11-22**] 06:42PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-2+ Target-1+ Schisto-1+
Stipple-1+
[**2140-11-22**] 05:40PM BLOOD PT-76.9* PTT-41.8* INR(PT)-9.6*
[**2140-11-22**] 06:42PM BLOOD Glucose-135* UreaN-86* Creat-3.4*#
Na-166* K-3.6 Cl-124* HCO3-30 AnGap-16
[**2140-11-22**] 11:24PM BLOOD ALT-20 AST-41* LD(LDH)-365* CK(CPK)-334*
AlkPhos-58 Amylase-15 TotBili-0.7
[**2140-11-22**] 05:40PM BLOOD Calcium-9.3 Phos-8.5*# Mg-3.6*
[**2140-11-22**] 11:24PM BLOOD Osmolal-357*
[**2140-11-22**] 11:24PM BLOOD TSH-3.3
[**2140-11-22**] 11:24PM BLOOD Free T4-1.0
[**2140-11-22**] 05:40PM BLOOD Lactate-9.2* K-4.5
URINE STUDIES:
[**2140-11-22**] 06:42PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.019
[**2140-11-22**] 06:42PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-8* pH-6.5 Leuks-TR
[**2140-11-22**] 06:42PM URINE RBC-0-2 WBC-0-2 Bacteri-MANY Yeast-NONE
Epi-[**1-26**]
[**2140-11-22**] 06:42PM URINE CastHy-21-50*
[**2140-11-23**] 01:43AM URINE Hours-RANDOM UreaN-898 Creat-100 Na-65
Cl-61
[**2140-11-23**] 01:43AM URINE Osmolal-636
OTHER STUDIES:
[**2140-11-24**] 03:53AM BLOOD VitB12-1418*
[**2140-11-22**] 11:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Corisol [**11-23**] 20.4, [**11-25**] 7.5
[**12-4**] TSH 19
CARDIAC ENZYMES:
[**2140-11-22**] 06:42PM BLOOD cTropnT-0.53*
[**2140-11-22**] 11:24PM BLOOD CK-MB-9 cTropnT-0.31*
[**2140-11-23**] 09:05AM BLOOD CK-MB-10 MB Indx-3.2 cTropnT-0.29*
[**2140-11-22**] 06:42PM BLOOD CK(CPK)-235*
[**2140-11-22**] 11:24PM BLOOD CK(CPK)-334*
[**2140-11-23**] 09:05AM BLOOD CK(CPK)-310*
EKG: Atrial fibrillation, normal axis, LVH with non-specific ST
changes (T wave inversions in V2-V6 not seen on prior from
[**5-1**]), question of ST depression in II, but not consistent--poor
baseline. RBBB
MICROBIOLOGY:
[**2140-11-22**] Blood Cultures x 2: negative
[**2140-11-22**] Urine Cultures: negative
[**2140-11-23**] Urine Cultures: negative
[**2140-12-2**] 10:22 am URINE Source: Catheter.
**FINAL REPORT [**2140-12-4**]**
URINE CULTURE (Final [**2140-12-4**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**12-18**] Cdiff negative
RADIOLOGY:
[**2140-11-22**] CXR:
UPRIGHT AP VIEW OF THE CHEST: Mild cardiomegaly is
redemonstrated. The
mediastinal and hilar contours are unchanged and within normal
limits. The
pulmonary vascularity is normal. The lungs are clear. There is
no focal
consolidation, pleural effusions or pneumothorax. Right upper
quadrant
abdominal surgical clips denote prior cholecystectomy.
IMPRESSION: No acute cardiopulmonary abnormality.
[**2140-11-23**] KUB:
There is no evidence of ileus, obstruction, or free air. There
is
normal bowel gas pattern. Clips are seen in the right upper
abdominal
quadrant likely from previous cholecystectomy. There is a single
clip in the left lateral mid abdomen.
IMPRESSION: No evidence of obstruction or ileus.
[**2140-11-23**] TTE:
The left atrial volume is markedly increased (>32ml/m2). The
interatrial septum is aneurysmal. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are myxomatous.
There is moderate/severe mitral valve prolapse. An eccentric,
posteriorly directed jet of severe (4+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is severe pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Severe prolapse of the anterior leaflet of the
mitral valve with severe, posteriorly directed mitral
regurgitation, severe pulmonary hypertension and an inter-atrial
septum that is bowed towards the right. Biventricular systolic
function looks normal. There is no pericardial effusion.
[**2140-11-29**] HEAD CT w/o CONTRAST:
1. No acute intracranial hemorrhage or edema.
2. Marked, disproportionate enlargement of the 3rd, 4th and left
more
than right lateral ventricles, with no prior study available for
comparison.
.
[**12-5**] MR head / MRA:
1. Markedly dilated ventricles again demonstrated, unchanged
from prior CT.
Findings could be consistent with communicating hydrocephalus
and correlation
for possible NPH is recommended.
2. Multiple old infarcts again identified, not significantly
changed from
prior CT.
3. Left vertebral artery not definitely visualized, possibly
occluded at the
origin versus hypoplastic artery, consider MRA neck for further
evaluation.
.
[**12-14**] CXR: Interval increase in right upper lobe opacification
consistent
with worsening aspiration or pneumonia. Persistent mild
congestive heart
failure and bilateral lower lobe air space consolidation.
.
[**12-23**] digoxin level 1.8, WBC 3.8, HCT 28, Na 140, K 4.4, HCO 33,
Cr 0.6, BUN 12
Brief Hospital Course:
HYPOTENSION:
Ultimately Ms. [**Known lastname 95983**] hypotension was thought to be due to
profound volume depletion in the setting of poor PO intake. Her
baseline SBP was noted to be low in the 100's, according to
out-patient records. On arrival she was admitted to the ICU. She
was started on vancomycin and zosyn for presumed sepsis, though
she remained afebrile and no infectious source was identified
(CXR was unremarkable, abd exam benign, UA/UCx negative, no
diarrhea, no skin lesions). MAPS's were maintained greater than
65 on norepinephrine upon admission. She was gradually weaned
from pressors by [**2140-11-27**] and maintained SBP in the 90-100 range
while awake (pressures dropped slightly to the 80's while
sleeping).
.
Other causes of hypotension were ruled out. There was no
evidence of bleeding. She has known hypothyroidism and is on
levothyroxine, but TSH/free T4 were normal. She was not
adrenally insufficient, as she passed a CortStim test. TTE did
not show worsening valvular disease or focal wall motion
abnormalities; although she had a slight troponin elevation on
admission, CK-MB fractions were normal and there was no evidence
of ischemia on EKG's. PE was considered unlikley given the
patient's supratherapeutic INR on admission and good
oxygenation.
.
She was transfered to the medical floor the first time on
[**2140-12-1**]. She remained asymptomatic there but relatively
hypotensive. On [**12-5**], she received a dose of zyprexa prior to an
MRI, and her SBP was noted to be drop to the 60s. She also has
found to have a UTI in the setting of this hypotension. She
received 2L NS with improvement to the 80s, and was transferred
back to the ICU, where levophed was again initiated. During her
second ICU [**Last Name (un) 26796**] she was also aggressively diuresed as she had
evidence of [**Last Name (un) 1534**] body volume overload and anasarca. With her
known 4+ MR, it was felt that afterload reduction would improve
her hemodynamics. She also received a transfusion of 1 unit of
pRBCs to boost her intravascular oncotic pressure. She was
slowly weaned down off pressors by [**12-14**]. Of note, she had no
evidence of hypoperfusion as evidenced by venous lactates of 1.1
despite a MAP in the 40s on one occasion.
.
She was transfered but to the medical floor on [**12-15**] where her
blood pressure remained stable on midodrine with occasional
brief hypotensive episodes to the upper 70s. Even at these
pressures mental status and urine output were maintained.
Diuresis with bolus IV lasix was continued and then transfered
to PO. However it was discontinued on [**12-20**] because of increased
autodiuresis and worsening tachycardia. With improved afib
control with amio and dig her blood pressures improved to
120/80s. When a steady state if dig is reached, downtritration
of midodrine showed be considered.
.
FAILURE TO THRIVE, PEG TUBE PLACEMENT:
Ms. [**Known lastname 54135**] has been noted by family members, group home members
and her out-pateint doctors to have had FTT over the [**1-25**] several
months with profound behavioral changes, including withdrawal
and refusal to eat. Within the last year, she had been given a
diagnosis of Alzheimer's Dementia (confirmed with neurologist
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10983**] in [**Location (un) 1411**], MA). Per Dr. [**Last Name (STitle) 95984**] prior
medical work-up for dementia and behavioral change had been
negative, although it was difficult to obtain imaging studies as
an out-patient due to the patient's inabilit to cooperate with
the tests. Head CT was performed on [**2140-11-29**] in-house to complete
a dementia work-up and showed no acute bleed or mass effect, but
large 3rd & 4th ventricles.
On admission, an NG tube was placed to deliver nutrition
(albumin was noted to be 2.1), although the patient pulled out
the NGT. Multiple conversations were had with the patient's HCP
(her brother [**Name (NI) **] and sister-in-law about goals of care and the
family's wishes. It was decided that she should have a PEG tube
placed for feeding given her refusal to eat (throughout the
admission she refused PO intake and medications, as well as
mouth care). The surgical service placed a PEG tube on [**2140-11-30**]
without complication. Medications were switched to PO and tube
feedings were started on [**2140-12-1**].
After transfer to the floor Ms [**Known lastname **] had an episode of
hypoglyemia even with ongoing Tube feeds without residuals.
Finger sticks were monitored, however no further hypoglyemia was
noted.
.
ASPIRATION PNEUMONIA:
During her second MICU stay she remained on TFs via her PEG
tube. She did become nauseated and vomited x 1 on [**12-8**], with an
associated desaturation and increased O2 requirement. It was
felt c/w an aspiration event, and subsequent CXRs were c/w
aspiration. She was begun on an empiric course of Vanc/Zosyn for
a possible HAP x 10 day course ([**12-9**] - [**12-18**]). She was
aggressively diuresed for concern of ARDS, but her O2
reuqirement was easily weaned back to baseline. Her paxil was
d/c'ed out of concern for any contribution to an altered mental
status.
.
ATRIAL FIBRILLATION:
The patient was on sotalol and warfarin as an out-patient. INR
was 11.3 on admission likely from poor nutritional status. She
was given Vitamin K 5 mg and warfarin was held on admission with
gradual improvement in INR. Sotalol was held while not taking
PO medications; no other rate controlling agents were started
given hypotension, and HR was generally in the 80-90 BPM range.
By [**2140-11-26**], her HR had started to climb to the 110-120's with
occassional increases to the 130-140's (BP remained stable
during these episodes). She was started on IV amiodarone for
rhythm control on [**2140-11-26**] with good effect. After placement of
the PEG tube, she was started on amiodarone 400 mg TID which was
later deceased to 200 mg daily once a loading dose was finished.
Warfarin was started on [**2140-11-30**]. On [**12-20**] tachycardia worsening
and unresponsive to metoprolol and fluids. Amio was increased to
400mg daily and Digoxin was loaded with 0.25mg x 4 IV. This load
resulted in improved HR control with HR in 80-90s and a large
increase IN BPs to 120s/80s. She is to continue on dig at .125mg
daily. Please have her blood drawn on Tuesday, [**12-27**] to
measure her digoxin level. Fax this result to Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) **] (office phone [**Telephone/Fax (1) **]) and obtain
recommendation from him regarding dosage changes of this
medication. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], her long-standing cardiologist, was
aware of the plan to anticoagulate and discharge on PO
amiodarone and Dig. He plans to electrically cardiovert in [**2-27**]
weeks after discharge. At the time of d/c INR had diped to 1.6
after decreasing the dose in the setting of a previously rising
INR to 2.7. On [**12-22**] coumadin was adjusted to previous home dose
of 1 mg daily. INR is anticipated to rising quickly with this
adjustment and subsequent increase in amiodarone dosage. INR
should continue to be monitored closely.
ACUTE RENAL FAILURE:
Given history and lab studies, ARF on admission was supsected to
be pre-renal in etiology. In addition to poor PO intake, she
was noted to be on lasix when admitted. Her baseline creatinine
from [**7-/2140**] was around 1.0, but Cr was 3.4 on admission (with
BUN 86). UA/UCx were negative for infection. Cr improved to
0.7 with aggressive hydration. Cr remained stable during her
later aggressive diuresis.
.
A foley has been in place to prevent decub infection and left in
at time of transfer. Upon arrival foley should be removed and a
voiding trail performed. After 1st void or after 12 hr (which
ever comes first) please perform a bladder scan and reinsert
foley for residual urine > 450 cc.
UTI:
E coli urinary tract infection was noted on [**12-2**] culture and IV
cipro was started for a 3 day course
HYPOTHYROIDISM:
Patient was euthyroid on admission (see above). She was
continued on levothyroxine 37.5 mcg IV (equivalent to home dose
of 75 mcg PO) while not taking PO's in-house. She was changed
backed to PO thyroid replacement. TFTs and PFTs should be
monitored as an outpatient with the addition of amiodarone.
QUESTION OF SEIZURE DISORDER, ON DEPAKOTE:
Patient with unclear history of seizure disorder; home
medication list on admission listed trileptal and depakote.
History was clarified with home neurologist, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 10983**], who said patient was on these medications for mood
stabilization and has no known seizure disorder. Dr. [**Last Name (STitle) 10983**]
had initially tried her on triletptal, but this gave her
hyponatremia; she was later changed to depakote. While
in-house, she was maintained on the equivalent dosage of
valproic acid because she was not taking PO's. If her mood
worsens may consider restarted home doses of depakote and
trileptal
Mental staus: Her mental status has rapidly deterioated over the
last year, and PTA was not oriented, responding only with moans
and simple words. She was diagnosed with alzhemers by her
neurologist prior to admission. In house a paxil trial has
attempted, to see if depression treatement would improve mental
status. No improvement was seen and paxil was later d/ced for
fear that in was overly sedating. Imaging showed She has
extensive atrophy of her medial temporal lobes and hippocampus.
She also has extensive regions of brain infarction and
leukoencephalopathy both frontally and cerebellar. Neuro was
consulted for management and evaluation for possible
communicating hydrocephalus. Per neuro the hydrocephalus is
explained by two preocesses- 1) ex vacuo due to atrophy and
infarction of brain tissue and 2) loss of white matter firmness
and support leads to further ventricular enlargement. These
processes are not improved by shunting which carries a
substantial risk. Neuro strongly favored not performing an LP or
considering placement of a shunt. Secondly, her history of
sedatives before MRI leading to profound hypotension is another
risk that may outweigh any benefit.
.
PENDING ISSUES FOR FOLLOW-UP:
(1) Needs to follow up with cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for
follow-up and possible elective electric cardioversion and dig
management
(2) Patient was discharged on warfarin with goal INR of 2.0 -
3.0. INR should be followed closely as recently increased amio
could alter metabolism
(3) Needs a follow-up appointment with her PCP [**Name Initial (PRE) 176**] 1-2 weeks
following rehab discharge.
(4) Further management of midodrine, and mood stabilizers should
be considered
Medications on Admission:
Home Medications:
(per office visit note faxed over)
- Coumadin 1 mg daily
- Senna 8.6 mg daily
- Sotalol 120 mg [**Hospital1 **]
- Potassium Chloride 40 mEq daily
- Lasix 40 mg daily
- Ketaconazole as needed
- Triamcinolone cream as needed
- Prilosec 20 mg [**Hospital1 **]
- Bacitracin ointment PRN
- Amoxicillin prior to dental procedures
- Levothyroxine 75 mcg
- Lorazepam 1 mg prior to medical procedures
- Depakote 1500 mg daily
- Trileptal 300 mg [**Hospital1 **]
Discharge Medications:
1. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed.
2. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day) as needed.
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Levothyroxine 88 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Midodrine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a
day).
9. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
11. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO
DAILY (Daily).
12. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
13. Warfarin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM.
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Prochlorperazine 5 mg IV Q6H:PRN
16. Dextrose 50% 12.5 gm IV PRN BG < 60
17. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
18. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times
a day).
19. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup [**Last Name (STitle) **]: Two
Hundred (200) mg PO Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
failure to thrive
malnutrition
paroxysmal a fib with RVR
Alzheimer's dementia
severe mitral regurgitation
urinary tract infection
aspiratin pneumonia
.
secondary diagnosis:
Down's syndrome
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital for failure to thrive after
not eating for a prolonged time. Your blood pressure was very
low, requiring time in the ICU and vasopressors to raise your
blood pressure. Your hypotension was partially due to extreme
dehydration. Your blood pressure further improved with improved
management of your irregular heart rythem.
.
Your stay was also complicated by an iregular heart beat (atrial
fibrillation) which has been controled with drugs. You also
developed an urinary tract infection and lung infection whcih
were treated with antibiotics
.
Have your blood drawn on Tuesday, [**12-27**] to measure your
digoxin level. Fax this result to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) **]
(office phone [**Telephone/Fax (1) **]) and obtain recommendation from him
regarding dosage changes of this medication.
.
You had a PEG (feeding) tube place to give you nutrition.
.
The following changes have been made to your medications:
Midodrine was added for your blood pressure
Sotolal was discontinued and replaced with amiodarone and
digoxin
Depakote and Trilepal were replaced with valproic acid
.
Please follow up with your doctors as detailed below.
.
If you develop fevers, chills, lightheadedness or dizziness,
abdominal pain, diarrhea, cough, chest pain, difficultly
urinating, or any other worrisome symptoms please call your
doctor or go to the emergency room.
Followup Instructions:
PCP: [**Last Name (LF) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 608**]
.
Cardiology: MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Date and time: 2/25/09@1:15pm
Location: [**Hospital6 **], [**Doctor Last Name 3649**] Building, [**Apartment Address(1) **]
Phone number: [**Telephone/Fax (1) 7960**]
.
Have your blood drawn on Tuesday, [**12-27**] to measure your
digoxin level. Fax this result to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) **]
(office phone [**Telephone/Fax (1) **]) and obtain recommendation from him
regarding dosage changes of this medication.
Completed by:[**2140-12-23**]
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32,348
| 141,650
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3518
|
Discharge summary
|
report
|
Admission Date: [**2142-7-16**] Discharge Date: [**2142-7-19**]
Date of Birth: [**2068-1-28**] Sex: M
Service: MEDICINE
Allergies:
Clonidine
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
Colonoscopy, argon laser treatment
History of Present Illness:
74 year old male with recent NSTEMI with BMS to RCA on
plavix/aspirin, Afib on coumadin, radiation proctitis and
diverticulosis presents with BRBPR for 24 hours. He noticed some
blood on his seat after standing up at noon on the day prior to
admission. He has had this previously, so hoped it would go
away. However, he continued to notice small amounts of BRB
whenever he stood or went to the bathroom, therefore he came to
the ED today.
ROS: +LE edema. No SOB, cough, CP, nausea, vomiting, dysuria,
fever, chills, diarrhea, constipation.
In ED: T 98.6, HR 79, BP 169/53, R 18, 99% RA. Transfused 1 unit
PRBCs, given vitamin K 10 units SC, 1 L NS.
Past Medical History:
CAD: s/p NSTEMI [**6-4**] with BMS to RCA, 70% LCx and 70% LAD w/
diffuse disease, planned CABG in [**4-1**] months
HTN
Hypercholesterolemia
Type II DM dx at age 40 - on insulin
CHF [**6-4**] echo EF= 35%, 2+MR
Afib - on coumadin h/o embolic CVA - 15 yrs ago, right leg and
arm weakness
CRF - b/l Cr 4.5; attributed to fleets prep for c-scope
h/o prostate cancer s/p XRT
h/o Colonic polyps (2 benign, 1 hyperplastic [**6-3**])
Radiation proctitis ([**6-3**], 0-8 cm from verge)
diverticulosis
Social History:
Lives with his 2 sons. [**Name (NI) **] h/o tob or illicit drug use. +
occasional glass of wine. Worked in computers. Trained as a
physicist.
Family History:
No liver or renal dz. + MI and CVA in dad at age 70.
Physical Exam:
Physical Exam on admission:
96.6, 174/66, 67, 18, 97% RA
GEN: NAD, pleasant
HEENT: pale conjunctiva, MMM, eomi
CV: Irreg irreg, [**3-6**] sm
PULM: CTA, decreased BS at bases
ABD: + BS, soft, NT, ND
Rectal: BRB per ED
EXT: b/l LE edema, R>L
Pertinent Results:
Laboratory studies on admission:
[**2142-7-16**]
WBC-9.5 HGB-8.9* HCT-25.7* MCV-93 RDW-15.8* PLT COUNT-383
NEUTS-86.3* LYMPHS-7.6* MONOS-4.5 EOS-1.1 BASOS-0.5
PT-27.3* PTT-31.8 INR(PT)-2.8*
GLUCOSE-204* UREA N-66* CREAT-4.2* SODIUM-137 POTASSIUM-5.0
CHLORIDE-104 TOTAL CO2-23
CK(CPK)-77 CK-MB-NotDone
U/A BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
[**2142-7-16**] 03:10PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**7-16**] EKG: Atrial fibrillation, average ventricular rate 75. Left
axis deviation. Borderline intraventricular conduction delay.
Possible old anteroseptal myocardial infarction. Non-specific
lateral repolarization changes. Compared to the previous tracing
of [**2142-6-27**] no significant change.
Laboratory studies on discharge:
[**2142-7-19**]
Hct-31.9*
Radiology
[**7-16**] CXR: Compared with [**2142-6-19**], as well as to the chest CT of
[**2142-6-5**], the bilateral upper lobe infiltrates have cleared. The
right hemidiaphragm remains elevated, but in addition to
associated atelectasis at the right base, air bronchograms are
now seen consistent with right lower lobe
collapse/consolidation/aspiration. The remainder of the lung
fields appear clear.
[**7-18**] CXR PA/lat: There is likely no significant change from the
prior semi-upright radiograph performed at the bedside. The
heart size is probably normal. Mediastinal contours are within
normal limits. There is elevation of the right anterior
hemidiaphragm, with associated subsegmental atelectasis of the
right base. I doubt the presence of a consolidation. There is no
overt congestive failure. The left lung is well aerated. No
definite effusion. No pneumothorax. Coarse calcifications of the
carotid are noted on the left. A vague density overlying the
soft tissues of the right neck is new and likely external to the
patient.
IMPRESSION: No short interval change in right subsegmental
atelectasis. No definite pneumonia.
[**7-18**] right LENI: No right lower extremity DVT.
Brief Hospital Course:
74 year old male w/ h/o CAD (NSTEMI [**5-/2142**]) on Plavix/ASA, AF on
Coumadin, and h/o radiation proctitis and diverticulosis
initially admitted to ICU [**7-16**] with BRBPR
1) Rectal bleeding/acute blood loss anemia: This was most likely
due to radiation proctitis in the setting of
ASA/Plavix/Coumadin. The patient was admitted to the ICU,
continued on ASA/Plavix, although Coumadin was held. His INR was
reversed with FFP, and he received 4 units of PRBC for a nadir
HCT of 25 (the last transfusion [**7-17**]). He underwent a
colonoscopy [**7-17**] which showed diverticulosis, rectal
angioectasias with friable rectal mucosa), and grade 1 internal
hemorrhoids. An Argon-Plasma Coagulator was applied to the
angioectasias successfully. He was transferred to the general
medical floor, where he remained hemodynamically stable with a
stable HCT (31 at time of discharge). He was continue on iron
supplementation; his vitamin B12 and folate levels were normal.
2) Right lower lobe atelectasis: The patient's initial CXR
raised concern for RLL pneumonia; repeat PA/lateral revealed
elevated right hemidiaphragm with associated atelectasis. Given
the absence of fever, leukocytosis, or cough, pneumonia was felt
to be unlikely.
3) h/o CHF (systolic): EF 35%, 2+ MR. The patient was diuresed
in the ICU following transfusion and, by the time of transfer to
the general medical floor, he was euvolemic.
4) CAD s/p recent NSTEMI with bare metal stent: The patient was
continued on aspirin, Plavix, statin. His metoprolol was
restarted once he hemodynamically stabilized. The patient will
follow-up with his cardiologist Dr. [**Last Name (STitle) **] as an outpatient.
5) Atrial fibrillation: As mentioned above, the patient's
Coumadin was held given rectal bleeding. He remained
well-rate-controlled on metoprolol. He will follow-up with his
cardiologist within 1-2 weeks following discharge; if his HCT
remains stable, warfarin will be started at the discretion of
his cardiologist.
6) Chronic kidney disease: The patient was followed by the renal
service during his admission. He will follow-up with Dr.
[**Last Name (STitle) 4883**] as an outpatient to discuss initiating peritoneal
dialysis. His creatinine remained stable and he was continued on
Renagel and PhosLo.
7) Type II DM well-controlled w/ complications: The patient was
discharged on his home dose of NPH/RI
8) HTN: By the time of discharge, the patient had been restarted
on his home doses of Cardizem/metoprolol
Medications on Admission:
Renagel 800 TID
Lopressor 25 mg [**Hospital1 **]
Regular Insulin 10 U qAM
NPH 15 U qAM
FeSO4
Cardizem 240 mg qday
Digoxin 0.125 mg every other day
Plavix 75 mg qday
Phoslo 1334 TID
Lipitor 10 mg qhs
Coumadin 2.5 mg qhs
aspirin
bumex (dose unknown, takes PRN edema)
Discharge Medications:
1. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous QAM.
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection once a day.
6. Cardizem SR 120 mg Capsule, Sust. Release 12 hr Sig: Two (2)
Capsule, Sust. Release 12 hr PO once a day.
7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Bumex 2 mg Tablet Sig: as directed Tablet PO as directed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: rectal bleeding, radiation proctitis
Secondary: systolic congestive herat failure, coronary artery
disease, atrial fibrillation, chronic kidney disease, Type II
diabetes, hypertension
Discharge Condition:
Good. hematocrit 31.9
Discharge Instructions:
You were admitted with rectal bleeding due to radiation
proctitis in the setting of aspirin, Plavix, and warfarin.
1) Please follow-up as indicated below.
2) Please take all medications as prescribed. Do not restart
warfarin until directed to so by your primary care physician or
cardiologist.
3) Please call your primary care physician or come to the
emergency room if you develop recurring rectal bleeding,
abdominal pain, fevers, chills, or other symptoms that concern
you.
Followup Instructions:
1) Cardiology: Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 10012**])
tomorrow to schedule an appointment to be seen within 1-2 weeks
following discharge
2) Primary care: Please follow-up with Dr. [**First Name8 (NamePattern2) 324**] [**Last Name (NamePattern1) 311**] as
previously scheduled, [**2142-7-25**] at 11 a.m.
3) Nephrology: Please follow-up with Dr. [**Last Name (STitle) 4883**] as previously
scheduled Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-7-30**] 3:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2142-7-20**]
|
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|
[
[
[]
]
] |
7870, 7876
|
4087, 6575
|
286, 323
|
8113, 8137
|
2026, 2045
|
8662, 9344
|
1696, 1751
|
6890, 7847
|
7897, 8092
|
6601, 6867
|
8161, 8639
|
1766, 1780
|
2846, 4064
|
231, 248
|
351, 1003
|
2059, 2832
|
1025, 1520
|
1536, 1680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,248
| 193,330
|
21412
|
Discharge summary
|
report
|
Admission Date: [**2173-6-18**] Discharge Date: [**2173-7-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Hypoxic respiratory failure
Major Surgical or Invasive Procedure:
Intubation.
History of Present Illness:
81 yo man w/ho CAD, COP, PVD, AAA xfered from OSH for mngmt resp
failure. Pt was found @ home by EMS followign c/o [**5-25**]
"crushing", nonradiating SSCP. Pt diaphoretic during transport.
Sat 84-->94% on NRB. Given [**Month/Year (2) **], NT, nebs en route to OSH where
started on BIPAP and eventually intubated. BP on arrival
240/140 so started on NTG drip titrated up until BP fell to
90/58 resulting in IVF, dopamine. Given 80 IV lasix. First set
enzymes negative and BNP 1700. Pt xferred for further
management.
.
On arrival, pt intubated but responsive to y/n questions.
Indicated CP similar to what he had in past when he was cathed.
Started on hep gtt in ED.
Past Medical History:
PVD, AAA- 5 x 5 cm, PAF, CVA, COPD, depression, symptomatic
bradycardia (dig and B-B held during [**1-20**] admit w/ resolution of
brady)
Social History:
TOB: quit, reports 2ppd x 52 years
EtOH: "quite a bit" in past but denies any use x several mos
Lives alone. 2 children in area.
Family History:
M died when he was a child
Physical Exam:
[**2173-6-24**]
96.8 126/72 (117-153/60-78) 18 94RA 1700/2300 & 100/950
MMM
JVD @9cm, nl s1/s2
ctab; cont dtp bil bases, R higher than L
abd soft, nt, nd
ext warm X 4
A&O X 3
cont bipedal pitting edema to knees
Pertinent Results:
[**6-18**] Echo:
1. There is symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is difficult to assess but is probably normal
(LVEF>55%).
2. The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis.
3. The mitral valve leaflets are mildly thickened.
4. There is a small pericardial effusion.
...
[**6-23**] PA/Lat CXR
Cardiomegaly, tortuous aorta, and improving CHF and atelectasis,
with persistent bilateral pleural effusion. Discrete nodular
opacities in
bilateral lungs, which are probably unchanged and represent
granulomas,
however, please repeat the PA and LAT study after CHF has been
resolved.
...
Renal artery US with doppler: No findings to suggest renal
artery stenosis. Echogenic kidneys consistent with the known
chronic parenchymal disease. If clinically [**Last Name (LF) 56542**], [**First Name3 (LF) **] MR
could be performed.
...
[**1-17**] sputum Cx + for Hafnia Alvei; no other growth
Brief Hospital Course:
This 81 yo man w/ho CAD, COP, PVD, AAA was xfered from MVH for
mngmt resp failure.
.
Resp failure- Etiology likely volume overload [**2-17**] diastolic chf,
renal failure. Pt was diuresed in the CCU then extubated and
subsequently oxygenated well and was called out to the stepdown
unit. The patient initially failed diuresis with lasix alone,
then with lasix 100 IV / diuril 500. Thus, despite lack of
systolic HF, nesiritide was used in the urgent situation of
hypoxic respiratory failure w/good diuresisi, allowing
extubation. Following this, the patient did respond to lasix
100 IV w/500 diuril. Following recommendation of renal
consultation, 60 PO lasix with 5 metolazone was attempted with
good results. No diuretics given after [**6-26**] and patient
continued to autodiurese about 1 L/day. Will d/c patient on PO
lasix, 20 mg /day. He was instructed to call his cariologist or
PCP if he gains >3 pounds to adjust doses of this medication.
Pt reports dry weight is about 200lbs (91kg).
.
CHF: The likely contributors to decompensated acute pulmonary
edema was acute HTN, diastolic HTN and renal dysfunction. BNP at
MVH was 7000 and pro-BNP was 17,700 here. Stat echocardiography
performed on admission demonstrated no wall motion abnormalities
and good LV function. The patient was diuresed as above.
.
HTN- CCB changed to clonidine. Hydral/nitro were added for
afterload reduction. Final regimen as listed under DC meds. Pt
developed chest pain while in the MRI suite when getting study
for transient aphasia. Recieved 2 SL nitro and SBP remained 145.
Pt was briefly transfered to neurology service on [**6-26**] for
further work up/evaluation of aphasia at which time all BP meds
were stopped. ON transfer back to cardiology service on [**6-28**]
patient was restarted on metoprolol 24mg [**Hospital1 **] which was increased
to 50mg [**Hospital1 **] on [**6-29**]. He was d/c'ed on this dose. Imdur (30mg
daily) was added back on [**6-29**].
.
Neuro - ?CVA/TIA: Pt appreared to have TIA. Had acute episode of
confusion and aphasia. Completely resolved with no further
episodes. Neuro followed pt during admission, and he was
transfered to neurology service briefly for further eval and
treatment of transient aphasia. MRA with unchanged evidence of
small vessel dz but no acute infarct; evidence of TO of ICA but
there is reconstitution of the right anterior cerebral artery
and right middle cerebral artery branches from the left side via
anterior communicating artery - unchanged from prior exam. It
was thought that his transient aphagia was likely TIA [**2-17**]
cardioembolic event. He was restarted on coumadin and plavix was
discontinued.
Keep SBP 130-160. pt has been on coumadin in the past for h/o
Afib. wil lrestart coumadin [**6-28**] 10mg X2 nights followed by 5mg
QHS. cont heparin ggt until therapeutic at INR of [**2-18**]. His INR
was 2.6 on [**6-30**] and he was discharged on 5mg coumadin QHS. He is
to follow up with his PCP on [**Hospital3 4298**] for INR and
coumadin adjustments.
.
Ischemia- ?ACS, but no sig EKG changes and enzymes flat, no wall
motion abnormalities. There was thus no ischemia.
.
ARF: On admission, creatinine bumped from baseline 1.5-2.0 to 4.
FENa of .06 indicates effect intravascular depletion or renal
inability to excrete Na. [**Month (only) 116**] be poor renal perfusion from being
off Starling Curve but this is less like as it did not improve
with diuresis. 24 hour urine demonstrated protein of [**Numeric Identifier 56543**] and
creatinine of 1444 demonstrated nephrotic range proteinuria.
Dopplers OK. OP renal bx strongly suggested to patient, but he
refused as he does not wish this intense of a level of care.
.
The patient was full code throughout his stay.
.
Dispo: PT was consulted but reported that the patient has no PT
needs. He was dischareged with VNA services for BP control and
INR follow ups.
Medications on Admission:
vit E 400 [**Last Name (LF) **], [**First Name3 (LF) **] 325 qd, Sertraline 50 QD, Plavix 75 qd, folic
acid 1 qd, lipitor 40 qd, buspirone 15 mg tid, amlodopine 10 mg
qd
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lansoprazole 30 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*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Please have your PCP follow your coumadin levels and
adjust dose of this medications as recommended.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNS/[**Hospital3 **] community Svcs
Discharge Diagnosis:
Primary Diagnosis:
Congestive Heart Failure
Secondary Diagnosis:
1. PVD
2. AAA- 5 x 5 cm
3. PAF
4. CVA
5. COPD
6. depression
Discharge Condition:
Fair
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
Please take all medications as directed.
Followup Instructions:
Provider [**Name9 (PRE) 703**] WEST INTERVENTIONAL/PROSTATE US [**Name9 (PRE) 706**] Where: [**Hospital 4054**] [**Hospital 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2173-7-1**]
9:30
Please call your cardiologist for a followup appointment within
one week of your discharge.
You have an appointment with your primary care physician,
[**Name10 (NameIs) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 36558**] to follow up on your CHF, blood
pressure, to arrange neuropsych evaluation, to check your INR
and to further evaluate nodular opacities visualized during this
hospitalization.
|
[
"496",
"518.0",
"311",
"584.9",
"443.9",
"V45.82",
"403.91",
"428.30",
"427.31",
"518.81",
"441.4",
"428.0",
"435.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
7732, 7798
|
2649, 6538
|
289, 303
|
7967, 7973
|
1611, 2626
|
8186, 8789
|
1333, 1361
|
6759, 7709
|
7819, 7819
|
6564, 6736
|
7997, 8163
|
1376, 1592
|
222, 251
|
331, 1008
|
7884, 7946
|
7838, 7863
|
1030, 1170
|
1186, 1317
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,244
| 186,756
|
28987
|
Discharge summary
|
report
|
Admission Date: [**2176-6-21**] Discharge Date: [**2176-7-1**]
Date of Birth: [**2115-6-6**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
Right facial twitching, neck contracting, and eyes rolling to
right
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
Ms [**Known lastname 12330**] is a 60 year old right handed woman with history of
end-stage renal failure secondary to polycystic kidney disease
(with renal and liver cysts) status post DCD renal transplant on
[**2175-6-16**] complicated by delayed graft function now off dialysis,
two previous subarachnoid hemorrhages([**2167**] and [**2169**]) secondary
to aneurysmal rupture status post clipping and
Ventriculoperitoneal shunt with residual aphasia, seizures and
history of convulsive seizures and nonconvulsive status,
presents with breakthrough seizures. History taken from prior
records and Son at bedside.
She was recently admited from [**2176-6-11**] - [**2176-6-14**] for UTI; She
had been treated for UTI for the past several weeks prior to
[**Hospital1 18**] admission on an outpatient basis, the initial leading
cause of fever was considered to be UTI. After obtaining
outpatient records of urine cultures and drug sensitivities, was
given Meropenem 500mg IV once, and then she was transitioned to
ceftazadime 1g q12h. She remained afebrile on these medications.
As for potential seizures, she reportedly had a seizure on night
prior to that admission, which including "twitching" thought to
be induced by her fever and infection. She was discharged this
past friday on bactrim (per renal as ongoing prophylaxis) and
ertapenem; for seizures, vimpat (150 mg [**Hospital1 **]) and levetiracetam
(1000/1250) were prescribed. Of note, she has not missed any
doses of the medications.
On [**2176-6-20**], she began having frequent focal motor seizures, with
right facial twitching, neck contractions, eyes rolling up and
deviated to the right, lasting 1-5 minutes, with ability to
speak in between. They were only a few yesterday but today has
been almost persistent off and on throughout the day,
leading the family to bring her to [**Hospital1 18**] ED.
REVIEW OF SYSTEMS: Could not be elicited from the patient,
however son
denies recent fevers (temp at home 98), nausea, vomiting,
changes in
bowels, cough, or SOB.
Past Medical History:
- ESRD [**12-28**] polycystic kidney disease (renal and hepatic cysts)
now s/p renal transplant [**2175-6-16**] was on HD since [**2170-1-24**]
- s/p two previous SAH ([**2167**] and [**2169**]) [**12-28**] aneurysmal rupture
s/p clipping and VP shunt at [**Hospital1 112**]
- h/o convulsive seizures and was on phenytoin since a
convulsive seizure after dialysis in [**2171-1-24**], after her
second
hemorrhagic stroke and now on Keppra and Vimpat
- HTN
- Depression.
- T2DM
.
PSH:
- Renal transplant [**2175-6-16**] with delayed graft function now
resolved s/p three renal biopsies since transplant
- Multiple access procedures and history of right upper arm AV
fistula.
- Craniotomy and clipping of a ruptured ACA aneurysm and
unruptured right MCA aneurysm [**2169**] and VP shunt insertion
Social History:
She lives at home with her husband, son, son's girlfriend, and
her niece. She came to the United States in [**2139**]. Independent on
feet indoors but uses a cane outdoors. Patient isnot driving.
She has been mostly a housewife. She does not use tobacco,
alcohol, or illicit drugs.
Family History:
Family history is notable for kidney disease in her father, who
died in his 50s, a sister, daughter, and son.
Father - had polycystic kidney disease and may have died from
intracranial hemorrhage at the age of 50.
Mother - died several years ago with cancer.
Sibs - has a brother with hypertension.
Children - She has two younger children who are twins. Her
daughter and son were tested for aneurysms; her daughter
reportedly had none and her son was awaiting the results of his
test. Her oldest son died of [**Name (NI) 8751**]. There is no history of
seizures, developmental disability, learning disorders, migraine
headaches, strokes less than 50, neuromuscular disorders, or
movement disorders.
Physical Exam:
EXAMINATION ON ADMISSION
********************
Physical Exam:
Vitals: T:98.3F, P:62, R:12, BP:132/74, SaO2: 97% RA
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Decreased breath sounds L>R with few left base
crackles
Cardiac: RRR, no M/R/G
Abdomen: soft, NT/ND, +BS
Extremities: warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status:
Patient has a global aphasia with severe expressive and
receptive deficits at baseline. She was very somnolent, to deep
sternal rub will open eyes and would localize pain with the left
hand.
-Cranial Nerves:
PERRL 4.5 to 2.5mm and somewhat sluggish. + corneals, +dolls, no
facial droop, facial musculature symmetric. jaw was clenched
closed
-Motor: decrease balk on the left vs increased on the right
lower extremity. spastic tone on the left. localized pain on
the left upper, sluggish withdrawal in bl lowers.
-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 extensor bilaterally.
-Coordination: Not assessed
****************
DISCHARGE EXAM:
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: clear to auscultation b/lk
Cardiac: RRR, no M/R/G
Abdomen: soft, NT/ND, +BS
Extremities: warm and well perfused
Skin: no rashes or lesions noted.
Neuro:
aphasic, but will use some [**12-29**] word sentences in portugese
decrease balk on the left vs increased on the right lower
extremity. spastic tone on the left. localized pain on the
left upper, sluggish withdrawal in bl lowers. Moves arms and
legs symmetrically
Pertinent Results:
[**2176-6-21**] 06:15PM LACTATE-1.5
[**2176-6-21**] 06:00PM GLUCOSE-135* UREA N-22* CREAT-1.1 SODIUM-144
POTASSIUM-3.9 CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
[**2176-6-21**] 06:00PM ALBUMIN-4.3 CALCIUM-10.8* PHOSPHATE-2.2*
MAGNESIUM-2.1
[**2176-6-21**] 06:00PM ALBUMIN-4.3 CALCIUM-10.8* PHOSPHATE-2.2*
MAGNESIUM-2.1
[**2176-6-21**] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2176-6-21**] 06:00PM WBC-9.7# RBC-4.61 HGB-11.8* HCT-36.3 MCV-79*
MCH-25.6* MCHC-32.6 RDW-16.4*
[**2176-6-21**] 06:00PM NEUTS-88.0* LYMPHS-6.8* MONOS-4.3 EOS-0.6
BASOS-0.3
[**2176-6-21**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-70 KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG
[**2176-6-21**] 06:00PM URINE RBC-<1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-<1 TRANS EPI-<1
[**2176-6-21**] 06:00PM URINE AMORPH-FEW
[**2176-6-21**] 06:00PM URINE MUCOUS-RARE
IMAGING:
CT HEAD W/O CONTRAST
IMPRESSION: No evidence of acute intracranial hemorrhage or
other acute
process. Left frontal post-operative extra-axial thickening,
similar to
[**2175-11-5**]. Left temporoparietal encephalomalacia,
similar to prior. Right parietal approach VP shunt catheter
terminates in similar position to prior.
EEG [**2176-6-26**]
This is an abnormal continuous video EEG telemetry due to sharp
discharges over the left frontal and temporal leads. There were
no pushbutton activations and no electrographic seizures. The
background on the left hemisphere is continuous slowing in delta
range intermixed with breach rhythm.
Brief Hospital Course:
Ms [**Known lastname 12330**] is a 60 year old right handed woman with history of
ESRF [**12-28**] polycystic kidney disease (with renal and liver cysts)
s/p DCD renal transplant on [**2175-6-16**] c/b delayed graft function
now off dialysis, two previous SAH ([**2167**] and [**2169**]) [**12-28**]
aneurysmal rupture s/p clipping and VP shunt with residual
aphasia, seizures and hx of convulsive seizures and
nonconvulsive status, presents with breakthrough seizures.
Neurologic:
The patient remained aphasic as per her baseline for the course
of her hospitalization. Some twitching was noted on [**6-22**] in the
afternoon. Of note two lumbar punctures were attempted at
bedside without successful return of cerebrospinal fluid. On
[**6-23**] at noon, had epileptiform activity in left frontal and
temporal lobes. Had LP in IR on [**6-24**] which showed no elevated
WBCs or RBCs. Did have elevated protein to 363 of unclear
significance as pt not ill or febrile. On [**6-24**] at 3pm, pt spit
up mucous and was quite difficult to arouse. Suspected seizure
activity. Placed pt back in bed. ~20 min later, completely
unresponsive, eyes rolling up. A few minutes later, was
lethargic but responsive, tracking. Given this event was c/w
epileptiform activity. She was increased on Keppra to 1500 mg
[**Hospital1 **] and Vimpat to 200 mg [**Hospital1 **]. Dilantin was continued and she was
transitioned oral dosing of 330 mg of extended release tabs. Her
dilantin level was 11 on [**6-28**].
Cardiovascular:
Ms. [**Known lastname 12330**] was not hypertensive on admission; however, she
has had periods of hypertension throughout her admission running
between 150-180 systolic blood pressures. During seizures the
patient was noted to have systolic blood pressures which
exceeded 200mmHg for which Hydralizine was acutely used to
resolve events. Lisinopril was increased to 40mg qDay which
improved her pressures to 130-150mmHg. She was also started on
Imdur and since these interventions has been stable.
Renal:
Transplant nephrology was consulted for the course of Ms.
[**Known lastname 12330**] hospital stay. They recommended continuing Bactrim as
UTI prophylaxis. Also, ceftazadmine was added to the patients
regiment as per the sensitivities reported from the [**6-11**] Urine
culture. Per nephrology, the patient was continued on cellcept
and rapamune for her DCD renal transplant, with an increase of
Rapamune to 5mg per day.
Infectious:
On presentation, concern for infection was high given the
patient's immunosuppressed status, temperature of 100.3F, and
breakthrough seizures. Two lumbar punctures were attempted
without success. Empiric antibiotics/antivirals were started.
A lumbar puncture revealed a cell count within reference ranges
with the exception of elevated protein. Infectious Disease was
consulted for further management who after receiving a negative
Herpes Simplex Virus titer from the CSF culture recommended
cancellation of all antibiotics/antivirals as their course had
been completed to treat her UTI, and presumed pneumonia. The
patient had clinically improved with no further complaints or
signs of infection on discharge.
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD Q72H
She got her last patch at home on [**2176-6-10**]
3. Lacosamide 150 mg PO BID
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. LeVETiracetam 1000 mg PO AM
6. LeVETiracetam 1250 mg PO PM
7. Lisinopril 5 mg PO HS
8. Mycophenolate Mofetil 250 mg PO BID
9. PredniSONE 5 mg PO DAILY
10. Sirolimus 1.5 mg PO DAILY
Daily dose to be administered at 6am
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. NPH insulin human recomb *NF* 12 units Subcutaneous qHS
13. Ertapenem *NF* 1 gram Injection qdaily UTI Duration: [**10-9**]
Days
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QMON
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Lacosamide 200 mg PO BID
5. LeVETiracetam 1500 mg PO BID
6. Lisinopril 40 mg PO DAILY
7. Mycophenolate Mofetil 250 mg PO BID
8. Phenytoin Sodium Extended 330 mg PO DAILY
9. PredniSONE 5 mg PO DAILY
10. Sirolimus 5 mg PO DAILY
Daily dose to be administered at 6am
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. NPH 12 Units Bedtime
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
Seizure - poorly controlled
Urinary Tract Infection
Hypertension
Pneumonia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital in the setting of breakthrough
seizures. On the day prior to admission,there were frequent
focal motor seizures, with R facial twitching, neck
contractions, eyes rolling up and deviated to the right, lasting
1-5 minutes, but able to speak in between events. In the ED she
had several of these events and was intermittently responsive
between them. As for the cause of this breakthough in seizures,
it most likely is related to infection and antibiotics.
1. ID
You had a left lower lobe pneumonia and had come in on
antibiotics. You additionally had a urinary tract infection and
were on a course of antibiotics. Infectious Disease was
consulted and you were switched to IV Ceftazadine, Vancomycin
and Acyclovir and completed this course.
2. Hypertension
Your blood pressure was elevated during your stay and your
antihypertensives were increased.
3. Seizures
You were on Vimpat and Keppra ([**Last Name (un) **] of which were increased) and
then started on Dilantin to control your seizures, all of which
were switched to oral dosing.
4. Renal Translpant
You were followed by nephrology who recommended increasing your
dose of sirolimus
You should make an appointment with your epilepsy doctor ([**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]) for 2-4 weeks after discharge.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2176-7-3**] 2:00
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2176-8-8**] 9:40
Please call [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] to set up an appointment after discharge.
[**Street Address(2) 69870**], [**Hospital Ward Name 860**] Bldg, [**Location (un) 861**]
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3294**]
Completed by:[**2176-7-1**]
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29,035
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18065
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Discharge summary
|
report
|
Admission Date: [**2156-2-14**] Discharge Date: [**2156-3-4**]
Date of Birth: [**2089-12-13**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Indomethacin / Actonel / Reglan / linezolid
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
UTI
Major Surgical or Invasive Procedure:
Lumbar puncture
Endotracheal Intubation
Central venous catheter placement and removal
PICC line placement
History of Present Illness:
Mrs [**Known lastname **] is a pleasant 66 yo woman with extensive PMH
including renal/hepatic transplant in [**2153**], recurrent UTIs who
presents for direct admission today from rehab for treatment of
a urine culture positive for klebsiella. Pt has had multiple
admissions for multidrug resistant klebsiella in the past and
was treated with meropenem. On this occassion, she is unsure of
why the initial cultures were drawn 3 days ago, as she does not
remember having any sxs at that time. She states that she did
have a fever of 100.1 which may be why she was tested. Over the
last 24 hrs, she has developed burnining and frequency with
urination, states her urine is a foul odor. She denies fever,
chills, or back pain, however does state that she has had a
decrease in PO intake over the last few days because of general
malaise. ROS positive for non-productive cough x 1wk, SOB on
exertion which is not significiantly worse from baseline.
.
On the floor, pt states that she is generally feeling well, but
anxious, c/o tremor which is chronic for her. Denies pain.
.
ROS: per HPI, 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:
- Diabetes Mellitus Type 2, on Insulin, c/b retinopathy,
nephropathy, and neuropathy
- End-stage renal disease, [**3-11**] diabetes & contrast-induced
nephropathy, s/p cadaveric transplant [**2153-7-21**]
- Hx frequent MDR UTIs, most recently ESBL Klebsiella [**Month (only) 216**]
[**2155**]
- Dyslipidemia
- Hypertension
- Atrial fibrillation
- High-degree AV block, s/p PPM [**2154-2-5**] ([**Company 1543**] Sensia DDD
pacemaker), now pacer dependent
- Diastolic heart failure, NYHA II-[**Last Name (LF) 1105**], [**First Name3 (LF) **] >75% on TTE [**1-/2154**]
- Calcific aortic stenosis, moderate (area 1.0-1.2cm2) on TTE
[**1-/2154**]
- Moderate mitral annular calcification and mitral regurgitation
- Mild tricuspid regurgitation
- Moderate pulmonary hypertension
- Non-alcoholic steato-hepatitis cirrhosis (Stage IV, Grade 2),
c/b portal HTN, ascites, encephalopathy, grade I-II esophageal
varices s/p banding s/p TIPS [**8-/2152**], s/p OLTx [**2153-7-21**]
- Saphenous vein interposition graft repair of the hepatic
artery and harvesting of the left saphenous vein graft [**2154-3-14**],
Hepatic artery s/p stent [**2154-4-25**]
- [**3-/2155**] - Exploratory laparotomy, evacuation of intra-
abdominal blood, exploration of retroperitoneal hematoma,
left salpingo-oophorectomy for RP bleeding
- s/p VATS decortication [**11/2153**]
- Splenic vein thrombosis, on coumadin
- Anemia
- Thrombocytopenia
- h/o C.diff
- h/o Seizures
-headaches ? [**3-11**] occipital neuralgia
- Meningioma, small left frontal lobe
- GERD
- OSA has CPAP at home but does not use
- Cervical DJD
- Dermoid cyst
- Right adrenal mass
- osteoporosis
- Status post cholecystectomy followed by tubal ligation
- Status post left oopherectomy
- Status post appendectomy
- ? Restless legs syndrome
- hypothyroid
- gout
Social History:
(per OMR) Widowed, lives in [**Hospital3 **] facility in [**Hospital1 6930**]
MA. Has 4 children, 3 in MA, one in [**State 3908**]. Smoking: None;
EtOH: Never; Illicits: None. Previously worked as a nurse.
Family History:
(per OMR) father died of stroke, mother died of cerebral
hemorrhage. sister with diabetes.
Physical Exam:
ADMISSION EXAM:
VS: 98.4 149/72 73 16 99 3L
GENERAL: obese 66 yoF who appears stated age. Somewhat confused
appearing with prominent tremor.
HEENT: Sclera anicteric. PERRL, EOMI. MM dry.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, 3/6 SEM loudest at RUSB. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: obese, soft, non-tender to palpation. No HSM or
tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+
LE edema on R side, LUE. Surgical scar on R-side with staples
in palce, no drainage or errythema, mildly ecchymotic
.
DISCHARGE EXAM:
Tm 98.1 96.9 130-175/40-70s p60s RR18-20 99-100 2L FSG 137-265
GENERAL: obese 66 yoF who appears stated age. Comfortable
appearing. Alert and oriented x3, tremor resolved.
HEENT: Sclera anicteric.
NECK: Supple with low JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, 3/6 SEM loudest at apex. No S3 or S4 appreciated.
LUNGS: CTAB
ABDOMEN: obese, soft, non-tender to palpation. No HSM or
tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.
Trace LE R. [**2-9**]+ pitting edema in LUE, Surgical scar on R-side
with staples removed, no drainage or erythema, mildly ecchymotic
Pertinent Results:
Admission Labs
[**2156-2-14**] 09:30PM UREA N-60* CREAT-2.2* SODIUM-138
POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-24 ANION GAP-21*
[**2156-2-14**] 09:30PM estGFR-Using this
[**2156-2-14**] 09:30PM ALT(SGPT)-16 AST(SGOT)-19 ALK PHOS-180* TOT
BILI-0.5
[**2156-2-14**] 09:30PM ALBUMIN-3.4* CALCIUM-8.6 PHOSPHATE-5.1*
MAGNESIUM-2.0
[**2156-2-14**] 09:30PM tacroFK-9.9
[**2156-2-14**] 09:30PM WBC-15.7* RBC-2.94* HGB-9.2* HCT-29.1*
MCV-99* MCH-31.4 MCHC-31.8 RDW-19.3*
[**2156-2-14**] 09:30PM PLT COUNT-643*#
[**2156-2-14**] 09:30PM PT-11.6 PTT-29.2 INR(PT)-1.1
.
DISCHARGE LABS:
[**2156-2-25**] 05:07AM BLOOD WBC-12.7* RBC-3.22* Hgb-10.3* Hct-31.6*
MCV-98 MCH-31.9 MCHC-32.4 RDW-20.6* Plt Ct-582*
[**2156-2-25**] 05:07AM BLOOD Glucose-166* UreaN-34* Creat-0.9 Na-142
K-4.0 Cl-105 HCO3-28 AnGap-13
.
Tacrolimus levels:
[**2156-2-14**] 09:30PM BLOOD tacroFK-9.9
[**2156-2-15**] 07:05AM BLOOD tacroFK-7.8
[**2156-2-16**] 06:50AM BLOOD tacroFK-8.2
[**2156-2-17**] 05:25AM BLOOD tacroFK-7.8
[**2156-2-18**] 06:25AM BLOOD tacroFK-7.9
[**2156-2-19**] 04:09AM BLOOD tacroFK-6.9
[**2156-2-20**] 03:40AM BLOOD tacroFK-7.1
[**2156-2-21**] 03:34AM BLOOD tacroFK-9.8
[**2156-2-22**] 06:00AM BLOOD tacroFK-7.4
[**2156-2-23**] 05:50AM BLOOD tacroFK-7.1
[**2156-2-24**] 06:00AM BLOOD tacroFK-6.7
[**2156-2-25**] 05:07AM BLOOD tacroFK-5.6
[**2156-2-28**] 06:01AM BLOOD tacroFK-4.0*
[**2156-2-29**] 06:09AM BLOOD tacroFK-4.1*
[**2156-3-1**] 05:13AM BLOOD tacroFK-6.1
[**2156-3-2**] 06:20AM BLOOD tacroFK-4.6*
[**2156-3-3**] 06:15AM BLOOD tacroFK-5.1
[**2156-3-4**] 05:35AM BLOOD tacroFK-4.5*
.
CSF:
[**2156-2-19**] 05:14PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-36*
Polys-60 Lymphs-40 Monos-0
[**2156-2-19**] 05:14PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-12*
Polys-56 Lymphs-44 Monos-0
[**2156-2-19**] 06:49PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS - PCR
NEG
[**2156-2-19**] 05:14PM CEREBROSPINAL FLUID (CSF) VARICELLA DNA
(PCR)-NEG
[**2156-2-19**] 05:14PM CEREBROSPINAL FLUID (CSF) [**Male First Name (un) 2326**] VIRUS (JCV) DNA
PCR-NEG
[**2156-2-19**] 05:14PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-NEG
.
URINE:
[**2156-2-19**] 08:16PM URINE RBC-7* WBC-126* Bacteri-FEW Yeast-NONE
Epi-0
[**2156-2-20**] 02:00PM URINE RBC-5* WBC-134* Bacteri-FEW Yeast-NONE
Epi-0
[**2156-2-19**] 08:16PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-5.0 Leuks-TR
[**2156-2-20**] 02:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-5.0 Leuks-LG
URINE CULTURE (Final [**2156-2-23**]):
[**Female First Name (un) **] (TORULOPSIS) [**Female First Name (un) **]. 10,000-100,000
ORGANISMS/ML.
.
STUDIES
Renal US:
IMPRESSION:
Echogenic shadowing material within the collecting system of the
right lower quadrant transplanted kidney, suggestive of
emphysematous pyelonephritis. There is no hydronephrosis or
abscess. If the patient has not undergone recent instrumentation
to account for air within the collecting system, emphysematous
pyelitis should be considered. If further imaging is desired, CT
would be recommended.
.
CT CHEST/ABD
IMPRESSION:
1. No new focal fluid collection. Stable retroperitoneal
hematoma in the
left iliac fossa and slightly increased size of superficial
hematoma adjacent to the right gluteus muscle both represent
areas of possible infection.
2. Air within the collecting system of the right pelvic
transplanted kidney may represent infection in the absence of
recent instrumentation or reflux of air, but this finding is new
from [**2156-2-6**]. CLINICAL CORRELATION IS ADVISED.
3. Small to moderate left-sided pleural effusion with
compressive atelectasis and air bronchograms. Infection cannot
be excluded.
.
CT HEAD
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Mild mucosal thickening in the ethmoid air cells and fluid in
the sphenoid sinus.
3. Slightly hypodense appearance of the left caudate and left
insular cortex is of equivocal significance. Given the slightly
noisy images, the component of cerebral edema cannot be
completely excluded. Correlate clinically.
[**2156-2-26**] 06:00AM BLOOD tacroFK-4.8*
.
IMPRESSION:
1. Chronic-appearing thrombus in one of three brachial veins,
unchanged from [**2155-12-1**].
2. Non-occlusive thrombus in the mid portion of the left
cephalic vein is new from [**2155-12-1**] but is otherwise
age-indeterminant.
Brief Hospital Course:
Pleasant 66 yo female with MMP, hx of kidney liver failure,
presented intially to the hospital with recurrent multi-drug
resistant UTI, was transferred to the ICU for altered mental
status and hypoxemia, electively intubated for LP and CT studies
found to have gas pockets in her transplanted kidney.
.
# Emphysematous Pyelonephritis: She presented with UTI that had
grown multidrug resistant klebsiella that was sensitive
meropenem. She was started on meropenem. However she continued
to spike fevers and her mental status was noted to be decreased
from her baseline. She was later transferred to the MICU for AMS
and hypoxia. There she underwent renal US and abd CT which
showed gas in the collecting duct of her transplanted kidney.
Urine cultures here did not grow any bacteria but did grow
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] and she was started on Micafungin. After
starting micafungin her fevers stopped and her mental status
improved. She will be treated with a three week course of
meropenem and micafungin. She will follow up with ID and urology
for further management of her recurrent UTIs. She should have
weekly Chem7, CBC w/ diff, ESR/CRP, ALT, AST, Tbili, and Alk
Phos checked and all laboratory results should be faxed to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at ([**Telephone/Fax (1) 1353**].
.
#Hypoxia: During her admission she was noted to be hypoxic
requiring non-rebreather. This was felt to be from pulmonary
edema. She received IV lasix with improvement in her respiratory
status. While she was continuing to spike fevers and had altered
mental status she was briefly started on vancomycin in addition
to the meropenem for possible aspiration PNA. She was also
electively intubated to obtain head chest and abdominal CT.
Sputum cultures were negative and the Vancomycin was stopped.
She was extubated without complication. With improvement in her
volume status she no longer needed oxygen during the day and
only needed oxygen at night as she refuses her CPAP for sleep
apnea. Volume status can be tenuous and she was discharged on
torsemide 20mg [**Hospital1 **]. Home dose had been 40mg QAM, 20mg QPM but
she was euvolemic at time of discharge. Close attention should
be paid to volume status and diuretics increased as necessary.
.
# Acute Renal failure: While admitted she was noted to have
elevation in her creatinine. Her diuretics were held though she
later developed pulmonary edema. She was then diuresed with IV
lasix. Her creatinine rose again during the diuresis but later
returned to 1 which was actually below her recent baseline. Her
torsemide was restarted and the dose was increased to her
previous dose of 40mg in the morning and 20mg at night.
.
# Mental status: While admitted she had AMS. On admission she
had been taking haldol, seroquel, aripiprazole, venlafaxine, and
ativan as well as dilaudid for her hip pain. Haldol was
continued but the rest of the medications were held per
psychiatry recs. She also underwent an LP and head CT which were
normal. With treatment of her UTI, holding her psychotropic
medications and resolution of hypoxia her mental status returned
to her baseline and her tremor resolved. She was restarted on
her venlafaxine and ativan PRN but other medications were not
restarted on discharge.
.
# Hx kidney/liver transplant: Her tacrolimus was increased to
1.5mg [**Hospital1 **] and prednisone was continued unchanged(7.5mg [**Hospital1 **])
throughout this admission. Her MMF was stopped and was not
restarted on discharge. Bactrim was continued.
.
# Hip Fracture: She recently had a hip fracture that was
repaired by ortho in [**Month (only) 1096**]. She was taking dilaudid for pain
when she was admitted but this was held in the setting of AMS.
She was later changed to oxycodone as needed, which provided
adequate pain control without mental status changes. She will
need to go to rehab after this admission. She was continued on
lovenox for DVT/PE prevention. Staples were removed [**2-25**].
.
# Diabetes: continued insulin sliding scale, glargine decreased
to 15 unitsd QHS. This may need to be titrated up in the future.
.
# LUE Swelling: Pt. has known h/o chronic thrombus in LUE, s/p
fistula in RUE so not usable for access. LUE was accessed for
IR-guided PICC which was successfully placed. Pt. was noted to
have LUE swelling at admission which persisted after PICC
placement, non-tender, neurovascularly intact. US showed stable
brachial vein thrombus, PICC in other brachial vein without
thrombus, and new thrombus in mid portion of cephalic vein which
is not a deep vein. Encouraged LUE elevation.
.
# HTN: Briefly held her amlodipine and torsemide though these
were restarted later. she was persisitently hypertensive in the
morning and her amlodipine was increased to 5 mg [**Hospital1 **] prior to
discharge. This will need to be followed to confirm her BP
improves.
.
CHRONIC ISSUES:
.
# HLD: Cont atorvastatin
.
# Hx afib: continued carvedilol, asa, and plavix.
.
# Hx seizures: Continued keppra, no seizures while inpatient.
.
# Hypothyroidism: Continued levothroxine.
.
# GERD: continued ppi.
.
# Gout: Colchicine and allopurinol were held in the setting of
[**Last Name (un) **]. Her allopurinol was restarted but her colchine was
discontinued at discharge.
.
TRANSITIONAL ISSUES:
#Antibiotics: She will need a total of three weeks of meropenem
and micafungin. Her last day will be [**3-12**]. She will follow
up with infectious disease prior to this date.
.
#Recurrent UTIs: She has previously been on fosfomycin for
prophylaxis but still developed this infection. She will need to
follow up with urology and ID regarding prevention of future
infections.
.
#Hip fracture: Duration of Lovenox must be determined per
orthopedics that performed hip repair.
.
#Diabetes: Glargine may need to be increased if FSG persistently
>180.
.
#Hypertension: She has been hypertensive particularly in the
mornings during this admission. Her amlodipine was increased to
5 mg [**Hospital1 **] the day prior to discharge if she is persistently
hypertensive she may need medication changes as directed by Dr.
[**First Name (STitle) **] [**Name (STitle) **].
.
Please check weekly electrolytes with BUN/Cr, Tbili, ALT, AST,
Alk Phos, CBC/w diff, ESR, and CRP. Please also check tacrolimus
levels twice weekly as we have recently increased her dose. All
laboratory results should be faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at ([**Telephone/Fax (1) 10739**] and Dr. [**First Name (STitle) **] [**Name (STitle) **] at ([**Telephone/Fax (1) 12146**]
.
Please monitor blood sugars and titrate glargine insulin as
needed to maintain FSG 140-180.
.
Please continue IV meropenem and micafungin through [**2156-3-12**], last
dose to be given that day then remove PICC line.
Medications on Admission:
1. Seroquel 150 mg at bedtime
2. Lorazepam 1.5 mg at bedtime as needed
3. Keppra 500 mg [**Hospital1 **]
4. Plavix 75 mg daily
5. Lantus 20u at bedtime
6. Amlodipine 5 mg every day
7. Humalog sliding scale
8. Venlafaxine ER 225 mg daily
9. Colchicine 0.6 mg daily
10. Aripiprazole 5 mg daily
11. Mycophenolate 250 mg [**Hospital1 **]
12. Aspirin 325 mg daily
13. Haloperidol 0.5 mg in the morning, 1 mg at bedtime
14. Allopurinol 300 mg daily
15. Calcium/D daily
16. Torsemide 40 mg in the morning, 20 mg in the evening
17. Pantoprazole 40 mg daily
18. Levothyroxine 50 mg daily
19. Prednisone 7.5 mg daily
20. Ursodiol 300 mg [**Hospital1 **]
21. Bactrim SS daily
22. Tacrolimus
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. prednisone 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
8. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
11. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
12. haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for Pain.
14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. amlodipine 5 mg Tablet Sig: One (1) Tablet PO twice a day.
16. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
17. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO DAILY (Daily).
18. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet, Chewable
Sig: One (1) Tablet, Chewable PO once a day.
19. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
20. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for Last dose [**2156-3-12**] doses.
21. 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.
22. micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for Last dose [**2156-3-12**] doses.
23. torsemide 20 mg Tablet Sig: Two (2) Tablet PO QAM.
24. torsemide 20 mg Tablet Sig: One (1) Tablet PO QPM.
25. insulin glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
26. Humalog
Per sliding scale
27. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
28. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
29. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed for Anxiety.
30. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary Diagnosis:
Emphysematous pyelonephritis
Pulmonary edema
.
Secondary Diagnoses:
History of Kidney transplant
History of Liver transplant
History of recent hip fracture
Recurrent urinary tract infections
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
Thank you for coming to the [**Hospital1 1170**]. You were in the hospital because you had an infection of
your kidney and urinary tract. We treated this infection with
antibiotics called meropenem and micafungin. You will need to
continue these medications for a total of three weeks (last day
[**3-12**]).
.
You were also a little confused while in the hospital. We
believe this was from a combination of your infection and some
of the medications you were taking. We stopped several of these
medications.
.
Summary of Medication Changes:
Please Change tacrolimus to 1.5 mg twice a day
Please Start meropenem 500 mg three times per day, last dose 2/3
Please Start micafungin 100 mg every day, last dose 2/3
Please Start oxycodone 5 mg every 4-6 hours as needed for pain
Please Decrease Lantus (glargine insulin) to 15 units at bedtime
Please Decrease venlafaxine to 150mg once a day
Please Increase Amlodipine to 5 mg twice daily.
Please Increase Lovenox (enoxaparin) to 40 units once daily
Please STOP seroquel (quetiapine), abilify (aripiprazole),
colchicine, mycophenolate and dilaudid.
Pleaswe Continue takking all other medications as you have been
Please continue all other medications as instructed.
Followup Instructions:
Department: TRANSPLANT
When: TUESDAY [**2156-3-9**] at 9:30 AM
With: TRANSPLANT ID [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: THURSDAY [**2156-3-11**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**2156-3-18**] 11:30a [**Last Name (LF) **],[**First Name3 (LF) **] (RHEUM LMOB)
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), [**Location (un) **]
RHEUMATOLOGY LMOB WEST (SB)
Create Visit Summary
[**2156-3-18**] 08:00a [**Last Name (LF) 2106**],[**First Name3 (LF) 2105**]
LM [**Hospital Unit Name **], [**Location (un) **]
TRANSPLANT MEDICINE (NHB)
Create Visit Summary
Department: SURGICAL SPECIALTIES/UROLOGY
When: THURSDAY [**2156-4-1**] at 11:00 AM
With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: ORTHOPEDICS
When: THURSDAY [**2156-3-11**] at 8:00 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2156-3-11**] at 8:20 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
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icd9cm
|
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,988
| 177,047
|
4067
|
Discharge summary
|
report
|
Admission Date: [**2129-1-15**] Discharge Date: [**2129-1-25**]
Date of Birth: [**2072-9-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Intubation with mechanical ventilation
Femoral CVL placement
A-line placement
History of Present Illness:
56F w ESRD on PD last HD 3 days PTA ([**2129-1-12**]), history of
recurrent C. difficile infection currently on Flagyl and
Vancomycin taper discharged on [**2129-1-6**], whose friends
called EMS today after friends called them because the patient
hadn't contact[**Name (NI) **] them in a few days and she was found to be
slightly altered. She was brought to the ED where she was found
to have continued abdominal pain. She reports that her pain is
described as an [**7-4**] crampy nonradiating pain located across the
epigastrium that has not associations with food and is relieved
with psin medications. She reports that her BMs have increased
from ~4/day to ~7 loose, watery copius, nonbloody BMs. When she
was initially admitted on [**2129-1-6**] she reports having 24BMs per
day. This abdominal pain was associated with lightheadedness,
dizziness but no syncope. She denies any chest pain or
palpiations. She denies fevers. She does, however, report that
she's SOB with DOE with increasing leg swelling, but no increase
in orthopnea or PND. As above her last HD was 3 days PTA.
.
In the ED her vitals: 99.2 72/45 56. The hypotension (72/45)
was refractory to NS boluses thus requiring Levophed and R
femoral line placement. She had a leuckocytosis with left shift
and CT abdomen with evidence of colitis. Patient also had a
negative Head CT. She was given Dextrose for hypoglycemia,
cultures taken, and she was given Vanc/Zosyn empirically.
Past Medical History:
Past Medical History:
- ESRD on peritoneal dialysis daily (transitioned off HD just
before [**Holiday 1451**]), ? [**12-27**] HTN vs proliferative GN vs ? history
of lupus. Dry weight 78kg.
- [**Month/Day (2) 17911**] syndrome secondary to clots, on coumadin
- h/o Peritonitis (cloudy PD fluid)
- h/o E cloacae line bacteremia
- C diff colitis; first dx in [**6-/2128**], recurrence in [**10/2128**] and
[**12/2128**], requiring PO vancomycin w taper
- CAD--per OMR
- HTN
- Dyslipidemia
- Anemia: baseline Hct 25-31
- Asthma
- OSA on CPAP
- h/o right gluteal bleed while on heparin gtt
- h/o rheumatic fever
- OA in left shoulder
- h/o rotator cuff tear on left
- h/o TAH for fibroids
- s/p b/l total knee replacements [**2124**]
- h/o herpes zoster with post-herpetic neuralgia
-[**2128-12-14**] SBO
Social History:
Used to be a social worker. Currently smoking occasionally,
history of tobacco use of [**11-26**] PPD x 30 years. Occasional
alcohol. Former cocaine user in remote past.
Family History:
Father, uncle, and brother had CAD in their 40s.
Brother had renal disease and a stroke.
Physical Exam:
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
LABS ON ADMISSION:
.
[**2129-1-15**] 01:50PM BLOOD WBC-18.2*# RBC-3.49* Hgb-10.2* Hct-33.0*
MCV-95 MCH-29.3 MCHC-31.0 RDW-18.5* Plt Ct-375
[**2129-1-15**] 01:50PM BLOOD Neuts-90.4* Lymphs-5.2* Monos-3.7 Eos-0.5
Baso-0.3
[**2129-1-15**] 01:50PM BLOOD PT-57.1* PTT-53.6* INR(PT)-6.7*
[**2129-1-15**] 01:50PM BLOOD Glucose-58* UreaN-54* Creat-11.6* Na-136
K-4.4 Cl-99 HCO3-17* AnGap-24*
[**2129-1-15**] 09:44PM BLOOD ALT-5 AST-22 LD(LDH)-372* CK(CPK)-746*
AlkPhos-168* TotBili-0.1
[**2129-1-15**] 09:44PM BLOOD CK-MB-18* MB Indx-2.4 cTropnT-0.12*
[**2129-1-15**] 09:44PM BLOOD Calcium-7.2* Phos-7.0*# Mg-2.0
.
HOSPITAL COURSE:
[**2129-1-18**] 04:55AM BLOOD TSH-3.4
[**2129-1-18**] 04:55AM BLOOD Free T4-0.98
[**2129-1-18**] 04:55AM BLOOD Cortsol-22.1*
[**2129-1-18**] 02:42AM BLOOD Cortsol-12.3
[**2129-1-17**] 03:11AM BLOOD Cortsol-20.2*
[**2129-1-17**] 10:10AM BLOOD IgG-1171 IgA-523* IgM-81
.
CT HEAD:
CONCLUSION:
1. No acute intracranial process.
2. Small focus of heterotopic [**Doctor Last Name 352**] matter as described above,
present on
multiple prior examinations.
3. Prominence of the retropharyngeal soft tissues, although was
seen on the prior CT, warrants direct visual inspection.
.
CT Abd/Pelvis:
IMPRESSION:
1. No evidence for megacolon.
2. Extremely limited study due to suboptimal contrast phase and
paucity of
mesenteric fat and lack of oral contrast.
3. Mild colonic wall thickening could be seen in the setting of
colitis or
bowel wall edema in the setting of peritoneal dialysis.
4. Chest wall collaterals and suboptimal contrast phase raised
the
possibility of [**Doctor Last Name 17911**] stenosis/occlusion versus sequlae of surgical
A/V dialysis fistula.
.
CT Chest:
IMPRESSION:
1. Small bilateral bibasilar consolidation, right greater than
left.
2. Small bilateral pleural effusions.
3. Cardiomegaly.
.
CXR ([**1-21**]):
REASON FOR EXAM: Respiratory failure, pneumonia.
Comparison is made with prior studies including 2/24,25,26/[**2128**].
There are low lung volumes. Bibasilar opacities have improved
markedly on the right. Small right pleural effusion is
unchanged. Cardiomegaly is stable. There is no pneumothorax.
Brief Hospital Course:
In short, Ms [**Known lastname 1391**] is a 56F w multiple medical problems,
notably HTN, ESRD (on PD), [**Name (NI) 17911**] clot (on home Coumadin), and
recent admission w recurrent C. difficile colitis (on [**Doctor Last Name **]/vanc
PO), who was originally admitted to the MICU w altered mental
status, hypotension in the setting of worsened diarrhea. She was
found to be in respiratory failure from a pneumonia requiring
mechanical ventilation, was treated with Vanc/Zosyn x 7 days
(completed), Levofloxacin x 14 days (through [**1-30**]) and fluids.
She was also on norepinephrine drip temporarily for pressure
support. She was then transferred to medicine for further
treatment.
# Pneumonia: Patient presented with septic physiology,
initially with unclear source. In the ICU, patient was started
on Levophed gtt for BP support. She was treated empirically
with broad-spectrum coverage with Vancomycin and Zosyn at time
of admission. On [**1-17**], patient was intubated due to acute
respiratory decompensation. A CT chest revealed bilateral
infiltrates. Levofloxacin was added for double-coverage of a
hospital-acquired pneumonia, both due to worsening respiratory
status and radiographic worsening of right-sided pulmonary
infiltrate. Subsequently, her leukocytosis began to resolved,
and respiratory status gradually improved. Sputum sample was
unrevealing, and legionella testing was negative. On [**1-19**], she
successfully underwent at trial of PS at 5/5, but was found to
have no cuff leak. Given concerns for laryngeal edema due to
her facial edema (underlying [**Month/Year (2) 17911**] syndrome), she was treated per
protocol with Decadron 5 mg q 6 hours x 24 hours. She was
successfully extubated with Anesthesia at bedside on [**1-20**].
Vancomycin and zosyn were continued for 7-day day course. Plan
is to complete a 14 day course of levofloxacin given suspicion
for atypical infection.
# Hypotension: Patient was maintained on Levophed gtt with goal
MAP > 60. Cardiac enzymes were mildly elevated, secondary to
demand from ESRD. An urgent TTE on night of admission showed no
evidence of tamponade. Levophed was weaned on [**1-20**], and
subsequent BP's were in the high 70's systolic with MAPs > 60.
Cortisol stim (12 -> 22) ruled out adrenal insufficiency.
Septic physiology was treated as above. All culture data were
unrevealing. She received a dose of IV albumin 25 grams without
improvement of BP.
# Recurrent C. diff infection: Patient has documented history
of recurrent c. diff infection. Given that source of infection
was initially undetermined, she was empirically started on IV
flagyl and PO vancomycin at time of admission to cover for c.
diff infection. Her c. diff toxin was negative this admission,
and IV flagyl was discontinued. She was continued on PO
vancomycin given her high risk of recurrent c. diff infection
while on antibiotics. Plan is to complete previously prescribed
taper of PO vancomycin following completion of levofloxacin
course:
Vancomycin 125 mg qid [**2129-1-7**], through [**2129-1-28**].
Vancomycin 125 mg [**Hospital1 **] [**2129-1-29**] through [**2129-2-4**].
Vancomycin 125 mg daily [**2129-2-5**] through [**2129-2-11**].
Vancomycin 125 mg Capsule Sig: One (1) Capsule PO AS
DIRECTED for 8 doses: On [**4-16**], [**2-16**], [**2-19**], [**2-22**], [**2-25**], [**2-28**],
[**3-3**].
# ESRD on PD: PD was continued while inpatient. Her oral
medications including Lanthanum, Sevelamer, and Cinacalcet were
briefly held while she was NPO and intubated. She was started
on Calcitriol during this admission.
# [**Month/Day (4) 17911**] Syndrome: INR was supratherapeutic during length of ICU
stay in the setting of antibiotics, and Coumadin was held. Goal
INR [**12-28**]. Substantial facial edema was noted, and intubation was
difficult.
Medications on Admission:
Citalopram 20 mg daily
Lorazepam 0.5 mg 1-2 Tablets PO Q12H prn
Cinacalcet 60 mg daily
Lanthanum 500 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Sevelamer Carbonate 2400 mg PO TID W/MEALS
Gabapentin 300 mg DAILY
Acetaminophen 500 mg tid prn
Warfarin 5 mg Daily
Vancomycin 125 mg qid [**2129-1-7**], through [**2129-1-28**].
Vancomycin 125 mg [**Hospital1 **] [**2129-1-29**] through [**2129-2-4**].
Vancomycin 125 mg daily [**2129-2-5**] through [**2129-2-11**].
Vancomycin 125 mg Capsule Sig: One (1) Capsule PO AS
DIRECTED for 8 doses: On [**4-16**], [**2-16**], [**2-19**], [**2-22**], [**2-25**], [**2-28**],
[**3-3**].
Metronidazole 500 mg [**Hospital1 **] Day 1: [**2129-1-7**], through [**2129-1-28**].
Morphine 15 mg Tablet Sig: 1-2 Tablets PO q6h:prn
Saccharomyces boulardii 250 mg po daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for anxiety.
3. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
5. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Outpatient Lab Work
Twice weekly Labs at dialysis for INR to manage coumadin. Please
fax results to Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 445**]).
9. Vancocin 125 mg Capsule Sig: AS DIRECTED Capsule PO AS
DIRECTED: Through [**1-28**]: 1 tab four times daily; [**Date range (1) 17912**]: 1 tab
twice daily; [**Date range (1) 17913**]: 1 tab daily;
1 tab on [**4-16**], [**2-16**], [**2-19**], [**2-22**], [**2-25**], [**2-28**], [**3-3**].
10. Morphine 15 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain for 10 days.
11. Saccharomyces boulardii 250 mg Capsule Sig: One (1) Capsule
PO once a day.
12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
13. Miconazole Nitrate 2 % Ointment Sig: One (1) Topical once a
day for 2 weeks.
Disp:*1 bottle* Refills:*0*
14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 6 days: end date [**2129-1-30**].
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
sepsis
hypotension
acute respiratory failure
hospital-acquired pneumonia
.
C. difficile colitis
end-stage renal disease
superior vena cava syndrome
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital with confusion, worsened
diarrhea and low blood pressure. You were found to have a lung
infection and bowel infection. You were temporarily in the
intensive care unit for critical care. Your condition has
improved.
Your medications were changed as follows:
1. Added levofloxacin for pneumonia; to take until [**2129-1-30**]
2. Added calcitriol
3. Please continue your other medications as prescribed.
Should you have any worsening in your symptoms, please call your
physicians immediately.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Name (STitle) **] on Friday 6th at 11 am.
[**Telephone/Fax (1) 133**].
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2129-2-1**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2129-2-24**] 10:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-8-18**]
1:55
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2129-3-25**] 8:45
Completed by:[**2129-2-3**]
|
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"486",
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"272.4",
"782.3",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"96.04",
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icd9pcs
|
[
[
[]
]
] |
11944, 12001
|
5663, 9500
|
322, 401
|
12193, 12200
|
3493, 3498
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|
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|
1929, 2710
|
2726, 2898
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,274
| 188,489
|
49224
|
Discharge summary
|
report
|
Admission Date: [**2156-11-15**] Discharge Date: [**2156-12-12**]
Date of Birth: [**2096-10-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
EGD/panc. biopsy [**2156-11-26**]
redo AVR [**2156-12-3**] ( 21mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) **] porcine valve)
History of Present Illness:
60 year old male who presented to [**Hospital6 33**] by
ambulance with complaints of chest pain on [**11-15**]. He noted
substernal chest pressure lasting 3-10 min for the past 2 weeks.
The pain does not radiate. He had DOE. It is made worse by
exertion and he has difficulty climbing the stairs in his home.
The pain was worse during night and awoke him from sleep. When
he has the pain he has also noticed SOB. He was transferred to
[**Hospital1 18**] for further evaluation.
Past Medical History:
PMH:
1. Alcohol detox 2 wks ago
2. Abdominal malignancy - 2.7cm iliac LN/abdominal LAD currently
being worked up by Dr. [**Last Name (STitle) **]
3. Bicuspid aorta s/p aortic valve replacement with porcine
valve in [**2151**]
4.Presence of venous angioma vs AV malformation seen on prior
MRAs.
5. Status post traumatic splenectomy
6. Depression
7. Essential tremor
8. Status post bilateral herniorrhaphy
9. Status post right thumb surgery
[**59**]. Status post ACL repair.
Social History:
Divorced but pending re-marriage. 2 children. Smokes [**3-1**] cigars
per day. EtOH abuse (8 beers/day x 30 years) s/p detox 2 weeks
ago. 1 beer in last 2 weeks per patient.
Family History:
GM with open heart surgery (unclear indication)
Physical Exam:
Admission
Vitals: T: 98.0 BP: 104/79 P: 84 R: 20 SaO2:93%RA
General: Awake, alert, NAD.
HEENT: NC/AT, EOMI without nystagmus, no scleral icterus noted,
MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Decrease BS b/l with dullness to percussion
Cardiac: RRR, nl. S1S2, systolic murmur heard best at RUSB
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: Trace edema
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. bilateral
resting tremor.
-sensory: No deficits to light touch throughout.
Pertinent Results:
[**2156-12-9**] 07:10AM BLOOD WBC-14.3* RBC-2.96* Hgb-10.2* Hct-29.4*
MCV-99* MCH-34.4* MCHC-34.7 RDW-15.5 Plt Ct-208
[**2156-12-9**] 07:10AM BLOOD Plt Ct-208
[**2156-11-30**] 07:25AM BLOOD Ret Aut-2.2
[**2156-12-9**] 07:10AM BLOOD Glucose-106* UreaN-7 Creat-0.7 Na-134
K-4.1 Cl-96 HCO3-33* AnGap-9
[**2156-12-9**] 07:10AM BLOOD estGFR-Using this
[**2156-12-9**] 07:10AM BLOOD ALT-31 AST-43* LD(LDH)-337* AlkPhos-130*
Amylase-51 TotBili-0.8
[**2156-12-9**] 07:10AM BLOOD Lipase-38
[**2156-12-9**] 07:10AM BLOOD Albumin-3.3*
[**2156-11-30**] 07:25AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 103199**] (Complete)
Done [**2156-12-3**] at 9:52:21 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2096-10-21**]
Age (years): 60 M Hgt (in): 76
BP (mm Hg): 95/52 Wgt (lb): 200
HR (bpm): 64 BSA (m2): 2.22 m2
Indication: Aortic valve disease. Intra-op TEE for re-do AVR
ICD-9 Codes: 440.0, V42.2, 424.1
Test Information
Date/Time: [**2156-12-3**] at 09:52 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2006AW05-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 5.0 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 5.1 cm
Left Ventricle - Fractional Shortening: *0.16 >= 0.29
Left Ventricle - Ejection Fraction: 35% >= 55%
Aorta - Valve Level: 2.3 cm <= 3.6 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *5.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *114 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 72 mm Hg
Aortic Valve - LVOT diam: 2.3 cm
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.0 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 68 ms
Mitral Valve - MVA (P [**12-29**] T): 3.2 cm2
Findings
LEFT ATRIUM: Moderate LA enlargement. Good (>20 cm/s) LAA
ejection velocity. All four pulmonary veins identified and enter
the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Moderately depressed LVEF.
RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free
wall hypokinesis.
AORTA: Normal aortic root diameter. Focal calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in ascending aorta. Normal aortic arch diameter.
Simple atheroma in aortic arch. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Bioprosthetic aortic valve prosthesis (AVR). Thickened AVR
leaflets. Increased AVR gradient. Abnormal AVR. No masses or
vegetations on aortic valve. Severe AS (AoVA <0.8cm2). Mild (1+)
AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate mitral annular calcification. Calcified tips of
papillary muscles. No MS. Mild to moderate ([**12-29**]+) MR.
TRICUSPID VALVE: Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR. Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient received
antibiotic prophylaxis. The TEE probe was passed with assistance
from the anesthesioology staff using a laryngoscope. The patient
was under general anesthesia throughout the procedure. The
patient appears to be in sinus rhythm. Results were personally
post-bypass data
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
1. The left atrium is moderately dilated. No atrial septal
defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is globally moderately depressed.
3. The right ventricular cavity is mildly dilated. There is mild
global right ventricular free wall hypokinesis.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis (area <0.8cm2). Mild (1+)
aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Mild to
moderate ([**12-29**]+) mitral regurgitation is seen.
7. Moderate [2+] tricuspid regurgitation is seen.
POST-BYPASS: Pt is being A paced and is on an infusion of
epinephrine and phenylephrine
1. A 21 mm bioprosthesis well seated in the Aortic position,
leaflets appear to move well. No significant AI is seen.
2. LV systolic function is slightly improved.
3. Episode of moderate to severe RV hypokinesis during sternal
closure with moderate LV hypokinesis, improved with inotropes,
Mild to Moderate RV hypokinesis persisting with inotropic and
pressor support.
4. MR [**First Name (Titles) **] [**Last Name (Titles) 1506**]
5. Aorta is intact post decannulation
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician
[**Known lastname **],[**Known firstname **]:[**Hospital1 18**] Radiology Detail - CCC Record #[**Numeric Identifier **]
PRELIMINARY REPORT
HISTORY: Confusion after aortic valve replacement.
COMPARISON: MRIs on [**11-28**] and [**2156-11-24**], [**1-26**], [**2151**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no intracranial hemorrhage, shift of normally
midline
structures, alteration in the [**Doctor Last Name 352**]-white matter differentiation,
or new
hydrocephalus. There is no evidence of a major vascular
territorial infarct.
The sinuses are well aerated. The osseous structures and soft
tissues are
normal.
The known vascular anomaly in the left temporal region is not
appreciated on
this study.
IMPRESSION: No acute intracranial pathology.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 23304**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**]
?????? [**2152**] CareGroup IS. All rights reserved.
Brief Hospital Course:
Admitted on [**11-15**] from [**Hospital3 **] Hosp.to the cardiology
service with c/o angina for the past 2 weeks ( as noted above).
Troponin positive with EKG changes and signs of CHF. Weight loss
recently concerning for possibility of malignancy given
lymphadenopathy/alcoholism. Echo done as part of w/u which
revealed severe prosthetic aortic valve stenosis with [**Location (un) 109**] 0.4
cm2, peak gradient 131/mean 83, EF 20%, [**Doctor Last Name **], 1+ AI, 1+ MR, 2+
TR, moderate MAC, ascending aorta 3.9 cm, and severe PA systolic
hypertension. Right lung mass/opacity also seen on CXR.
Diuresis/ASA/ACE/beta blockade/digoxin commenced. Social work
consult done. CT torso also revealed mesenteric /mediastinal
lymphadenopathy.
Neuro consult done for history of venous AVMs of the brain and
they recommended avoiding long-term anti-coagulation which would
be required for a mechanical valve. Cath done [**11-19**] showed a 50%
diagonal lesion. CT surgery consulted for redo AVR. [**Month/Year (2) **]
/oncology consult also done with recs for abdominal node biopsy
to r/o malignancy. Carotid US did not show any significant
stenoses. Dental consult done and cleared for surgery. Liver
service consulted for evaluation. HIT panel sent for decreasing
platelet count to 91K and all heparin stopped but was ultimately
negative. Node biopsy specimen was nondiagnostic, and general
surgery was consulted for possible laparascopic node biopsy.
Treated for epistaxis on [**11-30**]. Nutrition consult done on [**12-1**].
Cleared for surgery and underwent redo AVR with porcine valve on
[**12-3**] with Dr. [**Last Name (STitle) **]. Transferred to the CSRU in stable
condition on epinephrine and propofol drips. Extubated that
evening and weaned from drips the next day.Transferred to the
floor on POD #2 to begin increasing his activity level.Developed
some sternal drainage on POD #4 and vancomycin started.He
remained afebrile.ACE restarted, but no beta blockade per
cardiology also, and treated for UTI that developed on POD #6.
Will f/u with heme/onc as an outpt. CT brain done for confusion
which did not show any intracranial pathology. He has had some
diarrhea, without abdominal pain. C Diff. was sent & is
pending. He was started on flagyl empirically. He had a brief
episode (less than 1 hour) of A Fib today, with a ventricular
rate of 80/minute, which converted spontaneously to NSR. He has
remained stable & is ready for discharge to rehab today,
[**2156-12-11**].
Medications on Admission:
Medications at home:
lexapro 20
ASA 81
advair prn
.
Meds on transfer:
ASA 325
coreg 6.25mg [**Hospital1 **]
captopril 6.25mg tid
digoxin 0.125mg qd
atorvastatin 40mg qd
lasix 20mg IV qd
lexapro 20mg qd
ambien 5mg qhs prn
valium 10mg po q2h prn CIWA
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: last dose 12/21 for UTI.
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
14. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
[**2156-12-3**] redo AVR (21mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) **] porcine valve)
prosthetic aortic stenosis with AVR [**2151**]
current ETOH abuse ( detox 2 weeks ago)
EGD/pancreatic biopsy [**2156-11-26**]
s/p traumatic splenectomy
depression
essential tremor
s/p bil. herniorrhaphies
s/p right thumb [**Doctor First Name **].
s/p ACL repair
UTI
Discharge Condition:
good
Discharge Instructions:
no driving for one month
no lotions, creams or powders on any incision
no lifting greater than greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, or drainage
may shower over incisions and pat dry
Followup Instructions:
follow up with Dr. [**Last Name (STitle) 8446**] 1-2 weeks
follow up with Dr. [**Last Name (STitle) **] in [**1-30**] weeks
Follow up with Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Should have CT scan in [**4-1**] weeks to evaluate ?malignancy workup
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD [**Last Name (Titles) 103200**]/Oncology
Phone:[**Telephone/Fax (1) 3237**] CC-7 [**Hospital Ward Name 23**] Date/Time:.........
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 14497**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/ONCOLOGY-CC9
Date/Time:...........
Completed by:[**2156-12-11**]
|
[
"785.6",
"303.00",
"228.02",
"783.21",
"286.7",
"784.7",
"287.5",
"427.31",
"424.1",
"599.0",
"996.02",
"333.1",
"458.29",
"571.0",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"39.61",
"99.07",
"35.21",
"45.13",
"88.56",
"88.72",
"37.23",
"00.17",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
14102, 14217
|
9873, 12360
|
335, 492
|
14646, 14653
|
2525, 7080
|
14925, 15621
|
1704, 1753
|
12660, 14079
|
14238, 14625
|
12386, 12386
|
14677, 14902
|
12407, 12438
|
2362, 2506
|
7129, 9850
|
1768, 2266
|
285, 297
|
520, 1000
|
2281, 2345
|
1022, 1497
|
1513, 1688
|
12456, 12637
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,983
| 188,596
|
48794
|
Discharge summary
|
report
|
Admission Date: [**2113-8-11**] Discharge Date: [**2113-8-13**]
Date of Birth: [**2055-8-29**] Sex: F
Service: [**Hospital Unit Name 196**]
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
Unstable angina
Major Surgical or Invasive Procedure:
Cardiac catherization with stent x 2 in right coronary art.
History of Present Illness:
The patient is a 57 year old female with cardiac history of
hyperlipidemia, borderline diabetes, CAD status post CABG in
[**2105**], former tobacco use who presented for elective cardiac
catheterization. One month ago, the patient began to notice
chest pain during exertion (two flights of stairs or several
blocks), which resolved with rest after a few minutes. The
patient reports that she experienced similar chest pain before
CABG but it was must less severe. To evaluate this symptom, the
patient underwent an ETT-MIBI which demonstrated a moderate
reversible defect in the inferior and lateral walls. The
patient consequently came to [**Hospital1 18**] on [**8-11**] for a scheduled
cardiac catheterization, where the following were found: right
dominant system; LMCA-30%; LAD-occluded mid; RCA-severe
calcifications with 80% mid and 90% distal; LIMA-LAD and radial
to diagonal and OM patent. There was reported difficulty to
pass a wire through the RCA calcifications. Unfortunately, when
the distal and mid stent placed there was a distal balloon
perforation as well as mid RCA perforation, and distal
dissection and prox deep cut (stable). Patient was left with
20% residual flow. Hemodynamics: RA 14; RV 32/9; PAP 35/19;
PCWP 18. L ventriculography 55%. Stat ECHO was performed without
evidence of a pericardial effusion. Pt remained hemodynamically
stable after this episode without symptoms of chest pain,
lightheadedness, or shortness of breath. After an evening of
close monitoring in the CCU, the patient was transferred to the
floor for further management.
Past Medical History:
* DM (borderline)
* Hypercholesteremia
* CABG [**2105**] LIMA to LAD, radial to OM+Diag
* cholycystectomy
* L CEA [**2-14**]
Social History:
Lives with mother, divorced
1 daughter
2.5 PPD x 30yr smoking history; quit 10yrs ago
Family History:
Adopted
Physical Exam:
On admission to the floor,
VS: afebrile HR 64 BP 119/60 O2 95% RA
Gen: no acute distress, lying in bed, appearing stated age
HEENT: PERRL, EOMI, no JVD
COR: RRR S1/S2 no m/r/g, no carotid bruits, no abdominal bruits,
no femoral bruits
[**Last Name (un) **]: clear to auscultation bilaterally
ABD: obese, nontender, nondistended, bowel sounds present
EXT: R groin cath site, no bruits, well circumscribed
ecchymosis, slight tenderness to deep palpation; DP and PT trace
bilaterally; no edema
NEURO: alert and oriented x 3, II-XII intact
Pertinent Results:
[**2113-8-13**] 06:40AM BLOOD WBC-5.4 RBC-3.55* Hgb-10.8* Hct-30.9*
MCV-87 MCH-30.3 MCHC-34.8 RDW-12.9 Plt Ct-174
[**2113-8-12**] 03:01PM BLOOD Hct-31.0*
[**2113-8-12**] 06:12AM BLOOD WBC-9.6 RBC-3.12* Hgb-9.5* Hct-27.5*
MCV-88 MCH-30.3 MCHC-34.4 RDW-13.0 Plt Ct-207
[**2113-8-13**] 06:40AM BLOOD Plt Ct-174
[**2113-8-12**] 06:12AM BLOOD Plt Ct-207
[**2113-8-12**] 06:12AM BLOOD PT-12.9 PTT-25.5 INR(PT)-1.1
[**2113-8-13**] 06:40AM BLOOD Glucose-127* UreaN-15 Creat-0.6 Na-142
K-4.2 Cl-109* HCO3-25 AnGap-12
[**2113-8-12**] 06:12AM BLOOD Glucose-109* UreaN-18 Creat-0.6 Na-142
K-3.8 Cl-107 HCO3-25 AnGap-14
[**2113-8-13**] 06:40AM BLOOD CK(CPK)-115
[**2113-8-12**] 09:23PM BLOOD CK(CPK)-175*
[**2113-8-12**] 02:05PM BLOOD CK(CPK)-206*
[**2113-8-12**] 06:12AM BLOOD CK(CPK)-192*
[**2113-8-11**] 05:00PM BLOOD CK(CPK)-55
[**2113-8-13**] 06:40AM BLOOD CK-MB-8 cTropnT-0.25*
[**2113-8-12**] 09:23PM BLOOD CK-MB-15* MB Indx-8.6*
[**2113-8-12**] 02:05PM BLOOD CK-MB-24* MB Indx-11.7*
[**2113-8-12**] 06:12AM BLOOD CK-MB-30* MB Indx-15.6* cTropnT-0.28*
[**2113-8-13**] 06:40AM BLOOD Calcium-9.4 Phos-2.5* Mg-1.9
[**2113-8-12**] 06:12AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.3
Brief Hospital Course:
1) CARDIOVASCULAR
ISCHEMIA: As discussed previously, the patient underwent cardiac
catheterization complicated by balloon perforation during
stenting of a heavily calcified RCA which consequently caused
dissection of the RCA itself. The dissection was self limited
and after two evaluatory ECHOs, there was no evidence of a
cardiac effusion. The patient was transferred from the CCU
after one evening of close monitoring and transferred to the
floor for further workup. On the floor, the patient remained
stable, without chest pain/palpitations/shortness of breath. At
discharge, there was slight increase in ecchymosis of the right
groin which was checked by the interventional fellow as well as
the attending and judged to be stable. There was no bruit,
pulsatile mass, hematoma, or flank pain.
PUMP: ECHO and cath data revealed preserved LV function ranging
from 50-55%.
RHYTHM: The patient remained without evidence of arrhythmias.
2) ANEMIA: The patient's hematocrit remained stable at 31 at
discharge. She refused transfusion when her Hct was at 27 and
subsequently was able to bring herself up to 31. She was
advised to seek medical attention should she feel sudden
weakness, dizziness, lightheadedness.
3) DIABETES: The patient's blood glucose levels were elevated
while on an insulin sliding scale. She informed the staff that
her glucose levels have been borderline high for several months
now. She was advised to discuss with her PCP whether an oral
[**Doctor Last Name 360**] would be appropriate at her next appointment.
4) HYPERCHOLESTEROLEMIA: The patient was discharge on 20 mg
lipitor daily due to her abnormal lipid profile. The patient
was asked why she was on a suboptimal dose and she reported that
there was a question of joint pain while on a more frequent
dose. Despite making the frequency less, the patient continues
to have joint pain (hip) so it was believed that lipitor was not
to blame. She was discharged on a more frequent dose of lipitor
with the thought that she is a high risk patient who requires
better lipid control. Liver function and evidence of muscle
pain should be closely monitored.
Medications on Admission:
* fenofibrate 160 qhs
* lipitor 20 m/w/f
* fish oil 3 caps/day
* provera 2.5mg m/w/f
* prozac liquid [**12-16**] tsp/day
* ASA 325 mg once a day
* premarin 0.625 m/th
* vitC 500
* MVI
* atenolol 25 mg once a day
* ibuprofen prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*0*
3. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
4. Fenofibrate Micronized 160 mg Tablet Sig: One (1) Tablet PO
qhs ().
5. Medroxyprogesterone Acetate 2.5 mg Tablet Sig: One (1) Tablet
PO QM,W,F ().
6. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
QM,TH ().
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Metoprolol Tartrate 25 mg Tablet Sig: Half Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 5 mg Tablet Sig: Half Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
11. Fenofibrate Micronized 160 mg Tablet Sig: One (1) Tablet PO
qhs ().
12. Multivitamin Capsule Sig: One (1) Cap PO QD (once a
day).
13. Medroxyprogesterone Acetate 2.5 mg Tablet Sig: One (1)
Tablet PO QM,W,F ().
14. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
QM,TH ().
15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
coronary artery disease
diabetes borderline
hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
1. Please take all of your medications.
2. Please seek medical attention should you experience any of
the following: shortness of breath, chest pain, palpitations,
sudden weakness, lightheadedness, dizziness, loss of
consciousness, fainting, nausea, vomiting, fever, chills
Followup Instructions:
1) Please see your PCP [**Name Initial (PRE) 176**] 1-2 weeks to discuss changes in
your medications (lipitor 20 mg daily) as well as a possible
oral [**Doctor Last Name 360**] for your blood glucose level that were slightly
elevated while you were in the hospital.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] Where: [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**]
Date/Time:[**2114-5-22**] 11:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2114-5-22**] 11:45
|
[
"414.01",
"E870.6",
"V45.81",
"250.00",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"36.07",
"88.53",
"99.20",
"37.23",
"88.56",
"36.06",
"36.01"
] |
icd9pcs
|
[
[
[]
]
] |
7805, 7811
|
4027, 6175
|
321, 382
|
7920, 7926
|
2840, 4004
|
8248, 8960
|
2260, 2269
|
6453, 7782
|
7832, 7899
|
6201, 6430
|
7950, 8225
|
2284, 2821
|
266, 283
|
410, 1993
|
2015, 2141
|
2157, 2244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,080
| 191,106
|
18229
|
Discharge summary
|
report
|
Admission Date: [**2176-12-26**] Discharge Date: [**2177-1-6**]
Date of Birth: [**2119-8-3**] Sex: F
Service: General Surgery Gold
HISTORY OF PRESENT ILLNESS: Patient is a 57-year-old female,
who has a history of progressive abdominal pain due to
pancreatitis secondary to an enlarging cystic lesion in the
body of the pancreas. The increasing size and radiographic
characteristics of the lesion suggested a cystic neoplasm
rather than a pseudocyst and an endoscopic ultrasound with
FNA biopsies was recently performed, which demonstrated
adenocarcinoma rather than mucinous cystadenoma. Local nodes
obtained at the time were negative for malignancy, and the
patient therefore presented to this institution for an
elective pancreatectomy.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Pancreatitis.
3. Hypothyroidism.
4. Depression.
5. Hypercholesterolemia.
6. New onset insulin dependent-diabetes mellitus.
7. Pancreatic adenocarcinoma.
PAST SURGICAL HISTORY:
1. Status post cholecystectomy.
2. Status post appendectomy.
MEDICATIONS:
1. Levothyroxine 175 mcg p.o. q.d.
2. Hydrochlorothiazide 12.5 mg p.o. q.d.
3. Verapamil 240 mg p.o. q.d.
4. Lisinopril 20 mg p.o. q.d.
5. Amitriptyline 50 mg p.o. q.h.s.
6. Celexa 50 mg p.o. q.h.s.
7. Lescol 80 mg p.o. q.d.
8. Pancrease four tablets p.o. before meals.
9. Aspirin 81 mg p.o. q.d.
10. Humalog insulin 10 mg subQ q.a.m. and 10 mg subQ q.p.m.
11. NPH insulin 10 units subQ q.p.m.
ALLERGIES:
1. Penicillins.
2. Lipitor.
PHYSICAL EXAMINATION: Vital signs: Temperature 99.1, blood
pressure 105/58, pulse 99, respirations 20. General:
Patient is a mildly obese female, who appears her stated age
and is in no apparent distress. HEENT: Anicteric sclerae.
Clear oropharynx. Moist mucous membranes. Neck is supple
and nontender with no lymphadenopathy or masses. Heart:
Regular rate and rhythm. Lungs are clear to auscultation
bilaterally. Abdomen: Soft, obese, nontender, and
nondistended. No palpable masses. Rectal: Normal tone,
fecal occult blood negative. Extremities: No cyanosis,
clubbing, or edema.
LABORATORIES: The preoperative white blood cell count was
7.6 with a hematocrit of 40.6 and a platelet count of
296,000.
HOSPITAL COURSE: On the date of admission, the patient was
taken to the operating room, where a subtotal pancreatectomy
along with a splenectomy were performed. The estimated blood
loss for the procedure was approximately 600 cc. Patient
tolerated this procedure well, and was discharged to the Post
Anesthesia Recovery Room in good condition with a nasogastric
tube, [**Location (un) 1661**]-[**Location (un) 1662**] drain, and a Foley catheter in place.
The patient's pain was controlled in the postoperative period
with an epidural catheter.
Given the patient's recent diagnosis of insulin
dependent-diabetes mellitus, the patient was placed on an
insulin drip in the immediate postoperative period and [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **] Diabetes consult was obtained. The patient's sugars
remained tightly controlled in the 140s-160 range. The
postoperative white blood cell count was 23.9, with a
hematocrit of 35.3, and a platelet count of 328,000.
The patient's early postoperative course was complicated by a
low grade temperature to 101.0 F on postoperative day two.
This was attributed to respiratory secretions and poor
pulmonary hygiene. Her epidural catheter was removed and her
pain was then controlled with a PCA analgesic pump. She also
was tachycardic to the 120s and was therefore placed on a
diltiazem drip.
On the evening of postoperative day two, the patient
developed respiratory distress with oxygenation in the low
80s and respiratory rate to the 30s. Upon discussion with
Dr. [**Last Name (STitle) **], it seemed prudent to intubate patient given her
smoking history and her appearance of respiratory fatigue.
The post intubation chest x-ray demonstrated congestive heart
failure which was treated with intravenous diuretics.
On postoperative day three, the patient received 1 unit of
packed red blood cells for a hematocrit of 25.9%. She also
had an elevated temperature to 101.2 F along with a
leukocytosis which is 28.5. He was therefore started on
Levaquin prophylactically. The white blood cell count
subsequently decreased to 18.8. The left upper quadrant
[**Location (un) 1661**]-[**Location (un) 1662**] drain was removed on postoperative day four.
The insulin drip was weaned off on postoperative day five,
and she was subsequently started on a subcutaneous sliding
scale along with long-acting glargine.
She was started on sips on postoperative day six after being
extubated the evening on postoperative day five. She was
subsequently advanced to a clear liquid diet on postoperative
day seven. Given her splenectomy, the patient received a
triple vaccine on this day as well. She was then transferred
to the floor.
On postoperative day eight, the patient was advanced to a
regular house diet, which she tolerated well and with stable
blood sugars. She finished up a seven day course of Levaquin
for her presumed pneumonia on postoperative day nine. Her
second [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed on postoperative day
10, and patient was discharged to home on postoperative day
11 in good condition.
Final pathology from her surgery was read as invasive
pancreatic adenocarcinoma, T3 N0 MX. The patient was
discharged to home with close followup by the [**Hospital **] [**Hospital 982**]
Clinic, and will be seeing her primary care doctor later in
the week.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Patient was discharged to home.
DISCHARGE DIAGNOSES:
1. Pancreatic adenocarcinoma.
2. Hypertension.
3. Insulin dependent-diabetes mellitus.
4. History of pancreatitis.
5. Hypercholesterolemia.
6. Depression.
7. Hypothyroidism.
8. Status post subtotal pancreatectomy.
9. Status post splenectomy.
DISCHARGE MEDICATIONS:
1. Verapamil 40 mg p.o. t.i.d.
2. Glyburide 5 mg p.o. q.a.m.
3. Glyburide 2.5 mg p.o. q.p.m.
4. Pancrease four capsules p.o. t.i.d. with meals.
5. Levothyroxine 175 mcg p.o. q.d.
6. Amitriptyline 50 mg p.o. q.h.s.
7. Protonix 40 mg p.o. q.d.
8. Celexa 50 mg p.o. q.h.s.
9. Vicodin 5/500 1-2 tablets p.o. q.4-6h. prn pain.
10. Lisinopril 20 mg p.o. q.d.
11. Aspirin 325 mg p.o. q.d.
FOLLOW-UP PLANS: The patient was instructed to followup with
Dr. [**Last Name (STitle) **] in approximately two weeks. She also has an
appointment with the [**Hospital **] [**Hospital 982**] Clinic and will be
seeing her primary care provider at the end of this week.
The patient was instructed to followup sooner if she develops
fevers greater than 101.5 F, vomiting, or severe abdominal
pain.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. 02.AAG
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2177-1-6**] 17:24
T: [**2177-1-7**] 09:22
JOB#: [**Job Number 50333**]
|
[
"244.9",
"250.00",
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"428.0",
"401.9",
"285.9",
"785.0",
"486",
"157.8"
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icd9cm
|
[
[
[]
]
] |
[
"41.5",
"96.71",
"99.03",
"52.59",
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] |
icd9pcs
|
[
[
[]
]
] |
5694, 5937
|
5960, 6343
|
2228, 5589
|
979, 1489
|
1512, 2210
|
6361, 6989
|
177, 760
|
782, 956
|
5614, 5673
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,396
| 152,279
|
28496
|
Discharge summary
|
report
|
Admission Date: [**2102-12-10**] Discharge Date: [**2102-12-23**]
Date of Birth: [**2023-12-4**] Sex: F
Service: SURGERY
Allergies:
Motrin / Tetracycline
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Gastric outlet obstruction
Intra-abdominal and retroperitoneal sepsis.
Major Surgical or Invasive Procedure:
1. Evacuation and drainage of retroperitoneal abscess.
2. Metal [**First Name3 (LF) **] retrieval.
3. Palliative gastrojejunostomy.
4. Palliative cholecystostomy tube.
5. Blind gastrostomy feeding jejunostomy tube placement.
History of Present Illness:
Mrs. [**Known lastname 1104**] was met by me this
afternoon in an emergency surgical consultation together with
her 2 daughters. At age 79, she has widespread intra-
abdominal cancer, most likely from the biliary tract, that is
surgically incurable. All attempts have been made to manage
her with endoscopic [**Known lastname **] placements and percutaneous biliary
[**Known lastname **] placements. When she had developed recurrent gastric
outlet obstruction, despite prior placement of a duodenal
metal [**Last Name (LF) **], [**First Name3 (LF) **] attempt was made to place another duodenal
[**First Name3 (LF) **]. Unfortunately, this likely migrated through tumor into
the retroperitoneum rendering intra-abdominal and
retroperitoneal sepsis. We operated for damage control and to
affect anything we could in a palliative manner
Past Medical History:
Metastatic intra-abdominal cancer
Gastric Outlet Obstruction
Painless jaundice
Breast cancer [**2089**] s/p lumpectomy with XRT and tamoxifen
"Prediabetes"
Hysterectomy, prolapsed uterus
s/p Appy
Social History:
denies etoh/cigarettes. Lives with daughter
Family History:
Sister with NHL, brother with lung cancer
Physical Exam:
In ED In ED, T 99.6, HR 128, BP 153/88, RR 18, Sat 96-97% on 2L
GEN: In NAD, conversant, pleasant.
HEENT: Dry MMM.
RESP: CTAB, without adventitious sounds.
CVS: RRR. Normal S1, S2. No murmur appreciated.
GI: BS present. Site of biliary drainage cath looks clean.
Abdomen soft, non-tender.
EXT: Without edema.
Pertinent Results:
[**2102-12-18**] 01:50AM BLOOD WBC-11.9* RBC-2.76* Hgb-9.0* Hct-25.2*
MCV-91 MCH-32.5* MCHC-35.6* RDW-15.4 Plt Ct-180
[**2102-12-10**] 01:45AM BLOOD WBC-16.9* RBC-4.06* Hgb-12.8 Hct-37.5
MCV-92 MCH-31.5 MCHC-34.2 RDW-15.6* Plt Ct-289
[**2102-12-18**] 01:50AM BLOOD Plt Ct-180
[**2102-12-18**] 01:50AM BLOOD Glucose-124* UreaN-8 Creat-0.4 Na-138
K-3.3 Cl-99 HCO3-33* AnGap-9
[**2102-12-10**] 01:45AM BLOOD Glucose-160* UreaN-22* Creat-0.5 Na-139
K-4.1 Cl-94* HCO3-30 AnGap-19
[**2102-12-16**] 02:49AM BLOOD ALT-15 AST-18 AlkPhos-91 TotBili-1.2
[**2102-12-10**] 01:45AM BLOOD ALT-62* AST-69* AlkPhos-156* TotBili-2.2*
[**2102-12-15**] 03:01AM BLOOD Lipase-13
[**2102-12-10**] 01:45AM BLOOD Lipase-24
[**2102-12-18**] 01:50AM BLOOD Calcium-7.4* Phos-2.3* Mg-1.8
[**2102-12-10**] 01:45AM BLOOD Albumin-3.1* Calcium-9.1 Phos-2.9 Mg-2.1
CTA ABD W&W/O C & RECONS [**2102-12-10**] 1:11 PM
IMPRESSION:
1. Enteric [**Month/Day/Year **] extends from antrum through second portion of
duodenum. The [**Month/Day/Year **] is filled with fluid. No definite enhancing
tumor material is seen growing through the [**Month/Day/Year **] arms, although
this cannot be completely excluded. The [**Month/Day/Year **] does appear
obstructed.
2. Metallic biliary [**Month/Day/Year **] appears patent with pneumobilia.
3. Unchanged large infiltrative mass in hepatic hilum, most
likely cholangiocarcinoma, either of biliary or gallbladder
origin.
4. Extensive peritoneal carcinomatosis along gastrocolic,
gastrohepatic ligaments, and along the peritoneal gutters, as
well as possibly in the pelvis adjacent to the hysterectomy
stump.
ERCP S/P DUODENAL/ENTERAL [**Month/Day/Year **] PLACEMENT [**2102-12-11**] 9:22 AM
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with gastric outlet obstruction trented with
enteral [**Hospital **] now with recurrent symptoms of GOO. ENDO performed
[**2102-12-11**], req sent [**2102-12-12**]
REASON FOR THIS EXAMINATION:
R/O Gastric Outlet Obstruction
INDICATION: Gastric outlet obstruction treated with [**Month/Day/Year **].
COMPARISON: [**2102-11-24**].
FINDINGS: Five fluoroscopic spot films during ERCP were provided
for interpretation. Images demonstrate previously placed enteral
[**Year (4 digits) **] and CBD [**Year (4 digits) **]. Images demonstrate a new enteral wall [**Year (4 digits) **]
subsequently placed withinthe prior [**Year (4 digits) **]. No radiologist was
present during the procedure.
CT ABDOMEN W/CONTRAST [**2102-12-12**] 12:29 PM
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with a pancreatic mass, with previous PTCA and
[**Hospital **], now s/p duodental [**Hospital **] with increased pain.
REASON FOR THIS EXAMINATION:
Eval for obstruction vs perforation. With Gastrografin.
IMPRESSION:
1. Apparent perforation of the duodenum at the junction of the
second and third parts with extravasation of contrast into the
right upper quadrant and right lower quadrant of the abdomen.
Free air also seen at the distal portion of the duodenal [**Hospital **]
supporting the evidence that this is a perforation. The duodenal
[**Hospital **] is seen to extend inferiorly/posteriorly by approximately
3-4 cm beyond the turn of the third portion of the duodenum.
2. Bilateral pleural effusions, slightly increased when compared
to the previous study. Right greater than left.
3. Essentially unchanged abdominal examination with hepatic mass
as described above.
Brief Hospital Course:
79 year-old female with recently diagnosed invasive
adenocarcinoma presumed cholangiocarcinoma per Hem/Onc notes,
status post biliary and duodenal stents and removal of external
biliary drainage, who presents with painless N/V.
*
1) N/V: Her presentation is most consistent with gastric outlet
obstruction, ? duodenal [**Hospital **] obstruction. She is otherwise
afebrile, without abdominal pain. Her LFTs and bilirubin are
trending down, without evidence for recurrent biliary
obstruction. She does have a mild leukocytosis, but no other
clinical signs for infection.
The ERCP fellow was [**Name (NI) 653**], and they likely will proceed with
EGD for evaluation.
She went to the OR on [**2102-12-12**] for 1. Evacuation and drainage
of retroperitoneal abscess. 2. Metal [**Date Range **] retrieval. 3.
Palliative gastrojejunostomy. 4. Palliative cholecystostomy
tube. 5. Blind gastrostomy feeding jejunostomy tube placement.
Neuro: She was intubated and sedated in the SICU.
Resp: She was extubated on POD 2 and tolerated extubation.
Abd: She had 2 JP drains and 1 Cholecystostomy tube drain and a
GJ tube. Her abdomen was soft, and slightly distended. She had a
NGT in place. The G/J tube was initially clamped.
GI: She was NPO. Once the NGT was removed she was started back
on a diet. TF were also initiated for comfort. She was then
ordered for a regular diet, but her appetite was lacking. TF can
be stopped if fullness, distention, nausea is noted.
Pain: She was on a Fentanyl drip while in the SICU. She was
switched to a Fentyl patch once transferred to the floor and was
mostly comfortable. She complained of difficulty moving and pain
with movement.
ID: Her WBC continued to be elevated post-operative and was
trending down. Her antibiotics were discontinued.
Renal: She received Lasix for diuresis on POD 3. A Foley was in
place and she had good urine output.
PT: She was a max assist, requiring [**Doctor Last Name 2598**] lift.
Social Work and Palliative Care: They were highly involved in
the decision making and discussing discharge options with the
family. Several family meetings were held to determine
disposition.
Medications on Admission:
Heparin 5000''', Colace 100'', Lopressor 25'', Senna, Reglan
Discharge Disposition:
Extended Care
Facility:
Maples Nursing & Retirement Center - [**Location (un) 6151**]
Discharge Diagnosis:
1. Metastatic intra-abdominal cancer.
2. Attempted metallic expandable duodenal [**Location (un) **] placement.
3. Duodenal perforation.
Discharge Condition:
Poor
Discharge Instructions:
Please resume all of your regular medications and take any new
medications as ordered.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 468**] for questions or concerns related to
your surgery. Call ([**Telephone/Fax (1) 9058**].
Completed by:[**2102-12-23**]
|
[
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icd9cm
|
[
[
[]
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[
"51.04",
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icd9pcs
|
[
[
[]
]
] |
7837, 7925
|
5577, 7726
|
353, 580
|
8106, 8113
|
2130, 3827
|
8249, 8413
|
1742, 1785
|
4656, 4793
|
7946, 8085
|
7752, 7814
|
8137, 8226
|
1800, 2111
|
243, 315
|
4822, 5554
|
608, 1444
|
1466, 1663
|
1679, 1726
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,211
| 112,297
|
10264
|
Discharge summary
|
report
|
Admission Date: [**2121-8-1**] Discharge Date: [**2121-8-9**]
Date of Birth: [**2056-10-31**] Sex: M
Service: SURGERY
Allergies:
Atorvastatin / Crestor
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
64y M w/prolapsing ostomy, parastomal hernia, ventral hernia,
resetting colostomy
Major Surgical or Invasive Procedure:
Ventral hernia, parastomal hernia repair with mesh
History of Present Illness:
Pt is a 64y M w/ underwent an [**Month (only) **] for rectal cancer,
subsequently had a prolapsing ostomy that was repaired, from
repaired and from that operation he developed the parastomal
hernia with a ventral hernia. He was offered repair.
Past Medical History:
Atrial fibrillation, on coumadin
CHF, EF of 40%
Type 2 Diabetes, poorly controlled on insulin, w/ neuropathy
Hypothyroidism
Right-sided lung mass that will require bronchoscopy
s/p colectomy, colostomy for colon cancer 5 years ago
Hernia at site of colostomy
Right foot debridement and skin graft 2 years ago
Social History:
The patient is married, his wife's name is [**Name (NI) **]. [**Name2 (NI) **] has a 40py
tobacco history. He used to drink a significant amount of
alcohol but quit about two years ago. No illicits. He is a
retired master plumber. He has three children.
Family History:
Mother died suddenly of presumed MI at age 62, father had
valvular disease and died of stroke at age 80. 3 children, in
good health; 3 siblings, in good health. No family history of
DM, cancer.
Physical Exam:
GEN: AXOx4, NAD,
HEENT: Atraumatic, normocephalic, PERRL,
RESP: CTAB, no wheezes, crackles, rubs
CV: RRR, no murmurs, gallops, rubs
ABD: Obese, colostomy on Left, large ventral hernia
EXT: no clubbing, cyanosis, [**12-18**]+ LE edema
Pertinent Results:
[**2121-8-2**] 12:40AM BLOOD Glucose-253* UreaN-37* Creat-2.9*# Na-142
K-4.9 Cl-104 HCO3-26 AnGap-17
[**2121-8-2**] 04:54AM BLOOD Glucose-189* UreaN-39* Creat-3.3* Na-143
K-4.9 Cl-104 HCO3-27 AnGap-17
[**2121-8-3**] 02:34AM BLOOD Glucose-184* UreaN-45* Creat-3.1* Na-143
K-4.3 Cl-106 HCO3-24 AnGap-17
[**2121-8-4**] 03:04AM BLOOD Glucose-69* UreaN-45* Creat-2.6* Na-150*
K-3.7 Cl-111* HCO3-31 AnGap-12
[**2121-8-6**] 06:10AM BLOOD Glucose-34* UreaN-39* Creat-2.1* Na-150*
K-3.1* Cl-110* HCO3-33* AnGap-10
[**2121-8-8**] 08:29AM BLOOD Glucose-145* UreaN-31* Creat-1.9* Na-142
K-3.3 Cl-104 HCO3-30 AnGap-11
[**2121-8-9**] 04:49AM BLOOD Glucose-67* UreaN-29* Creat-2.0* Na-143
K-3.4 Cl-105 HCO3-30 AnGap-11
[**2121-8-1**] 07:30PM BLOOD CK-MB-7 cTropnT-0.07*
[**2121-8-2**] 04:54AM BLOOD CK-MB-10 MB Indx-1.5 cTropnT-0.10*
[**2121-8-2**] 01:28PM BLOOD CK-MB-9 cTropnT-0.06*
[**2121-8-2**] 12:40AM BLOOD WBC-17.4*# RBC-4.78 Hgb-12.0* Hct-38.8*
MCV-81* MCH-25.1* MCHC-30.9* RDW-16.8* Plt Ct-277
[**2121-8-4**] 03:04AM BLOOD WBC-12.8* RBC-4.00* Hgb-9.9* Hct-32.6*
MCV-82 MCH-24.7* MCHC-30.3* RDW-16.8* Plt Ct-209
[**2121-8-9**] 04:49AM BLOOD WBC-9.7 RBC-3.95* Hgb-10.3* Hct-30.9*
MCV-78* MCH-26.0* MCHC-33.2 RDW-16.4* Plt Ct-358
Brief Hospital Course:
Pt admitted for same day procedure noted previously. Case
lasting approximately 5 hrs, patient received 1800cc of
crystalloid, procedure was without complications.
Post-operatively, patient resuscitated in PACU with total of 6L
of crystalloid. Epidural was decreased, then held at
apporximately 10pm. Pt [**Name (NI) **] responding to resuscitation
initially, then decreasing to 6cc/hr at 12am. Fluid bolus of
1500mL given, [**Name (NI) **] did not respond. Echo from [**4-23**] demonstrated
evidence of diastolic CHF with EF of 45-60%.
POD1 [**8-2**] : Pt admitted to SICU w/oliguria and hypotension,
cardiology service was consulted, enzymes were cycled, cardiac
echo was obtained, Vanc, Zosyn, Flagyl were continued. BP 90's
systolic, CVP was 15-17. Dopamine was initiated. Creatinine 3.3
POD2 [**8-3**] : Dopamine tirated off, urine output improving, O2
sat's stable on 6LNC. BP's systolic 100-140, CVP 15. Creatinine
3.1->2.8
POD3 [**8-4**] : Lasix drip started, goal net neg 1-2L/day.
Creatinine-2.6/ Na-150, free water given, await return of bowel
function. Rhythum a-fib w/ventricular rate 70-90's controlled
with lopressor. SBP 110-130's, CVP 15-17.
POD4 [**8-5**] : Lasix drip continued at 1mg/hr, creatinine-2.3/
Na-152. Free water deficit replacement, continued Abx
Vanc/Zosyn/Flagyl, plan for transfer to floor.
SBP 120-150, CVP 9-11.
POD5 [**8-6**] : Transfer to floor, on IV lasix 20mg q6h, NGT out,
comfortable with no N/V
Cr-2.1/ Na-150. Deit advanced, free water given, lasix held.
drain #1 d/c'd, abx continued.
POD6 [**8-7**] : Cr 2.0/ Na 143. Tolerating diet, out of bed, refuses
rehab, worked with PT. Drain #2 d/c'd. Abx continued.
POD7 [**8-8**] : Cr 1.9/ 142. No events, ambulation, CVL d/c'd.
Worked with PT, plan for discharge. Abx continued
POd8 [**8-9**] : d/c home
Medications on Admission:
Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
7. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTUES (every Tuesday).
Discharge Disposition:
Home
Discharge Diagnosis:
Ventral hernia, parastomal hernia
Discharge Condition:
Improved
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. Return to ED if fever >101.4, Chest
pain, shortness of breath, severe pain not relieved by
medication, intractable nausea and vomiting, significant
discharge or drainage from wound. Call office for other
concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2998**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2121-9-30**] 8:00
Completed by:[**2121-8-13**]
|
[
"250.60",
"428.30",
"553.1",
"569.69",
"428.0",
"V10.06",
"244.9",
"553.20",
"584.9",
"357.2",
"V58.61",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.42",
"53.69",
"53.41"
] |
icd9pcs
|
[
[
[]
]
] |
6076, 6082
|
3021, 4831
|
363, 416
|
6160, 6171
|
1775, 2998
|
6535, 6839
|
1309, 1505
|
5380, 6053
|
6103, 6139
|
4857, 5357
|
6195, 6512
|
1520, 1756
|
242, 325
|
444, 689
|
711, 1022
|
1038, 1293
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,482
| 101,046
|
36051
|
Discharge summary
|
report
|
Admission Date: [**2189-7-6**] Discharge Date: [**2189-7-13**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
CoreValve placement
Major Surgical or Invasive Procedure:
CoreValve placement
Repeat Right and Left heart catheterization
Temporary pacemaker placement
History of Present Illness:
[**Age over 90 **]-year-old caucasian female with CAD, NSTEMI [**2189-5-6**] pulmonary
HTN, and known critical aortic stenosis (AoVA = 0.6cm2, EF 40%)
now symptomatic with increasing chest pain, SOB, and dizziness.
Patient had been seen in [**2185**] and declined surgical intervention
at that time. She was also admitted for CHF exacerbation 20
lbs over her baseline in [**2189-5-13**] and considered for
valvuloplasty, however this was not done due to concerns
regarding significant aortic regurgitation. She underwent a
complete evaluation for TAVI during the stay including carotid
ultrasound, presantine perfusion scan, dipyridamole stress, and
CT of the chest/ abdomen/ and pelvis.
Recently, the patient has been experiencing decline in her
functional status due to worsening SOB and lightheadedness and
is limited to walking to the bathroom. (Adapted from Aortic
Valve Service History & Physical)
At baseline, patient has a history of anxiety.
NYHA Class: III
Aortic valve replacement was uneventful and the LVEDP was
measured at 33. The patient required 2 units of PRBCs.
Upon arriving to the floor, patient became acutely dyspnic,
gasping for breath with saturations in the mid 80s.
Simultaneously, the patient had increased blood pressures
measured at 200s/100s by arterial line. Initial ABG was drawn
and demonstrated 7.29/52/72 (pH/pCO2/pO2). An urgent chest x-ray
demonstrated acute pulmonary edema with no evidence of
pneumothorax and was treated with 40mg lasix IV. Echo showed
[**12-14**]+ AR/MR and mild paravalvular leak. Patient was given
albuterol and ipratropium nebulizer treatments followed by 125mg
methylprednisolone and patient was put on a non-rebreather mask.
Patient was also given 0.5mg morphine sulfate, 0.5mg lorazepam.
Repeat ABG demonstrated increasing academia and hypercarbia
(7.20/73/108) and patient was transitioned to BiPAP 15/5.
Repeat ABG after 30 minutes of BiPAP showed 7.40/ 40/97 and
patient was weaned off the BiPAP.
Past Medical History:
1. CARDIAC RISK FACTORS:
- Hypertension
- Hyperlipidemia
2. CARDIAC HISTORY:
- Critical Aortic Stenosis
- Severe two-vessel CAD s/p NSTEMI ([**2189-2-6**])
- Congestive Heart Failure
3. OTHER PAST MEDICAL HISTORY:
- Pulmonary Hypertension
- Asthma
- Anemia
- Depression
- h/o right leg fracture s/p ORIF
- s/p knee replacement
Social History:
Lives at [**Hospital **] Nursing Home. Limited ambulation. Daughter
supportive, lives about 20 min away. Retired from clerical work.
Denies alcohol and tobacco.
Family History:
Mother died at age [**Age over 90 **] and father died at 78 from heart disease.
Physical Exam:
Admisson Exam:
Tmax: 35.9 ??????C (96.7 ??????F)
HR: 53 (53 - 58) bpm
BP: 109/43(65) {109/43(65) - 158/59(94)} mmHg
RR: 24 (8 - 24) insp/min
SpO2: 100%
HEENT: NC/AT sclera anicteric, MMM, pupils dilated
JVP: Unable to assess with pacing wire in right neck, but
appears flat on left
Lungs: Patient is gasping for air with labored breathing. Upper
airway sounds present with poor air movement.
Cardiac: Tachycardic, with no murmurs heard.
Abdomen: Soft, non-tender, non distended. Positive bowel
sounds.
Extremities: No edema, pulses 2+ dp/pt. No edema.
.
Discharge Exam:
GENERAL: Comfortable in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated. Right next with mod bruising
and 2 cm hematoma from large central line that is slowly
resolving
CHEST: CTABL no wheezes, no rales, no rhonchi, [**Month (only) **] at bases.
CV: S1 S2 nl, 2/6 systolic murmur at RUSB.
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: wwp, no edema. DPs, PTs 2+.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL (biceps, achilles, patellar).
SKIN: no rash
Pertinent Results:
ADMISSION LABS:
[**2189-7-6**] 02:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2189-7-6**] 05:45PM WBC-7.1 RBC-3.52* HGB-10.2* HCT-30.3* MCV-86
MCH-29.0 MCHC-33.7 RDW-16.9*
[**2189-7-6**] 05:45PM PLT COUNT-212
[**2189-7-6**] 05:45PM PT-12.6 PTT-21.6* INR(PT)-1.1
[**2189-7-6**] 05:45PM ALBUMIN-4.1 CALCIUM-9.6
[**2189-7-6**] 05:45PM CK-MB-3 proBNP-[**Numeric Identifier **]*
[**2189-7-6**] 05:45PM ALT(SGPT)-18 AST(SGOT)-26 CK(CPK)-70 ALK
PHOS-66 TOT BILI-0.6
.
DISCHARGE LABS:
.
PERTINENT STUDIES:
TTE ([**2189-7-7**]): The left atrium is dilated. Overall left
ventricular systolic function is mildly depressed with basal
inferior and basal to mid lateral hypokinesis (LVEF= 50 %).
Right ventricular chamber size and free wall motion are normal.
An aortic CoreValve prosthesis is present. The transaortic
gradient is normal for this prosthesis. Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-14**]+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is a
very small pericardial effusion. There are no echocardiographic
signs of tamponade.
.
TTE ([**2189-7-8**]): The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with focal inferior and basal to mid inferolateral
hypokinesis. The remaining segments contract normally (LVEF = 50
%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size is mildly dilated and free wall motion is normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. An aortic CoreValve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. Moderate (2+) aortic regurgitation is seen. The
aortic regurgitation jet is eccentric. The mitral valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2189-7-7**],
the severity of tricuspid and mitral regurgitation have
increased. The trans-Corevalve gradient is higher while the
severity of aortic regurgitation is unchanged. Pericardial
effusion is smaller. The right ventricle appears mildly dilated.
.
TTE ([**2189-7-9**]): Overall left ventricular systolic function is
mildly depressed (LVEF= 45 %). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm/premature beats. Right
ventricular chamber size is normal. with borderline normal free
wall function. An aortic CoreValve prosthesis is present. The
transaortic gradient is higher than expected for this type of
prosthesis. A paravalvular aortic valve leak is present. Mild to
moderate ([**12-14**]+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric. Moderate (2+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a trivial/physiologic
pericardial effusion.
.
Cardiac Cath ([**2189-7-9**]):
1. Elevated LVEDP
2. Mild to moderate aortic insufficiency
3. No gradient across the Corevalve (no aortic stenosis)
4. Mild to moderate pulmonary hypertension (from diastolic
dysfunction)
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: [**Age over 90 **]-year-old caucasian female with
CAD, NSTEMI [**2189-5-6**] pulmonary HTN, and known critical aortic
stenosis (AoVA = 0.6cm2, EF 40%) s/p corevalve.
Active Diagnoses:
.
# COREVALVE
Patient's perioperative course was complicated by flash
pulmonary edema after 2 units PRBCs in the cath lab. She was
treated with diuresis and BiPAP, with succesful weaning onto
nasal canula. 24 hours after placement, [**7-8**] Echo demonstrated
high trans gradients and continued aortic regurgitation. The
picture was complicated by decreased MAPs below 65 and urine
output to 15-20 cc/h and creatinine increasing to 1.6. Patient
was clinically stable throughout with no further episodes of
dyspnea. Patient was started on Dopamine drip at 2mcg/kg/min
with increase in UOP and MAPs above 65. On [**7-9**] reassessment in
cath lab with PCWP was 20-22 mmHg and the PA systolic pressure
was < 50 mmHg. The RA pressure was [**9-23**]. The LVED was 30 mmHg
(due to diastolic dysfunction and unchanged from pre) and there
was a minimal trans-aortic gradient. Patient began to
clinically improve with activity around the CCU including
walking. She was weaned of the dopamine gtt. Subsequent TTE
showed continued AR, but the patient remained stable and was
transferred to the floor and then rehab.
# WENCHIBACH WITH PERSISTENT BRADYCARDIA
Likely etiolgy is sick sinus syndrome. Patient was evaluated by
EP team with decision made to not place a pace maker.
# CAD
Patient was continued on Aspirin 81 mg daily, Plavix 75mg daily
and Crestor 20 mg daily. She was not on BB secondary to sinus
bradycardia.
# ASTHMA
Pt was continued on Fluticasone-Salmeterol Diskus (250/50) and
Montelukast 10 mg daily.
# CHF
Furosemide 20mg was started within 48 hours of CoreValve
placement with Spironolactone 25. HCTZ 25 was discontinued.
She was started on lisinopril 10mg/day during this admission.
# GERIATRIC CARE:
Pt was continued on home trazadone for sleep throughout her
course. She intermittently required benzos for anxiety, which
she tolerated well.
#ANXIETY/ INSOMNIA
We continued home escitalopram and trazadone. Trazodone was
briefly discontinued due to prolongation of QT on one EKG, but
was restarted with no incident.
Medications on Admission:
Medications - Prescription
ALPRAZOLAM - 0.25 mg Tablet - one Tablet(s) by mouth twice daily
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth once a day
FLUTICASONE [FLONASE] - (Prescribed by Other Provider) - Dosage
uncertain
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - Dosage uncertain
FUROSEMIDE - 20 mg Tablet - one Tablet(s) by mouth daily
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) - 30 mg
Tablet Extended Release 24 hr - 1 (One) Tablet(s) by mouth once
a
day
MONTELUKAST [SINGULAIR] - (Prescribed by Other Provider) - 10
mg
Tablet - 1 Tablet(s) by mouth once a day
ROSUVASTATIN [CRESTOR] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
SPIRONOLACTON-HYDROCHLOROTHIAZ [ALDACTAZIDE] - (Prescribed by
Other Provider) - 25 mg-25 mg Tablet - 1 Tablet(s) by mouth once
a day
TRAZODONE - 50 mg Tablet - one Tablet(s) by mouth at bedtime
Medications - OTC
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) -
500
mg Tablet - 1 Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider; OTC) - 81 mg Tablet,
Chewable - 1 Tablet(s) by mouth once a day
VITAMIN E - (Prescribed by Other Provider) - 600 unit Capsule -
2 Capsule(s) by mouth once a day
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
3. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 701**]
Discharge Diagnosis:
Critical Aortic Stenosis
Coronary Artery Disease
Systolic congestive heart failure
Hypertension
Anemia
Bradycardia
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 had a percutaneous replacement of your aortic valve. The
procedure went well and the valve is functioning appropriately.
You had some slow heart rhythms after the procedure that has now
resolved. We expect that the shortness of breath with gradually
improve over the next month. Weigh yourself every morning, call
Dr. [**Last Name (STitle) **] if weight goes up more than 3 lbs in 1 day or 5 pounds
in 3 days.
.
We made the following changes to your medicines:
1. Stop taking Imdur, aldactazide, Vitamin c and Vitamin E.
2. STart Lisinopril to help your heart pump better
3. Change Aprazolam to Lorazepam to treat your anxiety
Followup Instructions:
Department: CARDIAC SERVICES
When: FRIDAY [**2189-8-7**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: FRIDAY [**2189-8-7**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
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"272.4",
"285.9",
"780.52",
"V43.65",
"427.89",
"416.9",
"424.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"35.96",
"88.53",
"37.23",
"35.22",
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] |
icd9pcs
|
[
[
[]
]
] |
12255, 12329
|
7754, 7951
|
270, 365
|
12488, 12488
|
4189, 4189
|
13319, 13926
|
2921, 3002
|
11366, 12232
|
12350, 12467
|
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|
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|
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|
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|
2475, 2581
|
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|
211, 232
|
393, 2376
|
4206, 4734
|
12503, 12640
|
2612, 2726
|
7969, 10011
|
2398, 2455
|
2742, 2905
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,187
| 149,016
|
632
|
Discharge summary
|
report
|
Admission Date: [**2162-6-8**] Discharge Date: [**2162-6-18**]
Date of Birth: [**2103-3-15**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4854**]
Chief Complaint:
Shortness of [**First Name3 (LF) 1440**]
Major Surgical or Invasive Procedure:
Bipap
History of Present Illness:
59 year old female with type 1 diabetes, hypertension, frequent
UTI on tetracycline immunosuppresion, ESRD s/p CRT in [**2149**], who
presents with acute onset of dyspnea.
.
The patient was recently admitted from [**Date range (1) 4859**]/09 for
pyelonephritis and e. coli bacteremia. She presented with
weakness and fever. She was on Zosyn and ciprofloxacin until
sensitivies returned and then switched to oral ciprofloxacin.
She was on tetracycline for UTI suppression by her ID MD, Dr.
[**Last Name (STitle) 724**]. She was discharged with 2 week course of ciprofloxacin.
Also, Cr elevated and felt to be prerenal secondary to
bacteremia but also with some component of ATN, which resolved
with IVFs. Diuretics slowly restarted upon discharge.
.
The patient went to her appointment with her NP this morning.
Today, her wt was noted to be up 28 lbs from [**2162-5-20**]. The plan
was to increase lasix from 80 mg [**Hospital1 **] to 120 mg qAM and 80 mg QPM
and to follow up with Dr. [**Last Name (STitle) 1366**] on [**6-11**]. After her
appointment, she went home, and around noon, while walking, she
felt acute onset of dyspnea. She notes increased wt gain since
her recent discharge from [**Hospital1 18**] on [**6-1**], but notes that she is
on increased doses of her lasix. She also denies any medication
noncompliance. Denies dietary indiscretions, but has been
eating only chicken soup which her daughters prepare for her (1
tsp salt in each batch). She also drinks 2 glasses of cranberry
juice, cup of coffee, and cup of tea. She also has been eating
many low salt saltine crackers and ginger ale per her daughter.
[**Name (NI) **] daughter visited her the night prior to discharge, and noted
that her mom wsa tired and weak but not SOB. Today, though, the
patient called her daughter and complained of "gasping for air"
and then she was instructed to call 911. The patient then
presented to [**Hospital1 18**] ED. She states she has had subjective fevers
at night for the last 2 days with a cough. Chest pain with
presentation to ED, but now resolved. No abdominal pain, N/V or
diarrhea. She has been making good UOP at home.
.
In the ED, initial VS: T(not recorded) HR 96 BP 147/93 RR 44
O2 36% --> then 60% on NRB with good pleth per ED. Labs were
drawn, significant for leukocytosis 13, Cr 2.3. Blood culture x
2 and urine culture pending. VBG 7.24/70/36/31. UA negative.
EKG and portable CXR obtained. PE c/w with fluid overload with
bilateral LE pitting edema. Pt was confirmed DNR/DNI by patient
and daughter. She was placed on bipap (settings FiO2 100%, PS
10, PEEP 5) with O2 sat 100%.
.
In the ED, she was started on NTG SL x 1 then NTG gtt for
elevated BP (SBP 170-213s) and lasix 80 mg IV x 1 was given
after foley placement. Ceftriaxone 1 gm IV x 1 and levofloxacin
750 mg IV x 1 given. She was given 2 mg IV morphine x 1 for abd
pain and repeat 80 mg IV lasix given. Per ED verbal signout,
she had made 500 cc of UOP.
.
Review of systems:
(+) Per HPI
(-) Denies chest pain, n/v, diarrhea, constipation, abd pain
currently.
Past Medical History:
1. Hypertension
2. Diabetes-45+ years, type I
3. Status post renal transplant in [**0-0-**] crt 1.3-1.6
4. Sciatica
5. Multinodular goiter
6. Cataract surgery.
7. Hyperlipidemia.
8. Depression.
9. History of vertigo.
10. History of nephrolithiasis.
11. s/p left eye vitreous hemorrhage
Social History:
The patient is divorced with two adult children. She lives
alone in a one family house with stairs. Her two daughters and
ex-husband see her regularly and lve near by. No tobacco, ETOH,
illicit drug use. From [**Location (un) 4708**].
Family History:
Father with CAD, died age 55yo.
Physical Exam:
On discharge-
VITAL SIGNS: T 97.4 HR 64 BP 152/93 RR 18 96% 2L NC
GEN: Comfortable, in no acute distress
HEENT: anicteric, OP - no exudate, no erythema, unable to see
JVP secondary to anatomy
CHEST: lungs clear to auscultation bilaterally
CV: RRR, nl S1, S2, no m/r/g
ABD: NDNT, soft, obese, NABS
EXT: [**1-26**]+ pitting edema to bilateral knees
NEURO: A&O x 3
DERM: no rashes
Pertinent Results:
Admission:
.
[**2162-6-8**] 11:18AM WBC-7.6 RBC-3.32* HGB-8.0* HCT-27.1* MCV-82
MCH-24.1* MCHC-29.6* RDW-16.5*
[**2162-6-8**] 11:18AM PLT COUNT-300
[**2162-6-8**] 11:18AM UREA N-72* CREAT-2.3*# SODIUM-144
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-29 ANION GAP-21*
[**2162-6-8**] 11:18AM GLUCOSE-125*
[**2162-6-8**] 02:55PM LACTATE-2.9*
[**2162-6-8**] 02:55PM TYPE-ART PO2-36* PCO2-70* PH-7.24* TOTAL
CO2-31* BASE XS-0
.
Discharge:
.
[**2162-6-18**] 06:20AM BLOOD WBC-8.3 RBC-3.34* Hgb-8.1* Hct-27.2*
MCV-81* MCH-24.3* MCHC-29.9* RDW-16.1* Plt Ct-279
[**2162-6-18**] 06:20AM BLOOD Glucose-188* UreaN-77* Creat-2.8* Na-135
K-4.3 Cl-92* HCO3-32 AnGap-15
[**2162-6-18**] 06:20AM BLOOD Calcium-8.9 Phos-5.4* Mg-2.2
.
Studies:
1. pCXR: Diffuse bilateral lung opacities likely represent
pneumonia
although an element of CHF is also possible.
.
2. Renal transplant u/s: Persistent elevated resistive indices
in the renal transplant, with interval development of forward
diastolic flow. No evidence of perinephric fluid collection or
hydronephrosis
.
TTE [**6-11**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate pulmonary hypertension.
.
Compared with the prior study (images reviewed) of [**2162-3-26**],
pulmonary hypertension is identified. Aortic regurgitation is no
longer seen.
.
[**6-11**] RUQ U/S
FINDINGS: No focal abnormality is seen within the liver and
there is no
biliary dilatation seen. The extrahepatic common duct measures
0.4 cm. The
gallbladder is normal with no stones identified and no signs of
cholecystitis. No gallbladder wall thickening is seen and there
is no pericholecystic fluid. A small right pleural effusion is
seen but there is no ascites in the right upper quadrant.
IMPRESSION:
1. No gallstones and no signs of cholecystitis.
2. Small right pleural effusion.
.
CXR [**6-14**]
CHEST RADIOGRAPHS, AP UPRIGHT AND LATERAL VIEWS: Heart size
remains mildly
enlarged and mural calcifications are again noted along the
aortic arch. Right lung base consolidation is improved, with
improved definition of the right hemidiaphragm. Likely bilateral
small pleural effusions persist, along with left retrocardiac
likely atelectasis. No new pneumothorax is seen. A right upper
extremity PICC tip is again seen terminating in the right
subclavian vein region.
IMPRESSION: Right lung base consolidation is slightly improved.
Small
likely bilateral pleural effusions persist.
.
Micro:
Blood cx [**6-8**]: negative
Urine cx [**6-8**]: negative
Respiratory viral cx [**6-8**]: negative
Brief Hospital Course:
1. Dyspnea: Clinical picture most consistent with CHF
exacerbation with flash pulmonary edema in setting of
hypertensive urgency. Initially required nitro gtt and placed
on bipap in ED and admitted to the MICU for further management.
Also presented with low grade fever/infiltrates/sob and
therefore could not rule out pneumonia and she was treated with
vanc/zosyn for possible HAP given recent admission. She was
diuresed aggressively in the ICU with Lasix 160 mg IV/500 mg IV
Diuril combination and was 2L negative on [**6-8**] and continued to
be negative. She required 2 doses of diuretics per day and
nitroglycerin gtt discontinued early on arrival to ICU.
Electrolytes were stable, however creatinine bumped to 3.7 from
2.3 and therefore diuresis was held on [**6-11**]. Diuretics were
restarted on [**6-15**] at home dose of 80mg lasix [**Hospital1 **] when Cr
decreased to 2.8 which was close to patient's baseline. Her
respiratory status continued to improve and she was weaned down
from 4L NC to 2L NC with sats in high 90s. While working with
PT on [**6-16**] she was noted to desat with ambulation to 85% on 3L
NC and therefore it was felt that a short course of rehab with
continued diuresis and respiratory care would be necessary. She
continued to diurese well to lasix, however her weight remained
stable and therefore metolazone was added on [**6-17**], 5mg daily
with am lasix. Her Cr remained stable. On transfer to the
floor her antibiotics were changed to Levaquin and she completed
a total of 10 days, last day [**6-18**].
2. Fever/infiltrate/sob: febrile at home, tmax 100 in the ICU.
espiratory viral screen was negative as was Legionella urinary
antigen. Treated for HAP as above with Vanc/Zosyn that was
transitioned to levaquin on the medicine floor. Beta glucan was
sent given she is immunosuppressed and this was negative. She
completed 10 days of abx on [**6-18**]. Her WBC was normal at 8.3 on
the day of discharge and she remained afebrile her entire stay
on the floor.
3. ESRD s/p transplant: renal transplant followed. She was
continued on her home regimen of immunosuppressants and ESRD
medications. Held sodium bicarbonate as HCO3 rose in setting of
diuressis. Transplant ultrasound normal. Cr on day of discharge
was 2.8 and patient's baseline is 2.4-3. Her UOP remained
stable. She has follow up with her transplant nephrologist Dr.
[**Last Name (STitle) 1366**] next week.
.
4. DM1: Patient was continued on home lantus and HISS, however
lantus dose the decreased to 7 units qhs while in the ICU. On
the floor her FS were elevated to 200s and this was uptitrated
to 10 units qhs. Suspect the elevation was in setting of
increased prednisone dose to treat gout flare and will likely
need to be decreased once she resumes her home dose of 5mg
prednisone on [**6-21**]
5. Hypertension: goal SBP 140s, Nifedipine CR was increased to
90 mg daily while in the ICU and she was continued on home dose
of metoprolol. While in ICU her BP dropped with increased
nifedipine dose to 89/44 in addition to diuresis and sitting up
to eat, so her dose was decreased back to nifedipine 60 mg
daily. Her BP remained stable on the floor. If it increases
again may consider increasing nifedipine to 90mg once again.
6. Anemia: Patient's baseline Hct ranges 25-30. Felt to be
anemia of chronic disease. Hct slowly trended down to 22 and
she received one unit pRBCs on [**6-14**] with appropriate bump. Hct
remained stable at 27 the day of discharge. She was maintained
on epo.
7. Hyperlipidemia: continued simvastatin
8. Frequent UTIs: remained on tetracycline suppression
9. Obesity: sibutramine held while in the hospital and may be
resumed on discharge.
10. Gout: she was maintained on allopurinol, renally dosed. On
[**6-15**] the patient began complaining of increased pain, swelling
and erythema of her right hand, particularly in her thumb and
first digit. This was felt to be consistent with her typical
gout flare and her prednisone was increased to 40mg daily for a
5 day burst. She will need 3 more days of 40mg and then will
need to resume her daily immunosuppression dose of 5mg daily.
11. Access: PICC was placed for IV access for antibiotics. This
was removed [**6-18**] prior to discharge.
Medications on Admission:
Acetaminophen-Codeine 300-30 1-2 tablets po BID prn pain/fever
Albuterol Sulfate 90 mcg inhaler - 1 inhaled puffs q4-6 hours
prn SOB
Allopurinol 100 mg po QOD
Calcitriol 0.25 mcg po daily
Cyclosporine 75 mg po q12 hours
Epo 20,000 units SQ weekly
Fluticasone 50 mcg 1 inh nasally daily
Lantus 25 units SQ [**Hospital1 **]
Lactulose 30 ml po q8 hours prn constipation
Metoprolol Tartrate 200 mg po BID
Mycophenolate Mofetil 500 mg po BID
Nifedipine 60 mg SR po daily
Nystatin 100,000 unit [**Unit Number **] application topical [**Hospital1 **]
Prednisone 5 mg po daily
Roxicet 5-325 mg 1-2 tablets po q4-6 hours
Sibutramine 10 mg po daily
Simvastatin 5 mg po daily
Calcium carbonate 1000 mg po TID
Ferrous sulfate 325 mg po daily
Ciprofloxacin 500 mg po q24 hours x 7 days (day 1 = [**6-1**])
Lasix 80 mg po qAM
Lasix 40 mg po qhs
Novolog sliding scale
Tetracycline 250 mg po BID after completion of cipro
Sevelamer Carbonate 800 mg po TID with meals
Sodium bicarbonate 1300 mg po TID
Discharge Medications:
1. Albuterol Sulfate 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation every 4-6 hours as needed for shortness
of [**Month/Day (4) 1440**] or wheezing.
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours).
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal once a day.
6. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
7. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale as
directed Subcutaneous four times a day.
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
9. Metoprolol Tartrate 100 mg Tablet Sig: Two (2) Tablet PO
twice a day.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
12. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 2 days: then resume home dose of 5mg.
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please restart 5mg daily on monday [**6-21**].
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
16. Sibutramine 10 mg Capsule Sig: One (1) Capsule PO once a
day.
17. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
18. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
19. Epoetin Alfa 10,000 unit/mL Solution Sig: 10,000 units
Injection QMOWEFR (Monday -Wednesday-Friday).
20. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
23. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
24. Tetracycline 250 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
25. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
26. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
27. Metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
to be given with am lasix.
28. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
29. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 4860**] - [**Location (un) 4310**]
Discharge Diagnosis:
Primary: Pneumonia, Pulmonary edema, Acute on chronic renal
failure, anemia, gout
Secondary: End stage renal disease s/p transplant, Diabetes
Discharge Condition:
Afebrile. Sats stable on 2L O2. Ambulating with walker.
Discharge Instructions:
You were admitted to the hospital for pneumonia and fluid in
your lungs. You were initially admitted to the ICU for close
monitoring where you received strong IV antibiotics and
agressive medication to help you lose your fluid through urine.
You were eventually transferred to the medicine floor, and your
antibiotics were changed to oral medications. Your lasix was
held transiently because it wornsened your kidney function and
was restarted on [**6-15**].
.
Please seek immediate medical attention if you experience
shortness of [**Month/Year (2) 1440**], chest pain, fevers, chills, abdominal pain,
cough, or any change from your baseline health status.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2162-6-24**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2162-6-29**] 10:00
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **], RNC Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2162-9-1**] 11:40
[**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**] MD, [**MD Number(3) 4858**]
|
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23,701
| 159,505
|
27002+27003
|
Discharge summary
|
report+report
|
Admission Date: [**2198-2-8**] Discharge Date: [**2198-2-16**]
Date of Birth: [**2142-5-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2198-2-9**] - CABGx5 on IABP (Lima->LAD, SVG-Diag, SVG->OM1, OM2,
SVG-PDA)
[**2198-2-8**] - Cardiac Catheterization with IABP placement.
History of Present Illness:
The patient is a 55 year-old gentleman who has had stuttering
chest pain for the last week. He had a stress test which was
markedly positive. He
was taken urgently to the cath lab due to chest pain which was
ongoing after his stress test. His chest pain was relieved in
the cath lab at the time of his cardiac cath with the insertion
of an intra-aortic balloon pump. Diagnostic
cath revealed severe three vessel coronary artery disease with
relatively well preserved left ventricular function. His
ejection fraction was estimated at 50 to 55% by LV gram. His
left main was 50% stenotic. There was a second obtuse
marginal coronary artery which had an 80% stenosis. The LAD
coronary artery had a proximal 60% stenosis followed by a mid
80% stenosis. There was a large first diagonal coronary artery
which was in between the 2 lesions in the LAD. The right
coronary artery was subtotally occluded and filled the posterior
descending and posterior lateral vessels very poorly. The
patient was very stable overnight on IV medications as well as
the intra-aortic balloon pump. The patient was felt to be a
good candidate for urgent surgical revascularization. The
patient understood the risks and benefits of the procedure,
including but not limited to bleeding, infection, myocardial
infarction, stroke, death, renal and pulmonary insufficiency, as
the possibility of a blood transfusion and future
revascularization procedures.
The patient understood these and wished to proceed. In
addition, I spoke to his wife over the phone about the risks and
benefits of the procedure and she wished to proceed.
Past Medical History:
Hypercholesterolemia
HTN
Type 2 diabetes
Remote PUD
Nepholithiasis
Rib Fractures
Social History:
Rare ETOH. Quit smoking 25 years ago after a 25pack year
history. Lives with wife.
Family History:
Father died of MI at age 59
Mother with heart problems
Brother with angioplasty
Physical Exam:
Vitals: BP 115/84, HR 75, RR 14, SAT 95% on 2L
General: well developed male in no acute distress
HEENT: oropharynx benign
Neck: supple, no JVD
Heart: regular rate, normal s1s2, IABP sounds
Lungs: distanr but clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, 2+ edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2198-2-8**] 11:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.049*
[**2198-2-8**] 11:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2198-2-8**] 08:28PM GLUCOSE-146* UREA N-14 CREAT-0.7 SODIUM-137
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15
[**2198-2-8**] 06:30PM ALT(SGPT)-21 AST(SGOT)-15 ALK PHOS-43 TOT
BILI-0.5
[**2198-2-8**] 06:30PM WBC-8.0 RBC-4.16* HGB-12.3* HCT-34.4* MCV-83
MCH-29.4 MCHC-35.6* RDW-13.6
[**2198-2-8**] 06:30PM PT-13.2* PTT-39.6* INR(PT)-1.2*
[**2198-2-14**] 12:30PM BLOOD Hct-31.1*
[**2198-2-13**] 08:55PM BLOOD Plt Ct-388
[**2198-2-14**] 12:30PM BLOOD UreaN-14 Creat-0.8 K-4.8
[**2198-2-8**] Cardiac Catheterization
1. Selective coronary angiography revealed a right dominant
system with
severe three vessel disease. The LMCA had a 30% lesion. The LAD
had a
80% proximal lesion and 70% distal diffuse disease. The OM1 had
a 70%
lesion. The RCA had a 80% mid vessel lesion and was occluded
distally;
the distal vessel filled via collaterals.
2. Hemodynamics on entry revealed systemic hypotension (SBP 82
mm Hg),
which was thought to be secondary to a vagal episode during
arterial
access. Patient's blood pressure improved with 1 mg IV atropine.
After
the atropine, the patient had normal central pressure with
elevated
left sided filling pressure (LVEDP 25 mm Hg). There was no
gradient
across the aortic valve on pullback.
3. Left ventriculography revealed a mildly reduced ejection
fraction
(50%) with inferobasal hypokinesis.
4. Patient develope 4/10 chest pain after the diagnostic
angiogram was
done, which did not improved with a total of 15 mg IV
metoprolol. At
that time, an intra-aortic balloon pump was placed and the
patient's
chest pain resolved.
[**2198-2-9**] ECHO
Pre bypass: A tiny pinhole secundum atrial septal defect is
present. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Evaluation of LV
function is limited by poor transgastric views, especially the
mid papillary views. Overall left ventricular systolic function
is mildly depressed. LVEF 50%. Resting regional wall motion
abnormalities include severe basal inferior hypokinesis and mild
inferoapical and apical hypokinesis. Right ventricular chamber
size and free wall motion are normal. The ascending aorta is
mildly dilated. There are simple atheroma in the aortic
arch. There is an Intraaortic balloon pump in the descending
thoracic aorta with the tip positioned 3 cm below the left
subclavian. Due to IABP, unable to quantify atheroma in
descending thoracic aorta. The aortic valve leaflets (3)appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Mild to moderate ([**12-18**]+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. On color
M-mode, the jet comprises 25% of the LVOT at the level of the
Aortic valve. The presence of an IABP may contribute to
worsening appearance of the AI jet. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
Post bypass: No change in biventricular function or gross wall
motion. LVEF still 50%. Transgastric views still extremely
limited. AI unchanged [**12-18**]+, MR remains trace. Aortic contours
intact without visible dissection. IABP remains in good
position. Remaining exam unchanged. Findings discussed with
surgeons at time of the exam.
[**2198-2-14**] CXR
Small bilateral pleural effusions, without significant interval
change. Elevation of left hemidiaphragm.
Brief Hospital Course:
Mr. [**Known lastname 66373**] was admitted to the [**Hospital1 18**] on [**2198-2-8**] for further
management of his chest pain. He underwent a cardiac
catheterization which revealed severe three vessel disease with
an ejection fraction of 50%. An intra-aortic balloon pump was
placed for chest pain during the procedure. Due to the severity
of his disease, the cardiac surgical service was consulted for
surgical revascularization. Mr. [**Known lastname 66373**] was worked-up in the
usual preoperative manner and deemed suitable for surgery. On
[**2198-2-9**], Mr. [**Known lastname 66373**] was taken to the operating room where he
underwent coronary artery bypass grafting to five vessels.
Please see operative report for further details. Postoperatively
he was taken to the cardiac surgical intensive care unit for
monitoring. His intra-aortic balloon pump was weaned off and
removed without complication. On postoperative day one, Mr.
[**Known lastname 66373**] awoke neurologically intact and was extubated. The
diabetes service was consulted for assistance with his diabetes
medication management. He developed atrail fibrillation which
was treated with beta blockade and digoxin. He ultimately
converted back to normal sinus rhythm. On postoperative day
three, he was transferred to then cardiac surgical step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. Mr.
[**Known lastname 66373**] continued to make steady progress and was discharged to
home on postoperative day seven. A short course on antibiotics
was started for a right arm phlebitis. He will follow-up with
Dr. [**Last Name (STitle) 914**], his cardiologist and his primary care physician as
an outpatient.
Medications on Admission:
Lisinopril 20mg QD
Aspirin 81mg QD
Metformin 850mg TID
Glyburide 5mg [**Hospital1 **]
lipitor 10mg QD
Byetta 10 SC BID
Actos 45mg QD
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
7. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once
a day for 7 days.
Disp:*7 Packet(s)* Refills:*0*
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-22**]
hours as needed.
Disp:*40 Tablet(s)* Refills:*0*
14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
16. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
18. Byetta 5 mcg/0.02 mL Pen Injector Sig: Five (5) mcg
Subcutaneous twice a day.
Disp:*60 pen injectors* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
CAD
Hypercholesterolemia
HTN
Type 2 diabetes
PUD
Nephrolithiasis
Phlebitis
Discharge Condition:
Good.
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) No lotions, creams or powders to wound until it has healed.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
6) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] in 4 weeks.
Follow-up with cardiologist in [**12-18**] weeks.
Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) 5936**] in 2 weeks.
Follow up at [**Last Name (un) **] after discharge.
Completed by:[**2198-4-11**] Admission Date: [**2198-2-17**] Discharge Date: [**2198-2-22**]
Date of Birth: [**2142-5-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
55yo M with syncopal episode and feeling lightheaded after
discharge from CABGx5 [**2198-2-9**]. Found to be in rapid afib in ED
Major Surgical or Invasive Procedure:
None
History of Present Illness:
55year old male s/p CABGx5 [**2198-2-9**] with presyncopal episode
after voiding. Pt called 911 and was transferred to [**Hospital1 18**]. BP
104 palpated HR 70's no afib per EMS report.
Past Medical History:
NIDDM
Hypercholesteremia
Hypertension
CAD
Social History:
Rare ETOH. Quit smoking 25 years ago after a 25pack year
history. Lives with wife.
Family History:
Father died of MI at age 59
Mother with heart problems
Brother with angioplasty
Physical Exam:
55yo M in bed NAD
Neuro AA&Ox3, nonfocal
Chest CTAB resp unlab median sternotomy stable, c/d/i no d/c,
RRR no m/r/g
chest tubes and epicardial wires removed.
Abd S/NT/ND/BS+
EXT warm with trace edema open/EVH SVG incisions c/d/i
Pertinent Results:
[**2198-2-22**] 11:30AM BLOOD UreaN-11 Creat-0.9 Na-135 K-4.8
[**2198-2-22**] 11:30AM BLOOD PT-21.8* PTT-95.7* INR(PT)-2.1*
[**2198-2-22**] 11:30AM BLOOD Hct-32.0* Plt Ct-639*
PATIENT/TEST INFORMATION:
Indication: S/P CABG x 5
Height: (in) 71
Weight (lb): 205
BSA (m2): 2.13 m2
BP (mm Hg): 100/50
HR (bpm): 80
Status: Inpatient
Date/Time: [**2198-2-19**] at 15:19
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W002-0:30
Test Location: West Echo Lab
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.4 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.4 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.5 cm
Left Ventricle - Fractional Shortening: 0.43 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: *4.4 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A Ratio: 1.14
Mitral Valve - E Wave Deceleration Time: 275 msec
TR Gradient (+ RA = PASP): >= 25 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Low
normal LVEF. No
resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal
motion consistent with prior cardiac surgery.
AORTA: Moderately dilated aortic root. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. LV
inflow pattern
c/w impaired relaxation.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal/small.
Overall left ventricular systolic function is low normal (LVEF
50-55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is
moderately dilated. The aortic valve leaflets (3) appear
structurally normal
with good leaflet excursion. There is no aortic valve stenosis.
Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with
trivial mitral regurgitation. The left ventricular inflow
pattern suggests
impaired relaxation. The pulmonary artery systolic pressure
could not be
determined. There is no pericardial effusion.
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2198-2-19**] 16:49.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Brief Hospital Course:
55yo M admitted on [**2198-2-17**] for presyncopal episode. On HOD3 he
went into atrial fibrillation with rapid ventricular response
into the 150's. His rate was controlled with IV lopressor.
Amiodarone bolus and drip were administered and his rhythm
converted to a sinus rhythm. Cardiology was consulted and
recommended anticoagulation. heparin and coumadin were started.
Electrical cardioversion was deemed to be not indicated and
medical management was continued. His oral lopressor was
titrated. Mr. [**Known lastname 66373**] was discharged on HOD 6 after obtaining a
therapuetic INR. He remained symptom free from HOD2 to
discharge after conversion of his rhythm. Mr. [**Known lastname 66373**] will keep
his scheduled follow up appointments with his PCP, [**Name10 (NameIs) 2085**],
and Dr. [**Last Name (STitle) 914**]. Dr. [**First Name (STitle) 5936**] (PCP) will follow his INR and
coumadin dosing.
Medications on Admission:
Lisinopril 20mg QD
Aspirin 81mg QD
Metformin 850mg TID
Glyburide 5mg [**Hospital1 **]
lipitor 10mg QD
Byetta 10 SC BID
Actos 45mg QD
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days: Then take one tablet daily for one week. Then take
a half tablet daily thereafter.
Disp:*30 Tablet(s)* Refills:*1*
6. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
7. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
syncopal episode secondary to atrial fibrillation
Discharge Condition:
Good
Discharge Instructions:
Shower, wash incisions with mild soap and water and pat dry. No
lotions, creams or powders to incisions.
Call with fever >101, redness or drainage from incision, or
weight gain more than 2 pounds in one day or five pounds in one
week.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
keep previously scheduled follow up with Dr. [**Last Name (STitle) 914**] and your
cardiologist. Schedule an appointment with Dr. [**First Name (STitle) 5936**] Thursday
or Friday for Coumadin/INR follow up
Completed by:[**2198-2-24**]
|
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"414.01",
"997.1",
"411.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"89.60",
"36.14",
"88.56",
"37.61",
"36.15",
"99.04",
"88.53",
"37.22",
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icd9pcs
|
[
[
[]
]
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17678, 17739
|
15590, 16511
|
11583, 11589
|
17833, 17840
|
12335, 12511
|
18210, 18449
|
11989, 12071
|
16695, 17655
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17760, 17812
|
16537, 16672
|
17864, 18187
|
12537, 15455
|
12086, 12316
|
11414, 11545
|
11617, 11807
|
15487, 15567
|
11829, 11873
|
11889, 11973
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,814
| 176,261
|
9399
|
Discharge summary
|
report
|
Admission Date: [**2166-7-7**] Discharge Date: [**2166-7-9**]
Date of Birth: [**2088-8-25**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
S/p Carotid Stent
Major Surgical or Invasive Procedure:
Angiography with placement of carotid stent
History of Present Illness:
Mr. [**Known lastname **] is a pleasant 77yo gentleman with h/o HTN, DM, and
hyperlipidemia who was incidentally found to have a carotid
bruit on routine examination by his PCP. [**Name10 (NameIs) **] [**Name11 (NameIs) 8019**]
revealed total occlusion of his left proximal ICA and severe
stenosis of right proximal ICA. CTA neck confirmed these
findings. The patient denies any symptoms of transient
weakness, dysarthria, or numbness. He does note a chronic
weakness in his left hand that has been present x years.
.
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] stenting of his Right ICA earlier today. He
received benadryl 25 IV, pepcid 20mg IV, solumedrol 60mg IV
prior to his procedure given his history of allergy to IV
contrast dye. He is currently feeling well and without
complaints.
.
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 except as noted above.
.
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:
Hypertension--borderline, recently diagnosed at Dr.[**Name (NI) 3101**]
office, not on any meds.
Hyperlipidemia.
Diabetes--no A1C available
Spinal stenosis status post repair with chronic back pain
History of bladder cancer.
History of appendectomy.
Peripheral [**Name (NI) 1106**] disease, asymptomatic carotid artery
disease.
Aortic stenosis, mild.
.
Cardiac Risk Factors: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
.
Cardiac History: CABG: none
.
Percutaneous coronary intervention: none
.
Pacemaker/ICD: none
Social History:
Social history is significant for the absence of current tobacco
use; he admits to smoking in the distant past. There is no
history of alcohol abuse. He lives with his wife of 58 years
and his 21yo grandson.
Family History:
There is a questionable family history of premature coronary
artery disease or sudden death; reports his mother had heart
trouble, though she passed away in her 70s.
Physical Exam:
VS: T 98.5 81 165/80->131/66 19 96% RA
Gen: Pleasant elderly man in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of [**5-13**] cm. No carotid bruits.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. +Systolic murmur at base. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Neuro: Language intact, appropriate. EOMI, face symmetric,
tongue midline. Strength 5/5 in UE proximally but distal UE
strength is mildly diminished (4+/5 in LUE) as compared with 5/5
in RUE. Has muscle wasting of his left hand. Distal strength
intact in LE b/l. Sensation intact in UE and LE b/l.
Pertinent Results:
[**2166-7-8**] 04:55AM BLOOD Glucose-209* UreaN-24* Creat-1.5* Na-133
K-4.6 Cl-95* HCO3-26 AnGap-17
[**2166-7-9**] 06:30AM BLOOD Glucose-163* UreaN-31* Creat-1.7* Na-137
K-4.5 Cl-99 HCO3-30 AnGap-13
[**2166-7-8**] 01:00AM BLOOD CK(CPK)-47
[**2166-7-8**] 04:55AM BLOOD CK(CPK)-53
ECG ([**2166-7-7**])
Sinus rhythm. Non-specific lateral ST-T wave changes. Compared
to the
previous tracing of [**2162-7-19**] there is ST-T wave flattening in
lead I and
biphasic T wave in lead aVL. Otherwise, no diagnostic interim
change.
Carotid Cath ([**2166-7-7**])
COMMENTS:
1. Access: Retro RFA with catheter selective in RCCA
2. Aorta: Aortography revealed a Type 1 arch with anomalous
take-off of
the RSCA (posterior).
3. Carotid/vertebrals: The left CCA is patent. The [**Doctor First Name 3098**] is
occluded. The
RCCA is normal. The [**Country **] has an eccentric 90% lesion. The [**Country **]
fills the
ipsilateral ACA and MCA with noted cross filling of the
contralateral
ACA and MCA.
4. Successful PTA/stent of right ICA with a 6-8mm Protege RX
stent and
posted with a 4.0mm balloon. Excellent result with normal flow
down
vessel and no residual stenosis. No neurological symptoms during
procedure. Patient left cathlab in stable condition.
FINAL DIAGNOSIS:
1. Severe 90% stenosis of right ICA.
2. Successful PTA/stent of right ICA with a 6-8mm
self-expandable stent
posted with a 4.5mm balloon.
Brief Hospital Course:
77yo man incidentally found to have severe carotid
atherosclerosis admitted following elective stenting of his
right ICA.
1. Carotid atherosclerosis:
Pt tolerated the procedure well. His ASA (increased to 325 mg),
plavix, and statin (atorvastatin used in-house) were continued.
He was started on a low dose beta blocker and ACE I, and his
blood pressure was maintained at a goal of SBP 100-160. Neuro
checks throughout hospital course were unremarkable, and pt
remained asymptomatic.
2. Diabetes [**Name (NI) **]
Pt reports poor compliance with oral hypoglycemics at baseline.
He was given 2 doses of solumedrol, once before and once after
the procedure, for his dye allergy. The following morning, his
fingerstick glucoses spiked into the 400s. Insulin by IV was
given and sliding scale tightened with substantial improvement
in his FSGs by evening. He was kept overnight for monitoring
with subsequent FSGs in the 100s. Pt to resume oral
hypoglycemics on [**2166-7-10**], 48 hours after the dye load.
3. Chronic renal insufficiency.
Pt has a baseline Cr of 1.4, increased after dye load. He
reported good urine output during hospital stay and will have
f/u labs done at his next PCP appointment to check his renal
function.
Medications on Admission:
Admits to poor compliance with his meds:
Plavix 75mg daily
Ultram 50mg PRN
Lescol 40mg daily
Protonix 40mg daily
Glipizide 5mg daily (rarely taking)
Metformin 500mg [**Hospital1 **] (often taking daily)
ASA 81mg daily
Robaxin 400mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ultram Oral
3. Lescol 40 mg Capsule Sig: One (1) Capsule PO once a day.
4. 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*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Robaxin Oral
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
***Please do not start again until Thursday, [**7-10**]***.
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Outpatient Lab Work
Please draw patient's potassium, BUN, and creatinine at his
office visit with Dr. [**Last Name (STitle) 17025**] on [**2166-7-16**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Carotid atherosclerosis
Secondary Diagnoses: Hypertension, diabetes [**Date Range **], chronic
renal insufficiency, iodine allergy
Discharge Condition:
Vital signs stable with appropriate follow-up arranged.
Discharge Instructions:
You were admitted for an elective placement of a stent to keep
open one of the arteries to your head. You tolerated the
procedure well.
1. Please take all medications as prescribed. Note that the
following medication changes were made during your stay:
- you were started on lisinopril 5mg daily
- you were started on metoprolol succinate 25mg daily
- we gave you a prescription for aspirin 325mg daily
- you should not take your metformin or glipizide until Thursday
morning, [**7-10**]
2. Please attend all follow-up appointments listed below.
3. Please call your doctor or return to the hospital if you
develop chest pain, shortness of breath, sudden weakness or
numbness or difficulty speaking, lightheadedness, fevers, or any
other concerning symptom.
Followup Instructions:
We scheduled you an appointment to see Dr. [**Last Name (STitle) 17025**] on
Wednesday, [**7-16**] at 2:15pm. Be sure to bring your medications
with you. You should also bring the prescription for lab work
with you so that Dr. [**Last Name (STitle) 17025**] knows to draw your blood to
check your kidney function and potassium levels.
We also scheduled you to see Dr.[**Name (NI) 3101**] nurse practitioner on
[**2166-7-22**] at 11am. [**Hospital Ward Name 23**] building, [**Location (un) 436**]. Call
[**Telephone/Fax (1) 62**] with questions.
Please be sure to attend all previously scheduled appointments:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2166-9-2**]
9:30
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2166-9-2**]
10:30 ***This is Dr.[**Name (NI) 3101**] nurse practitioner**
|
[
"V10.51",
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icd9cm
|
[
[
[]
]
] |
[
"00.45",
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] |
icd9pcs
|
[
[
[]
]
] |
7921, 7927
|
5309, 6546
|
302, 348
|
8123, 8181
|
3888, 5129
|
8991, 9898
|
2523, 2690
|
6834, 7898
|
7948, 7948
|
6572, 6811
|
5146, 5286
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8205, 8968
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2705, 3869
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8014, 8102
|
245, 264
|
376, 1738
|
7968, 7992
|
1760, 2280
|
2296, 2507
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,786
| 142,326
|
4266+55513
|
Discharge summary
|
report+addendum
|
Admission Date: [**2189-6-4**] Discharge Date: [**2189-6-28**]
Date of Birth: [**2129-2-24**] Sex: F
Service:
This is a discharge summary up until [**2189-6-20**]. A subsequent
dictation summary addendum will follow.
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old
female with a history of low grade Stage IV follicular
lymphoma, status post multiple recurrences auto bone marrow
transplant and questionable history of congestive heart
failure, who presented from clinic with fever and
neutropenia. She was recently admitted one week prior with
increasing neck lymphadenopathy and was treated with CEPP and
sent home with p.o. Etoposide and Prednisone. She had been
feeling well and has no complaints. She denies fevers,
chills, nausea, vomiting, diarrhea, dysuria, neck pain,
worsening cough or other symptoms. Her review of systems was
unremarkable. She did complain of chronic sore throat and a
herpetic lesion on her right lip. The patient came to clinic
today for regular follow-up care and it was not an episodic
visit. She was surprised to learn that she was febrile.
PAST MEDICAL HISTORY:
1. Low grade lymphoma initially Stage IV follicular lymphoma
diagnosed in [**2180**]. At the same time, Stage 0 lung
carcinoma was diagnosed. She is status post thoracostomy
[**2180-6-5**], for resection. She had multiple chemotherapy
cycles. auto bone marrow transplant in [**2183**], had eighteen
months of remission with recurrence and was treated with
Rituxan in [**2185**], [**2186**], and [**2187**]. In [**2188-9-5**], she was
found to have new anemia and progressive lymphadenopathy
in the axillary, hilar, subcarinal, inguinal regions. She
was admitted for Antastan and Cytoxan with the course
complicated by neutropenia. She was admitted again [**10-9**],
with another cycle with the course complicated by
congestive heart failure that responded to diuretics. She
was admitted again in [**11-8**], for a third cycle with a
complicated course in which she was intubated and required
monitoring in the Intensive Care Unit. She subsequently
went to [**State 108**] for the winter and was recently admitted
[**5-10**], for a cycle of CEPP with Cytoxan, Etoposide,
Prednisone for presumably large B cell lymphoma
transformation.
2. Paget's disease.
3. History of shingles T10 to T12 with postherpetic
neuralgia.
4. History of pneumonia.
5. History of gastroesophageal reflux disease.
6. Status post cholecystectomy.
7. Seasonal allergies.
8. Possible history of congestive heart failure with an
ejection fraction of 45 to 50 percent on previous
echocardiograms.
9. Total abdominal hysterectomy, bilateral salpingo-
oophorectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Ciprofloxacin 500 mg twice a day.
2. Colace 100 mg twice a day.
3. Detrol 2 mg twice a day.
4. Trazodone 150 mg q.h.s.
5. Allopurinol 300 mg once daily.
6. OxyContin 80 mg twice a day.
7. Compazine 10 mg p.r.n.
8. Nexium 40 mg once daily.
9. Lorazepam 0.5 mg q6-8hours p.r.n.
10. Paxil 30 mg once daily.
11. Multivitamin.
12. Bisacodyl 10 mg q.h.s.
13. [**Doctor First Name **] 60 mg twice a day.
14. Oxycodone 10 mg three times a day.
15. Prednisone taper 100 mg number six of eight today.
16. Etoposide 240 mg times two days which were given
[**2189-5-30**], and [**2189-5-31**].
17. Aranesp given two weeks in clinic.
SOCIAL HISTORY: She is a retired kindergarten teacher,
married, lives with her sister who is now her caretaker. [**Name (NI) **]
husband is currently in the [**Hospital **] Hospital.
PHYSICAL EXAMINATION: Initial vital signs showed a
temperature 98.4, blood pressure 112/74, pulse 60,
respiratory rate 16 breaths per minute, stable oxygen
saturation. General appearance, the patient is comfortable
in no apparent distress. Head and neck examination revealed
mild alopecia. The mucous membranes are moist. The
oropharynx showed some diffuse erythema. Neck - mild shotty
cervical lymphadenopathy, no swelling. Lungs revealed slight
decreased breath sounds at the bases bilaterally, right
greater than left. Cardiovascular examination revealed
regular rate and rhythm, no murmurs, rubs or gallops. The
abdomen is soft, nontender, nondistended. Extremities - no
cyanosis, clubbing or edema. Neurologic examination was
nonfocal.
LABORATORY DATA: Initial laboratories were notable for a
white blood cell count of 0.8 with 80 percent neutrophils, 7
percent bands, 10 percent lymphocytes, 2 percent monocytes,
hematocrit 31.5, platelet count 108,000, and ANC 180. Normal
Chem7. Normal liver function tests. Calcium, magnesium and
phosphorus within normal limits.
HOSPITAL COURSE:
1. Cardiovascular - The patient had stable blood pressure on
admission but with her fever and neutropenia, she did have
an episode of lower systolic blood pressure into the 80s.
She was briefly admitted into the Intensive Care Unit and
was given intravenous fluid hydration with improvement.
She had an echocardiogram at that time showing a normal
ejection fraction. Also of note, there was a sessile mass
in the right atrium unclear significance. Her blood
pressure was subsequently stable with no further episodes
of hypotension.
1. Oncology/neutropenia - The patient is followed by Dr.
[**First Name (STitle) 1557**]. She was persistently neutropenic during the first
several weeks of her hospital course. Her counts were
slowly beginning to recover. Her G-CSF was discontinued
[**2189-6-20**], for an ANC over 500. She had a small pleural
effusion tapped looking for source of infection which did
show atypical lymphocytes consistent with persistent
malignancy.
1. Pulmonary/infectious disease - The patient had febrile
neutropenia initially treated with Vancomycin, [**Month/Day/Year 18517**] and
AmBisome, as well as Flagyl. She developed some diffuse
erythema of unclear etiology and her [**Name (NI) 18517**] was changed to
Levofloxacin and AmBisome was changed to Voriconazole
although a clear allergy had not been documented. She
slowly developed increasing oxygen requirement. Although
her initial chest x-ray findings were negative, she seemed
to develop increasing infiltrates and effusions.
Pulmonary and infectious disease teams were involved. The
patient had sputum which was sent and consistent with a
pan-resistant Klebsiella which is only sensitive to
Meropenem. At that time, the patient was switched to
Vancomycin, Meropenem and Voriconazole as there did not
seem to be added benefit of Levofloxacin or Flagyl with
this regimen. She continued to have an increasing oxygen
requirement and at times required a nonrebreather. She
had been getting nebulizers and steroid treatments because
of a possible history of chronic obstructive pulmonary
disease and chronic outpatient steroid use. She was
aggressively diuresed for possible pulmonary edema
component of her hypoxia. She had a bronchoscopy done by
pulmonary. This showed significant mucous plugging and
also grew out some other pan-resistant Klebsiella. The
patient was persistently hypoxic at the time of this
dictation.
1. Code Status - It was explained to the patient that as her
white blood cell counts increased and that we now
beginning to treat this pan-resistant Klebsiella that her
pulmonary status may decline in the short term until this
pneumonia resolves. She stated clearly in the presence of
her family that she did not desire resuscitative measures
and did not want to be intubated if she were to decline.
The patient was made DNR/DNI and the [**Hospital Unit Name 153**] team was not
involved as the patient would not want more aggressive
measures.
1. Pain control - The patient had been on outpatient
OxyContin and her dose was lowered because of her tenuous
respiratory status.
1. Anxiety - The patient appears to have a component of
anxiety with her hypoxia. She was continued on Paxil.
She was initially placed on Ativan and was given Ativan
prior to procedures. Standing benzodiazepines were
discontinued because of her tenuous respiratory status.
1. Orthopedics - The patient was wearing a brace on her right
hand for a healing fracture. The patient self
discontinued her brace and was using her hand without any
significant discomfort.
1. Bladder spasms - The patient was continued on Detrol as
she was taking as an outpatient.
A follow-up dictation summary addendum will relay the
[**Hospital 228**] hospital course after [**2189-6-20**].
DR.[**Last Name (STitle) **],[**First Name3 (LF) **]
Dictated By:[**Last Name (NamePattern1) 2366**]
MEDQUIST36
D: [**2189-6-21**] 11:26:46
T: [**2189-6-21**] 12:58:47
Job#: [**Job Number **]
Name: [**Known lastname 2738**], [**Known firstname 2739**] Unit No: [**Numeric Identifier 2740**]
Admission Date: [**2189-6-4**] Discharge Date: [**2189-6-28**]
Date of Birth: [**2129-2-24**] Sex: F
Service: OME
ADDENDUM: This is a Discharge Summary Addendum for the dated
[**2189-6-21**] to [**2189-6-28**]. Please see previous dictation
for admission and hospital course summary.
Shortly after [**2189-6-22**] the patient was made comfort
measures only after continuing to have increasing oxygen
requirements and indicating that she did not wish to pursue
further treatment. The patient's family concurred with this
plan of action. Therefore, on [**2189-6-26**] the patient was
started on a morphine drip for comfort given her oxygen
requirement on a nonrebreather plus nasal cannula. She
passed away peacefully in the presence of her loved ones on
[**2189-6-28**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 2744**]
Dictated By:[**Last Name (NamePattern1) 2745**]
MEDQUIST36
D: [**2189-7-25**] 16:49:13
T: [**2189-7-25**] 18:30:32
Job#: [**Job Number 2746**]
|
[
"197.2",
"053.19",
"496",
"276.5",
"253.6",
"288.0",
"200.00",
"428.0",
"482.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04",
"38.91",
"33.24",
"34.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2830, 3499
|
4791, 10132
|
3708, 4774
|
268, 1115
|
1137, 2804
|
3516, 3685
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,581
| 120,312
|
11162
|
Discharge summary
|
report
|
Admission Date: [**2199-11-27**] Discharge Date: [**2199-12-19**]
Date of Birth: [**2127-9-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Found Unresponsive
Major Surgical or Invasive Procedure:
intubated in the ED on arrival, extubated [**12-8**]
History of Present Illness:
72 year old man with history of marginal zone lymphoma s/p
splenectomy presented to the ICU after being found unresponsive
for up to 1 hour. He was known to have had a recent flu
vaccination and exposure to [**Location (un) **] droppings while doing carpet
work. He had questionable recent history of shingles. On [**11-24**],
his wife reported the patient was in his usual state of health
excluding a mild cough. He was found down by his wife at home
and she had last seen him one hour beforehand. EMS found the
patient to be tachycardic, but with poor pulses and hypotension.
The patient was cardioverted x3 without much effect. In the ED,
he was still found to be unresponsive with the following vital
signs: T 101.3, HR 144, SBP 72, RR44. He was intubated and
started on 3 pressors. Initial WBC was 3.1 with 12% bands;
eventually the count rose to 13.1 with 44% bands. BUN/CR 23/2.1.
He was started on broad spectrum antibiotics for likely sepsis
but no clear source found (cultures unrevealing). His sputum
grew unspeciated yeast; gram stain showed rare squamous cells,
few polys, few yeast, and no bacteria. Otherwise, urine, sputum,
and CSF cultures were negative for any growth.
.
Initial workup at [**Hospital 1474**] Hospital included a negative head CT.
LP at the OSH with traumatic tap had 3 WBCs in tube #4. Gram
stain and CSF cultures were negative for microrganisms and
growth. Coagulation labs were elevated on admission with PT 22.8
and PTT 130.0. Fibrinogen was initially low and then increased.
During course of admission, his coags remained elevated and
platelets progressively dropped (to nadir of 46K). There was
evidence of schistocytes on peripheral blood smear.
.
Prior to transfer to the ICU, the patient was panscanned; head
CT at the OSH showed multiple areas of bilateral
hypoattenuation. A 2nd CT scan from the OSH demonstrated
multiple brain lesions, some located in watershed areas, but no
evidence of increased intracranial pressure. Chest CT had large,
dependent consolidations with air bronchograms and multiple foci
of airspace opacity. This was considered possibly pneumonia
secondary to aspiration versus CHF exacerbation. Over time, he
improved after diuresis and was successfully extubated on [**12-8**].
.
At time of transfer to the ICU, the patient was almost
completely unresponsive to voice/noxious stimuli (no real
sedation from OSH, small amounts on transfer, no sedatives while
in ICU). He had been treated broadly with antibiotics and
antifungals on vancomycin, ceftazadine, azithromycin,
clindamycin, acyclovir, and liposomal ambisome. Pressor support
included neosynephrin and vasopressin and the patient was
intubated on ventilator support. Once in the ICU, vent settings
were adjusted to AC 550 x20, FiO2 60%, PEEP 8. Antibiotics were
changed to vancomycin, levoquin, zosyn, and ambisome per ID
recommendations. Acyclovir was discontinued. The patient was
noted to have stable blood pressure on pressor support. Vital
signs in the ICU were the following: Tm 102.2 HR 97 BP 100/54 RR
31 96%O2 sat ABG 7.35/35/96 on AC. Generally, the patient
appeared jaundiced with icterus, had anasarca, and was
nonresponsive to painful stimuli. Petechiae were noted on the
oral mucous membrane. Breath sounds were decreased at the bases.
Cardiac and abdominal exam were unremarkable. Extremities had 3+
pitting edema to the thighs, flaccid muscle tone, and absent
reflexes. Pupil equal round reactive to light, doll's eyes
showed no movement, he was non responsive to painful stimuli,
and had minimal corneal or gag reflexes. A head MRI was
performed to better evaluate the brain lesions. Neuroradiology
observed basal ganglia and cerebellar lesions consistent with
watershed infarctions and some remaining lesions that were not
located in watershed areas. The questin of septic emboli was
raised since the patient appeared to be septic with hypotension
at presentation. However, a source for embolism was not found:
TTE/TEE were negative for vegetations, PFO, or suspicious aortic
disease.
.
In the course in the ICU, EEG showed no evidence of seizure
activity. It showed diffuse slowing consistent with
toxic/metabolic encephalopathy. n admission was almost
completely unresponsive to voice/noxious stimuli (no real
sedation from OSH, small amounts on transfer, no sedatives while
here). Neuro exam @ OSH w/ evidence of brainstem findings,
however, here, pt??????s PERRL, conjugate gaze, doll??????s eyes intact,
intact corneal, intact gag reflexes. Over time, he had slow
recovery in mental status. On [**12-9**], he was awake enough to be
extubated with appropriate RISB. Afterwards, he had
waxing/[**Doctor Last Name 688**] lethargy. Blood pressure was stable through most
of MICU course. The leading diagnosis was overwhelming sepsis
with hypotension and watershed infarctions. Cultures at OSH and
here were unrevealing, including tests for histoplasmosis,
cryptococcus, and nocardia. Thus, the patient's antibiotic
regimen on admission was limited to vancomycin, levofloxacin,
and zosyn. In the ICU, acyclovir and anti-fungal coverage were
held. Zosyn was later broadened to meropenem and the
levofloxacin was discontinued. The patient eventually
defervesced and was maintained on vancomycin and meropenem up
until time of transfer to the medicine floor. ID consult
recommended a 6 week course with follow up imaging on CT. Also,
at the time of transfer to the medicine service, the patient was
being evaluated by GI for possible PEG placement out of concern
that the patient may be unable to maintain his own nutritional
intake. He'd been NPO in the ICU and was getting free water
repletion for hypernatremia secondary to inadequate oral intake
and resulting hypoalbuminemia. He also had anasarca with
weeping fluid from lesions in the upper extremities due to the
volume overload. He'd had a 20kg wt gain after delivery of large
amounts of IV fluids. In the ICU, he was given standing lasix
40mg iv qam, 20mg iv qpm and was -11.9L overall. The patient
also developed acute renal failure likely ATN in setting of
hypoperfusion. However, he was never oliguric. Creatinine
trended down close to baseline while treated in the ICU.
Past Medical History:
Leukopenia
Marginal zone lymphoma
s/p splenectomy
Social History:
Retired biochemist. Lives with wife and family. Per family, no
alcholo, tobacco, or illicit drug use.
Family History:
Noncontributory
Physical Exam:
Tc 98.3 Tm=98.7 BP 162/78,126-162/18-80 HR 96,88-101 RR 24
O2 95% RA FSBG 160/203/203/294 yesterday; 134 this AM
I/O 1820/4500
GEN: NAD in bed, alert and awake, breathing comfortably on RA
HEENT: EOMI, MMMI, anicteric
PULM: clear anteriorly
CV: RRR nl s1 s2, 3/6 SEM at LUSB
ABD: soft/ND/NT, +bs, no masses.
EXT: anasarca improved, 2+ pitting edema to ankles, scrotal
edema improved, flaccid muscle tone, no reflex. +gauze and
tegaderm dressing on both hands c/d/i
Neuro: arousable to voice, can mouth/whisper simple one word
answers, following commands with facial muscles, not moving
extremities spontaneously, weak hand grips, slight movement of
right toes but not left, responsive to painful stimuli, no
babinski, +corneal reflex and gag reflex
Skin: no rash, multiple healing lesions on arms and hands
Pertinent Results:
LABS:
Admission Labs:
[**2199-11-27**] 10:25PM TYPE-ART TEMP-38.9 RATES-20/11 TIDAL VOL-550
PEEP-8 O2-70 PO2-96 PCO2-35 PH-7.35 TOTAL CO2-20* BASE XS--5
-ASSIST/CON INTUBATED-INTUBATED
[**2199-11-27**] 09:37PM TYPE-MIX PH-7.27*
[**2199-11-27**] 09:37PM LACTATE-5.4*
[**2199-11-27**] 09:37PM freeCa-0.75*
[**2199-11-27**] 07:31PM GLUCOSE-176* UREA N-84* CREAT-4.7* SODIUM-133
POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-19* ANION GAP-25
[**2199-11-27**] 07:31PM ALT(SGPT)-204* AST(SGOT)-288* LD(LDH)-837*
CK(CPK)-2674* ALK PHOS-98 AMYLASE-97 TOT BILI-11.9* DIR
BILI-8.9* INDIR BIL-3.0
[**2199-11-27**] 07:31PM LIPASE-43
[**2199-11-27**] 07:31PM CK-MB-7 cTropnT-0.36*
[**2199-11-27**] 07:31PM ALBUMIN-2.6* CALCIUM-5.8* PHOSPHATE-8.2*
MAGNESIUM-1.8
[**2199-11-27**] 07:31PM HAPTOGLOB-235*
[**2199-11-27**] 07:31PM VANCO-11.9*
[**2199-11-27**] 07:31PM WBC-9.9 RBC-2.61* HGB-8.3* HCT-24.7* MCV-95
MCH-31.8 MCHC-33.6
[**2199-11-27**] 07:31PM NEUTS-80* BANDS-4 LYMPHS-9* MONOS-5 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2199-11-27**] 07:31PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
TARGET-OCCASIONAL SCHISTOCY-1+ BURR-1+ ACANTHOCY-OCCASIONAL
[**2199-11-27**] 07:31PM PLT SMR-VERY LOW PLT COUNT-40*
[**2199-11-27**] 07:31PM PT-15.9* PTT-41.6* INR(PT)-1.6
[**2199-11-27**] 07:31PM FIBRINOGE-753* D-DIMER-8284*
Discharge Labs:
[**2199-12-18**] 04:20AM BLOOD WBC-7.7 RBC-3.23* Hgb-10.2* Hct-30.6*
MCV-95 MCH-31.6 MCHC-33.3 RDW-17.1* Plt Ct-369
[**2199-12-18**] 04:20AM BLOOD Neuts-22* Bands-0 Lymphs-69* Monos-7
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2199-12-18**] 04:20AM BLOOD Glucose-105 UreaN-17 Creat-0.5 Na-139
K-3.9 Cl-104 HCO3-30*
[**2199-12-19**] 05:41AM BLOOD Lipase-217*
[**2199-12-18**] 04:20AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.7
[**2199-12-15**] 05:20AM BLOOD Folate-11.1
[**2199-12-10**] 04:14AM BLOOD calTIBC-213* VitB12->[**2195**] Ferritn-1107*
TRF-164*
[**2199-11-27**] 07:31PM BLOOD Hapto-235*
[**2199-12-11**] 06:37AM BLOOD Triglyc-98 HDL-28 CHOL/HD-3.8 LDLcalc-57
[**2199-12-18**] 04:20AM BLOOD Triglyc-68
MICROBIOLOGY Overview:
[**12-4**], [**12-5**], [**12-8**] C. diff neg
[**12-2**] BCx M/F, routine ngtd
[**12-1**] sputum >25 P, <10 E, no org. Cx oral flora, sparse yeast
[**12-1**] BCx ngtd
[**12-1**] UCx neg
[**11-29**] BCx M/F ngtd. Cdiff neg
[**11-29**] cath tip R fem negative
[**11-28**] CrAg negative
[**11-28**] sputum GS negative, >25P<10E. fungal Cx C.albicans AFB
conc neg.Nocardia Cx neg
[**11-28**] UCx BCx neg
[**11-28**] C. diff neg
[**11-27**] BCx neg
10/27 M/F neg
[**12-9**] CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2199-12-9**]): FECES
NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. x3
Blood Cx
AEROBIC BOTTLE (Final [**2199-12-8**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2199-12-8**]): NO GROWTH.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED
Urine Cx
URINE CULTURE (Final [**2199-12-2**]): NO GROWTH.
Sputum
GRAM STAIN (Final [**2199-12-1**]): >25 PMNs and <10 epithelial
cells/100X field. NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2199-12-3**]):
SPARSE GROWTH OROPHARYNGEAL FLORA. YEAST. SPARSE GROWTH.
PREDOMINATING ORGANISM.
[**11-29**]: CRYPTOCOCCAL ANTIGEN (Final [**2199-11-29**]): CRYPTOCOCCAL
ANTIGEN NOT DETECTED
STUDIES:
[**11-27**] ECG
Sinus rhythm, Nonspecific inferolateral T wave changes, No
previous tracing
Rate PR QRS QT/QTc P QRS T
97 182 82 [**Telephone/Fax (2) 35947**] 39 48
[**11-28**] EEG- This is an abnormal portable EEG due to the presence
of a
slow and low voltage background rhythm predominantly in the [**3-5**]
Hz delta
frequency range with very low voltage superimposed theta
frequency
activity at times. In addition, there was occasional mild to
moderate
amplitude generalized delta frequency slowing. These findings
suggest
deep, midline, subcortical dysfunction and are consistent with a
moderate to severe encephalopathy. No lateralizing or
epileptiform
abnormalities were seen. Note was made of sinus tachycardia with
occasional ectopy on the cardiac monitor.
[**11-29**] MRI head - The MR [**First Name (Titles) 29765**] [**Last Name (Titles) 4059**] areas of
abnormal increased signal intensity on the FLAIR and fast
spin-echo images that were seen as hypodense areas on the CT
scan. These were identified in the cerebellar hemispheres
bilaterally, greater on the left than right, in the globus
pallidus bilaterally, and in the right frontal subcortical and
periventricular white matter. Also identified on the MR, but not
on the CT scan, is a region of hyperintensity in the mid-brain
on the left, as well as several smaller white matter lesions
bilaterally in the frontal white matter. There is no evidence of
hemorrhage. These areas demonstrate a normal slow diffusion on
the diffusion weighted series, and there is mild contrast
enhancment in the right frontal periventricular white matter,
the globus pallidus bilaterally, and the brainstem lesions.
These findings are most suspicious for infarction in these
locations. Given the multiplicity of vascular distributions, an
embolic source should be considered. Note that the globus
pallidus involvement is characteristic of severe hypoxia or
hypoperfusion. However, the remainder of the lesions are not
locations typical for this etiology.The magnetic resounance
arteriography study [**Last Name (Titles) 4059**] no significant abnormalities.
The vertebral arteries, vertebrobasilar junction, internal
carotid arteries, and their major intracranial branches appear
normal. Note that there is an artifact across the mid-portion of
the basilar artery, as well as across the internal carotid
arteries that produces an artifactual apparent
stenosis.CONCLUSION: Multiple posterior fossa, brainstem, and
supratentorial lesions, most suspicious for infarction. The
bilateral globus pallidus involvement would suggest global
hypoxia or hypoperfusion. However, the distribution of the
remainder of the lesions is more suspicious for an embolic
source.
[**11-29**] Echo TEE - no vegetations, no sign of endocarditis
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is
seen in the body of the left atrium/left atrial appendage or the
body of the
right atrium/right atrial appendage. Left ventricular wall
thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular
wall motion is normal. Right ventricular chamber size and free
wall motion are
normal. There are simple atheroma in the aortic arch. The aortic
valve
leaflets (3) appear structurally normal with good leaflet
excursion. The
aortic valve leaflets are mildly thickened. No masses or
vegetations are seen
on the aortic valve. There is no aortic valve stenosis. No
aortic
regurgitation is seen. The mitral valve appears structurally
normal with
trivial mitral regurgitation. No mass or vegetation is seen on
the mitral
valve. There is no pericardial effusion. Conclusion: No
evidence for endocarditis.
[**11-30**] Portable Abd Xray
The distribution of bowel gas is unremarkable. No evidence for
intestinal obstruction and no radiographic findings to suggest
ischemic bowel. The diaphragms and upper abdomen are not
included on the film. No soft tissue masses or radiopaque
calculi.
[**12-11**] Video Swallow
Fluoroscopic imaging assistance was performed in conjunction
with the Speech Pathology Department during a video
oropharyngeal swallow during which the patient ingested barium
material of varying consistencies including softs, thick liquid,
thin liquid, and a tablet. Bolus control and formation was noted
to be impaired. There was mild pooling of residue in the
vallecular space and to a lesser degree into the piriform
sinuses. Trace penetration during the secondary swallowing phase
was noted but no frank aspiration.IMPRESSION: No aspiration.
Minimal penetration of residue spillover during the secondary
swallow phase. Please refer to the detailed Speech Pathology
report in CCC for a comprehensive evaluation of this swallowing
study including comments and recommendations.
[**12-16**] Echo
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. Left ventricular systolic function is
hyperdynamic (EF
70-80%). There is an abnormal systolic flow contour at rest, but
no left
ventricular outflow obstruction. No masses or thrombi are seen
in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber
size and free wall motion are normal. The number of aortic valve
leaflets
cannot be determined. The aortic valve leaflets are mildly
thickened. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure
is normal. There is a trivial/physiologic pericardial effusion.
No vegetations
seen on any valve. Compared with the findings of the prior
study (tape reviewed) of [**2199-11-28**], the left ventricle is
now hyperdynamic. The absence of a vegetation by 2D
echocardiography does not exclude endocarditis if clinically
suggested.
[**12-17**] THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
There are moderate to large bilateral pleural effusions with
associated atelectasis. These are not significantly changed from
the prior study. The visualized heart is unremarkable. The
liver, gallbladder, pancreas, adrenals, and intra-abdominal
large and small bowel are normal in appearance. Both kidneys
contain several small hypodensities likely representing cysts.
The kidneys are otherwise normal in appearance. No spleen is
identified. There is no evidence of pancreatitis. There is no
dilation of the extra or intrahepatic bile duct. No free air,
free fluid, or pathologic lymphadenopathy is seen within the
abdomen.
CT OF THE PELVIS WITH IV CONTRAST:
The rectum, sigmoid, distal ureters, and bladder are
unremarkable in appearance. A Foley catheter is seen within the
bladder. A collection of fluid is seen in the pelvis in the
presacral area. A rounded low attenuation structure is seen in
the right paraspinal region inferior and posterior to the psoas
muscle and the right ureter which may be slightly anteriorly
displaced. This measures approximately 30HU in attenuation with
possible slight rim enhancement and is of uncertain cause or
significance. The adjacent vertebra is unremarkable and it
doesnot appear to represent a thrombosed vessel. There is no
pathologic inguinal or pelvic lymphadenopathy. A small right fat
containing inguinal hernia is present.The osseous structures are
unremarkable. The soft tissues demonstrate mild edema.
IMPRESSION:Moderate to large size bilateral pleural effusions
with associated atelectasis which are unchanged from the prior
outside study. No evidence of pancreatitis. No spleen is seen in
the left upper quadrant.
Presacral fluid collection and rounded right paravertebral low
attenuation structure posteriormedial to right psoas muscle, of
uncertain cause,as described above.
[**12-17**] portable chest xray
The tip of the PICC line is in the region of the junction of the
left brachiocephalic vein and SVC. There is opacity at the left
base obscurring the left hemidiaphragm as previously
demonstrated. No pneumothorax.
Brief Hospital Course:
The patient is a 72 year old man with history of diet controlled
DM and marginal zone splenic lymphoma s/p splenectomy. He was
found nonresponsive, underwent multiple cardioversions, and
presented to [**Hospital 1474**] hospital. He was transferred to [**Hospital1 18**] and
then the ICU. He was treated for sepsis, for which the etiology
is unknown and was complicated by suspected pulmonary and CNS
emboli. He also had hypotension complicated by CNS
hypoperfusion, respiratroy failure s/p intubation, ARF secondary
to ATN, and anemia of chronic disease. His mental status
improved over time and he was successfully extubated [**12-8**] and
transferred stably to the medicine floor [**12-9**].
.
His decreased mental status was considered secondary to presumed
sepsis and hypoperfusion. Per his family and prior notations, he
is very much improved compared with admission status. He is able
to communicate with nodding or mouthing one word answers to
simple questions. Extremities are mostly flaccid with very
slight movement of the fingertips and right toes. MRI showed a
cerbellar/basal ganglia watershed infarct with other areas
suspicious for an embolic event. The neurology service did not
recommend anticoagulation. Carotid ultrasound and TEE were
negative for thrombus, diminishing likelihood of septic emboli.
No organism was identified since blood, urine, CSF, and sputum
cultures had no growth. ID consultation provided
recommendations for antibiotic regimen and the patient has
appeared to improve on broad spectrum antibiotics. IV
vancomycin was started [**11-27**] at 1g every day and was increased
to 1g twice daily on [**12-17**] for a trough of 8.5 thought to be due
to improved renal clearance. Meropenem was changed to imipenem
[**12-17**] since meropenem was difficult to obtain outside the
hospital. These IV medications need to be continued empirically
for a 6 week course via PICC line (started [**12-17**]) since they
offer broad covererage and penetrate the CNS. After completing
the approx 6 weeks of IV antibiotics on [**2200-1-11**], the patient is
scheduled to follow up in [**Hospital **] clinic with Dr. [**Last Name (STitle) **] on [**1-13**], [**2199**], at 10AM on [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] Bldg Ste 6B. Labs to
be checked every 3-4 days in the [**Hospital1 1501**] including CBC w/diff and
ANC, LFTs, chemistry panel that can be faxed to Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 35948**]. These are needed since the antibiotics can cause
liver damage and decrease blood cell counts. The patient's
neutrophil count has trended downward and is now near pt's
baseline per old clinic records given his underlying marginal
zone lymphoma and longstanding history of leukopenia. It likely
is resolving neutrophilia with possible contribution of
meropenem-induced leukopenia. Folate was normal. A repeat head
and chest CT at the end of the antibiotic course has been
scheduled for [**2200-1-8**]. Additionally, the patient should follow
up in stroke clinic with Dr. [**First Name (STitle) **]. Call [**Telephone/Fax (1) 35949**] to make an
appointment.
.
Anasarca resolved over the course on the medicine floor. It was
likely due to hypoalbuminemia (albumin 2.2 [**12-9**]). He
autodiuresed large quantities of urine and improved greatly
after he started thin liquid/pureed diet with supplemental sugar
free shakes. He passed a swallowing study including videography
and did not require PEG placement. The anasarca was resolved at
discharge and the patient's upper extremity hand and arm wounds
from past weeping of fluid were healed or healing well.
Oral intake should be encouraged with aspiration precautions and
appropriate swalowing protocol. He had required free water
replacement for hypernatremia in the ICU and again on the
medicine floor, likely due to third spacing of intravascular
fluid. He was given free water replacement with appropriate
correction and had normal serum sodium for several days
following an oral diet. A heart murmur detected [**12-13**] that may
have previously been muffled due to anasarca. Repeat
echocardiogram showed hyperdynamic LV function, so the changing
murmur was likely due to fluid shifting as third-spaced fluid
was mobilized and excreted. CHF was resolved at discharge.
Bilateral pleural effusions and multiple peripheral
consolidations documented improving on serial chest CT before
leaving the ICU. At discharge, he was oxygenating well on room
air and had been successfully weaned off oxygen supplementation
for several days.
.
Increased lipase, although overall stable ranging from 161-214
over past 2weeks, was noted. The patient denies abdominal pain
and does not appear tender to palpation. Lasix was discontinued
upon arrival to the medicine floor for concern of pancreatitis
induced by lasix; however, lipase remained elevated. There were
no clinical signs or symptoms of pancreatitis and abdominal CT
with oral and iv contrast (w/prehydration for renal prophylaxis)
showed no evidence of pancreatitis or biliary obstruction.
Repeat abdominal CT scan with contrast is recommended in [**4-6**]
months to evaluate for pancreatitis and for evolution of an
incidentally identified uniformly appearing small presacral
fluid collection with adjacent hypodensity. Radiology did not
consider the fluid collection infectious in nature as there was
no stranding nearby and it appeared stable.
.
The patient's blood pressure was elevated in the 120-160s. He
started hctz po 25mg daily on [**12-14**] and then metoprolol was
added [**12-16**] and is gradually being titrated up for optimal
control.
.
The patient has anemia of chronic disease with hematocrit at
baseline in the high 20s since admission. etiology unknown. iron
studies suggest chronic disease. folate is normal.
.
For diabetes, regular insulin per sliding scale was provided
with standing NPH in the morning and evening started [**12-16**].
.
For prophylaxis, the patient was given a PPI, sc heparin,
aspiration and fall precautions, colace/senna, and an air
mattress.
.
He is full code and his wife and family are active in his
caregiving and care planning. He will need treatment at an
extended care facility for delivery of IV antibiotics and
continued rehabilitation.
Medications on Admission:
none
Discharge Medications:
1. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl
Topical TID (3 times a day) as needed.
2. Chlorhexidine Gluconate 0.12 % Liquid Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day) as needed.
3. Acetaminophen 160 mg/5 mL Elixir Sig: Six [**Age over 90 1230**]y (650)
mg PO Q6H (every 6 hours) as needed.
4. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
6. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO
DAILY (Daily).
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold SBP<100, HR<55.
13. Vancomycin HCl 10 g Recon Soln Sig: 1000 (1000) mg
Intravenous Q12H (every 12 hours): please check vanco trough on
[**12-19**] (goal [**11-15**])
last dose 12/11.
14. Imipenem-Cilastatin 500 mg Recon Soln Sig: Five Hundred
(500) mg Intravenous Q6H (every 6 hours): last dose 12/11.
15. Pantoprazole Sodium 40 mg Recon Soln Sig: Forty (40) mg
Intravenous Q24H (every 24 hours).
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight
(8) units Subcutaneous twice a day: please adjust based on QID
FSG.
Disp:*480 units* Refills:*2*
17. Insulin Regular Human 300 unit/3 mL Syringe Sig: please see
SSI below units Subcutaneous four times a day: SSI:
BG <70 give OJ
BG 70-150 do nothing
BG 151-200 give 2 units
BG 201-250 give 4 units
251-300 give 6 units
301-350 give 8 units
351-400 give 10 units
>401 give 12 units
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
sepsis, etiology unknown c/b pulmonary and CNS emboli
hypotension c/b CNS hypoperfusion
respiratory failure, s/p intubation
ARF secondary to ATN
anemia of chronic disease
Discharge Condition:
stable- afebrile with gradually improving mental status,
profoundly weak, tolerating oral diet with assistance
Discharge Instructions:
Continue with prescribed medications to complete a 6 week course
of imipenem and vancomycin, to be continued until [**2200-1-11**]. Patient recently changed to q12 hour on [**12-18**] for
persistently low troughs. Please check vancomycin trough, CBC
with diff, LFTs and chemistry panel with renal function on [**12-19**]
(prior to vanco dose) and fax to Dr. [**First Name (STitle) **] [**Name (STitle) **] (infectious
disease) at # [**Telephone/Fax (1) 35948**]. Goal vanco trough [**11-15**]. Continue
to check above labs q 4 days and fax to Dr. [**Last Name (STitle) **]
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2200-1-8**] 10:30
Provider: [**Name10 (NameIs) **] SCAN Where: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) RADIOLOGY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2200-1-8**] 10:45
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Where: LM [**Hospital Unit Name 4337**]
DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-1-13**] 10:00
He will need a follow up CT scan of the abdomen in approximately
3 months, around [**2200-3-4**], to assess for pancreatitis and
to look for interval change in a presacral fluid collection with
nearby hypodensity located next to the psoas muscle.
|
[
"685.1",
"202.80",
"415.19",
"434.11",
"584.5",
"250.00",
"458.9",
"276.0",
"284.8",
"286.6",
"785.52",
"518.82",
"273.8",
"428.0",
"038.9",
"995.92",
"790.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"96.04",
"38.93",
"96.6",
"99.05",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
27374, 27446
|
19049, 25327
|
334, 388
|
27661, 27773
|
7669, 7675
|
28396, 29242
|
6809, 6826
|
25383, 27351
|
27467, 27640
|
25353, 25360
|
27797, 28373
|
9064, 10494
|
6841, 7650
|
10527, 19026
|
276, 296
|
416, 6600
|
7691, 9048
|
6622, 6674
|
6690, 6793
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,372
| 103,145
|
11476+11477
|
Discharge summary
|
report+report
|
Admission Date: [**2193-9-27**] Discharge Date: [**2193-10-2**]
Date of Birth: [**2135-10-8**] Sex: M
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 36633**] is a 57-year-old
male with a history of laryngeal cancer, status post
tracheostomy and percutaneous endoscopic gastrostomy
placement approximately five years ago with recent admission
and [**9-26**] secondary to traumatic subarachnoid hemorrhage
and intraventricular hemorrhage secondary to a fall caused by
alcohol intoxication.
He was on the Surgical Intensive Care Unit Service and
subsequently was discharged to [**Hospital6 6296**]. He
was in [**Hospital6 6296**] for approximately one to two
[**Hospital6 6296**] in the setting of a temperature
spike to 103. He was also noted to have increased agitation
complicated by self discontinue of Foley catheter which led
to hematuria. He also had one witnessed seizure episode in
this setting.
He was initially brought to an outside hospital where a
workup included a head CT which revealed an improving
right-sided hematoma and no new bleed. Chest x-ray which
revealed question of right lower lobe infiltrate. The
patient was empirically diagnosed with aspiration pneumonia
and treated with clindamycin. He was also loaded with
Dilantin with a transfer to [**Hospital1 188**].
At [**Hospital1 69**] he presented
hypotensive with a systolic blood pressure in the 90s,
without response to 2 liters of intravenous fluids. The
workup was notable for left shift leukocytosis, negative
chest x-ray, negative head CT. The patient was given one
dose of vancomycin to expand antibiotic coverage, as he has a
recent history of methicillin-resistant Staphylococcus aureus
pneumonia, and the patient was admitted to the Medical
Intensive Care Unit for supportive care for presumed sepsis.
PAST MEDICAL HISTORY:
1. Laryngeal cancer.
2. Status post tracheostomy.
3. Status post percutaneous endoscopic gastrostomy.
4. Subarachnoid hemorrhage/intraventricular hemorrhage on
[**2193-9-11**].
5. Alcohol abuse.
6. Osteoarthritis.
7. Peripheral vascular disease.
8. Seizure disorder; unclear how old this is.
9. History of aspiration pneumonia.
10. History of detached retina.
MEDICATIONS ON ADMISSION: (At [**Hospital6 6296**])
Lisinopril 30 mg p.o. q.d., Dilantin 100 mg p.o. t.i.d.,
thiamine 100 mg p.o. q.d., folate 1 mg p.o. q.d.,
multivitamin, Prevacid suspension 30 cc p.o. q.d., and
Ultra-Cal tube feeds 75 cc per hour goal.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature 98.9,
blood pressure 91/63, pulse 96, respirations 20, oxygen
saturation 100% on 6-liter tracheostomy mask. In general, he
was response, alert, followed commands, nontoxic, eating
without difficulty. Complained of penile pain. HEENT
revealed tracheostomy was in place. The patient was stable.
No jugular venous distention. Lungs were clear to
auscultation bilaterally. Heart had sinus tachycardia, faint
S1 and S2, no extra sounds. The abdomen was soft, nontender,
and nondistended, active bowel sounds. Percutaneous
endoscopic gastrostomy site stable on the left side.
Extremities had no edema, 2+ distal pulses. Neurologic
examination revealed right-sided weakness, [**12-24**] in the lower
extremities. Upper right extremity had [**2-21**]; otherwise
nonfocal.
LABORATORY DATA ON PRESENTATION: White blood cell
count 22.3, hematocrit 32.7, platelets 233. White blood cell
count differential was 89 neutrophils, 3 bands,
4 lymphocytes, and 2 monocytes. Sodium 134, potassium 4.2,
chloride 97, bicarbonate 27, BUN 12, creatinine 0.6, glucose
of 116. Dilantin level was 8.5 (which was low). Urinalysis
had large blood, negative nitrites, small bilirubin, 11 to 20
red blood cells, 6 to 10 white blood cells, and occasional
bacteria. Microbiology from previous admission revealed
methicillin-resistant Staphylococcus aureus sputum culture
which was sensitive to gentamicin, levofloxacin, and
vancomycin.
RADIOLOGY/IMAGING: Chest x-ray revealed a patchy opacity in
the right lower lobe; otherwise, no infiltrates or congestive
heart failure. Cardiac silhouette was within normal limits.
Head CT revealed hematoma in the posterior corpus collasum
extending into the right lateral ventricle which was improved
since prior studies.
Electrocardiogram revealed sinus tachycardia at 106 beats per
minute, normal axis and intervals. No acute ST changes.
HOSPITAL COURSE BY SYSTEM:
1. INFECTIOUS DISEASE: His blood cultures grew 1/4 bottles
of methicillin-resistant Staphylococcus aureus; and
therefore, the patient was continued on vancomycin
intravenously. His Flagyl and Levaquin were stopped. A
transthoracic echocardiogram was done to rule out
endocarditis, which was negative. A peripherally inserted
central catheter line was placed for long-term antibiotic
treatment. There was no evidence of osteomyelitis or septic
joints on examination throughout his hospital course.
2. PULMONARY: The patient received good tracheostomy care.
He was able to tolerate being weaned from the oxygen and had
no issues with his tracheostomy.
3. CARDIOVASCULAR: The patient's blood pressures were
initially treated with fluid hydration and Neo-Synephrine.
He was ultimately weaned off the Neo-Synephrine and was
transferred to the floor. The patient's ACE inhibitor was
held initially, but then was restarted before discharge.
4. GASTROINTESTINAL: The patient developed abdominal pain
on hospital days two and three, and his liver function tests,
and amylase, and lipase increased. When he was admitted the
differential for this was between biliary stone disease, tube
feed induced and shock liver. His liver function tests,
amylase, and lipase returned back to normal. He also had no
further complaints of abdominal pain.
5. NUTRITION: The patient's tube feeds were held in the
initial setting of pancreatitis; however, they were restarted
and ProMod with fiber was increased to a goal of 75 cc per
hour. He tolerated this well. He received a swallowing
evaluation and a video swallowing study to evaluate for
aspiration, and there was evidence of Macroaspiration.
Therefore, he only received a small amount of apple sauce,
but was otherwise kept n.p.o., and tube feeds were continued.
6. RENAL: There were no issues.
7. ENDOCRINE: There were no issues.
8. HEMATOLOGY: There were no issues.
9. NEUROLOGY: The patient was given a loading dose of
Dilantin when he came into the outside hospital, and free
Dilantin level was checked which was slightly low; and,
therefore, the patient's Dilantin dose was increased to
125 mg p.o. t.i.d. He was continued at this dose until
discharge. He had no further seizure activity or neurologic
complaints during this admission.
DISCHARGE PLAN: Discharged back to [**Hospital6 19936**]. Outpatient transesophageal echocardiogram was
arranged to definitively rule out endocarditis.
CONDITION AT DISCHARGE: The patient was stable and at his
current baseline.
MEDICATIONS ON DISCHARGE:
1. Lisinopril 30 mg p.o. q.d.
2. Dilantin 125 mg p.o. q.8h.
3. Thiamine 100 mg p.o. q.d.
4. Folate 1 mg p.o. q.d.
5. Multivitamin.
6. Prevacid suspension 30 cc p.o. q.d.
7. Vancomycin 1 g intravenously q.12.h. times two weeks
total for methicillin-resistant Staphylococcus aureus
bacteremia through peripherally inserted central catheter
line.
DISCHARGE DIAGNOSES:
1. Methicillin-resistant Staphylococcus aureus bacteremia.
2. Question of methicillin-resistant Staphylococcus aureus
pneumonia, right lower lobe.
3. Seizure disorder.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 35154**], M.D. [**MD Number(2) 36634**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2193-10-1**] 16:10
T: [**2193-10-1**] 15:31
JOB#: [**Job Number 36635**]
(cclist)
Admission Date: [**2193-9-27**] Discharge Date: [**2193-10-3**]
Date of Birth: [**2135-10-8**] Sex: M
Service:
ADDENDUM: The patient will follow up on Tuesday, [**2193-10-8**] at 9:00 a.m. at [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]
for a transesophageal echocardiogram for evaluation of his
heart valve to rule out endocarditis. If there is any
evidence of endocarditis, his vancomycin should be continued
for a total of six weeks, instead of a total of two weeks, at
1 gram intravenously every 12 hours.
Also, the patient should call for a follow-up appointment
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The appointment should be about three
weeks from the discharge date and he should call [**Telephone/Fax (1) 250**]
to set up the appointment.
Diet: The patient should remain on nothing by mouth until he
is evaluated by speech and swallow at [**Hospital 38**]
Rehabilitation and he should receive ProMod with fiber tube
feeds, the maximum is 75 cc/hour.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 36636**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2193-10-3**] 16:27
T: [**2193-10-3**] 16:20
JOB#: [**Job Number **]
|
[
"780.39",
"V10.21",
"507.0",
"482.41",
"443.9",
"038.11",
"305.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"88.72",
"96.6",
"42.23"
] |
icd9pcs
|
[
[
[]
]
] |
7430, 9202
|
7057, 7409
|
2251, 4458
|
4486, 6799
|
6978, 7031
|
151, 1822
|
6816, 6963
|
1845, 2224
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,431
| 164,227
|
22681
|
Discharge summary
|
report
|
Admission Date: [**2192-4-6**] Discharge Date: [**2192-4-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hip fracture
Major Surgical or Invasive Procedure:
ORIF
pacer battery change
History of Present Illness:
HPI: [**Age over 90 **] yo man with HTN, PCM dependent, fell down last night -
unable to recall details - + LOC, awoke on living room floor,
unable to get up. Wife with severe dementia and cannot provide
details.
Past Medical History:
PCM - pacer-dependent
HTN
CRI - Baseline Cr [**2-22**]
BPH, elevated PSA at 17
Social History:
SH: Lives in [**Hospital3 **] with wife (girlfriend according to
NF, ? details) Wife with severe dementia. 2oz a scotch 3x/week
Family History:
non contributory
Physical Exam:
Gen: elderly
Cor: bradycardic, paced
Neuro: AAAX3
Pertinent Results:
CXR: CM, ? early infiltrate
.
EKG: LBBB,V-paced at 55
.
CT Head: neg bleed
.
Films: + Femur Fracture
Brief Hospital Course:
[**Age over 90 **] yo man with syncope/fall and now with femur fracture
.
Femur Fracture: S/p femur fracture repair.
.
Syncope:
Tele monitoring, per EP no evidence of artrythmia on
interrogation.
Cycle enzymes - trop 0.02-> 0.07,
Echo revealed Nl EF
.
cardiac: PCM interrogation - patient was pacer dependent with
intrinsic rate
in the 20's. PCM battery was near end of life and it was
changed in the hospital. After this procedure the pt went into
respiratory failure with CXR c/ CHF. He was then diuresed
aggressively causing ARF. While fluid appeared necessary to
rescue his kidneys he continued to go into resp. distress and
CHF with hydration.
The family decided not to pursue aggressive therapy and opted to
make him CMO.
He was started on a morphine drip and passed away shorthy after.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
expired
Discharge Condition:
hip fracture, arrhytmia, dying pacer battery, CHF, ARF
Discharge Instructions:
none
Followup Instructions:
none
|
[
"820.22",
"E888.9",
"V53.31",
"287.5",
"285.1",
"401.9",
"593.9",
"427.31",
"518.81",
"584.5",
"428.0",
"780.2",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"37.87",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
1863, 1936
|
1035, 1840
|
273, 300
|
1987, 2043
|
909, 965
|
2096, 2103
|
806, 824
|
1957, 1966
|
2067, 2073
|
839, 890
|
221, 235
|
328, 542
|
974, 1012
|
564, 645
|
661, 790
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,900
| 100,114
|
49103
|
Discharge summary
|
report
|
Admission Date: [**2157-9-18**] Discharge Date: [**2157-10-6**]
Date of Birth: [**2107-2-1**] Sex: M
Service: TRAUMA SURGERY
CHIEF COMPLAINT: Here for pancreas transplant.
HISTORY OF THE PRESENT ILLNESS: The patient is a 50-year-old
status post a cadaveric renal transplant in [**2157-3-5**]
complicated by delayed graft function. His baseline
creatinine is 2.7. He is now here for a pancreas transplant.
His CRT postoperative course has been complicated by elevated
BUN and creatinine and hyperkalemia which have all resolved.
He has a long-standing history of type I diabetes with
nephropathy and retinopathy as well as hypertension. He
denied any recent fever, chills, nausea, vomiting, diarrhea,
or urinary tract symptoms.
PAST MEDICAL HISTORY:
1. End-stage renal disease.
2. Type 1 diabetes.
3. Diabetic retinopathy.
4. Hypertension.
PAST SURGICAL HISTORY:
1. Cadaveric renal transplant in [**2157-3-5**].
2. Hernia repair in [**2153**].
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Prograf 2 mg b.i.d.
2. Rapamycin 5 mg q.d.
3. Valcyte 450 mg q.o.d.
4. Bactrim single-strength tablet p.o. q.d.
5. Aspirin 81 mg p.o. q.d.
6. Labetalol 200 mg b.i.d.
7. Norvasc 10 mg q.d.
8. Zantac 150 mg b.i.d.
9. NPH 15 units in the morning.
10. Humalog sliding scale.
SOCIAL HISTORY: No tobacco, no ethanol, no IV drug use.
FAMILY HISTORY: The patient's father had an MI.
PHYSICAL EXAMINATION ON ADMISSION: General: The patient was
in no apparent distress, alert and oriented times three. He
was normocephalic, with no icterus. Heart: RRR. Chest:
CTAB. Abdomen: Well-healed left lower quadrant scar with a
transplanted kidney in the left lower quadrant. The rest of
the examination was soft, nontender, nondistended with
positive bowel sounds. Extremities: There was 1+ edema in
the lower extremities and a right forearm AV fistula with
positive thrill and bruit. neurologic: He was grossly
intact. Rectal examination: Deferred.
HOSPITAL COURSE: The patient was admitted to Transplant with
a normal preoperative workup performed. He went for surgery
for his pancreas transplant. Please refer to the previously
dictated operative note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] detailing the
details of this operation.
Postoperatively, the patient was transferred to the Surgical
Intensive Care Unit on Rapamune, tacrolimus, and antithymo
globulin and Solu-Medrol for immunosuppression as well as
Octreotide for reducing the secretions of the pancreas.
Unfortunately, postoperatively, the ultrasound on
postoperative day number one showed question of blood flow to
the transplanted pancreas and it was decided that the patient
would go back for evaluation of the transplant. The patient
was started on heparin. Unfortunately, he became hypotensive
and had a drop in his hematocrit level. He was brought
urgently to the Operating Room for a washout of his abdomen.
Please refer to the previously dictated operative note by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from [**2157-9-19**].
Briefly, what happened is that about 1 liter of old clot was
retrieved from the abdomen. This was irrigated and a source
for this bleed was found in the region of the body of the
pancreas which was controlled with a clip. No other bleeding
was noted and the abdomen was washed out again and the
patient was closed satisfactorily.
Postoperatively, the patient was transferred to the
Postanesthesia Care Unit and subsequently to the floor
without complication. His floor course was relatively
unremarkable. He was continued on immunosuppression and at
the time of his discharge, his immunosuppression regimen
includes Prograf 2 mg b.i.d. and Rapamune 4 mg q.d. His last
Prograf level was 9.7 on this dose and his last Rapamune
level was 18.5 on 5 mg q.d.
The patient's pancreatic functions have been relatively
normal; amylase and lipase have remained within normal limits
for the majority of this operative stay and the last levels
measured were 29 and 26 respectively. He does have a mild
insulin requirement. He has been receiving a sliding scale
and will be discharged on a dose of Lantus 5 mg q.h.s. as
well as with a sliding scale.
The only other postoperative complication was a fever on
[**2157-9-30**], postoperative day number 12 and 11, which
revealed a fever to 101.3. Workup at this time did not
reveal any source for his fever. He was treated on
intravenous Unasyn and subsequently p.o. Augmentin for a
total course of eight days without recurrence of this fever.
He is also contained on a prophylactic antibiotic regimen
with Valcyte, Bactrim, and Nystatin swish and swallow which
he has tolerated well. On the day of discharge, the patient
is currently tolerating a p.o. diet without nausea, vomiting,
or abdominal pain or diarrhea. He is in general doing very
well. He is being discharged home in good condition on
[**2157-10-6**].
DISCHARGE DIAGNOSIS:
1. Status post pancreas transplant.
2. Hypertension.
3. Insulin-dependent diabetes mellitus.
4. Diabetic retinopathy.
5. End-stage renal disease.
6. Status post renal transplant in [**5-7**].
7. Status post hernia repair.
8. Anemia of chronic renal failure.
9. Hyperkalemia.
10. Chronic blood loss anemia requiring multiple blood
transfusions.
11. Leukopenia.
12. Postoperative atelectasis.
13. Hypovolemia requiring fluid resuscitation.
14. Postoperative hematoma and blood loss requiring
reoperation.
15. Status post exploratory laparotomy.
16. Metabolic acidosis.
DISCHARGE MEDICATIONS:
1. Valcyte 450 mg p.o. q.o.d.
2. Protonix 40 mg p.o. q.d.
3. Bactrim single-strength p.o. q.d.
4. Labetalol 100 mg p.o. b.i.d.
5. Colace 100 mg p.o. b.i.d.
6. Sodium bicarbonate 650 mg p.o. q.i.d.
7. Epogen 5,000 units subcutaneously once a week.
8. Hydromorphone 2-4 mg p.o. q. four hours p.r.n pain.
9. Ambien 5 mg p.o. q.h.s. p.r.n. insomnia.
10. Aspirin 325 mg p.o. q.d.
11. Dulcolax 10 mg p.r. q.h.s. p.r.n. constipation.
12. Sirolimus 4 mg p.o. q.d.
13. Tacrolimus 2 mg p.o. b.i.d.
14. Nystatin 5 cc p.o. q.i.d. as needed for thrush.
15. Lantus 5 units subcutaneously q.h.s. as a regular insulin
sliding scale.
The patient is also recommended to have outpatient laboratory
work every Monday and Friday starting on [**2157-10-7**].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2157-10-6**] 11:39
T: [**2157-10-8**] 16:08
JOB#: [**Job Number 103031**]
|
[
"362.01",
"583.81",
"998.89",
"996.81",
"E878.0",
"403.91",
"780.6",
"250.53",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.19",
"52.80",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
1411, 1465
|
5623, 6644
|
5023, 5600
|
2034, 5002
|
1052, 1336
|
891, 1029
|
160, 751
|
1480, 2016
|
773, 868
|
1353, 1394
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,925
| 131,825
|
40879
|
Discharge summary
|
report
|
Admission Date: [**2152-1-9**] Discharge Date: [**2152-2-23**]
Date of Birth: [**2101-2-27**] Sex: M
Service: SURGERY
Allergies:
Nafcillin / Zosyn / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
abominal pain, fevers, malaise
Major Surgical or Invasive Procedure:
[**2152-1-11**]: Paracentesis
[**2152-1-12**]: Right hemicolectomy with end ileostomy
[**2152-1-15**]: ABO incompatible liver transplant with splenectomy
[**2152-1-16**]: Abdominal hematoma washout, liver biopsy, Abdominal
closure
[**2152-1-18**] Feeding tube placement
[**2152-1-25**]: Feeding tube placement
[**2152-1-27**]: Liver Biopsy, feeding tube placement
[**2152-1-31**]: Feeding tube placement
[**2152-2-4**]: Liver Biopsy
[**2152-2-8**]: Feeding tube placement
[**2152-2-16**]: Common Hepatic Angiography
[**2152-2-17**]: Liver Biopsy
[**2152-2-17**]: replacement of phresis line/pheresis
[**2151-2-21**]: Feeding tube placement
Plasmapheresis per and post transplant
History of Present Illness:
50 year old male with h/o HCV and ETOH cirrhosis (MELD score of
26 undergoing transplant eval) c/b Ascites and Jaundice,
Hyponatremia, CKD, h/o MSSA left foot osteomyelitis ([**2151-6-13**])
presenting from OSH with concern with SBP.
.
[**Doctor First Name 4049**] reports that he felt okay when presented to [**Hospital1 18**] on [**1-7**]
to get a chest CT but had onset of symptoms later that day.
Symptoms consisted of increased abd distention/pain, generalized
weakness, fevers up to 101.6, shortness of breath, and nausea
without vomiting. Except for his fever which has come down a
bit, his symptoms have gotten worse in the last 24hrs to the
point where today he couldn't really get out of bed and didn't
have the energy to take his home medications. He has no appetite
and only ate a few crackers in the last 24hrs. Similar but more
severe to past SOB and abd pain in setting of worsening ascites.
No exacerbating or relieving factors. He also reports diarrhea
which started this afternoon along with a cough (non-productive)
he's had the last few days and thinks he picked up from his
wife. [**Name (NI) **] feels less clear mentally than normal. Pt denies HA,
vomiting, dysuria, rash, or pleuritic chest pain.
.
Of note, last para was on [**2151-12-20**] at which time 5L fluid removed
and albumin given.
.
In the ED: In the ED, initial VS: 99.4 108 106/70 24 100% 2L. On
exam pt tachy with sigmata of liver disease and ascites. OSH had
done diagnostic para with prot 1.2, ldl 83, glucose 128. No cell
counts or cx available but ED resident called and talked to
attending to confirm that they had been sent and would be run -
should be available in AM. Pt had been given 500mg IV
levofloxacin at OSH as well as dose of 40mg IV lasix as they
thought he was in heart failure and since he hadn't taken his
home lasix today. At [**Hospital1 18**] he was given 1g CTX for SBP concern
as well as 4mg IV morphine. Cr also slightly up from prior
baseline raising concern for HRS (not previously known to have)
but albumin held until pt to arrive on floor. Transfer VS: 98.7,
99, 118/70, 24, 99% 3L
.
Currently, pt is in [**9-22**] pain in his lower abdomen. He feels
very short of breath and like he is only able to take shallow
breaths. No pleuritic chest pain.
.
REVIEW OF SYSTEMS - see above for ROS:
Past Medical History:
HCV/EtOH Cirrhosis c/b Jaundice, Ascites
3 cords of grade I varices were seen starting at 30 cm ([**2151-6-3**])
Heterozygous for H63D MUTATION
Hyponatremia
MSSA osteomyelitis of the L foot s/p debridement [**5-24**]
GERD
HTN
Gout
CAD - pt does not recall h/o MI or stents
Cervical laminectomy
Social History:
Lives w/ wife, walks w/ a cane and is independent w/ ADLs. He
quit ETOH in [**2151-5-14**]. He quit smoking for three months but
has started again and is smoking 1 cig per day (last 3 days
PTA).
Family History:
No h/o liver disease
Physical Exam:
Admission Physical Exam:
VS - Temp 99.2F, BP 118/67, HR 106, R 30, O2-sat 100% RA
GENERAL - uncomfortable and sick appearing male, obviously
jaundiced
HEENT - PERRLA, EOMI, sclerae grossly icteric, dry MM, OP clear
NECK - supple, no JVD, no cervical LAD
LUNGS - Diffuse insp/exp wheezing in all lung fields on exam,
mildly decreased lung sounds at L base, no crackles
HEART - PMI non-displaced, mildly tachy, no MRG, nl S1-S2
ABDOMEN - Very distended, tympanytic to percussion around
umbilicus, dull on sides, tender to palpation most prominently
around umbilicus and lower quandrants, no masses felt
EXTREMITIES - trace peripheral edema in b/l LE, ext are warm and
well perfulsed with 2+ peripheral pulses (radials, DPs)
SKIN - spider angiomas diffusely on chest, no palmar erythema
NEURO - awake, A&Ox3, No asterixis, CNs II-XII grossly intact,
muscle strength 5/5 throughout, sensation grossly intact
throughout
.
Pertinent Results:
On Admission: [**2152-1-9**]
WBC-9.1# RBC-3.37* Hgb-10.8* Hct-31.1* MCV-92 MCH-32.2*
MCHC-34.9 RDW-15.5 Plt Ct-48*
PT-21.7* PTT-43.6* INR(PT)-2.0* Fibrinogen-73*
Glucose-132* UreaN-28* Creat-1.7* Na-127* K-4.3 Cl-99 HCO3-18*
AnGap-14
ALT-35 AST-62* AlkPhos-133* TotBili-11.0*
Calcium-8.6 Phos-4.7* Mg-1.8
TSH-3.9
[**2152-1-15**] HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE
At Discharge [**2152-2-23**]
HIV Ab-NEGATIVE
WBC-11.9* RBC-3.32* Hgb-9.4* Hct-28.8* MCV-87 MCH-28.4 MCHC-32.7
RDW-16.1* Plt Ct-412
PT-10.4 PTT-67.9* INR(PT)-1.0
Glucose-199* UreaN-30* Creat-1.1 Na-135 K-4.3 Cl-100 HCO3-25
AnGap-14
ALT-15 AST-25 AlkPhos-148* TotBili-0.8
Albumin-2.9* Calcium-8.4 Phos-3.7 Mg-1.3*
tacroFK-9.5
Brief Hospital Course:
50 year old male with h/o HCV and ETOH cirrhosis (MELD score of
26 undergoing transplant eval) c/b Ascites and Jaundice,
Hyponatremia, CKD, h/o MSSA left foot osteomyelitis ([**2151-6-13**])
presenting from OSH with concern with SBP and some concern for
HRS with slight Cr bump.
.
# Sepsis - due to SBP: On admission, the patient met sepsis
criteria on HR and tachypnea (fever reported to 101.6 at home,
although Tmax on admission 99.2). Source is ascitic fluid where
OSH tap shows 8820 WBC. The patient was given Levofloxacin at
OSH. Upon transfer, he was started on ceftriaxone 2mg IV daily
and albumin 1.5 mg/kg. His lactate on admission rose from 2.5
to 3.4, but improved to 1.9 following administration of albumin.
# [**Last Name (un) **]: The patient was admitted with a mild elevation in
creatinine from 1.5 to 1.7. He had episode of ATN [**3-16**] to
interstitial nephritis back in [**Month (only) 547**], and Cr has never gotten
below 1.3 since that time. Albumin was continued for a 3rd day
per SBP prophylaxis. By time of discharge, the creatinine was
1.1 with excellent urine output.
.
# Tachypnea with subjective SOB: The patient was admitted with
tachypnea, likely secondary to only being able to take shallow
breaths due to abdominal girth and in response to acidosis from
infection (admission HCO3 18). He did have diffuse wheezing on
pulmonary exam. CXR negative for acute pulmonary process. The
patient was started on ipratropium nebs for wheezing.
.
# Cirrhosis - Due to EtOH/HCV: Decompensated by ascites,
jaundice, and encephalopathy. MELD 30 on admission. Patient
completed transplant workup the day prior to admission. Alb of
2.6 with known ascites. The patient undergoes intermittent
large vol [**Doctor First Name 4397**] as outpt, last [**2151-12-20**]. Also on standing
diuretics. The patient was transferred from an OSH for SBP as
above. On admission, the patient's diuretics were held in the
setting of SBP. He was treated with albumin and ceftriaxone.
.
On [**2152-1-12**], patient was seen by transplant surgery and on same
day, patient taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
Exploratory laparotomy, right hemicolectomy and end-ileostomy
for Pneumatosis intestinalis.
The patient was kept in the ICU following the initial surgery,
was treated with broad spectrum antibiotics, and on [**1-15**] was
deemed adequately treated and underwent an orthotopic liver
transplant and splenectomy for an ABO incompatible liver. Donor
was A, patient is Type O.
Prior to the transplant, the patient was given plasmapheresis,
which was continued for two weeks based upon Anti-A levels. He
was taken back to the OR the following day for Abdominal
hematoma washout, liver biopsy, Abdominal closure, which was
successful.
He received routine immunosuppression at time of transplant to
include solumedrol with taper, mycophenylate and due to ABO
incompatibility, received 7 days of Anti-thymoglobulin (100 mg
daily except induction of 125 mg)
Prograf was started on the evening of POD 1, levels were
followed throughout the hospitalization, and doses adjusted
accordingly.
The patient had multiple feeding tube placements throughout the
hospitalization, and is currently receiving cycled tube feeds.
On [**2152-1-27**], he underwent Liver Biopsy, as the bilirubin, which
was 11.8 0n admission, and had dropped to 4.3, had increased to
8.7, and then peaked at 10.7. He has never undergone ERCP, but
had several liver ultrasounds demonstrating patency of vessels.
He was also having increased abdominal pain, and ultrasound on
[**1-27**] demonstrated a large hematoma, and he underwent ultrasound
guided drainage of the hematoma with good relief of symptoms.
Culture of the hematoma was no growth.
White count was persistently elevated and on [**1-21**] it was
increased to 21, blood cultures grew out Saccharomyces
Cerevisae. He was initially on fluconazole, ( Cefepime, Vanco
and Flagyl courses from time of transplant had been discontinued
by that time). Daily surveillance cultures were drawn, and on
[**1-27**] he again had positive blood cultures, this time with
[**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) **] and then started treatment with Ambisome (8
days) As of surveillance cultures from [**2-9**] on, there have been
no positive blood cultures, he will remain on Micafungin, which
was started on [**2-8**] through one months treatment.
On [**2152-2-4**] another Liver Biopsy was performed for persistently
elevated alk phos and bilirubin. No evidence of rejection was
found, and changes looked inflammatory.
On [**2152-2-16**] a Common Hepatic Angiography was done to further
evaluate liver vasculature. No stent was placed, however he was
placed on a heparin drip due to HA stenosis and also splenic
vein thrombosis. He was started on coumadin and will be
discharged on a lovenox bridge.
PICC line has been placed
Another liver biopsy was performed on [**2152-2-17**]. Findings were
consistent with changes associated with hepatic arterial
stenosis.
He was also advised to have repeat Anti A titers, had a pheresis
line placed and received 2 more treatments of pheresis [**2152-2-17**],
pheresis lines was d/c'd
All JP drains have been removed, however a VAC had been placed
to an area of the incision, wound is granulating well.
Patient has been working with physical therapy. Had a minor
slide off bed while sitting on day of discharge. No trauma to
head and no evidence of bruising or scrapes. He has had an
increase in tremors, thought to be associated with the
sertraline he was started on. It has enhanced his mood
favorably, so propranolol has been started to attempt control.
Prograf levels have not been significantly elevated, and a less
likely cause of tremor.
He is to be discharged to rehab for further strengthening,
nutrition management, VAC management, ostomy care and teaching,
medication teaching.
Medications on Admission:
1. furosemide 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. spironolactone 50mg PO DAILY
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) 1 Qd
6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One Qd
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
10. Centrum Silver
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA).
5. micafungin 100 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 14 days: end date [**2152-3-9**].
6. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
7. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
8. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
9. psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily):
give at noon to avoid binding other drugs .
10. prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily):
start [**2-24**], follow transplant clinic taper.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours).
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
17. loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
18. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
19. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain: no more than 2000mg per day.
20. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
Two (22) units Subcutaneous once a day.
21. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty
Two (32) units Subcutaneous at bedtime.
22. insulin regular human 100 unit/mL Solution Sig: follow
sliding scale units Injection four times a day.
23. Outpatient Lab Work
Stat labs every Monday and Thursday for CBC, chem 10,
ast,alt,alk phos, t.bili, albumin , PT/inr and trough prograf
level
Fax to [**Hospital1 18**] Transplant coordinator [**Telephone/Fax (1) 14253**]
24. propranolol 60 mg Capsule,Extended Release 24 hr Sig: One
(1) Capsule,Extended Release 24 hr PO DAILY (Daily).
25. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg
Subcutaneous [**Hospital1 **] (2 times a day): 0.9 ml
Until therapeutic on warfarin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 686**]
Discharge Diagnosis:
HCV cirrhosis
s/p A incompatible liver transplant
fungal peritonitis
Fungemia
abdominal hematoma
abdominal incisional wound
malnutrition
Acute Kidney injury: resolving
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:
Daily PT/INRs should be drawn and faxed to transplant clinic for
management, once stable, PT/INR can be combined with weekly labs
q Monday and Thursday
Labs will be drawn every Monday and Thursday for transplant
monitoring
Abdominal wound vac should be changed every 3 days
Continue tube feeds
Continue Micafungin via PICC line through [**3-9**]
No heavy lifting
Please do not adjust medications without consulting with the
transplant clinic
Will require follow up with [**Hospital **] clinic, will speak with
transplant coordinator to attempt same day clinic visit
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2152-3-2**] 3:00, [**Last Name (NamePattern1) **], [**Hospital **] Medical Building,
[**Location (un) 436**], [**Location (un) 86**] MA
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2152-3-6**] 11:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2152-3-13**] 11:20
Completed by:[**2152-2-23**]
|
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icd9cm
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[
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icd9pcs
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[
[
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14723, 14790
|
5606, 11544
|
340, 1021
|
15002, 15002
|
4882, 4882
|
15775, 16378
|
3906, 3928
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12123, 14700
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14811, 14981
|
11570, 12100
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15185, 15752
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3968, 4863
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270, 302
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1049, 3358
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4896, 5583
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15017, 15161
|
3380, 3677
|
3693, 3890
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,318
| 134,725
|
42240
|
Discharge summary
|
report
|
Admission Date: [**2166-8-10**] Discharge Date: [**2166-8-20**]
Date of Birth: [**2119-7-9**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Worst headache of life
Major Surgical or Invasive Procedure:
Diagnostic cerebral angiogram x 2
History of Present Illness:
Mr. [**Known lastname 91567**] is a 47 yo Right handed man who has no
substantial medical history who developed WHOL shortly after
coitus at about 10:30pm. He states that this came on very
abruptly and became excruciating.
He presented to [**Hospital6 **] where he received
morphine with some relief of his headache. He also reports some
nuchal rigidity.
He never lost consciousness. He denies any diplopia, ptosis,
dysarthria, unilateral weakness or numbness, vertigo.
Past Medical History:
GERD
Social History:
Works as a pipe fitter. Smokes 1.5 PPD for several
years. Drinks 2-3 beers a day.
Family History:
NC
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: 1 [**Doctor Last Name **]: 2 GCS E: 5 V: 5 Motor: 5
O: T: Afebrile BP: / HR: R:
Gen: WD/WN, comfortable, NAD.
HEENT: MMM, O/P clear
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Orientation: Oriented to person, place, and date.
Recall: [**2-20**] objects at 5 minutes. Language: Speech fluent with
good comprehension and repetition. Naming intact. No dysarthria
or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-24**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin.
On discharge - He is awake alert and oriented with a non focal
neuro exam except for mild headache. He is afebrile, tolerating
good oral intact and voicing without difficulty. He is
independent in ADL's and ambulatory.
Pertinent Results:
CTA Head and neck [**2166-8-10**]
1.Non-contrast CT head: Small amount of SAH pools just above the
sella
tursica at the bifurcation of the internal carotid arteris,
unchanged from the priror OSH study. Tiny hemorrhage pools in
the bioccipital horns. No
midline shift.
2. CTA head/neck. Pending 3-D rendering. Major cervical and
intra-cranial
vessels patents. No evidence of aneurysm > 3 mm.
[**2166-8-10**] INTERVENTIONAL PROCEDURE PERFORMED: Diagnostic cerebral
angiogram.
ANESTHESIA: The patient was sedated with Versed and fentanyl. 1
mg of
Versed, and 50 mcg of fentanyl iv was administered for a total
intra-service time of 70 minutes.
PHYSICIANS: [**First Name8 (NamePattern2) **] [**Doctor Last Name **] (attending), K.C. Tan (fellow).
DETAILS OF THE PROCEDURE:
The patient was brought to the angiography suite. IV anesthesia
was induced in the supine position. A safety timeout was
obtained.
Following this, access was gained into the right common femoral
artery using a micropuncture needle, and a Seldinger technique.
The right brachiocephalic artery was catheterized with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
2 5 French catheter. Under roadmap guidance, a right internal
carotid artery, and a right external carotid artery arteriograms
were obtained. Following this, the left common carotid artery
was catheterized. A left common carotid artery arteriogram was
obtained. Under roadmap guidance, the left ICA, and left ECA
were subsequently selected. Selective arteriograms were then
obtained. The catheter was then withdrawn into the aortic arch,
and the right vertebral artery was catheterized using roadmap
guidance, and the [**Doctor Last Name **] 2 catheter. A selective right
vertebral artery arteriogram was obtained.
The left subclavian artery was then selected, and the left
vertebral artery was catheterized. A left vertebral artery
arteriogram was obtained. Following this, a right common femoral
arteriogram was performed, and a 6 French Angio- seal Evolution
closure device was used to secure hemostasis at the right common
femoral artery arteriotomy site.
FINDINGS: The right external carotid artery was patent, and
showed no
significant stenosis. In particular, there was no evidence of a
dural AV
fistula.
The right common carotid artery showed no significant stenosis
at the
bifurcation.
The right internal carotid artery angiogram demonstrated the
presence of two MCA branches. This is reminiscent of an
accessory MCA variant. One branch arises directly from the
internal carotid artery, and the other arises from the
bifurcation. The MCA is otherwise unremarkable, and patent.
Right vertebral arteriogram demonstrates reflux into the left
vertebral
artery. Both the superior cerebellar artery, and PICA were well
visualized, and appeared unremarkable. There is no aneurysm at
the basilar apex.
Left external carotid arteriogram demonstrated no dural AV
fistula. The left external carotid artery was unremarkable, and
patent.
The left common carotid artery demonstrated no significant
stenosis at the
bifurcation.
A left internal carotid artery angiogram appeared unremarkable.
The left
internal carotid artery showed a normal cervical, petrous, and
supraclinoid segment. The anterior and middle cerebral artery
did not show any evidence of aneurysms.
The left vertebral artery is patent. The PICA origin was noted
to be normal. There is a muscular branch arising from the left
vertebral artery anastomosing with the occipital branch artery
of the left external carotid artery.
Right common femoral arteriogram showed a patent common femoral
artery with no significant stenosis.
IMPRESSION:
Unremarkable diagnostic cerebral angiogram. In particular, no
aneurysm, AVM or dural AV fistula was noted.
[**2166-8-18**] CTA OF HEAD
There is near resolution of the previously seen subarachnoid
hemorrhage in the basal cisterns bilaterally. Note in this study
is fenestration of the right ACA. There is a focal narrowing
found in the A2 segment of the left ACA also seen in the
previous study and is unchanged. This finding is most likely
related to atherosclerotic narrowing of the vessels and does not
represent vasospasm.
There is no evidence of new hemorrhage. No edema, masses, mass
effect or
infarction. The ventricles are normal in size and configuration
and are now free of hemorrhage previously seen.
No fractures are identified.
The carotid and vertebral arteries and the major branches are
patent with no evidence of stenosis. The distal cervical
internal carotid arteries measure 3 mm in diameter bilaterally.
There is no evidence of aneurysm formation.
IMPRESSION:
1. No evidence of vasospasm. Near resolution of previously seen
subarachnoid hemorrhage. Focal narrowing of the left ACA segment
A2, not likely representing vasospasm.
2. No edema, masses, mass effect or infarction. The ventricles
are normal in size and configuration with no evidence of
hydrocephalus. Previously seen blood in the dependent portions
of the ventricles are now resolved.
[**2166-8-18**] LENIE
FINDINGS: Grayscale, color and pulse Doppler images of the right
and left
common femoral, superficial femoral, and popliteal veins were
obtained.
Normal flow, compressibility, augmentation, and waveforms
demonstrated. No
intraluminal thrombus is identified. Normal compressibility is
demonstrated in the posterior tibial and peroneal veins
bilaterally.
IMPRESSION: No deep venous thrombosis in right or left lower
extremity.
[**2166-8-18**] CXR
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Normal heart, lungs, hila, mediastinum and pleural surfaces.
Brief Hospital Course:
Pt was admitted to the neurosurgery service and the ICU for
further workup and care of his SAH. A CTA was negative for
aneurysm and he was taken for cerebral angiogram on the morning
of [**8-10**]. His angiogram was negative and plan was for a repeat
procedure in 1 week. On [**8-14**], patient reported headache that was
not relieved with pain medication, he was started on the a
prednisone taper. He remained intact throughout the day.
Mr. [**Known lastname 91567**] remained neurologically stable and was transferred
out of the ICU to the Step down unit on [**8-15**] with plans to
undergo and CTA on Monday [**8-18**]. On TCD, patient seen to
have bilateral MCA spasm and was trasferred back to ICU. His
exam remained nonfocal. On [**8-17**], patient complained of headache
and his pain medication was adjusted accordingly. On [**8-18**],
patient underwent CTA of the head, bilateral lower extremity
vein doppler scan, and was transferred to the Neurosurgery
inpatient unit's step-down bed.
He underwent cerbral angiography on [**2166-8-20**] which revealed mild
vasospasm to the ICA but clinically the patient remained
nonfocal. No aneurysm or other vascular malformation was noted
on the angiogram. Post-angio he was monitored and on bedrest for
two hours. He was then able to ambulate and tolerate a regular
diet. He was discharged with a rx for Nimodipine and a two day
hospital supply.
Medications on Admission:
PPI
Discharge Medications:
1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 11 days.
Disp:*132 Capsule(s)* Refills:*0*
2. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every four
(4) hours for 2 days.
Disp:*24 Capsule(s)* Refills:*0*
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. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-22**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*90 Tablet(s)* Refills:*1*
6. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for Pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Perimesencephalic subarachnoid hemorrhage
Headache
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your groin puncture site may be left uncovered, unless you
have small amounts of drainage from the wound, then place a dry
dressing or band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 4 weeks, you may resume sexual activity.
?????? After 4 weeks, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest E
Followup Instructions:
Please call the office to schedule an appointment with Dr.
[**First Name (STitle) **] to be seen in 1 month for follow up. You will need a Head
CT w/o contrast for this appointment. Please call [**Telephone/Fax (1) 4296**]
to make this appointment.
Completed by:[**2166-8-20**]
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77,524
| 162,509
|
3993
|
Discharge summary
|
report
|
Admission Date: [**2113-2-8**] Discharge Date: [**2113-2-13**]
Date of Birth: [**2060-3-18**] Sex: M
Service: MEDICINE
Allergies:
Iodine / Atenolol
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
Diarrhea
Hypotension
Major Surgical or Invasive Procedure:
Central venous line placement and removal
History of Present Illness:
Mr. [**Known lastname 17669**] is a 52 year old man with complicated medical
history including Asperger's syndrome, ulcerative colitis s/p
total colectomy, type 2 diabetes mellitus, atrial fibrillation,
sleep apnea and morbid obesity who presents to [**Hospital1 18**] [**Location (un) 620**]
with malaise for past few days. Was markedly dry SBP 60 with
lactate of 2.4 by [**Location (un) **] records (although ED report of lactate
of 10 as OSH). Got 10L IVF and still hypotensive. Was on Dopa
then switched to phenylepinephrine. CT scan negative. CXR
negative. Urine negative. Was anuric but now making urine. Was
given vanc/zosyn. Transferred due to lack of ICU beds.
[**Location (un) 620**] labs notable for
AST 103
ALT 86
EtOH of 12
WBC 12-->16
INR 3.6
BUN 59
Cr 4.8
Trop of 0.04 --> 0.02
In the ED, initial VS were: 98.1 80 138/87 18 100%. Patient was
continued on phenylephrine and vanc/zosyn. Had some transient
hypotension with SBP in the 70's.
Transfer vs:
P91 CVP 10 Satting 100% on NRB (refused NC) was 91% on RA. BP
91/40 MAP 51.
On arrival to the MICU, patient is poor historian. He reports
that he has been feeling ill for some time. Endorses cough for
several days for which he has been taking mucinex. Also endorsed
some increased ostomy output of uncler duration. No fevers. No
Chills. Unable to comment on degree of PO intake. Denies EtOH
use.
Past Medical History:
* Morbid Obesity, with most recent BMI 49.6 .
* Ulcerative colitis, status post colectomy and ileostomy
creation in [**2084**]. He takes iron and magnesium supplementation.
* Type 2 diabetes mellitus, diagnosed in [**2110**], treated with
metformin and glipizide, and followed by the [**Hospital **] Clinic.
* Atrial fibrillation, controlled with digoxin and
anticoagulated
with warfarin.
* Obstructive sleep apnea, associated with trachobronchomalacia.
He is unable to tolerate CPAP.
*Hyperlipidemia, controlled on atorvastatin.
*Hypertension, well-controlled on metoprolol and moexipril.
* Chronic venous insufficiency of legs with peripheral edema,
complicated by venous ulcers in [**2110**].
* Chronic renal insufficiency
* Congenital agenesis of right kidney
* Asperger's syndrome
* Depression
* History of cellulitis
* History of functional heart murmur
* Carpal tunnel syndrome
* Osteoarthritis of knees
* Vitamin D deficiency, most recently normal with total Vitamin
D
level of 23 ng/mL in 4/[**2109**].
* History of iron deficiency anemia, currently treated with oral
iron.
* History of blood transfusion in [**2083**].
Social History:
He does not use alcohol, recreational drugs, or tobacco.
Family History:
Noncontributory
Physical Exam:
Physical exam on admission to MICU
Vitals: 95/53 P 99 RR O2 Sat: 95 % on shovel
General: AAO x3 however somnolent but arrousable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, no meningismus
CV: Irregulary irregular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse bilateral breathsounds
Abdomen: Obese, Mildly TTP in LLQ/LUQ. Ostomy bag with copious
green stool. Pink well perfused ostomy
GU: foly in place
Ext: Cool extremities with 2+ pulses
Neuro: Grossly intact
Physical exam on day of discharge
VS: T 97, BP 149/78 (SBP range 140-150s), HR 74, RR 20, O2Sat
96% RA
Gen: obese, NAD
HEENT: sclera anicteric, MMM, OP clear
Neck: supple, JVP difficult to assess due to body habitus
CV: irregularly irregular, no m/r/g, normal S1 & S2
Resp: diminished breath sounds on the bases, no w/c/r, clear
otherwise
Abd: obese, NT, soft, no guarding or rebound. Ostomy back with
small amount of brownish stool
GU: no Foley
Extremities: warm, 2+ pulses bilaterally, edema to the shins
Pertinent Results:
[**2113-2-8**] 03:45AM URINE RBC-10* WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0
[**2113-2-8**] 03:45AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2113-2-8**] 03:45AM WBC-18.1*# RBC-4.51* HGB-12.8* HCT-39.4*
MCV-87 MCH-28.4 MCHC-32.6 RDW-14.3
[**2113-2-8**] 03:45AM ALT(SGPT)-60* AST(SGOT)-77* ALK PHOS-167* TOT
BILI-0.2
[**2113-2-8**] 10:43PM LACTATE-2.2*
[**2113-2-8**] 08:13PM GLUCOSE-270* LACTATE-3.1* K+-4.7
[**2113-2-8**] 08:13PM TYPE-ART O2-40 PO2-86 PCO2-33* PH-7.29* TOTAL
CO2-17* BASE XS--9 INTUBATED-NOT INTUBA
[**2113-2-8**] 06:14AM BLOOD Cortsol-47.5*
[**2113-2-8**] 06:14AM BLOOD HAV Ab-NEGATIVE
[**2113-2-8**] 03:45AM BLOOD Digoxin-1.6
[**2113-2-8**] 06:14AM BLOOD Lipase-113*
[**2113-2-8**] 03:45AM BLOOD Albumin-3.3*
[**2113-2-10**] 03:15AM BLOOD ALT-32 AST-28 LD(LDH)-169 AlkPhos-120
TotBili-0.2
[**2113-2-13**] 05:30AM BLOOD WBC-9.9 RBC-4.01* Hgb-11.4* Hct-34.9*
MCV-87 MCH-28.4 MCHC-32.6 RDW-14.6 Plt Ct-192
[**2113-2-13**] 05:30AM BLOOD PT-17.6* PTT-25.2 INR(PT)-1.7*
[**2113-2-13**] 05:30AM BLOOD Glucose-137* UreaN-18 Creat-1.4* Na-139
K-4.5 Cl-108 HCO3-19* AnGap-17
[**2113-2-13**] 05:30AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.4*
EKG [**2113-2-8**]
Baseline artifact. Atrial fibrillation with a controlled
ventricular response. Inferior axis. Late R wave progression.
Since the previous tracing of [**2109-8-2**] atrial fibrillation is now
present and there is an axis shift. Clinical correlation is
suggested.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
81 0 114 364/400 0 0 8
Transthoracic Echo [**2113-2-8**]
The left atrium is mildly dilated. The left atrium is elongated.
The estimated right atrial pressure is 0-5 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Preserved biventricular global and regional systolic
function. No significant valvular disease. Trivial pericardial
effusion.
CXR portable [**2113-2-8**]
Size of the cardiac silhouette has increased. This could be due
to increasing cardiomegaly or pericardial effusion. If any,
there are small bilateral pleural effusions. There is mild
vascular congestion. Right IJ catheter tip is in the mid SVC.
There is no pneumothorax.
RUE U/S [**2113-2-12**]
The right internal jugular, subclavian, axillary, brachial,
basilic, and
cephalic veins were interrogated, demonstrating normal
compressibility, flow, and augmentation. There is no echogenic
intraluminal thrombus identified. The contralateral subclavian
vein was interrogated for comparison purposes, demonstrating
symmetric respiratory phasicity.
IMPRESSION: No evidence of right upper extremity DVT.
Brief Hospital Course:
52yo man with a h/o Asperger??????s, UC s/p total colectomy with
ostomy, DM type II, A fib on Warfarin, morbid obesity, OSA (not
on CPAP), who presented to [**Location (un) 620**]-[**Hospital1 18**] with fatigue found to
have [**Last Name (un) **] with a creatinine of 4.8 and shock requiring pressors.
# Shock / C diff enteritis. The patient's shock on presentation
was likely mixed with septic / distributive pathophysiology and
hypovolemia contributing to his presentation. He was adequately
volume resuscitated, retained some component of decreased
vasomotor tone due to on-going distributive shock. The etiology
of his distributive shock is likely C diff enteritis. He was
initially treated with Vanc PO/IV, Cefepime, and Flagyl IV, but
without evidence of an alternative infection, he was kept on
only PO vanc and did well. His urine output was matched with LR
(hold on NS given evolutionary hyperchloremia). He came off
pressors, stool output trended down, and he was discharged to
the floor. Patient remained normotensive to hypertensive while
on the medicine floor. His metoprolol was restarted on the day
of transfer. ACE inhibitor was held [**2-16**] ARF. Patient was
started on amlodipine upon discharge in anticipation to
transition back to ACE inhibitor once his renal function returns
to normal. His 3 c. diff toxins were negative. C. diff PCR was
pending upon discharge. Patient was discharged with the
instruction to continue oral vancomycin until [**2112-2-22**] unless C.
diff PCR returns negative.
# Acute renal failure. Most likely ATN given that his kidney
function deteriorated in the setting of septic shock, with his
creatinine remaining elevated despite volume resuscitation in
the MICU. However, his creatinine trended toward his baseline
(1.2). His creatinine was 1.4 at the time of discharge. He was
restarted on home dose digoxin on the day of discharge. His
moxipril and metformin were held given that ARF has not yet
resolved.
# Cough/vagal episodes. He had significant vagal episodes
during paroxysms of coughing in the MICU which improved with the
addition of Robitussin and oropharyngeal lidocaine. Beyond
cough suppressants and reflexive care for vagal episodes, no
other acute interventions were required. The etiology of his
cough may be a URI as he has CT evidence of airway inflammation
and no parenchymal changes consistent with or concerning for
pneumonia. There, no antibiotics were given for the URI. His
symptoms improved over the course of his stay in the hospital.
# Transaminitis, likely [**2-16**] shock liver. Transaminitis improved
with resuscitation. He did not have any synthetic dysfunction.
# Arial fibrillation. He was rate controlled Beta blocker was
initially held given septic shock. His warfarin was also
initially held due to supratherapeutic level. His warfarin was
restarted at 5 mg on [**2113-2-10**] and he was also restarted on his
metoprolol after transfer to the medicine floor. Digoxin was
restarted on the day of discharge as his creatinine was
returning to baseline. He was instructed to have VNA draw blood
to monitor his INR level.
# T2DM. Glipizide and metformin were held initially. He was
kept on insulin sliding scale. Upon further review, patient was
recently initiated on insulin (Lantus) at the [**Hospital **] Clinic.
Because his renal function has yet to return to normal, he was
discharged on home Lantus 20 units and glipizide 10 mg daily
only. As his renal function improve, he can potentially restart
metformin as directed by his [**Last Name (un) **] providers.
Transitional Issues:
[] follow up Chemistry and coagulation panel on [**2-15**] and [**2-17**]
(drawn by VNA): monitor creatinine and electrolytes. Adjust
warfarin prn for INR goal [**2-17**] for AFib.
[] f/u C. diff PCR, if negative, can discontinue po vancomycin
[] once creatinine returning to baseline, restart ACE inhibitor
[] once creatinine returning to baseline, discontinue amlodipine
[] once creatinine returning to baseline, restart metformin
[] arrange to have nephrologist
Medications on Admission:
Digoxin 62.5 mcg QD
Glipizide 10mg QD
Metformin 859 mg QD
Metoprolol ER 50mg QD
Moxipril 7.5mg QD
Omeprazole 20mg QD
Rosuvastatin 20mg QD
Warfarin 5-10mg QD
Ferrous sulfate QD
Magnesium QD
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: [**1-16**] Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please follow the direction from your warfarin clinic.
5. ferrous sulfate 325 mg (65 mg iron) Tablet, Delayed Release
(E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
6. magnesium 250 mg Tablet Sig: One (1) Tablet PO twice a day.
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 8 days.
Disp:*32 Capsule(s)* Refills:*0*
9. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Please check CHEM7 (sodium, potassium, chloride, bicarbonate,
BUN, creatinine), coagulation panel (PT, PTT, on [**2-15**] and [**2-17**].
Please fax result to Dr. [**First Name (STitle) **] [**Name (STitle) 1395**] at [**Telephone/Fax (1) 7922**]. Telephone
number [**Telephone/Fax (1) 2205**]
11. Lantus 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime: Please check morning fasting blood
sugar.
12. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
- Septic shock
- Possible C. difficile enteritis
- Supratherapeutic INR
Secondary diagnoses:
- Atrial fibrillation
- Type 2 diabetes
- Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 17669**],
You were admitted to the hospital because of low blood pressure.
It is thought that you were possibly infected with C. diff in
your guts. You were given a lot of intravenous fluid and
medicine to support your blood pressure. You were started on an
antibiotics for C. diff infection. Your symptoms overall
improved.
Some of your medications were held because of your kidney
function, because your kidneys were injured with your low blood
pressure.
Please note the following changes in your medications:
- Please start Vancomycin 125 mg tab, 1 tab, by mouth, every 6
hours for your C. diff enteritis. You will need to complete a
total of 14 day course by the end of [**2113-2-21**]
- Pleast START amlodipine 5 mg, 1 tab, once a day, for your
blood pressure at this time while you are stopped on moxipril.
- Please STOP moxipril 7.5 mg daily for now because your kidney
function has not returned to [**Location 213**]. Your doctor will let you
know when you can start this medication.
- Please STOP metformin until your kidney function returns to
its baseline.
Followup Instructions:
You should ask your primary care physician to help you find a
kidney doctor if you don't already have one.
Department: [**State **]When: MONDAY [**2113-2-20**] at 12:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8428**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Completed by:[**2113-2-13**]
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|
[
[
[]
]
] |
12954, 13012
|
7189, 10776
|
298, 342
|
13224, 13224
|
4073, 7166
|
14503, 14944
|
2984, 3001
|
11504, 12931
|
13033, 13033
|
11290, 11481
|
13375, 14480
|
3016, 4054
|
13146, 13203
|
10797, 11264
|
238, 260
|
370, 1739
|
13052, 13125
|
13239, 13351
|
1761, 2893
|
2909, 2968
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,265
| 112,833
|
11425
|
Discharge summary
|
report
|
Admission Date: [**2111-5-16**] Discharge Date: [**2111-5-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84 year old female with recent diagnosis of adeno CA of
pancreatic biliary origin with pulm and liver mets, history of
diverticulosis and colonic polyps, AF and recently d/c'd off
coumadin, presents from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] after having large amount
of bleeding (500cc) with clots per rectum; son elected to send
in; would want transfusion; DNR/DNI status per prior
hospitalization.
.
In the ED, HCT 18 and passing large BRBPR (450cc), Right groin
line placed. 1 Liter, and 1 u PRBC. BP 80's HR 120's. unknown
UO. Mentation, speaking with son. EKG
.
After family meeting in [**Hospital Ward Name 332**] MICU today it was decided that
she and the family would not want aggressive measures including
excessive medications, endoscopy, lines, or surgery. Pt.
transferred to floor with goals of care CMO.
Past Medical History:
1. Colon Polyps - s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**10-26**]
--Sigmoid polyp, (biopsy): Adenoma.
--Grade 1 internal hemorrhoids.
--Diverticulosis of the entire colon.
2. Diverticulosis
3. Type 2 DM
4. S/P CVA - on coumadin
5. Tachybrady s/p pacer (EF >55%, [**11-24**]+ MR, 1+TR, mod pulm HTN -
[**5-26**])
6. Glaucoma
7. Cataracts
8. OSA
9. Anemia-source thought to be genitourinary
Social History:
The patient lives alone. She has a caretaker overnight and goes
to daycare during the day. She walks with a cane. She does not
have a history of alcohol/tobacco use.
Family History:
Unknown if GI malignancy, no CAD/DM
Physical Exam:
Physical Exam:
Deferred exam as pt. resting comfortably CMO, many family
members at her bedside
Pertinent Results:
[**2111-5-16**] 11:04PM WBC-24.1* RBC-4.06*# HGB-11.2*# HCT-32.9*
MCV-81* MCH-27.4# MCHC-33.9# RDW-19.6*
[**2111-5-16**] 11:04PM PLT SMR-LOW PLT COUNT-82*
[**2111-5-16**] 05:12PM POTASSIUM-5.0
[**2111-5-16**] 05:12PM CALCIUM-7.9*
[**2111-5-16**] 05:12PM HCT-31.4*
[**2111-5-16**] 05:12PM PT-16.9* PTT-31.4 INR(PT)-1.6*
[**2111-5-16**] 12:54PM LACTATE-4.0*
[**2111-5-16**] 06:20AM GLUCOSE-339* UREA N-57* CREAT-1.3* SODIUM-134
POTASSIUM-6.1* CHLORIDE-100 TOTAL CO2-20* ANION GAP-20
[**2111-5-16**] 06:20AM ALT(SGPT)-45* AST(SGOT)-75* ALK PHOS-402*
AMYLASE-20 TOT BILI-1.5
[**2111-5-16**] 06:20AM LIPASE-5
[**2111-5-16**] 06:20AM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-2.5*
MAGNESIUM-3.2*
Brief Hospital Course:
# GIB: likely lower either from diverticular bleed or colonic
polyp
-initially transfused to support hct and BP, but family decided
they did not want lines/pressors/endoscopy/surgery so pt. was
made CMO in the [**Hospital Unit Name 153**].
-plan for CMO per family meeting in [**Name (NI) 153**], pt. deceased [**5-17**] with
family at bedside
.
# Hypotension: In setting of GIB. CMO
-no further vitals
.
#Zoster: Morphine IV gtt to control pain
.
#Pulm edema: scopolamine patch prn
-can add additional patches prn
.
# Biliary CA: CMO, goals discussed with family at bedside
-morphine gtt to control pain
-scopolamine patch
-Palliative care consult in am
*
*Pain: Morphine gtt prn
-Palliative care consult
.
*FEN: NPO, mouth care and swabs prn
*Access: Fem line:
.
*Code Status: DNR/DNI and full CMO, no further
transfusions/blood draws, control pain with morphine
.
Communication: multiple family members at bedside, no formal
HCP, but in event of death contact son, [**Name (NI) **] [**Name (NI) **], at
[**Telephone/Fax (1) 36520**] (cell), or [**Last Name (LF) 36521**], [**First Name8 (NamePattern2) 36522**] [**Known lastname **], at [**Telephone/Fax (1) 36523**]
(cell)
Medications on Admission:
Lopressor 25mg po BID
Colace 100mg po BID
ASA 81mg po qd
MOM
[**Name (NI) 36524**] 15mg [**Name2 (NI) **] qd
RISS
Gabapentin 300mg TID
Off Coumadin x 10days.
Discharge Medications:
deceased
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Lower Gastrointestinal Bleed
Herpes Zoster Rash
Metastatic Adenocarcinoma
Congestive Heart Failure
Discharge Condition:
deceased
Discharge Instructions:
patient deceased, family made patient comfort measures only
Followup Instructions:
patient deceased, family made patient comfort measures only
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"V45.01",
"197.7",
"199.1",
"427.31",
"250.00",
"053.9",
"428.0",
"197.0",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4114, 4187
|
2693, 3873
|
268, 274
|
4329, 4339
|
1963, 2670
|
4447, 4635
|
1795, 1832
|
4081, 4091
|
4208, 4308
|
3899, 4058
|
4363, 4424
|
1862, 1944
|
223, 230
|
302, 1154
|
1176, 1595
|
1611, 1779
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,260
| 116,126
|
6381
|
Discharge summary
|
report
|
Admission Date: [**2198-11-22**] Discharge Date: [**2198-11-27**]
Date of Birth: [**2124-8-28**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Compazine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
hypoxia / hypotension.
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
74 F with EtOH cirrhosis who presents from rehab with hypoxia
and hypotension. Pt recently dc'd from [**Hospital1 18**] on [**11-15**] after
hospitalization for ARF (creatinine incrased to 4.8), VRE UTI,
and cellulitis. During that admission she was diagnosed with
pulmonary hypertension. The work up was unrevealing for
etiology. She was started on diltiazem on discharge empirically
per pulmonary consult for her pulmonary hypertension. Pt denies
any SOB, DOE, cough, F/C, dysuria, frequency. Pt feels well. She
does report some ? increased diarrhea with lactulose for which
the dose of her lactulose was halved recently. In [**Name (NI) **], pt
bradycardic to 30s. Noted to be hypotensive to 50s. Pt
resuscitated without effect with 3L NS. Throughout time in ED,
she was mentating and making urine. Pt also given Levoquin for
+UA.
Past Medical History:
1. Alcoholic cirrhosis with portal HTN, esophageal varices
(grade 1) and hepatic encephalopathy
2. a-fib. not anticoagulated
3. s/p meningitis with epidural abscess
4. BCC s/p MOHS excision
5. pseudogout
6. VRE UTI
7. Lower extremity edema
8. CRI, baseline cr 1.5-1.9 until recent admit [**10-24**]
9. Anemia of Chronic Inflammation
10. Chronic Thrombocytopenia
11. Pulmonary HTN / RV dysfunction
Social History:
Pt lived with her daughter in [**Name (NI) **]. She has not had alcohol
in [**3-23**] years. She continues to smoke [**1-21**] ppd.
Family History:
CAD, Hyperlipidemia
Physical Exam:
VS T 95. HR 47 BP 80/30s RR 22 O2 92% 2L
Gen: elderly F arousable. oriented x 3.
HEENT: PERRL. mild scleral and sublingual icterus. MM dry.
tongue midline. facial mm symmetic.
Neck: flat neck veins
CV: bradycardic. 2/6 sem with loss of S2 at apex
Lungs: + crackles focally in LLL. + decreased BS at bases
Abd: active BS. soft. NT. no masses. liver span 10 cm. no caput
Extr: 2+ pitting edema to knees b/l. DP 2+. feet warm. no palmar
erythema. no asterixis. + slight tremor.
Neuro: MAE.
Pertinent Results:
CXR: + increased interstitial markings. loss of L costaphrenic
angle. unchanged from [**2198-11-13**].
.
CXR ([**2198-11-26**]): An endotracheal tube has been withdrawn in the
interval and now terminates approximately 2 cm above the carina
with the neck in a flexed position. A left subclavian vascular
catheter remains in satisfactory position. Cardiac silhouette is
mildly enlarged. Previously reported minimal pulmonary edema has
resolved in the interval. Bilateral pleural effusions are again
demonstrated with improvement on the right and no significant
change on the left. Gastric distension appears decreased in the
interval with mild-to-moderate distention remaining.
.
EKG: nl axis. nl intervals. sinus brady. ST segment depression
in I, AVL unchanged from old EKG.
.
Renal U/S: The right kidney measures 9.8 cm, and the left kidney
measures 9.2 cm. There is no hydronephrosis. Nonobstructing
stones are present in both kidneys. There is an 11-mm stone in
the lower pole of the right kidney, which was previously seen on
[**2198-11-3**]. There is a 4-mm stone in the upper pole of the
left kidney. The bladder is decompressed by a Foley catheter. No
hydronephrosis. Bilateral nonobstructing renal stones.
.
echo ([**11-13**]): 1. The left atrium is mildly dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. 2. Left ventricular
wall thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal. 3.
The right ventricular cavity is dilated. Right ventricular
systolic function appears depressed. 4. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen.
5. Moderate [2+] tricuspid regurgitation is seen. 6. Compared
with the findings of the prior study of [**2198-11-5**], there has been
no significant change.
.
echo ([**2198-11-26**]): The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Left ventricular systolic function is hyperdynamic (EF>75%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated. Right ventricular
systolic function is normal. The aortic root 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. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is severe pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. The main pulmonary
artery is dilated. There is a trivial pericardial effusion.
There are no echocardiographic signs of tamponade.
Brief Hospital Course:
Mrs [**Known lastname **] initially presented with hypotension and bradycardia
in the setting of chronic liver failure and acute on chronic
renal failure. The presenting symptoms of hypotension and
bradycardia were due to nodal toxicity caused by recently
started dilitazem plus chronic nadolol, worsened by renal
failure. While she initially responded to treatment for beta
blocker toxicity, her hypotension was persistent, and
attributable to chronic vasodilatation with liver failure, and
severe right heart failure and low left ventricle filling in
context of severe pulmonary hypertension. Her chronic renal
failure worsened, and the consulting renal team agreed with the
assessment that her renal failure was due to a combination of
hepato-renal syndrome and pre-renal azotemia in the context of
her low flow state. No hemodialysis was pursed for the
worsening acidemia because of her hemodynamic instability.
Compounding her renal and liver failure, she developed
progressive respiratory distress and hypoxemia, for which she
was intubated and placed on assist control mechanical
ventilation. Patient was confirmed to be DNR in conversation
with her daughter, and after being apprised of the poor
prognosis given multi-organ system failure, her daughter elected
for terminal extubation. The patient was placed on a morphine
drip, extubated, and, after several hours with family and
friends, she died peacefully with her family and friends
present.
Medications on Admission:
Diltiazem 120 mg QD
Nadolol 20 mg po BID
Lactulose 15 cc TID
Phytonadione 5 mg po QD
Protonix 40 mg Q am
Ursodiol 600 mg Q AM and 300 mg Q pm
Linezolid (not on rehab record though pt just dc'd [**2198-11-15**])x 7
d. last day [**2198-11-21**]
Discharge Disposition:
Expired
Discharge Diagnosis:
Cirrhosis with portal hypertension and hepatic encephalopathy
renal failure
severe pulmonary hypertension
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2198-11-28**]
|
[
"427.89",
"584.9",
"572.3",
"682.6",
"572.4",
"572.2",
"276.2",
"571.2",
"428.0",
"585.6",
"416.8",
"592.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"00.11",
"00.14",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6909, 6918
|
5154, 6616
|
324, 331
|
7067, 7076
|
2325, 5131
|
7129, 7165
|
1782, 1803
|
6939, 7046
|
6642, 6886
|
7100, 7106
|
1818, 2306
|
262, 286
|
359, 1196
|
1218, 1616
|
1632, 1766
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,752
| 174,058
|
36093
|
Discharge summary
|
report
|
Admission Date: [**2152-12-6**] Discharge Date: [**2152-12-14**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
painless jaundice
Major Surgical or Invasive Procedure:
[**2152-12-6**]:
1. Exploratory laparotomy with primary duodenorrhaphy.
2. Palliative gastrojejunostomy.
3. Wedge liver biopsy--metastatic disease suspected.
4. Cholecystojejunostomy biliary bypass.
5. Omental flap closure duodenal perforation.
History of Present Illness:
Mrs. [**Known lastname **] is an 84-year-old woman who has apparent metastatic
breast cancer to the bone and perhaps the abdomen who has
developed full malignant obstructive jaundice. Dr. [**Last Name (STitle) **]
attempted to resolve this as minimally invasively as possible by
endoscopic means to provide her palliation. Unfortunately,
during that procedure an apparent duodenal perforation occurred
in the tenuous duodenal tissue and was immediately recognized.
She was then brought emergently to the operating room for the
procedures listed below.
Past Medical History:
Breast CA (mets to liver, bone, lungs), hiatal hernia
Physical Exam:
Exam on discharge:
Gen: AOx3, NAD, cooperative, engaging, responsive
HEENT: no LAD, no aparrent jaundice, no evidence for thyromegaly
CV: no overt m/r/g, regular rate
Pulm: CTAB
Abd: soft, incision is c/d/i,
Ext: normal strength, sensation
Pertinent Results:
[**2152-12-11**] 05:20AM BLOOD WBC-7.7 RBC-3.22* Hgb-8.7* Hct-27.3*
MCV-85 MCH-27.1 MCHC-32.0 RDW-17.7* Plt Ct-356
[**2152-12-10**] 04:40AM BLOOD WBC-9.4 RBC-3.20* Hgb-8.8* Hct-27.4*
MCV-86 MCH-27.6 MCHC-32.2 RDW-18.0* Plt Ct-342
[**2152-12-6**] 09:37PM BLOOD WBC-11.8* RBC-4.02* Hgb-11.2* Hct-34.9*
MCV-87 MCH-27.9 MCHC-32.2 RDW-17.0* Plt Ct-316
[**2152-12-7**] 02:54AM BLOOD WBC-13.7* RBC-3.63* Hgb-9.9* Hct-31.2*
MCV-86 MCH-27.2 MCHC-31.7 RDW-17.5* Plt Ct-305
[**2152-12-6**] 07:15PM BLOOD PT-15.2* PTT-78.5* INR(PT)-1.3*
[**2152-12-6**] 07:15PM BLOOD Plt Ct-219
[**2152-12-9**] 02:29AM BLOOD PT-12.4 PTT-31.3 INR(PT)-1.1
[**2152-12-11**] 05:20AM BLOOD Plt Ct-356
[**2152-12-6**] 09:37PM BLOOD Glucose-153* UreaN-6 Creat-0.6 Na-136
K-3.9 Cl-104 HCO3-24 AnGap-12
[**2152-12-13**] 03:51AM BLOOD Glucose-116* UreaN-5* Creat-0.6 Na-137
K-4.0 Cl-107 HCO3-24 AnGap-10
[**2152-12-7**] 02:54AM BLOOD ALT-146* AST-133* AlkPhos-331* Amylase-43
TotBili-9.8* DirBili-7.8* IndBili-2.0
[**2152-12-13**] 03:51AM BLOOD ALT-61* AST-51* AlkPhos-231* TotBili-2.8*
[**2152-12-7**] 02:54AM BLOOD Albumin-2.4* Calcium-7.3* Phos-3.0
Mg-2.7*
[**2152-12-13**] 03:51AM BLOOD Calcium-7.0* Phos-2.4* Mg-2.0
[**2152-12-11**] 05:20AM BLOOD Lipase-93*
________________________________________________________________
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) 251**] P.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) 251**] on WED [**2152-12-13**] 10:57
AM
Name: [**Known lastname 279**], [**Known firstname **] I Unit No: [**Numeric Identifier 81871**]
Service: [**Last Name (un) **] Date: [**2152-12-6**]
Surgeon: [**Name6 (MD) **] [**Last Name (NamePattern4) 7542**], MD 2365
FIRST SURGICAL ASSISTANT: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
PREOPERATIVE DIAGNOSIS:
1. Endoscopy-related duodenal perforation.
2. Peritonitis.
3. Metastatic breast cancer.
4. Malignant obstructive jaundice.
POSTOPERATIVE DIAGNOSIS:
1. Endoscopy-related duodenal perforation.
2. Peritonitis.
3. Metastatic breast cancer.
4. Malignant obstructive jaundice.
OPERATIVE PROCEDURE:
1. Exploratory laparotomy with primary duodenorrhaphy.
2. Palliative gastrojejunostomy.
3. Wedge liver biopsy--metastatic disease suspected.
4. Cholecystojejunostomy biliary bypass.
5. Omental flap closure duodenal perforation.
ANESTHESIA: General endotracheal.
SPONGE AND NEEDLE COUNTS: Correct.
ESTIMATED BLOOD LOSS: 500 cc.
INDICATIONS FOR OPERATION: Mrs. [**Known lastname **] is an 84-year-old
woman who has apparent metastatic breast cancer to the bone
and perhaps the abdomen who has developed full malignant
obstructive jaundice. Dr. [**Last Name (STitle) **] attempted to resolve this
as minimally invasively as possible by endoscopic means to
provide her palliation. Unfortunately, during that procedure
an apparent duodenal perforation occurred in the tenuous
duodenal tissue and was immediately recognized. Dr. [**Last Name (STitle) **]
noticed and identified this and immediately called me hoping
for operative treatment. Prior to the operation, Dr. [**First Name (STitle) **],
my chief resident on my behalf, as I became available, spoke
by telephone with the patient's son in [**Name (NI) 21380**] who provided
informed consent for us to proceed. This was an emergency
operation in a very high risk patient with malignant
obstructive jaundice, probably very poor nutrition and would
have high risk but was absolutely necessary that we proceed
given that she had a free intestinal perforation in her
abdomen.
OPERATIVE PROCEDURE: Following satisfactory induction of
general endotracheal anesthesia, the abdomen was widely
prepped with Betadine and sterile drapes were placed. After a
suitable team time out, identifying the patient and the
planned operative procedure, we entered the abdomen through
an upper midline incision. There was not really a lot of
soilage in the upper abdomen, although there was some free-
fluid which was cultured. We explored the upper abdomen and
specifically went over the duodenum where we found a 1.3 cm
fresh perforation just about the size of an endoscope
actually in the anterolateral aspect of the second portion of
the duodenum. It was leaking bile and enteric fluid. This was
all aspirated around and cleared up with irrigation. I now
went ahead and explored this area more to find sclerotic,
most likely tumor metastasis in and around the duodenum and
the head of the pancreas which were not biopsied at this
location.
I used two techniques to close the duodenal perforation.
First, a primary duodenorrhaphy was provided well by multiple
interrupted 3-0 silk sutures, reapproximating full closure of
the duodenal perforation. This combined with the degree of
constriction of the duodenum would measurably decrease
luminal patency and so she would need something more because
of a partial gastric outlet obstruction. This will follow in
the description of the gastrojejunostomy. The second approach
was mobilizing omentum at the superior aspect of the
transverse colon and then bringing this up such that it
overlay on top of the duodenorrhaphy, at which point it was
sutured down for additional sealing effect.
We next excised with a wedge liver biopsy a lesion near the
gallbladder bed which was almost certainly a metastasis. This
was for staging and documentation of lymphatic metastatic
disease. This bled terribly unfortunately, probably requiring
200-300 cc blood loss before I could finally get this
bleeding stopped with high-voltage cautery and mattress
sutures of chromic. A small amount of bile was leaking from
this small 1 cm peripheral wedge biopsy site. A drain would
subsequently be placed over this. It seemed to settle down as
the operation continued.
We next performed a palliative gastrojejunostomy. The greater
curvature of the stomach was cleaned off of some of the blood
vessels in the dependent location. The jejunum 20 cm distal
to the ligament of Treitz was brought up in a retrocolic
manner and a side-to-side stapled gastrojejunostomy
anastomosis constructed smoothly. It was secured at the end
with silk sutures to protect the staple line. The mesentery
of the transverse mesocolon was sutured around it to prevent
internal hernia. The final procedure now was to establish
biliary bypass of some degree for palliation. She had a
distended Courvoisier gallbladder and so I thought that this
would be a suitable and safe conduit for extrahepatic biliary
ductal bypass. About 50 cm below the gastrojejunostomy I
brought up a lazy loop of jejunum to the fundus of the
gallbladder where a two-layer hand-sewn silk and Vicryl side-
to-side cholecystojejunostomy anastomosis of 1 cm wide
patency was achieved. This would provide a decompressive
route for her obstructive biliary system.
The patient was generally stable during the operation,
although she did suffer 500 cc of blood loss but not any
significant hemodynamic trouble. She was profoundly icteric
at the beginning of the operation without preoperative labs
but I would estimate her bilirubin was at least 11 or 12.
This, I am sure, affected her blood clotting capabilities. We
now irrigated and washed out the upper abdomen and then
placed a 19 French [**Doctor Last Name 406**] drain up in the right upper quadrant
near the liver biopsy site and the cholecystojejunostomy
anastomosis and the duodenorrhaphy to drain those three
perilous areas.
So in this emergency operation I was able to control the
duodenal perforation itself but also, I hope, provide some
effective palliation for her should she recover from this
emergency aggressive but necessary operation. She was taken
to the intensive care unit in guarded condition. As her
attending operating surgeon, I was present for her entire
operation and I performed all of its components.
[**Name6 (MD) **] [**Last Name (NamePattern4) 7542**], [**MD Number(1) 7543**]
_
________________________________________________________________
Pathology
DIAGNOSIS:
Liver, wedge biopsy:
Metastatic poorly-differentiated adenocarcinoma consistent with
breast origin, see note.
Note: The tumor cells are positive for cytokeratin 7 and
estrogen receptor and focally positive for gross cystic disease
fluid protein. The cells are negative for cytokeratin 20 and
mammaglobin. The histologic features and immunophenotype are
consistent with a breast origin.
Brief Hospital Course:
[**2152-12-6**]: The patient had second ERCP attempted at [**Hospital1 18**] (first
was [**12-5**] at OSH) which was complicated by duodenal perforation
with a CT showing free peritoneal air. The patient was brought
to the ICU and subsequently transferred to the operating room
for emergent repair. postoperatively she was brought to the ICU
for monitoring still intubated. She was started on Unasyn
immediately.
[**12-7**]: patient was transferred to the [**Hospital Ward Name **] for more
definitive management in the T/SICU. She required 3L of NS
boluses for hypotension and low UOP
[**12-8**]: the patient was extubated and stable with normal UOP and
normal pressures
[**12-9**]: she was transferred from the unit to the floor
[**12-10**]: NGT discontinued, stable and minimal complaints
[**12-12**]: slight nausea, self regulating on clears
[**12-13**]: tolerating normal diet, JP discontinued, clear to d/c
home by PT with home PT
[**12-14**]: small stitch applied to JP drain site for drainage;
stopped Unasyn, afebrile
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Pancreatic duct stricture, endoscopy related duodenal
perforation, peritonitis, malignant obstructive jaundice,
metastatic breast cancer
Discharge Condition:
Stable
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**11-8**] lbs) until your follow up appointment.
Followup Instructions:
Please call Dr.[**Name (NI) 9886**] office to schedule a follow up
appointment for 2-3 weeks. ([**Telephone/Fax (1) 14347**]
Completed by:[**2152-12-14**]
|
[
"280.0",
"458.29",
"576.2",
"174.9",
"518.5",
"E870.4",
"197.0",
"198.5",
"567.81",
"553.3",
"998.2",
"197.8",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.32",
"96.04",
"50.12",
"96.71",
"44.39",
"46.71"
] |
icd9pcs
|
[
[
[]
]
] |
11533, 11582
|
9914, 10942
|
279, 526
|
11763, 11772
|
1460, 9891
|
13499, 13656
|
10965, 11510
|
11603, 11742
|
11796, 11796
|
11812, 13476
|
1199, 1199
|
222, 241
|
554, 1107
|
1219, 1441
|
1129, 1184
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,919
| 128,315
|
13051
|
Discharge summary
|
report
|
Admission Date: [**2163-8-17**] Discharge Date: [**2163-9-1**]
Date of Birth: [**2080-8-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Trachael Tumor
Major Surgical or Invasive Procedure:
[**2163-8-17**] Cervical tracheal resection and reconstruction,
sternothyroid muscle flap, flexible bronchoscopy.
[**2163-8-25**] Flexible Bronchoscopy
History of Present Illness:
Mr. [**Known lastname **] is an 83-year-old gentleman who has had dyspnea and
was found to have a proximal posterior tracheal tumor. The
pathology was consistent with an endocrine neoplasm, potentially
related to his resected thyroid cancer from over 20 years ago.
He has been admitted for pharyngeallaryngectomy with gastric
pull-up and esophagectomy. He agreed to proceed.
Past Medical History:
Thyroid mass "precancerous growth" s/p resection w/resulting
Hypothyroidism
Hypertension
Hyperlipidemia
Early dementia
Gait abnormality
Spinal stenosis (receives "injections for back pain")
BPH
history of anxiety
Benign abd tumor in small intensine that burst causing massive
hematemsis s/p resection ([**2147**], done at [**Hospital1 18**])
s/p appendectomy
Social History:
Married with children, lives w/wife, able to walk
around house, +hx smoking (remote, quit >20 years ago), no EtOH
at present (drank while in the service), WWII Veteran (flew
planes in Europe)
Family History:
unknown
Physical Exam:
VS: temp 96.4, BP 106/60, HR 80, RR 20
PE: gen: pt is laying in hospital bed with NAD
Lungs: clear t/o to auscultation.
CV: RRR S1, S2, no M/R/G.
Abd: soft, NT, NT, active BS x 4 quad PED tube sutured intact.
Ext: warm, left arm 2+ edema, otherwise no edema
Neuro: Alert and oriented x 1, MAE to command. PERRLA
Pertinent Results:
[**2163-9-1**] WBC-3.8* RBC-3.04* Hgb-10.3* Hct-29.9* Plt Ct-313
[**2163-9-1**] Glucose-110* UreaN-11 Creat-1.1 Na-138 K-3.5 Cl-102
HCO3-26
[**2163-9-1**] Calcium-9.2 Phos-2.9 Mg-2.209/30/09 WBC-5.8# RBC-3.10*
Hgb-10.0*
[**2163-8-18**] calTIBC-273 Ferritn-404* TRF-210
[**2163-8-28**] Video Swallow: FINDINGS: A swallowing video fluoroscopy
study was done in conjunction with the speech pathology service.
Varying consistencies of oral barium were administered. Moderate
penetration and aspiration was noted with both thin and nectar
thick liquids. This was lessened somewhat with a chin tuck
maneuver though still present. The patient did not respond well
to cues for cough, and a delayed spontaneous cough was
inadequate for clearing this aspiration.
IMPRESSION: Penetration and aspiration of thin and thick liquids
as above
[**2163-8-22**] Chest CT
IMPRESSION:
1. No pulmonary embolism, aortic dissection or aneurysm.
2. Post-surgical changes in the upper trachea is noted with
extensive
subcutaneous soft tissue with small pockets of air. Marked
expiratory
collapsibility of the tracheobronchial tree is consistent
significant
tracheobronchomalacia which is causing air trapping particularly
throughout the right lung.
3. Coronary artery calcification is moderate in the left
anterior descending and circumflex artery.
4. Sub 2-mm left upper lobe pulmonary nodules are unchanged to
[**2163-4-25**]
CXR:
[**2163-8-24**] Since the previous study the subcutaneous edema in the
neck has
reduced, the lungs are fully expanded and clear with the
exception of minor atelectasis in the left lower lobe. No
consolidation, pleural effusion or pneumothorax, the left
costophrenic angle has not been included on this study.
Cardiomediastinal silhouette is unchanged with degenerative
change in the thoracic spine.
[**2163-8-21**] Focal tracheal narrowing at the thoracic inlet may be
due to recent surgery. Cardiomediastinal contours are normal in
appearance. Minimal linear foci of atelectasis are present at
the left base with otherwise clear lungs.
[**2163-8-17**] There is no evidence of pneumothorax, minimal left
basal
atelectasis. No evidence of other focal parenchymal opacities.
[**2163-8-31**] UA positive.
[**2163-8-31**] Ucx pending
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2163-8-17**] for Cervical tracheal
resection and reconstruction, sternothyroid muscle flap,
flexible bronchoscopy. He tolerated the procedure and was
admitted to the SICU.
Respiratory: Successfully Extubated POD1. Aggressive pulmonary
toilet,nebs, mucolytics, humidification were administered. He
had mild stridor immediately postoperative and Heliox was
administered. He weaned off the Heliox once the stridor
resolved. He transferred to the floor on [**2163-8-21**]. On [**2163-8-22**]
he developed respiratory distress requiring nasal-oropharyngeal
suction. He transferred back to the SICU in stable condition.
PE CT was negative. His oxygenation improved. On [**2163-8-25**] he
had Flexible Bronchoscopy which showed normal anastomosis with
diffuse inflammation of the trachea.
He was followed by serial chest films which showed improved
subcutaneous emphysema of the neck and lower lobe atelectasis.
ENT: Guardian suture remained in place until POD7 then was
removed. The neck drain was removed on POD2. ENT followed him
closely with multiple scoping to assess vocal cords and
anastomosis. Medialization of the left vocal cord was seen.
Cardiac: Hemodynamically stable in sinus rhythm.
GI: He was seen by speech & swallow multiple times. A
video-swallow revealed loss of his recurrent laryngeal nerve
during surgery. Pharyngeal contraction was absent on the
right-side,significantly reducing patient's ability to clear any
bolus, and
resulting in severe pharyngeal residue ultimating leading to
aspiration. A PEG was done [**2163-8-30**]. fibersource tube feeds
were started on [**2163-8-30**] at 15cmL an hour advancing up to 10
ML/hr as tolerates to goal of 75 ml/hr continuous. The patient
has tolerated TF thus far. Potassium on [**2163-8-31**] was repleted.
ID: He remained afebrile throughout. Baseline Leukopenia WBC
3.0. UA positive [**2163-8-31**] started on Ciproflox 10 day course.
Please repeat UA after UA completed.
GU: Urinary retention requiring re-insertion of foley [**2163-8-30**].
Failed Foley trial [**8-31**], re-inserted for 650 urinary retention.
Flomax given. Please repeat foley trial.
Neuro: Geriatric was consulted and followed him for mild
dementia. He was easily re-oriented. His ativan was slowly
titrated to off. Seroqueal was given with good results. His
electrolytes were repleted as needed.
Disposition: he was followed by physical therapy who recommended
rehab. Discharged to [**Hospital **] rehab. He will follow-up with
Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
lopressor 50 mg [**Hospital1 **], fexofenadine 60 mg [**Hospital1 **], Levothyroxine 100
mcg daily
Lorazepam 0.5 mg [**Hospital1 **], Procardia 30 mg daily, Paroxetine 12.5 mg
daily
Discharge Medications:
1. Levothyroxine 100 mcg Tablet [**Hospital1 **]: One (1) Tablet PO once 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. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice
a day: hold if SBP <100, HR <60.
5. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for sleep/anxiety: [**Month (only) 116**] repeat x 1 if
needed.
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Month (only) **]: One (1)
Capsule, Sust. Release 24 hr PO at bedtime: may take crushed
with applesauce.
7. Ciprofloxacin 500 mg Tablet [**Month (only) **]: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**]
Discharge Diagnosis:
Recurrent Thyroid Cancer
Trachael Tumor
Hypertension/Hyperlipidemia
Early Dementia
BPH
Spinal Stenosis
Gait Abnormality
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-PEG tube falls out or site becomes red, purulent or drainage.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on Tuesday [**2163-9-13**] 1:30pm on
[**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **]. Please get a chest xray 45
minutes prior to appointment on the [**Location (un) **]. Call if questions
[**Telephone/Fax (1) 2348**]
Please follow up with Dr. [**Last Name (STitle) 1837**] as an outpatient you can
reach his office at ([**Telephone/Fax (1) 6213**]. You should see him in [**11-26**]
weeks. We have left a message witht the office to try and
arrange for same day follow up as Ganghadaran, however this is
not secured. Please follow up.
Completed by:[**2163-11-30**]
|
[
"263.9",
"293.0",
"519.19",
"198.89",
"272.4",
"401.9",
"600.00",
"294.8",
"478.33",
"599.0",
"518.82",
"197.3",
"288.50",
"V10.87",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"33.23",
"83.82",
"31.79",
"31.5",
"43.11"
] |
icd9pcs
|
[
[
[]
]
] |
7882, 7929
|
4130, 6714
|
334, 488
|
8093, 8109
|
1860, 4107
|
8383, 9027
|
1502, 1512
|
6947, 7859
|
7950, 8072
|
6740, 6924
|
8133, 8360
|
1527, 1841
|
280, 296
|
516, 893
|
915, 1276
|
1292, 1486
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,098
| 189,272
|
2741
|
Discharge summary
|
report
|
Admission Date: [**2193-10-4**] Discharge Date: [**2193-10-16**]
Date of Birth: [**2132-1-9**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Morphine Sulfate / Heparin Agents
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Ulcerative Colitis
Major Surgical or Invasive Procedure:
Paracentesis [**2193-10-8**]
Flexible sigmoidoscopy [**2193-10-9**]
Left subclavian central Line [**2193-10-12**]
Peripherally inserted central venous catheter [**2193-10-14**]
History of Present Illness:
This is a 61 y/o woman with PMH notable for ulcerative colitis
and PBC admitted to [**Hospital3 3583**] on [**9-30**] with hypokalemia.
Patient was contact[**Name (NI) **] by GI fellow here at [**Hospital1 18**] for K of 2.5 on
[**9-30**]. She then went to [**Hospital3 3583**] for K repletion and
further treatment of her IBD. Please see d/c summary from most
recent hospitalization for course of IBD. Patient reports she
was taking her prednisone taper as directed, currently on 20 mg
daily prior to admission. At [**Hospital1 46**], she was treated with iv
ciprofloxacin, iv hydrocortisone, mesalamine, and hydrocort
enemas with minimal improvement. As her primary GI/Hepatology
providers are here at [**Hospital1 **], she is transferred for further
treatment/evaluation. She was transfused 2 U prbcs this
tuesday/wednesday per patient.
On arrival to the floor, the patient denies abdominal pain.
Reports bloody diarrhea after eating anything.
ROS: Reports no fevers, chills, rigors. Able to tolerate low
residue diet today at other hospital without vomiting. No
nausea. No headaches, dizziness, chest pain, difficulty
breathing, dysuria, leg swelling
Past Medical History:
1. Ulcerative Colitis
- Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]
- Last sigmoidoscopy [**10/2193**] without dysplasia
- Recent flares refractory to steroids, currently on Remicade
2. Primary biliary cirrhosis
- Diagnosed 10 yrs ago
- Complicated by ascites, occasional hepatic encephalopathy,
variceal bleed
- Last EGD [**4-/2193**] without varices
Social History:
The patient is married, lives in [**Location 3320**] with her husband. She
is currently employed for Ocean Spray.
Tobacco: None
ETOH: None
Illicits: None
Family History:
Father: UC, alive age [**Age over 90 **]
Mother: [**Name (NI) **] IBD, + ovarian Cancer
Physical Exam:
VS T98.1 HR 102 BP 113/75 RR 16 Sat 95% on RA
Gen: thin woman in NAD, lying in bed
HEENT: PERRL, EOMI, sclerae anicteric, MMM
Neck: supple, no lad
CV: tachy but regular, no murmur
Resp: CTAB no R/R/W
Abd: soft, NT, ND, + bowel sounds, no rebound, no gaurding
Extrem: no c/c, 2+ pitting edema
Skin: no rashes or lesions
Neuro: A&O x3, speech clear, face symmetric, moving all
extremities without difficulty
Pertinent Results:
Admission blood work:
[**2193-10-11**] 05:00AM BLOOD WBC-14.4* RBC-3.11* Hgb-9.6* Hct-28.3*
MCV-91 MCH-31.0 MCHC-34.0 RDW-16.6* Plt Ct-189
[**2193-10-7**] 04:50AM BLOOD WBC-9.2 RBC-2.52* Hgb-7.8* Hct-23.1*
MCV-92 MCH-30.9 MCHC-33.6 RDW-16.6* Plt Ct-206
[**2193-10-11**] 05:00AM BLOOD PT-15.0* PTT-28.2 INR(PT)-1.3*
[**2193-10-11**] 05:00AM BLOOD Glucose-108* UreaN-17 Creat-0.6 Na-133
K-4.2 Cl-100 HCO3-27 AnGap-10
[**2193-10-5**] 12:30AM BLOOD ALT-172* AST-207* LD(LDH)-243
AlkPhos-767* TotBili-2.5*
[**2193-10-11**] 05:00AM BLOOD Calcium-8.4 Phos-1.8* Mg-2.1
Discharge blood work:
[**2193-10-16**] 06:26AM BLOOD WBC-9.9 RBC-3.38* Hgb-10.5* Hct-30.6*
MCV-91 MCH-31.2 MCHC-34.4 RDW-17.7* Plt Ct-92*
[**2193-10-16**] 06:26AM BLOOD Neuts-91.9* Bands-0 Lymphs-3.4* Monos-2.9
Eos-1.7 Baso-0.3
[**2193-10-16**] 06:26AM BLOOD PT-17.2* PTT-34.4 INR(PT)-1.6*
[**2193-10-16**] 06:26AM BLOOD Glucose-94 UreaN-16 Creat-0.6 Na-136
K-3.6 Cl-109* HCO3-22 AnGap-9
[**2193-10-15**] 05:46AM BLOOD ALT-82* AST-54* AlkPhos-414* TotBili-2.6*
[**2193-10-16**] 06:26AM BLOOD Albumin-1.7* Calcium-8.6 Phos-1.6* Mg-2.2
TEST RESULT
---- ------
HEPARIN DEPENDENT ANTIBODIES POSITIVE
Micro:
C.diff negative
Blood Cx: negative
[**10-16**] Lower ext doppler
IMPRESSION: No evidence of deep venous thrombosis in the lower
extremities.
[**10-6**] Abd U/S
IMPRESSION:
1. Cirrhosis with ascites.
2. Cholelithiasis with no evidence of cholecystitis.
3. Not possible to exclude non-occlusive portal vein thrombus,
although no occlusive thrombus is identified.
[**10-13**] Portable Abd X-ray
One portable view. Comparison with [**2193-10-12**]. Chronic dilatation
has improved and there is no longer evidence of bowel wall gas.
Mild thickening of colonic haustral folds and
edematous-appearing segments of small bowel are again noted.
IMPRESSION: Interval improvement in right colonic dilatation.
Results
discussed with covering house physician [**Last Name (NamePattern4) **] 9:10 a.m.
[**10-9**] Flex Sig
Findings:
Mucosa: Ulceration, granularity, friability, erythema and
congestion with contact bleeding were noted in the rectum,
sigmoid colon and descending colon. These findings are
compatible with ulcerative colitis.
Impression: Ulceration, granularity, friability, erythema and
congestion in the rectum, sigmoid colon and descending colon
compatible with ulcerative colitis
Otherwise normal sigmoidoscopy to 50cm
Recommendations: Bleeding most likely due to underlying UC. Have
Surgery (Dr [**Last Name (STitle) 13542**] or Dr [**Last Name (STitle) 13543**] see her before she leaves
the hospital. Continue steroids without taper. Infliximab
infusion as outpatient within 7 days. Follow up with Dr [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1940**] at time of the Infliximab infusion.
Brief Hospital Course:
1. Ulcerative colitis flare: The patient has recently had quite
refractory disease despite steroid treatment. She was
transferred from [**Hospital3 3583**] for further management of her
UC, her stool cultures at [**Hospital1 46**] were negative. She was
initially managed with IV methylprednisolone, Cipro, and
Mesalamine. She continued to have multiple bloody bowel
movements during her admission. She therefore, underwent a
flexible sigmoidoscopy that showed friable mucosa and ulceration
in the rectum, sigmoid colon and descending colon, these
findings were consistent with UC. She was followed closely by
GI during her admission. The patient was also seen by surgery,
but is a poor surgical candidate given her comorbidities. Due to
her continued symptoms she received an infusion of remicade on
[**10-10**]. She improved post-infusion with a decrease in her bloody
bowel movements and more formed stools. During her
hospitalization she received a total of 8U pRBC due to blood
loss. Her Hct remained stable for 72hrs prior to discharge. She
was discharged on 60mg prednisone, and flagyl to complete a
14-day course. She was also discharged on mesalamine. It should
be noted that she completed a 14-day course of Ciprofloxacin
while in house. She will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] as
an outpatient within one week.
2. Primary biliary cirrhosis: The patient was continued on
ursodiol and cholestyramine. She had symptomatic ascites and
had a therapeutic paracentesis which evacuated 2.5 L on [**10-8**].
The fluid was negative for SBP. On [**10-12**] the patient developed
hepatic encephalopathy and was treated with lactulose and
rifaximin. She was transferred to the ICU for close monitoring
and started on ceftriaxone (empirically for bacterial
peritonitis), flagyl and continued on cipro. It should be noted
that a repeat paracentesis was not performed. The patient's
mental status improved on the above therapy, and we elected to
complete an empiric 7-day course of cephalosporin (po
cefpodoxime at discharge). She had serial KUB in the ICU, which
showed improving colonic dilation. Therapy with lasix 40mg daily
and aldactone 100mg daily was also restarted prior to discharge.
The patient was followed by hepatology during her admission and
will f/u as an outpatient in 2 weeks.
3. Portal vein thrombosis: A review of her CT from [**Hospital1 46**] showed
a possible clot in her portal vein. An U/S performed at [**Hospital1 18**]
showed no evidence of clot. Hepatology was consulted and
recommended repeat CT-scan in 2 weeks. She was not a candidate
for anti-coagulation given her continued GI bleed. She will
follow-up with hepatology as an outpatient in 2 weeks.
4. Leukocytosis: The patient had an elevated white count of 24.8
on [**10-12**], up from 12.9 on admission. She was afebrile. She was
treated with broad spectrum antibiotics including ceftriaxone
for possible peritonitis, cipro and flagyl. At discharge, she
had completed 14 days of cipro. She was discharged on flagyl to
complete a 14 day course, and Cefpodoxime to complete a 7 day
course. Her leukocytosis resolved during her stay.
5. Thrombocytopenia / HIT: The patient's platelet count dropped
from 337 at admission to 92 at discharge. The etiology for the
thrombocytopenia was thought likely multifactorial, including
consumption, chronic liver disease and splenomegaly. The
patient also had similar decreases in her platelets on previous
admissions. However, given the patient's recent exposure to
heparin flushes for her PICC line (pt was not on subq heparin),
heparin dependent antibodies were sent (intermediate suspicion),
and surprisingly returned positive. A functional assay
unfortunately was not obtained, and it remains unclear whether
she truly had heparin-induced thrombocytopenia, since
alternative explanations were present for her thrombocytopenia.
Nonethelss, in the abscence of confirmatory data, we assumed the
test to be a true positive. Her ongoing GI bleed and limited
options for escalation of therapy represented contraindications
in our opinion to anticoagulation, and for this reason direct
thrombin inhibitor therapy was not initiated. We explained the
above to the patient, and reviewed her high-risk of thrombosis
despite discontinuation of heparin products should this truly be
HIT. She was informed of the signs and symptoms of
thromboembolic disease, and asked to return in the presence of
any of them. Bilateral LENIs prior to discharge were negative
for DVT.
6. Hypokalemia: The patient had a potassium level of 3.6 on
admission. She was repleted as necessary throughout her
admission.
Medications on Admission:
Meds at home:
prednisone 20 mg daily
vitamin D
asacol 1200 mg TID
protonix 40 mg daily
ursodiol 300 [**Hospital1 **]
caco3 500 mg tid
mvi daily
cholestyramine-sucrose 4 g [**Hospital1 **]
ferrous sulfate 325 mg daily
ambien prn
Meds on transfer:
cipro 400 mg IV q12h
hydrocortisone 100 mg iv q8h
mg chloride 64 mg [**Hospital1 **]
mesalamine 1200 mg po tid
hydrocortisone 10% pr qhs
reglan 5-10 mg q6h prn
compazine 5-10 mg iv q6h prn
lorazepam 0.5 mg po qhs prn
magaldrate 10 mL po four times daily prn
Discharge Medications:
1. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4)
Capsule, Sustained Release PO QID (4 times a day).
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
4. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*42 Tablet(s)* Refills:*0*
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. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): Take up to TID and titrate to 3 bowel movements a
day.
Disp:*2700 ML(s)* Refills:*2*
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 9 days.
Disp:*27 Tablet(s)* Refills:*0*
10. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: please
take if increasing ascites or lower ext edema.
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Lab work for CBC and Chem-7 to be done within the next 2-4 days.
Please forward results to:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Phone: [**Telephone/Fax (1) 13266**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. Ulcerative colitis exacerbation
2. Hypokalemia
3. Hepatic encephalopathy
4. Blood loss anemia secondary to lower GI bleed
5. Probable heparin-induced thrombocytopenia
6. Portal vein thrombosis
7. Primary biliary cirrhosis
8. Portal-hypertension related ascites
Discharge Condition:
Stable, normotensive, HR 90-110, satting well on room air, [**12-6**]
small bloody bowel movements/day, Hct stable
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital.
.
You were admitted to [**Hospital1 18**] for low levels of potassium in your
blood and for a flare of your ulcerative colitis. We gave you
additional potassium and your levels improved. While you were
here, you had many bloody bowel movements due to your colitis.
These caused your blood counts to drop. We monitored your blood
counts carefully, and gave you blood transfusions. You had a
procedure called a flexible sigmoidoscopy, where we took a thin
camera and looked at the bottom part of your colon and rectum.
This study showed that the walls of your lower colon and rectum
were very thin and bled easily. You were treated with steroids
for your colitis. Since you continued to bleed, you received an
infusion of Remicade, a medication that slows your body's immune
response and helps your body recover from the colitis flare.
.
A review of your recent CT scan from [**Hospital3 3583**] showed a
possible clot in a vein in your liver. We did an [**Hospital3 950**] of
your liver which did not show a clot. However, there is still
the possibility that a clot is there. You will be seen at Liver
Clinic to evaluate this clot. You should also have a CT-scan
prior to your appointment to evaluate, please call [**Telephone/Fax (1) 327**]
to schedule.
.
While you were here, you had a period of time where you were
confused and did not know where you were. This is called
hepatic encephalopathy and is related to your cirrhosis. We
gave you medication to help reverse this.
.
You had fluid in your abdomen called ascites that was due to
your liver cirrhosis. This caused you discomfort and we took
out the fluid by a procedure called a paracentesis. An analysis
of the fluid from this procedure showed no bacteria or signs of
infection.
.
You have been precribed lasix for your edema and ascites.
Please take if you begin to notice increasing edema and/or
ascites.
You were also prescribed lactulose to prevent confusion due to
your liver disease. You can take it up to 3 times a day until
you have 3 bowel movements a day.
.
*** You were found to have an allergey to HEPARIN. You should
NOT have any Heparin products in the future. This is a new
allergy for you. Having this allergy to heparin increases your
chances of having blood clots. We did an [**Telephone/Fax (1) 950**] of your
lower legs which did not show any blood clots. However, you are
still at increased risk for blood clots. If you experience
acute shortness of breath, chest pain, pain with breathing,
asymetric leg swelling or calf pain please call your PCP or go
to the ED. We will also give you a prescription to get your lab
work checked and should be forwarded to your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 10733**].
.
Please take all of your prescribed medications. Please keep all
of your outpatient appointments. Please call your doctor or come
to the hospital if you experience significant bleeding,
lightheadedness, chest pain, difficulty breathing, worsening
belly swelling, fevers,chills, nausea, vomiting, confusion or
any other concerning symptoms.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 13266**]
Please call your PCP and make an appointment to be seen by him
within [**12-5**] week of your discharge from the hospital
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2193-11-12**] 10:15
***Please call [**Telephone/Fax (1) 327**] to schedule a CT-scan prior to your
appointment at liver clinic (within 2 weeks of discharge).
.
Provider: [**Name Initial (NameIs) 703**] (C4) TCC [**Name Initial (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2193-11-13**] 8:00
.
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2193-12-16**] 4:15
Please call [**Location (un) 13544**] at Dr.[**Name (NI) 13540**] office at [**Telephone/Fax (1) 13545**] and
arrange to be seen within one week of your discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
Completed by:[**2193-10-20**]
|
[
"285.1",
"571.6",
"276.8",
"789.59",
"572.2",
"289.84",
"578.9",
"572.3",
"556.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"38.93",
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
12462, 12513
|
5700, 10378
|
324, 502
|
12821, 12938
|
2825, 5677
|
16131, 17275
|
2294, 2383
|
10934, 12439
|
12534, 12800
|
10404, 10633
|
12962, 16108
|
2398, 2806
|
266, 286
|
530, 1688
|
1710, 2106
|
2122, 2278
|
10651, 10911
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,341
| 175,630
|
2101
|
Discharge summary
|
report
|
Admission Date: [**2182-5-20**] Discharge Date: [**2182-5-31**]
Date of Birth: [**2115-6-19**] Sex: F
Service: MEDICINE
Allergies:
Iodine / Amiodarone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
dyspnea, hypoxia
Major Surgical or Invasive Procedure:
arterial line placement
PICC line placement
History of Present Illness:
Ms. [**Known lastname 11372**] is a 66 yo female with PMH of CAD, dCHF and chronic
dyspnea with minimal exertion, afib s/p AVJ ablation and pacer,
COPD, moderate to severe pulm HTN thought secondary to elevated
left atrial pressures and not intrinsic lung disease, possible
lupus pneumonitis vs cryptogenic organizing pneumonia (based on
pulmonologist note), and DM who is transferred from [**Hospital 11373**] for management of respiratory distress and hypoxia.
.
She presented to [**Location (un) **] on [**5-15**] two days after sudden shortness
of breath and DOE which she experienced while folding clothes.
She normally uses prn home oxygen, but had used it at all times
in the 2 days prior to presentation. She also had a HA, dysuria,
right LE edema. She denied CP, palpitations, LH, wheezing, upper
respiratory symptoms, hemoptysis. She reportedly appeared volume
overloaded on CXR. She was given a diagnosis of bronchitis. An
LE ultrasound in their ED was negative for ED and she was sent
home on inhalers. She had a chinese food meal that night. She
represented to their ED the next day after she awoke and felt
worse. The CXR at that point was oncerning for pna. A BNP was
483, later up to 1050. She was given 40mg of IV lasix and
admitted. She developed worsening SOB during her stay. A CT scan
was read as consistent with pneumonitis and on [**5-16**], she was
started on IV solumedrol. On [**5-18**], she received another 60mg IV
lasix. Other complications during her stay included ARF with Cr
up to 1.9, felt likely prerenal, and hyponatremia to 124 thought
[**1-29**] hypovolemia.
.
On [**5-19**], she had an episode of respiratory distress requiring
transfer to the ICU. At that time, notes report that she was
still felt to be fluid overloaded. She was on 2L of O2 upon
admission with sats in the low 90s. Starting on [**5-18**], she
consitently required 5-7L to sat around 90%.
.
Her pulmonologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], saw her at [**Location (un) **], was
concerned about inflammatory pneumonitis and initiated the
steroids. He feels that this is probably vascular pneumonitis
and less likely hypersensitivity pneumonitis. He reports that
she has had a negative [**Doctor First Name **], normal ANCA, ACE level borderline at
73, and negative hypersensitivity pneumointis panel. Her ESR has
been persistantly elevated.
.
She was given 2g CTX and 750mg of levofloxacin prior to
transfer.
.
7.47/31/61 on 6L [**5-18**]
7.49/22/59 on 6L
.
CK 37, trop 0.04 on [**5-18**]
.
An ECHO during her stay showed distal septal and apical
hypokinesis with EF of 40-50% and [**12-29**]+ MR, moderate to sever TR,
pulm HTN with pulm systolic pressure estimated at 50-60, and
right-sided pressure and volume overload.
.
.
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] (cardiology) recently prescribed Revatio on
[**2182-4-22**] to trial for her dCHF. She started in on [**2182-4-26**].
.
On the floor, she is tachypneic and fatigued appearing.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: MIDCAB with a LIMA to LAD which failed on the first day
and she had a median sternotomy the next day with a redo LIMA to
LAD with vein patch arterioplasty according to notes. LIMA to
the LAD, SVG to DIAG and SVG to LCX in [**2167**]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- Diabetes
- Dyslipidemia
- Hypertension
- ? pneumonitis from vasculitis or hypersensitivity
- COPD
- moderate-to-severe pulmonary hypertension
- dCHF with a normal left ventricular ejection fraction of
approximately 60%, followed by Dr. [**First Name (STitle) 437**]
- paroxysmal Afib status post permanent pacemaker implantation
in [**2181-10-28**] and AVJ ablation in [**2181-11-27**].
- paroxysmal Afib with multiple cardioversions on amiodarone,
then subsequent lung toxicity to Amiodarone
- anxiety
- depression
- sleep apnea
- GERD
- Right groin infection s/p cath requiring surgical debridement
Social History:
Lives at home with her husband.
- Tobacco: 25 pack yrs, quit 25 years ago
- Alcohol: denies
- Illicits: denies
Family History:
Her daughter died from complications related to sarcoidosis
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory
Physical Exam:
Vitals: 95.9 104/73 70 29 95%on 6L NC
General: Alert, oriented, tachypneic though no use of accessory
muscles
HEENT: Sclera anicteric, MMD, oropharynx clear
Neck: supple, triphasic JVP 12cm, no LAD
Lungs: bilateral basilar rales, bronchial breath sounds in left
base.
CV: Regular rate and rhythm, normal S1 + S2, SEM, rubs, gallops.
+ RV heave.
Abdomen: soft, non-tender, non-distended, bowel sounds
hypoactive, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2182-5-20**] 12:52PM BLOOD WBC-12.7* RBC-4.33 Hgb-10.6* Hct-33.1*
MCV-77* MCH-24.4* MCHC-31.9 RDW-18.6* Plt Ct-301
[**2182-5-21**] 05:49AM BLOOD WBC-12.3* RBC-4.43 Hgb-10.8* Hct-33.7*
MCV-76* MCH-24.4* MCHC-32.1 RDW-18.6* Plt Ct-285
[**2182-5-21**] 03:40PM BLOOD WBC-10.7 RBC-4.13* Hgb-10.7* Hct-31.1*
MCV-75* MCH-25.9* MCHC-34.3 RDW-18.7* Plt Ct-220
[**2182-5-20**] 12:52PM BLOOD PT-37.4* PTT-34.0 INR(PT)-3.9*
[**2182-5-21**] 05:49AM BLOOD PT-59.1* PTT-35.1* INR(PT)-6.7*
[**2182-5-21**] 03:40PM BLOOD PT-31.1* PTT-33.8 INR(PT)-3.1*
[**2182-5-20**] 12:52PM BLOOD Glucose-275* UreaN-70* Creat-2.0* Na-120*
K-5.1 Cl-83* HCO3-22 AnGap-20
[**2182-5-21**] 03:40PM BLOOD Glucose-223* UreaN-82* Creat-2.1* Na-126*
K-4.8 Cl-87* HCO3-24 AnGap-20
[**2182-5-20**] 12:52PM BLOOD Albumin-3.5 Calcium-9.7 Phos-4.4 Mg-2.7*
[**2182-5-21**] 05:49AM BLOOD Calcium-9.7 Phos-5.2* Mg-3.0*
[**2182-5-21**] 03:40PM BLOOD Calcium-9.6 Phos-4.4 Mg-2.9*
[**2182-5-20**] 12:52PM BLOOD ALT-107* AST-96* LD(LDH)-507* AlkPhos-93
TotBili-1.5
[**2182-5-20**] 12:52PM BLOOD proBNP-[**Numeric Identifier 11374**]*
[**2182-5-20**] 12:52PM BLOOD CRP-178.0*
[**2182-5-20**] 12:52PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2182-5-20**] 12:52PM BLOOD C3-129 C4-35
.
[**5-21**] ECHO
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is mild global left ventricular
hypokinesis (LVEF = XX %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. [In the
setting of at least moderate to severe tricuspid regurgitation,
the estimated pulmonary artery systolic pressure may be
underestimated due to a very high right atrial pressure.] There
is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2181-5-3**], the
right ventricle is probably more dilated and hypokinetic than on
prior. As a result, the left ventricle is now more compressed in
the pericardial sac. LV systolic function is not as vigorous -
particularly in the septum (the septal hypokinesis is also
partly due to RV pressure/volume overload. The degree of mitral
regurgitaiton has increased (may have been UNDERestimated on
prior). Degree of tricuspid regurgitation has also increased
slightly.
.
[**5-21**] CXR
IMPRESSION: Worsening bilateral airspace opacities consistent
with worsening alveolar pulmonary edema.
.
[**5-20**] CXR
IMPRESSION: The differential diagnosis is broad and includes an
infectious
process, likely viral or atypical pneumonia
Brief Hospital Course:
Ms [**Known lastname 11372**] was initially admitted to the MICU for shortness of
breath likely due to diastolic heart failure exacerbation.
Associated with her diastolic failure, she had acute renal
failure, and congestive hepatopathy along with hyponatremia. An
echo on [**2182-5-21**] revealed a large and dilated RV compressing the
LV in the pericardial sac. For diuresis, a lasix drip was
started to goal negative of 2 L daily; she was continued on [**First Name8 (NamePattern2) **]
[**Last Name (un) **] and beta-blockade. Repeat echo following diuresis showed
marked reduction of mitral regurgitation however had continued
intra and interventricular dysynchrony. We attempted to upgrade
to a [**Hospital1 **]-ventricular pacer but the LV lead slipped out of
position overnight. She will return on Monday [**6-3**] for
reposition of the lead.
.
Her acute renal failure improved with diuresis. Her
hyponatremia also improved, which was thought to be secondary to
hypervolemic hyponatremia. Transaminitis improved. She was
maintained on coumadin for paroxysmal atrial fibrillation
although her INR was supratherapeutic on admission. She was
initially reversed with Vitamin K and FFP and her coumadin was
restarted with goal of [**1-30**] INR. She was rate-controlled on
metoprolol. In addition to her shortness of breath secondary to
congestion, we felt she could have an element of pneumonitis:
inflammatory markers were elevated, however [**Doctor First Name **], ANCA,
complements were negative. Anti-GBM were pending at time of
discharge. Following diuresis with IV lasix, she was switched
to PO torsemide. Her coumadin was held around time of pacer
revision and she was put on full dose aspirin for clot
prevention.
Medications on Admission:
Home Meds:
calcium carbonate 1 tab daily
colchicine 0.6 mg qday
nexium 40
lasix 40 [**Hospital1 **]
amaryl 4mg qday
synthroid 37.5mcg qday
lopressor 75mg [**Hospital1 **]
pravachol 80mg qday
zoloft 25mg qday
sildenafil 20mg tid
spironolactone 25mg qday
calan SR 120mg qday
coumadin 5mg alt with 7mg
ambien 10mg qhs
Discharge Medications:
1. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Amaryl 4 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lantus 100 unit/mL Solution Sig: Thirty Six (36) units
Subcutaneous at bedtime.
8. Levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
10. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
11. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Acute on Chronic Diastolic congestive Heart Failure
Atrial Fibrillation on Coumadin
Pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for fluid overload and we gave you extra
medicine to get rid of the fluid. WE tried to revise your
pacemaker so that there is a lead in the left side. When we
checked the x-ray this morning, we found the lead was not in the
right place and we want you to come in on Monday to try it
again. We made the following changes to your medicines:
1. discontinue lasix (furosemide), Calen SR, coumadin and
spironolactone. You will resume the coumadin after the pacer
revision on Monday.
2. Start Torsemide instead of the Lasix. Take once daily
3. Start Cephlexin four times a day for one week. This is to
prevent an infection at the pacer site.
4. Start Losartan to help your heart work better and control
your blood pressure
5. Start aspirin while you are off the coumadin. This will
prevent blood clots.
.
Your white blood cell count is high and we sent a urine culture
today to make sure you don't have an infection. We will call you
at home if the culture is positive.
.
Weigh yourself daily and report any weight gain of more than 3
pounds in 1 day or 6 pounds in 3 days to Dr. [**First Name (STitle) 437**].
.
Pacemaker revision on Monday [**6-3**]:
Please come to the holding area at 9am on [**Hospital Ward Name **] [**Location (un) **]. Hold
your amaryl on Sunday night and in the morning on Monday. You
can take your regular dose of Lantus (Glargine) the night
before. Nothing to eat or drink after midnight on Monday
morning. You can take the Lantus as usual. You will be staying
overnight after the revision is done.
Followup Instructions:
Cardiology:
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2182-6-10**] 3:30
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2182-7-31**] 11:00
.
Dr [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] Phone: [**Telephone/Fax (1) 250**] Date/time: Monday [**6-10**] at
1:30pm.
.
Primary Care:
[**Last Name (LF) 11375**],[**First Name3 (LF) **] R. Phone: [**Telephone/Fax (1) 11376**]
Date/time: Please keep any previously scheduled appts.
Completed by:[**2182-5-31**]
|
[
"428.33",
"V45.81",
"250.00",
"584.9",
"424.0",
"573.0",
"585.9",
"599.0",
"276.1",
"414.00",
"V58.61",
"397.0",
"416.9",
"300.4",
"790.92",
"428.0",
"404.91",
"518.81",
"272.4",
"486",
"496",
"790.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.76",
"38.91",
"37.87",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11832, 11900
|
8515, 10255
|
305, 350
|
12051, 12051
|
5334, 8492
|
13799, 14313
|
4574, 4748
|
10620, 11809
|
11921, 12030
|
10281, 10597
|
12236, 13776
|
4763, 5315
|
3502, 3793
|
249, 267
|
378, 3394
|
12066, 12212
|
3824, 4429
|
3416, 3482
|
4445, 4558
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,466
| 155,569
|
34915
|
Discharge summary
|
report
|
Admission Date: [**2107-12-22**] Discharge Date: [**2107-12-30**]
Date of Birth: [**2025-11-13**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82 year old male with known cerebellar mass. He was imaged
at the OSH and the mass has approximately doubled in size
headache, no dizziness, no n/v, no visual changes.
Past Medical History:
1. Asthma
2. Osteoporosis
3. Osteoarthritis
4. s/p bilateral catarect surgery
Social History:
Lives with his step-son who is his only child and his HCP, his
name is [**Name (NI) **] [**Name (NI) 36913**] and his cell phone number is: [**Telephone/Fax (1) 79899**]. According to Mr. [**Last Name (Titles) 36913**], his step-father is DNR/DNI. His
PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27542**] at [**Location (un) **]. He is an
ex-smoker, smoking up to two packs per day (not known over the
number of years). Mr. [**Known lastname 61509**] does not drink alcohol. His bedroom
is on the [**Location (un) 1773**], and he normally manages his ADLs.
Family History:
non-contributory
Physical Exam:
Exam upon admission:
T:96.3 BP:146/78 HR:104 RR:15 O2Sats:95% RA
Gen: Patient is pleaseant, coopertive with exam and does not
appear to be in pain
HEENT: Pupils: PERRL EOMs-intact
Neck: Very kyphotic, but no tenderness to palpation.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place.
Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equal round, reactive to light. 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: Hard of hearing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Strength 5/5 throughout, except [**4-16**] left AT.
No pronator pronator drift.
+dysmmetria left side. Patient unable to mirror alternating hand
movements. Slower with left heel-to-shin compared to right.
Sensation: Grossly intact to light touch bilaterally.
Toes downgoing bilaterally
Upon discharge:
Exam unchanged
Pertinent Results:
MRI [**12-22**]:
The study is partially limited by motion artifacts. Allowing
these
limitations, the previously described right cerebellar mass is
again
visualized. The mass now measures 29 x 21 mm compared to 18 x 23
mm prior,
representing interval increase in size. In pre-contrast axial T1
images,
there is a hyperintense center with hypointense surrounding.
There is evidence of interval reduction of surrounding edema,
likely resolving edema from the [**2107-10-27**] biopsy. Again seen is
enhancement in the cerebellar sulci, representing leptomeningeal
seeding from the tumor.
IMPRESSION:
1. Right cerebellar mass, with appeareance of a malignant
hemorrhagic tumor, consistent with the known biopsy finding.
Interval increase in size. Decreased surrounding parenchymal
edema.
2. Persistent evidence of leptomeningeal seeding to the right
cerebellar
sulci.
Result of video swallow evaluation [**12-27**]:
RECOMMENDATIONS:
1. The safest recommendation is for the pt to remain NPO, as no
consistencies are without aspiration.
2. However, if the pt and his HCP wish to allow him to eat
against these recommendations given that the goals of care are
now hospice related, I would suggest a diet of honey thick
liquids and pureed solids, as these will result in the least
amount of aspiration.
3. Meds crushed with puree only until discussion with pt and HCP
regarding goals.
4. Q4 oral care.
On [**12-29**]:
K 3.2
On [**12-30**]:
K 4.0
Brief Hospital Course:
The patient was adirect admit from an OSH for increased size of
his cerebellar mass. He was in the ICU until a stepdown bed
became available for him. The patient was neurologically stable
for his stay here. He was evaluated by medicine for complete
heart block. The EP team did not recommend a pacemaker due to
his prognosis. They also requested that he did not be given any
beta blockers, given his heart block. The medical team did not
recommend any follow-up with them after discharge.
Mr. [**Known lastname 61509**] was transferred to a regular floor since he was
neurologically stable and since there were no interventions for
his heart block. It was determined that he would not undergo any
neurosurgery during this hospitalization. Palliative care was
consulted who recommended longterm care placement for comfort
care. PT and OT evaluated him and agreed with the plan.
Speech/swallow did a video swallow evaluation and recommended a
modified diet for comfort.
On [**12-29**] he was ready for discharge however his potassium was
low. Due to pharmacy delays he did not receive his potassium
repletion until the afternoon and this was too late for him to
be transferred. Therefore on [**12-30**] in the morning he was
discharged.
Medications on Admission:
Albuterol Inhaler, Colace, Advair, FoLIC Acid, Levothyroxine
Sodium, Lorazepam, Metoclopramide, Pantoprazole, Risperidone,
Trazadone
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Pantoprazole 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 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Cerebellar Mass
Complete Heart Block
Anemia
Hypokalemia
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions/Information
?????? 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, and
Ibuprofen etc.
?????? If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
?????? If you are being sent home on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
-Follow up with Dr. [**Last Name (STitle) **] in 4 weeks with a head CT. Call
[**Telephone/Fax (1) 1669**] to make an appointment.
Completed by:[**2107-12-30**]
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51,039
| 184,276
|
38495
|
Discharge summary
|
report
|
Admission Date: [**2129-7-15**] Discharge Date: [**2129-7-28**]
Date of Birth: [**2077-8-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Cefepime
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fever and sternal drainage
Major Surgical or Invasive Procedure:
[**2129-7-15**] Sharp debridement of sternal incision/Wound vac placed
[**2129-7-25**] Removal of 7 sternal wires, sternal debridement.
Plating with 3 transverse plates and one H plate in the
manubrium using the synthes system. Bilateral pectoralis
musculocutaneous advancement flaps.
History of Present Illness:
Mr. [**Known lastname **] is a 51 yo s/p emergent CABGx4 with IABP on [**6-5**] with
post op course complicated by post op CVA with L sided weakness,
post op atrial fibrillation, LV thrombus, DVT, post op
respiratory failure requiring trach and PEG on [**6-17**] who was
discharged to [**Hospital3 7665**] on [**7-5**]. He was progressing well
when he developed fever/chills on [**7-11**] up to 103.9 with WBC up
to 17. He was transfered to [**Hospital3 **] where he was
hypotensive to the low 80s and 3 of 4 blood and sputum cultures
grew MRSA. He was started on vancomycin and Fortaz, got a few
doses of steroids for sepsis and stabilized after about 24
hours. He did not require pressors. He had rapid atrial
fibrillation and was started on digoxin. He had an
echocardiogram which showed an EF of [**10-7**]%. He had been
improving with a decreasing WBC and stabilized hemodynamics when
he developed large amount of purulent drainage from a hole in
his mid sternal incision with air bubbling out. A CXR did not
show a pneumothorax and he was transfered here for further
evaluation.
Past Medical History:
Emergent Coronary bypass grafting [**6-5**] w/Intra Aortic ballon
pump preoperatively
Post-operative CVA
LV thrombus
lower extremity DVT
Diabetes Mellitus
fatty liver
DM
Social History:
Occupation:computer tech analyst
Tobacco:denies
ETOH:social
Family History:
noncontributory
Physical Exam:
Physical Exam on Admission
Pulse:72 Resp: 24 O2 sat: 99 on 35%TM
B/P Right: 91/54 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x] petechae on anterior chest and upper
arms
HEENT: PERRLA [x] L lid lag, L eye w/dysconjugate gaze
Neck: Supple [x] Full ROM [x]
Chest: Lungs rhoncherous bilat no wheezes
Heart: RRR [x] no audible Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] hypoactive
bowel sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema [**12-25**]+
Neuro: awake, follows commands, hand grasp equal bilat. dorsi
and
plantar flexion w/slight L sided weakness
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
trach site w/small amount of yellow drainage, erythema just
distal to trach
sternum w/diffuse erythema, 1cm hole mid sternum w/large amount
of turbid fluid draining, drainage fluctuating w/respiration;
sternum w/click at upper portion
Pertinent Results:
[**2129-7-15**] Chest CT Scan:
1. Newly appeared infectious fluid retention in the presternal
areas.
2. No evidence of changes in the post-sternal areas, no evidence
of
mediastinitis.
3. A newly appeared left lower lobe consolidation is suspicious
for
pneumonia.
4. Moderate bilateral pleural effusions.
[**2129-7-15**] WBC-6.9 RBC-3.46* Hgb-9.8* Hct-29.8* RDW-14.9 Plt
Ct-277
[**2129-7-16**] WBC-5.7 RBC-3.60* Hgb-10.1* Hct-30.6* RDW-15.0 Plt
Ct-315
[**2129-7-15**] PT-30.6* PTT-33.1 INR(PT)-3.0*
[**2129-7-16**] PT-33.2* PTT-31.8 INR(PT)-3.4*
[**2129-7-15**] Glucose-160* UreaN-8 Creat-0.5 Na-134 K-3.7 Cl-100
HCO3-27
[**2129-7-16**] Glucose-147* UreaN-4* Creat-0.6 Na-138 K-3.8 Cl-102
HCO3-28
[**2129-7-16**] ALT-12 AST-12 LD(LDH)-133 AlkPhos-86 Amylase-18
TotBili-0.2
[**2129-7-18**] Echocardiogram:
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. Right atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect is seen by
2D or color Doppler. LV systolic function appears depressed. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque to 30 cm from the
incisors. The aortic valve leaflets (3) are mildly thickened. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
[**2129-7-20**] Echocardiogram:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated with moderate to severe global hypokinesis
(LVEF = 25-30 %). The estimated cardiac index is normal
(>=2.5L/min/m2). No left ventricular mass/thrombus is seen, but
cannot be excluded due to suboptimal apical images. Right
ventricular chamber size is normal. with borderline normal free
wall function. The descending thoracic aorta is mildly dilated.
The aortic valve leaflets are mildly thickened (?#). Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a small to moderate sized circumferential pericardial effusion
without evidence of hemodynamic compromise.
[**2129-7-28**] 05:32AM BLOOD WBC-7.3 RBC-4.61# Hgb-12.9*# Hct-39.1*#
MCV-85 MCH-28.0 MCHC-33.0 RDW-16.6* Plt Ct-200
[**2129-7-26**] 04:44AM BLOOD WBC-10.0# RBC-2.92* Hgb-8.3* Hct-24.8*
MCV-85 MCH-28.4 MCHC-33.4 RDW-16.4* Plt Ct-331
[**2129-7-28**] 05:32AM BLOOD PT-16.0* PTT-64.4* INR(PT)-1.4*
[**2129-7-27**] 02:44PM BLOOD PT-15.6* PTT-74.2* INR(PT)-1.4*
[**2129-7-27**] 05:06AM BLOOD PT-15.0* PTT-57.6* INR(PT)-1.3*
[**2129-7-26**] 04:44AM BLOOD PT-14.2* PTT-37.9* INR(PT)-1.2*
[**2129-7-25**] 12:59PM BLOOD PT-14.1* PTT-26.2 INR(PT)-1.2*
[**2129-7-25**] 12:59PM BLOOD PT-14.1* PTT-26.2 INR(PT)-1.2*
[**2129-7-25**] 06:19AM BLOOD PT-14.1* PTT-63.9* INR(PT)-1.2*
[**2129-7-24**] 05:16AM BLOOD PT-14.3* PTT-57.1* INR(PT)-1.2*
[**2129-7-23**] 05:58AM BLOOD PT-14.8* PTT-52.0* INR(PT)-1.3*
[**2129-7-22**] 09:55PM BLOOD PT-15.1* PTT-56.8* INR(PT)-1.3*
[**2129-7-28**] 05:32AM BLOOD Glucose-165* UreaN-14 Creat-0.7 Na-133
K-4.0 Cl-95* HCO3-29 AnGap-13
[**2129-7-26**] 04:44AM BLOOD Glucose-123* UreaN-12 Creat-0.8 Na-138
K-4.2 Cl-99 HCO3-30 AnGap-13
[**2129-7-25**] 12:59PM BLOOD Glucose-109* UreaN-9 Creat-0.7 Na-137
K-4.5 Cl-101 HCO3-27 AnGap-14
[**2129-7-25**] 06:19AM BLOOD Glucose-132* UreaN-11 Creat-0.7 Na-136
K-4.2 Cl-97 HCO3-32 AnGap-11
Brief Hospital Course:
Readmitted from rehab on [**7-15**] to the CVICU for sternal drainage
and unstable sternum. Blood and sputum with MRSA. Coumadin held
and heparin started for history of LV thrombus and atrial
fibrillation. Wound opened at bedside and VAC placed. Chest CT
showed fluid collection suprasternally with no evidence of
mediastinitis. ID consult done and recommended Vancomycin for a
minimum of [**5-31**] weeks. Serial echocardiograms were done on [**7-18**]
and [**7-20**] found no evidence of endocarditis - see result section
for further details. Although LV thrombus was not identified on
echo, it could not be ruled out. Therefore, he continued to be
anticoagulated for previous evidence of LV thrombus. He was
evaluated by the plastic surgery team. On [**2129-7-25**] he underwent
sternal debridement, plating and pectoralis flaps with Dr.
[**First Name (STitle) **]. Overall he tolerated this procedure well and returned
to the telemetry floor post-operatively. Drains were removed
prior to discharge. ID continued to follow and recommendations
include the following:
**Per ID recommendations, following completion on Vancomycin,
patient will most likely require chronic suppressive therapy
with Rifampin. While on Vancomycin, patient will require weekly
CBC, BUN/Cr and Vancomycin trough levels with results faxed to
Dr. [**Last Name (STitle) 85650**] at [**Telephone/Fax (1) 1419**].**
At the time of discharge, the wound was healing without erythema
or drainage. Appropriate follow-up appointments and
instructions are advised. He is discharged to [**Hospital3 7665**]
in [**Hospital1 3597**], NH.
Medications on Admission:
albuterol neb every 6 hours as needed
atrovent neb every 6 hours as needed
tylenol 650 mg every 6 hours as needed
amiodarone 200mg twice daily
vitamin C 500 mg twice daily
aspirin 81mg daily
carvedilol 3.125 mg twice daily
digoxin 0.25mg daily
colace 100 mg twice daily
doxazosin 2mg daily
iron sulfate 300mg twice daily
folate 1mg daily
prevacid 30mg daily
nystatin 500,000units daily
potassium chloride 20 mEq twice daily
vancomycin 1.5grams twice daiy
glargine insulin 25 units twice daily
regular insulin sliding scale
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
2. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Carvedilol 3.125 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
5. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2
times a day).
6. Doxazosin 1 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at bedtime).
7. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day).
8. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for T>101.
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Hospital1 **]: [**12-25**]
Tablets PO Q4H (every 4 hours) as needed for pain.
10. Simvastatin 10 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY
(Daily).
11. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
13. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
14. Vancomycin 1,000 mg Recon Soln [**Last Name (STitle) **]: One (1) Intravenous
twice a day.
15. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
16. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Last Name (STitle) **]: One (1) 2100 units Intravenous ASDIR (AS
DIRECTED).
17. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation .
18. Warfarin 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM: dose to change daily for goal INR [**1-26**], indication: LV
thrombus.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
s/p emergency CABG [**6-5**] w/Intra Aortic balloon pump
preoperatively
Post-operative CVA
s/p trach/PEG
LV thrombus
lower extremity DVT
Diabetes Mellitus
fatty liver
DM
Discharge Condition:
Alert and oriented x3
Incisional pain managed with percocet
Incisions:
Sternal: no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema- minimal
Deconditioned
Moves all extermities
left lid drooping but can open to command-disconjugate gaze
Trach collar
PEG feeding tube
Voids spontaneously
Discharge Instructions:
Bathe daily including washing incisions gently with mild soap,
no baths until cleared by surgeon. Look incisions daily for
redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
- Cardiac Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] Date/Time:[**2129-8-30**]
1:30
- Plastic Surgeon: Dr. [**First Name (STitle) **] in 1 week [**Telephone/Fax (1) 1416**]
- Neurologist: Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 2574**] call for
appt.
- Primary Care Dr. [**Last Name (STitle) 71537**] in [**12-25**] weeks, call for appt
- Cardiologist Dr. [**Last Name (STitle) 39975**] in [**12-25**] weeks, call for appt
- [**Hospital **] Clinic, Dr. [**Last Name (STitle) 6137**] for [**Name6 (MD) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2129-8-15**] 9:50
**Per ID recommendations, following completion of Vancomycin,
patient will most likely require chronic suppressive therapy
with Rifampin. While on Vancomycin, patient will require weekly
CBC, BUN/Cr and Vancomycin trough levels with results faxed to
Dr. [**Last Name (STitle) 6137**] at [**Telephone/Fax (1) 1419**].**
Labs: PT/INR for Coumadin ?????? indication LV thrombus
Goal INR [**1-26**]
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as indicated
Completed by:[**2129-7-28**]
|
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"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10981, 11028
|
6754, 8368
|
311, 600
|
11244, 11569
|
3051, 6731
|
12295, 13567
|
2010, 2027
|
8942, 10958
|
11049, 11223
|
8394, 8919
|
11593, 12272
|
2042, 3032
|
244, 273
|
628, 1723
|
1745, 1916
|
1932, 1994
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,010
| 101,939
|
48090
|
Discharge summary
|
report
|
Admission Date: [**2199-10-21**] Discharge Date: [**2199-10-25**]
Date of Birth: [**2141-3-24**] Sex: F
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
right renal mass
Major Surgical or Invasive Procedure:
Right laparoscopic partial nephrectomy, laparoscopic
cholecystectomy
History of Present Illness:
58yF with 1.5 cm right posterior renal lesion and gallbladder
polyp now s/p CCY (Dr [**Last Name (STitle) **]/right partial Nx.
Additionally, she does have a history of Factor [**Doctor First Name 81**] def (Dr
[**Last Name (STitle) 3060**], [**Hospital1 18**]) and has rec'd 4FFP/Benadryl/Tylenol pre-op which
has been used in the past for this.
IVF: 2.0L + 8U FFP(!!) (plus 40IV lasix) EBL: 200cc
Plan:
Lap Partial Pathway
No Toradol
PACU labs
Run light, may HLIV in AM given large fluid load
q24 ptt and factor [**Doctor First Name 81**] levels
Hematology (Fellow, Dr. [**Last Name (STitle) **], [**Numeric Identifier 101405**]) following
If bleed tonight, the on call hematologist aware, will give more
FFP.
Past Medical History:
PMH: factor [**Doctor First Name 81**] deficiency, depression, recurrent genital herpes,
Hx of iron deficiency anemia, hypertension,
hypercholesterolemia, status post appendectomy , status post
tonsillectomy, C-section, ex-smoker and she quit smoking in
[**2176**].
Brief Hospital Course:
Patient was admitted to Urology after undergoing laparoscopic
right partial nephrectomy and cholecystectomy. No concerning
intraoperative events occurred; please see dictated operative
note for details. The patient received perioperative antibiotic
prophylaxis. The patient was transferred to the ICU given her
history of factor [**Doctor First Name 81**] defiency and drowsiness. She was
transferred to the floor on POD 1 in stable condition. On POD
0, pain was well controlled on PCA, hydrated for urine output
>30cc/hour, and provided with pneumoboots and incentive
spirometry for prophylaxis. She recieved 8 units of FFP on POD
0. On POD1, the patient ambulated, restarted on home
medications, basic metabolic panel and complete blood count were
checked, pain control was transitioned from PCA to oral
analgesics, diet was advanced to a clears/toast and crackers
diet. Hematology recommended 2 units of FFP that were given on
POD 1. On POD2, JP and urethral catheter (foley) were removed
without difficulty and diet was advanced as tolerated.
Hematology recommended another 2 units of FFP that were given on
POD 2. Her central line was removed on POD 2. The remainder of
the hospital course was relatively unremarkable. The patient was
discharged in stable condition, eating well, ambulating
independently, voiding without difficulty, and with pain control
on oral analgesics. On exam, incision was clean, dry, and
intact, with no evidence of hematoma collection or infection.
The patient was given explicit instructions to follow-up in
clinic with Dr. [**Last Name (STitle) 3748**] in 3 weeks.
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for break through pain only
(score >4) .
Disp:*30 Tablet(s)* Refills:*0*
2. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for heartburn: over
the counter.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): while taking narcotics, over the counter.
Disp:*60 Capsule(s)* Refills:*0*
4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
7. Bupropion 150 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO QAM (once a day (in the morning)).
Discharge Disposition:
Home
Discharge Diagnosis:
right renal mass
Discharge Condition:
stable
Discharge Instructions:
-You may shower but do not bathe, swim or immerse your incision.
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up.
-Do not drive or drink alcohol while taking narcotics.
-Resume all of your home medications, except hold NSAID
(aspirin, advil, motrin, ibuprofin) until you see your urologist
in follow-up.
-Call your Urologist's office today to schedule a follow-up
appointment in 3 weeks AND if you have any questions.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest ER.
Followup Instructions:
1-2 weeks
Completed by:[**2199-10-23**]
|
[
"573.8",
"272.0",
"401.9",
"054.10",
"E878.8",
"575.11",
"189.0",
"560.1",
"280.9",
"997.4",
"311",
"286.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.23",
"55.4",
"50.14",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
3915, 3921
|
1462, 3064
|
334, 404
|
3981, 3989
|
4752, 4793
|
3087, 3892
|
3942, 3960
|
4013, 4729
|
278, 296
|
432, 1149
|
1171, 1439
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,893
| 157,656
|
35996
|
Discharge summary
|
report
|
Admission Date: [**2167-2-21**] Discharge Date: [**2167-3-17**]
Date of Birth: [**2102-12-5**] Sex: M
Service: MEDICINE
Allergies:
Tetracycline
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Fever and chills and with bilateral hip pain.
Major Surgical or Invasive Procedure:
Endo-tracheal extubation.
Trans-esophageal echocardiogram.
Blood transfusions.
PICC placement in right arm.
History of Present Illness:
Mr. [**Known firstname **] [**Last Name (NamePattern1) **] is a 64 year-old gentleman with prior
history of OA of both hips (w/o hardware or surgery) with fever,
chills, hip pain and MSSA septic joints who is being transfer to
medicine for further management. He first started on [**2-14**] with
subjective fevers and quantified T 102.x on [**2-15**] with groin
pain. The following day he went to his PCP who performed blood
and urine cultures. On [**2-17**] he could not ambulate due to hip
pain anr presented to [**Hospital6 **] after having onset of
sweats and chills on [**2-14**] and bilateral (L > R) hip pain on
[**2-15**]; chronic much milder hip pain for >= 6 months. He was
admitted to [**Hospital6 **] on [**2-17**] after a clinic visit,
noted to have fevers; an initially normal WBC with significant
bandemia gradually increased to leukocytosis. Blood cultures
demonstrated MSSA, aspiration of both hips demonstrated MSSA. A
TEE was performed on [**2-17**] at NEBH without any anatomical
abnormality or vegetation seen. Subsequently, he had a
Girdlestone procedure on the left on [**2-19**] and on the right on
[**2-20**] (first operative report does not describe findings; second
operative report describes "rush of white pus" and bony
erosions, soft superiorly). After the second surgical
procedure, he had difficulty weaning from the ventilator. A CT
of the head was performed and demonstrated a left cerebellar
stroke. He was subsequently transferred to the neurology
service, in the SICU, at [**Hospital1 18**] on [**2167-2-21**]. He remained
intubated for 5 days w/o any pressor need. He had RIJ in place
at NEBH removed and cultured on [**2-22**] and then had L subclavian
placed and A line ([**2-18**]). RIJ was pulled on [**2-26**] and tip was
not cultured. Patient was found on ARF of unknown etiology with
creatinine of 1.4, worsening up to 1.9 and now currently 1.5.
His baseline eGFR is unknown. Upon admission his LDH, AP, AST
were elvated and all trended down, but LDH has been stable in
the ~300 range (today 395). His hematocrit was 27.8 and trended
down up to 19. Pt also had an INR of 1.2-1.3. For these two
reasons heme-onc was consulted, who ruled out hemolysis. They
suggested Vit K deficiency as etiology for slighlty increased
INR. Mixing studies are pending. There has not been any source
of bleeding and pt is guaiac negative so far. Hips look intact.
However, patient has required 2 PRBC today (1/2 [**3-9**] fever).
Upon arrival patient was on Nafcillin and was switched to
Vanc/Zosyn. ID was consulted and suggested switching him from
Vanc/Zosyn to Nafcillin/Gentamycin (Day 1 [**2-21**]). Gentamycin was
stopped on [**2-28**]. Patient is still febrile up to 100.5. Cultures
have been negative so far. Upon arrival patient has inferior lip
ulcers comaptible with HSV and was treated with acyclovir
([**Date range (1) 81702**]). ID suggests repeat TEE and complete 6-week course
of Nafcillin.
.
Pt denies any history of sick contacts, has history of contact
with children, people with recent hospitalizations, and no
recent antibiotic treatment. Within the last week, he had a
significant pimple on his nose with pus, skinned his knuckles
doing housework, and has had long-standing dry, cracked
fingertips. He has not had significant dental procedures
(cleaning > 1 month prior), nor has he had any surgeries or
procedures or prior hospitalizations. He has long-standing
osteoarthritis only of the hips, and was planning
replacement surgery.
Past Medical History:
Hypertension
Hypercholesterolemia
Bilateral hip osteoarthritis
Social History:
Married, lives in [**Location 38640**], MA; 5 adult children. Retired school
principal. Tob: quit 30 years prior to admission. ~10 pack-year.
EtOH: scotch, 1-2 drinks daily. Illicit drugs: never.
Family History:
Father with DM, and stroke age 85. Mother with [**Name2 (NI) 499**] cancer age
78. No other history of DM, hypertension or other cancer. No
history of premature CAD.
Physical Exam:
VITAL SIGNS - Temp 99.3 F, BP 149/79 mmHg, HR 86 PM, RR 20 X',
O2-sat 99% RA
<br>
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
dry mucous membranes
NECK - supple, no thyromegaly, no JVD visible, 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 RG, nl S1-S2, SEM in
tricuspid area that decreases in phase [**2-6**] of Valsalva
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-9**] throughout (upper extremities) and lower extremities not
examined [**3-9**] pain; negative Babinsky, sensation grossly intact
throughout, DTRs 2+ and symmetric, cerebellar with abnormnal
nose-finger maneuver in R side, steady gait
Pertinent Results:
On Admission:
[**2167-2-21**] 07:15PM WBC-19.5* RBC-3.30* HGB-9.9* HCT-27.8* MCV-84
MCH-30.1 MCHC-35.8* RDW-14.6
[**2167-2-21**] 07:15PM NEUTS-89* BANDS-3 LYMPHS-4* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2167-2-21**] 07:15PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL
TEARDROP-OCCASIONAL
[**2167-2-21**] 07:15PM PLT SMR-NORMAL PLT COUNT-151
[**2167-2-21**] 07:15PM PT-14.2* PTT-45.9* INR(PT)-1.2*
[**2167-2-21**] 07:15PM GLUCOSE-114* UREA N-32* CREAT-1.4* SODIUM-138
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
[**2167-2-21**] 07:15PM ALT(SGPT)-31 AST(SGOT)-58* LD(LDH)-345*
CK(CPK)-414* ALK PHOS-173* AMYLASE-30 TOT BILI-1.0
[**2167-2-21**] 07:15PM LIPASE-23
[**2167-2-21**] 07:15PM CK-MB-2 cTropnT-0.06*
[**2167-2-21**] 07:15PM ALBUMIN-1.9* CALCIUM-7.4* PHOSPHATE-4.4
MAGNESIUM-2.2
[**2167-2-21**] 07:15PM OSMOLAL-292
[**2167-2-21**] 07:15PM CRP-294.5*
[**2167-2-21**] 08:02PM LACTATE-1.2
[**2167-2-21**] 08:02PM TYPE-ART RATES-14/ TIDAL VOL-550 PEEP-5
O2-100 PO2-99 PCO2-35 PH-7.45 TOTAL CO2-25 BASE XS-0 AADO2-609
REQ O2-95 INTUBATED-INTUBATED VENT-CONTROLLED
.
Labs Upon Discharge:
[**2167-3-17**] 04:42AM BLOOD WBC-12.3* RBC-2.86* Hgb-8.6* Hct-24.9*
MCV-87 MCH-30.0 MCHC-34.4 RDW-15.3 Plt Ct-460*
[**2167-3-17**] 07:25AM BLOOD PT-15.2* PTT-47.2* INR(PT)-1.3*
[**2167-3-17**] 04:42AM BLOOD Plt Ct-460*
[**2167-3-17**] 04:42AM BLOOD Glucose-95 UreaN-21* Creat-1.2 Na-137
K-3.6 Cl-102 HCO3-28 AnGap-11
[**2167-3-16**] 05:24AM BLOOD ALT-19 AST-35 LD(LDH)-489* AlkPhos-64
TotBili-0.6
[**2167-3-16**] 05:24AM BLOOD Albumin-2.0*
[**2167-3-16**] 05:24AM BLOOD CRP-156.2*
.
S AUREUS S AUREUS#2
M.I.C. RX M.I.C. RX
------- ------ ------- ------
AMOX/CLAV <=[**5-7**] S <=[**5-7**] S
AMPICILLIN >8 R >8 R
AMP/SULBAC <=[**9-8**] S <=[**9-8**] S
CEFAZOLIN <=8 S <=8 S
CEFTRIAXONE <=8 S <=8 S
CHLORAMPHENICOL <=8 S <=8 S
CLINDAMYCIN <=0.5 S <=0.5 S
ERYTHROMYCIN <=0.5 S <=0.5 S
GENTAMICIN <=4 S <=4 S
IMIPENEM <=4 S <=4 S
LEVOFLOXACIN <=2 S <=2 S
OXACILLIN 0.5 S 0.5 S
PENICILLIN >8 R >8 R
RIFAMPIN <=1 S <=1 S
TETRACYCLINE <=4 S <=4 S
TRIM/SULFA <=0.5/9 S <=0.5/9 S
VANCOMYCIN 2 S 1 S
DAPTOMYCIN <=0.5 S <=0.5 S
LINEZOLID (ZYVO 4 S 4 S
MOXIFLOXACIN <=2 S <=2 S
.
CXR [**2167-2-21**]:
Endotracheal tube terminates 5.6 cm above the carina and a right
internal jugular vascular catheter terminates in the proximal
superior vena cava with no evidence of pneumothorax. The heart
size is normal. Patchy opacities are present in the perihilar
and basilar regions, and may represent atelectasis and/or
aspiration. Questionable small left pleural effusion.
.
Pelvis AP [**2167-2-21**]:
There has been apparent interval resection of the proximal
femurs to the level of the intertrochanteric region. Within both
hip joints, areas of high- density material are present,
possibly representing local treatment for reported diagnosis of
septic arthritis; correlation with surgical procedure note
recommended (not currently available). Residual portions of the
femurs are only partially visualized, but the right appears more
laterally situated with respect to the acetabulum than the left.
Clinical correlation suggested.
.
CT head [**2167-2-21**]:
Large hypodensity involving the majority of the left cerebellar
hemisphere
with mild edema and mass effect, consistent with subacute
infarct.
.
MRA [**2167-2-22**]:
Limited study due to motion artifact. The diffusion images
confirm a left posterior inferior cerebellar artery distribution
infarction. There is also a tiny focus of diffusion abnormality
in the medial right cerebellar hemisphere, likely representing
further infarction from a left PICA
occlusion.
The cervical vertebral arteries are patent. However, the
intracranial vertebral arteries are not well evaluated, again
due to motion artifact. There is no evidence of hemorrhage.
.
MRA [**2167-2-22**]:
The right vertebral artery is small, and ends in a PICA. This is
a normal variant. The left vertebral artery is of normal
caliber, gives most of its flow to the PICA, and the basilar is
largely supplied by a left-sided persistent trigeminal artery.
.
Abdominal USG [**2167-2-22**]:
Mild splenomegaly but otherwise unremarkable ultrasound of the
abdomen with no evidence of cirrhosis.
.
TTE [**2167-2-24**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is excellent (LVEF>65%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets are
mildly thickened. No masses or vegetations are seen on the
aortic valve, but cannot be fully excluded due to suboptimal
image quality. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. No mitral regurgitation is seen. No masses
or vegetations are seen on the tricuspid valve. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Mild aortic valve
sclerosis. No pathologic flow or discrete vegetation identified.
Mild pulmonary artery systolic hypertension. Normal left
ventricular cavity size with excellent global systolic function.
.
MRI of C/T/L spine [**2167-2-25**]:
No evidence of epidural abscess. Mild-to-moderate degenerative
changes seen throughout the cervical and lumbar spine, without
evidence of significant canal stenosis.
.
TTE [**2167-3-3**]:
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. Overall left ventricular systolic function is
normal (LVEF>55%). There are simple atheroma in the descending
thoracic aorta to 40cm from the incisors. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is a small (0.6 x 0.3 cm)
mass on the base of the anterior mitral valve leaflet (clip
[**Clip Number (Radiology) **]). An eccentric jet of mild to moderate ([**2-6**]+) mitral
regurgitation is seen. There is no pericardial effusion.
Impression: No thrombus/mass in the left atrium/left atrial
appendage or the right atrium/right atrial appendage. No atrial
septal defect is seen. There is a small 0.6 x 0.2cm vegetation
on the base of the anterior mitral valve leaflet. An eccentric
jet of mild to moderate ([**2-6**]+) mitral regurgitation is seen.
.
CT pelvis w/o contrast [**2167-3-11**]:
A large left gluteal hematoma measures 19.2 TV x 8.1 AP x 18.1
CC cm, increased compared to [**2167-3-2**], when it measured
approximately 14.8 TV x 5.4 AP x 16.1 CC cm. A smaller right
gluteal hematoma is much more conspicuous today, measuring
approximately 9.4 x 5.3 cm in greatest axial dimension. There is
no evidence for retroperitoneal extension of hematoma.
.
LLL USG [**2167-3-12**]:
No left lower extremity DVT.
Brief Hospital Course:
Mr [**Known lastname 81703**] is a 64 year-old genleman with HTN, dyslipidemia,
OA with MSSA sepsis and septic hips bilateraly with peri-op
embolic stroke in R cerebellum, anemia and persistent fever who
is transfer to medicine for further management of all the issues
above.
.
#. Septic Arthritis - Patient presented to his PCP office with
fever and bilateral hip pain, then growing MSSA in the blood and
urine. He was unable to walk and went back to the ER, where he
underwent arthrosentesis of both joints and was diagnosed with
MSSA septic joints. A CT scan of the head was negative and a TEE
was negative for endocarditis. Pt was started on vancomycin and
oxacillin on [**2167-2-15**]. He underwent Gridlestone procedure on
left side on [**2-19**] and on the right on [**2-20**]. He was transfered
to the [**Hospital1 18**] SICU on [**2167-2-21**]. Upon admission he was started
on Vanc/Zosyn and ID was consulted, who suggested nafcillin 2g
q4hrs with Gentamycin (On [**2167-2-21**]). Then Gentamycin was
stopped on [**2167-2-28**]. Nafcillin dose was decreased to 1 mg q 4
hrs. Pt's ESR was 148, CRP 246.5, WBC 19.5 with 89% neutrophils
and 3% bands. He became febrile (see below for details) and Dr.
[**First Name (STitle) **] W. [**Doctor Last Name **] recommended Nafcillin 2g q4 hrs, so suggested
day 1 of treatment would be [**2167-3-2**]. Patient kept improving
clincally and wounds look clear without any drainage. Orthopedic
surgeon at NEBH was contact[**Name (NI) **] and expressed suggestion of
removing staples on Friday [**2167-3-20**]. Patient worked with
physical therapy and was transferred to the chair on daily
basis. Patient will need to receive at least 6 weeks of IV
antibiotics, so had PICC placed in right arm ([**2167-3-5**]). Patient
will need weekly CBC/diff, chem 7, LFTs, ESR/CRP and fax results
to the ID RN's at([**Telephone/Fax (1) 6313**]. He will need to follow up with
ID before stopping antibiotics. Pt will also need arthrosentesis
and document that infection has been eradicated before bilateral
hip replacement surgery. Pt will need PT to avoid decub ulcers
and further articulation disease. Pt will also need DVT
prophylaxis with pneumoboots since he is not expected to be very
mobile in at least 6 weeks and had bleeding on lovenox.
.
#. MSSA endocarditis - Patient with documented MSSA bacteremia
at OSH with negative TEE and unknown source upon arrival. Since
fever persisted and pt had an embolic stroke with bilateral
septic arthritis it was extremely suspected endocarditis. Pt met
clinical criteria. He was put on telemetry and had daily ECGs.
He underwent a TEE with bubble study that showed a single small
lesion in the mitral valve without any abcesses, significant
valve dysfunction and showed normal heart and valvular anatomy.
Pt was started on antibiotics as above with Day 1 of Nafcillin
[**2167-3-2**] for at least a 6 week course. Patient had daily blood
cultures and all were negative. Will need laboratory values as
above. Pt was incidentally found to have splenic infarcts as
well on CT scan.
.
#. Stroke - Patient was unable to be extubated after surgery, so
had a non-contrast CT scan of his head that showed an embolic
stroke in the left cerebellum in the territory of the PICA with
mild to moderate edema. The most likely source is the heart with
endocarditis. Patient had an MRI that did not show any other
lesions. Patient received manitol therapy and conservative
management. ASA and Plavix were not given due to bleeding
concerns. Patient's statin dose was maximized. BP was managed
medically as well as the sugars. Patient improved importantly
and now currently has only mild proximal weakness in the right
upper extremity and mildly abnormal finger-nose maneuver. It is
expected that patient will keep improving. The role of
antiplatelet agents in case of endocarditis with bleeding is
unclear, since the source is now controlled with antibiotics. IT
can be started once septic arthritis and surgery issues have
been resolved.
.
#. Anemia / Bleeeding - Patient with mildy increased INR, acute
renal failure with creatinine of 1.5, increase haptoglobin and
LDH without any dysmorphic RBCs and reticulocyte count of 0.2
after double correction. Pt was found to have a very poor RBC
production, most likely in the setting of malnutrition and
infection. His iron panel was ferritin 1729, TRF 105, calTIBC
137. His haptoglobin was 201 and there were only few number of
abnormal RBCs in the smear. He had a CT scan of the abdomen that
showed a left gluteal hematoma. HCT was trended and was stable.
Risk of draining hematoma outweigh the benefits. Further work up
was done to study his coagulation (See below). NSAIDs were
avoided. Pt will need to have HCT trended as outpatient. Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] helped throughout the case. Later throughout
hospitalization patient was started on lovenox for DVT
prophylaxis and within 24 horus his HCT dropped up to 18 and
repeat CT showed worsening of his L gluteal hematoma (19 cm) and
a right gluteal hematoma as well. His lovenox was continued and
he required more RBC units. Now he has been with HCT stable
22-25 during the last 90 hours without any transfusion
requirements. Please do HCT every second or third day.
.
#. Increased PTT: Patient had mixing studies done that did not
correct after 1:1 mix. Patient had inhibitor screening test,
that was positive for Lupus anticoagulant. Titer of
anticardiolipin was 7.6 IgG and 14.8 IgM. SInce patient does not
meet clinical criteria for antiphospholipid syndrome [**3-9**] no
evidence of clots and recent history of bleedint patient was not
anticoagulated. He will need to follow with Dr. [**Last Name (STitle) **]
(Hematology-Oncology).
.
#. Renal failure -Baseline of 0.9-1 per NEBH records, but
arrived with eGFR of 50 ml/min (MDRD) in the setting of
creatinine of 1.5 upon presentation. UA did not show any
abnormal RBC morphology/casts/proteinuria. Urine lytes had FeNa
of 0.1. Patient received blood and fluids and creatinine started
trending down and was 1.2 upon discharge. He was thought to have
pre-renal renal failure.
.
#. Hypertension - Patient hypertensive early in the
hospitalization, but was let autoregulate. Then, therapy was
maximized with metoprolol, hydrochlorothiazide HCL and
nifedipine. Will recommend ACEI once his renal funciton is
stable after hip replacement.
.
#. Hyperglycemia - patient with sugars between 100-200. Continue
Humalog. Not formaly diagnosed with DM and diagnostic criteria
were not designed in inpatient.
.
#. Dyslipidemia - LDL 41, HDL 13, Chol 88, TG 169. Will need to
repeat as outpatient. Continuing crestor upon discharge. Will
need to follow up LFTs.
.
#. TR - stable.
.
#. FEN - Regular cardiac healthy diet.
.
#. Access - Right side PICC ([**2167-3-5**]).
.
#. PPx -
-DVT ppx with pneumoboots. Not on lovenox since bleeding into
gluteal region twice.
-Bowel regimen with colace / Senna / Miralax
-Pain management with oxycodone 60 mg SR [**Hospital1 **] and 10 mg q4 hrs
PRN.
.
#. Code - Full code
.
#. Contact - wife: [**Name (NI) **] [**Telephone/Fax (1) 81704**]; son: Creg [**Telephone/Fax (1) 81705**].
.
#. Dispo - Going to [**Hospital 671**] Rehab at [**Hospital3 **]
[**Telephone/Fax (1) 81706**].
.
Medications on Admission:
Lisinopril 5 mg Daily
Crestor 10 mg Daily
Aspirin 81 mg Daily
Omega 3 (unknown)
Naproxen 2 pills (unknown) PRN
Discharge Medications:
1. Nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous
every four (4) hours: Until Infectious Disease decides to stop
treatment. Will need at least until [**2167-4-7**].
Disp:*60 grams* Refills:*4*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
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. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO twice
a day.
Disp:*90 Capsule(s)* Refills:*2*
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*20 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 Bottle* Refills:*2*
9. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day).
Disp:*2 Bottles* Refills:*2*
10. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Six (6)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*180 Tablet Sustained Release 12 hr(s)* Refills:*0*
11. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO
once a day.
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day).
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO BID (2 times a
day) for 7 days.
14. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
15. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
Radius [**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnosis:
MSSA endocarditis in mitral valve without abcess.
Bilateral septic joints (hips) s/p Gridlestone procedure at OSH
Embolic Left cerebellar stroke
Acute Renal Failure
Embolic splenic infarcts
Anemia due to bleeding in both gluteus and poor blood production
Malnutrition
.
Secondary Diagnosis:
Hypertension
Dyslipidemia
Osteoarthrosis
Pimple in face
Antiphospholipid antibody positive (ACL antibody)
Discharge Condition:
Stable, breathing comfortably on room air, tolerating diet,
moving to chair with help.
Discharge Instructions:
You were transfered to [**Hospital1 18**] after difficulty being extubated
after a procedure at the NEBH, where you were being seen for
MSSA (Staph aureus) bacteremia (bacteria in blood), endocarditis
(heart infection) and bilateral septic joints (infected hips)
s/p Gridlestone procedure. Upon arrival you were found to have
an embolic stroke, most likely due to your endocarditis (heart
infection). You were medically treated and improved and were
able to be extubated. Then you were transfered to the medical
floor.
.
You had a trans-toracic echocardiogram that did not show any
heart infection. Then you underwent a trans-esophageal
echocardiogram that showed a lesion in one of your heart valves.
You were continued in your antibiotic (Nafcillin) that you will
need for at least 6 weeks. You had a PICC placed in your right
arm to give you antibiotics.
.
Your blood level dropped and we found an antibody that was high
and explained your increased clotting times, but it may be a
false positive int he setting of infection. You will need
outpatient follow up for this. Then, we found that you bleed
into your buttocks (L>R) and required multiple transfusions to
keep your blood level stable. We consulted orthopedic surgeons
including the ones who did the surgery at the NEBH and all
agreed that watching and conservative management was the best
option. We also tested your platelet function. Your blood level
has been stable.
.
If you have drainage from your wounds, fever, blood in your
stools, do not feel ok or anything else that bothers you please
call your PCP [**Name Initial (PRE) 2678**].
.
The following changes were made to your medications:
* You were started on Nafcillin 2g Q4 hrs and will need to
complete 6 weeks of therapy at least and follow up with
infectious diesease (See below)
* Your lisinopril was stopped due to your renal failure. Will
need to restart once your kidneys back to baseline.
* Your naproxen was stopped
* Your aspirin was stopped; you can re-start it after talking to
your orthopedic surgeon, since they may want you off it before
the surgery
* We started you on oxycodone SR 30 mg [**Hospital1 **] for pain control
(constant)
* You can take oxycodone 5-10 mg q6hrs for breakthrough pain
* You were started on Hydrochlorothiazide for blood pressure
control
* You were started on colace 100 mg three times per day to help
you move your bowels, since you won't be moving much and the
pain medicaiton causes constipation.
* You were started on senna Tiwce a day to move your bowels
* You can take Miralax if the above medications do not help you
to move your bowels. You can take once a day.
* Keep your nose well hydrated
Followup Instructions:
You will need Infectious disease follow up as below:
* Please have liver function tests, basic metabolic panel (7),
blood level checked every week and fax results to the number
below:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2167-4-3**] 10:00
.
You will need to follow up with your orthopaedic surgeons at the
NEBH once infectious disease doctors think that the infection is
clean for the hip replacement.
.
Follow up with yout PCP once you get discharged from Rehab.
[**Last Name (LF) **],[**First Name3 (LF) **] W. [**Telephone/Fax (1) 5457**]
.
You will need to follow with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at NEBH for your
increased blood thining. You can follow after being discharged
to Rehab back to NEBH for your surgeries. You can get
appointment or contact him at ([**Numeric Identifier 81707**]
.
You will need to have your blood level (hematocrit) and your
potassium level checked every third day during the next couple
of weeks.
.
You will need to have your staples removed on Friday.
|
[
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"272.0",
"286.9",
"584.9",
"998.12",
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"285.1",
"995.91",
"421.0",
"449",
"711.05",
"434.11",
"261",
"795.79",
"038.11",
"401.1",
"054.9",
"486",
"E878.8",
"444.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"96.72",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
23011, 23064
|
13650, 20926
|
319, 429
|
23524, 23613
|
5482, 5482
|
26325, 27449
|
4268, 4435
|
21087, 22988
|
23085, 23085
|
20952, 21064
|
23637, 26302
|
4450, 5463
|
234, 281
|
6725, 13627
|
457, 3952
|
23395, 23503
|
23104, 23374
|
5496, 6709
|
3974, 4038
|
4054, 4252
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,123
| 149,954
|
43185
|
Discharge summary
|
report
|
Admission Date: [**2200-1-23**] Discharge Date: [**2200-2-3**]
Date of Birth: [**2124-1-3**] Sex: M
Service: MEDICINE
Allergies:
Diltiazem
Attending:[**First Name3 (LF) 5301**]
Chief Complaint:
SOB, altered mental status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
76-year-old male with hx CAD s/p IMI [**2189**], CHF with EF 15%, PVD,
CRI (on Epo) recently admitted for LGIB who presents from [**Hospital1 1501**]
(after [**Hospital 5610**] Rehab) with increased SOB/DOE and decreased
mental status.
.
On [**12-28**], patient was admitted to [**Hospital6 **] for three
to four days of progressive weakness and fatigue, was found to
have a hematocrit of 26 and was transfused and transferred to
[**Hospital1 18**]. At [**Hospital1 18**], had an endoscopy as well as colonoscopy, which
were unremarkable. He was discharged to [**Hospital1 **] on [**12-31**],
subsequently had an outpatient small bowel capsule study, which
showed an AVM at 2.5 hours into the jejunum suggesting that it
is beyond the reach of the endoscope. He has been receiving [**12-3**]
transfusion every month when these are needed for coronary
event. Pt has been seen by Dr [**Last Name (STitle) 2161**] who recommended a
double-balloon enteroscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10395**] at [**Hospital1 498**],
[**Hospital1 1559**]. He was discharged from [**Hospital1 **] on [**1-21**] to a [**Hospital1 1501**].
.
He comes back today for increased fatigue, SOB/DOE, and
decreased mental status. HCT today is 33.8 form 33.4. Pt poor
historian non conversant.
.
In ED, T 101.2 HR 68 BP 115/54 RR 26 O2 sat 92-93% on 5LNC,
then 97% on NRB. CXR suggestive of severe pulm edema/CHF, and he
was given lasix 40 IV, guaiac positive, Hct 34 so no [**Hospital1 **]
transfused, protonix 40IV, Vanc 1gm IV, Ceftriaxone 1gm IV. He
was transferred to the MICU for closer monitoring.
.
He denies any fever, chills, chest pain, hematemesis, nausea,
vomting, abdominal pain, but does relate an approximate 20 pound
weight loss over the past three months.
Past Medical History:
Past Medical History:
--CAD s/p MI in '[**89**] and CABG [**2189**] (LIMA-LAD, SVG-OM1 occluded,
SVG-OM2 patent, SVG-PDA patent) status post cath [**5-6**] revealing
3vd but patent LIMA and SVGs
--CHF w/ EF 10-15%, followed by Dr. [**First Name (STitle) 437**] in [**Hospital 1902**] clinic, status
post
thoracentesis in [**7-7**]
--Atrial tachycardia failed ablation, status post ICD implant in
[**2198-5-2**]
--Diabetes Type II (last HgbA1c 6.8 in [**2199-4-1**])
--PVD status post L subclavian stent [**5-6**]
--Bilateral carotid occlusion, [**Doctor First Name 3098**] 100%, [**Country **] about 90-95%
status post [**Country **] stent on [**5-6**]
--Hypertension
--Hyperlipidemia
--History of anemia
--Polymyalgia rheumatica
--Gout
--Chronic Renal Insufficiency (baseline Cr 2.5-3.0)
--History of guaiac positive stools baseline Hct ~30
--History of hypercoagulable state
--Depression
--Status post MVA associated with CVA
--Home oxygen 2-3L NC
Social History:
.
Social History:
Reports he quit smoking cigarettes 2 months ago after smoking 2
ppd for over 50 years. He drinks alcohol occasionally. He denies
illicit drugs. He lives in [**Hospital3 400**] in [**Location (un) 87405**] in
[**Hospital1 392**]. Single, with no children.
.
Family History:
.
Family History:
Non-contributory
.
Physical Exam:
PE: 100.0 104/41 72 93% on RA O2 Sats
Gen: conversant but slightly antagonistic
HEENT: Clear OP, MM dry
NECK: Supple, No LAD, JVP 8 cm
CV: RR, NL rate. No murmurs, rubs or [**Last Name (un) 549**]
LUNGS: very minimal air movementl coarse crackles [**1-4**]
ABD: Soft, NT, but slightly distended. NL BS.
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: CN 2-12 grossly intact.
Pertinent Results:
CHEST (PORTABLE AP)
Reason: r/o CHF, pna
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with crackles, hypoxia
REASON FOR THIS EXAMINATION:
r/o CHF, pna
HISTORY: 75-year-old male with hypoxia and concern for CHF or
pneumonia.
COMPARISON: [**2199-12-29**].
FINDINGS: Single frontal view of the chest demonstrates stable
moderate cardiomegaly with unchanged mediastinal contours. The
patient is status post sternotomy. Sternal sutures and
left-sided transvenous pacemaker leads are unchanged. Again
noted is fracture of the most inferior sternal suture. The
pulmonary vasculature is engorged, and peripheral Kerley B lines
are noted. There are small bilateral pleural effusions and
associated bibasilar atelectasis. There is no pneumothorax. The
bones are demineralized.
IMPRESSION: Congestive heart failure.
Brief Hospital Course:
A/P: The patient is a 76 y/o M with significant cardiac hx, EF
15%, smoking hx who presents with SOB
.
# Resp distress: Most likely [**1-3**] early pneumonia (? aspiration)
as well as CHF exacerbation. Given low EF, he has very poor
forward flow and may be total body depleted, but still have pulm
edema. A BNP was [**Numeric Identifier 17514**], consistent with an element of CHF, and
cardiac enzymes were slightly elevated to 0.11. However, in the
context of elevated creatinine, likely does not reflect ACS. He
was diuresed with standing lasix and fluid restricted. He was
started on vanc/cefepime to cover for aspiration and hospital
acquired pathogens. Standing nebs and mucinex were used to
improve air intake and secretions. He was started on a
prednisone taper. Upon transfer to the [**Hospital1 **] medicine service, he
was felt unlikely to have a pneumonia and antibiotics were
discontinued. The patient was seen by the renal consult team. He
was felt to be significantly volume overloaded and was
aggressively diuresed. He initially was diuresed with a
thiazide-lasix IV combination, but was on a po combination by
discharge. The patient was discharged on 100 mg po Lasix alone,
after being stable on this dose for several days, 500-1 L neg.
He was off oxygen at discharge, but likely to require some
during exertion given his deconditioning.
.
# Lower GI bleed: The patient has a known AVM seen on capsule
endoscopy thought distal to enteroscopy capabilities. He is a
chronic, low volume GI bleeder. He is a poor operative
candidate, at this point he is not profusely bleeding and does
not need emergent surgery. His hcts were maintained above 28
with one unit pRBCs. His plavix and asa were held. He was also
maintained on a ppi. The patient may consider outpatient
follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10395**] at [**Hospital1 498**] [**Hospital1 1559**] for
double-balloon enteroscopy as recommended by Dr. [**Last Name (STitle) 2161**] at a
prior evaluation. His hematocrit was stable throughout the
hospitalization.
.
# Leukocytosis. Etiology unclear. [**Name2 (NI) **] cultures were without
growth, stool culture and C Diff toxin assay were also negative.
The patient's leukocytosis resolved and was taken off of empiric
pneumonia antibiotics as above.
.
# CRI/Uremia. The patient was near his baseline Cr, though with
a BUN >100. On transfer to the Medicine floor service, the
patient was evaluated by renal. He was felt likely to be uremic
with asterixis on exam and a question of mental status changes.
The most likely etiology of his renal failure was felt due to
chronic CHF. The patient was aggressively diuresed. He
underwent renal artery ultrasound to rule out renal artery
stenosis, which was negative. The patient also had an echo for
rule out pericardial effusion in the setting of uremia and a
question of a rub (though without pulsus), which was also
negative. All meds were renally dosed. The renal team thought
there were no acute indications for hemodialysis given that he
was responsive to diuretics. At discharge, the renal team
recommended that the patient be titrated for a fluid balance of
negative 1 liter daily. It is likely that in the future, the
patient will require hemodialysis.
.
# CAD. Stable. No signs of acute MI and with negative cardiac
enzymes. The patient was continued on metoprolol, hydral, imdur,
zocor. His lisinopril was held in the setting of renal failure
and uremia. His aspirin and plavix were held in the setting of
known recent GI bleeding.
.
# Diabetes type II. The patient was continued on home lantus
with four times daily fingersticks, and insulin sliding scale.
His Lantus was titrated by the [**Last Name (un) **] attending consult. During
his steroid taper, his [**Last Name (un) **] glucose was elevated. It is likely
that he will require LESS lantus as his steroids are tapered
off, this decrease can be done at the discretion of the rehab
physicians. Pre-meal and pre-bedtime finger sticks should be
monitored.
.
# Depression. Continued on Celexa and Risperdal
.
# Atrial tachycardia: the patient was paced during the admission
and continued on his outpatient amiodarone.
.
# Gout. Continued on allopurinol.
.
# CODE: DNR, but pt OK to intubate if temporary to help
overcome [**Hospital 93071**] medical problems. Pt also OK for central
lines, pressors. Discussed with his HCP, his brother [**Name (NI) **]
.
# COMM: [**Name (NI) **] [**Name (NI) **] (brother) and HCP
Medications on Admission:
ASA 81 mg daily
plavix 75 mg daily
metoprolol 12.5 mg po bid
lisinopril 5 mg po qd
hydralazine 50 mg po q8h
imdur 30 mg po qd
lasix 40 mg po daily
amiodarone 200 mg po qd
zocor 40 mg po qd
allopurinol 100 mg po qd
celexa 20 mg po qd
lantus 20 units sq qam
flomax 0.4 po qd
protonix 40 mg iv bid
risperdal 0.25 mg po qam, 0.375 mg po qhs
ferrous sulfate 325 po bid
phenergan prn
tylenol prn
metamucil po qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
2. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Risperidone 0.25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh
Inhalation Q6H (every 6 hours).
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
17. Lantus 100 unit/mL Solution Sig: Thirty (30) units
units Subcutaneous qam.
18. Risperdal 0.25 mg Tablet Sig: 1.5 Tablets PO at bedtime.
19. Lasix 20 mg Tablet Sig: Five (5) Tablet PO once a day.
20. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
21. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per
sliding scale Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 23095**] - [**Location 8391**]
Discharge Diagnosis:
CHF exacerbation
COPD exacerbation
Acute renal failure on chronic renal insufficiency
Lower GI bleed from jejunal AVM
Hypertension
Hyperlipidemia
Diabetes Type II
CAD s/p MI and s/p CABG
Atrial tachycardia
PVD
Anemia of chronic disease
Polymyalgia rheumatica
Gout
Hypercoagulablility
Depression
Appendectomy
Oxygen dependence
Discharge Condition:
Stable, on 2L oxygen, to rehab
Discharge Instructions:
-Please return to the ED if you develop worsening shortness of
breath, chest pain, fevers, chills, or diarrhea.
Followup Instructions:
Dr. [**Last Name (STitle) 2903**] [**2200-2-18**], 2:15 pm. Phone [**Telephone/Fax (1) 2936**]
.
Renal follow up: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2200-2-25**] 4:00
.
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2200-3-25**] 1:30
|
[
"274.9",
"403.90",
"443.9",
"428.0",
"V45.81",
"427.31",
"416.8",
"272.0",
"425.4",
"250.92",
"300.4",
"585.9",
"725",
"491.21",
"285.29",
"414.00",
"V15.82",
"584.9",
"569.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11469, 11543
|
4711, 9207
|
295, 302
|
11913, 11946
|
3868, 3911
|
12106, 12209
|
3424, 3444
|
9667, 11446
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3948, 3987
|
11564, 11892
|
9233, 9642
|
11970, 12083
|
3459, 3849
|
12220, 12539
|
229, 257
|
4016, 4688
|
330, 2121
|
2165, 3095
|
3129, 3390
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,641
| 197,233
|
37162
|
Discharge summary
|
report
|
Admission Date: [**2175-9-13**] Discharge Date: [**2175-9-17**]
Date of Birth: [**2109-2-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
ERCP [**2175-9-13**] - complicated by ampullary bleeding for which 3U
PRBC was given.
History of Present Illness:
66 yo M radiologist with cholangiocarcinoma s/p stents in [**6-22**]
and follow-up ERCP that showed 20 mm malignant stricture who
presented to oncologist with RUQ pain and presyncope. Found to
be tachy with increased WBC -- ? cholangitis. Sent in for ERCP
-- at time of ERCP, had large amount of bleeding requiring
expanding stent to tamponade bleed. Admitted to [**Hospital Unit Name 153**] for
observation. In [**Hospital Unit Name 153**], he received 3 units of PRBCs. Hct was
24.8 on admission and now is 29.5 as of 3 PM this afternoon. No
longer tachy with stable BP. No evidence of current bleeding.
Given Vanco/Zosyn for ? cholangitis.
Vitals currently in [**Hospital Unit Name 153**]: 104 121/71 99% on RA.
No current complaints.
At time of transfer -- 2 18 gauges and a 20 gauge.
Past Medical History:
PMH: DM, Cholangiocarcinoma - s/p double pigtail stents in
[**6-/2175**]
PSH: PTC placement ([**2175-1-18**])
Social History:
No alcohol use, smoking, IV drug use, marijuana use, blood
transfusions, tattoos, hepatitis, or piercing. Married, works as
a radiologist, originally from [**Country 11150**]. He has two children. One
son is a physician in [**Name (NI) **] [**Name (NI) 1680**] and dtr is engineer.
Family History:
Mother died of tuberculosis, father of natural causes, sister of
HCC
Physical Exam:
on [**2175-9-14**] [**Company 83710**]=99.1 BP-118/68 HR=87 RR=20 SaO2 99% RA
Thin man in NAD
HEENT-negative
Neck-no masses or JVD
Lungs-decreased breath sounds halfway up on the right, otherwise
CTAB
CV-RR, no m/r/g
Abd-soft, NT, NO, NABS. We-helaed scar in RUQ
Extrem-warm, well-perfused, no edema, no calf tenderness
Neuro-non-focal screening exam
ROS: reports bloody stool immediately post the ERCP yesterday,
but no stool since. No abd pain. No nausea.
Pertinent Results:
[**2175-9-13**] 09:00AM BLOOD WBC-23.8*# RBC-2.78* Hgb-7.8* Hct-24.8*
MCV-89 MCH-28.2 MCHC-31.6 RDW-18.6* Plt Ct-470*#
[**2175-9-14**] 03:03PM BLOOD WBC-17.2* RBC-3.54* Hgb-10.1* Hct-29.5*
MCV-83 MCH-28.4 MCHC-34.2 RDW-16.7* Plt Ct-290
[**2175-9-13**] 09:00AM BLOOD Neuts-93* Bands-5 Lymphs-1* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2175-9-13**] 09:00AM BLOOD Gran Ct-[**Numeric Identifier **]*
[**2175-9-13**] 09:00AM BLOOD UreaN-19 Creat-0.7 Na-134 K-5.1 Cl-95*
HCO3-27 AnGap-17
[**2175-9-14**] 03:58AM BLOOD Glucose-125* UreaN-17 Creat-0.7 Na-135
K-3.6 Cl-100 HCO3-29 AnGap-10
[**2175-9-13**] 09:00AM BLOOD ALT-82* AST-126* AlkPhos-320* Amylase-53
TotBili-1.8* DirBili-1.4* IndBili-0.4
[**2175-9-14**] 03:58AM BLOOD ALT-66* AST-81* LD(LDH)-115 AlkPhos-237*
Amylase-108* TotBili-8.2*
[**2175-9-13**] 09:00AM BLOOD Albumin-3.2* Calcium-9.1 Phos-3.4 Mg-1.4*
[**2175-9-14**] 03:58AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.5 UricAcd-1.7*
[**2175-9-13**] 09:00AM BLOOD CA [**84**]-9 -PND
ERCP [**2175-9-13**]:
Impression: Two double pigtail plastic stents previously placed
in the biliary duct were found in the major papilla
The stents were removed with a snare and a rat tooth forceps
Evidence of a previous sphincterotomy was noted in the major
papilla
Cannulation of the biliary duct was successful and deep with a
balloon sphincter using a free-hand technique.
Time Taken Not Noted Log-In Date/Time: [**2175-9-13**] 1:59 pm
BLOOD CULTURE
**FINAL REPORT [**2175-9-16**]**
Blood Culture, Routine (Final [**2175-9-16**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
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.
Ertapenem Susceptibility testing requested by DR.
[**First Name (STitle) **] [**Doctor Last Name **]
([**Numeric Identifier 83711**]).
SENSITIVE TO Ertapenem , sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final [**2175-9-14**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2175-9-14**] AT 0145.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final [**2175-9-14**]): GRAM
NEGATIVE ROD(S).
Multiple irregular filling defects were noted in the CBD, CHD
and the right and left main intrahepatic ducts
Pus and clots were extracted with balloon sweeps from the CBD,
CHD and the left main intrahepatic ducts.
Large amount of bright red bleeding was noted after the last
balloon sweep.
The 15mm balloon was positioned in the distal CBD and inflated
to provide tamponade
The balloon was deflated after approximately 10 minutes with
complete cessation of bleeding.
At this time, to provide continued hemostasis and re-establish
biliary drainage, a fully covered WallFlex Biliary metal stent
10mm x 80mm was placed in the bile duct extending down from the
left side of the hilar bifurcation.
No further bleeding was noted.
Recommendations: Pt will be admitted to the [**Hospital Ward Name 332**] ICU for
monitoring
If further bleeding occurs, pt will need angiography
No aspirin or NSAIDs
Continue with broad coverage IV antibiotics
[**2175-9-16**] 09:05AM BLOOD WBC-8.2 RBC-3.29* Hgb-9.8* Hct-28.9*
MCV-88 MCH-29.7 MCHC-33.7 RDW-16.8* Plt Ct-236
[**2175-9-14**] 03:58AM BLOOD ALT-66* AST-81* LD(LDH)-115 AlkPhos-237*
Amylase-108* TotBili-8.2*
[**2175-9-15**] 08:10AM BLOOD ALT-64* AST-73* LD(LDH)-146 AlkPhos-276*
TotBili-4.5*
[**2175-9-16**] 09:05AM BLOOD ALT-61* AST-64* AlkPhos-287* TotBili-3.1*
[**2175-9-16**] 10:24AM BLOOD ALT-60* AST-62* AlkPhos-282* TotBili-2.8*
[**2175-9-13**] 09:00AM BLOOD CA [**84**]-9 -Test Pending
Brief Hospital Course:
Dr. [**Known lastname 83712**] is a 66 year-old gentleman with locally-advanced
cholangiocarcinoma who underwent ERCP due to concern for
evolving cholangitis, with bleeding after stent manipulation,
who was transferred to the ICU for monitoring after tamponade
with expanding stent in effort to control bleeding from the
billiary tree (see ERCP report).He was transferred to the
medical floor on [**2175-9-14**].
.
#. Bleeding from ampula:
Pt was mildly tachy at presentation to [**Hospital Unit Name 153**] and while this
resolved somewhat was still midly tachy at time of call out.
Maintained BP during [**Hospital Unit Name 153**] course. Pt received 2 L NS and 2 units
PRBC at evening of presentation with Hct going from 24.8 to
28.1. On the AM of [**9-14**] pt had a 700cc melanotic BM. The ERCP
team was notified and stated that most likely this was blood in
stool from bleeding that had been cause during proceedure and
not indicative of a new bleed. This correlated with the clinical
situation. Pt was given 5mg Vit K for slightly elevated INR of
1.7. He received another unit of pRBC for a total of 3 units
during ICU course with f/u Hct 29.5. Antiplatelet agents were
held while in ICU. At time of call-out to floor there was no
evidence of active or large volume bleeding and pt had
improvement in abdominal pain. Pt did have elevated Tbili from
1.8 -> 8.2 likely [**2-14**] to bleeding and biliary dysfunction from
the regional trauma related to the proceedure. Pt was
transitioned to clears on AM of [**9-14**], however, pt was told that
solid foods would be held until he was a little futher out from
his ERCP. Full liquid diet with diabetic restrictions were
started in the evening of [**9-14**].
.
#. Cholangitis w/ bacteremia: Leukocytosis, hyperbilirubinemia,
RUQ pain - likely from cholangitis. Was tachycardic with
low-grade fever, concerning for sepsis. He was covered for
GN/anaerobes with zosyn and GP/MRSA with vanco. Clinic blood Cx
from [**9-13**] came back with gram negative rods which speciated as
ESBL E. Coli on [**2175-9-16**] sensitive to Meropenem on which he was
started. This will be continued for 14 days to [**2175-9-29**]. WBC
normalized. ERCP team saw him and removed previously placed
stents from the CBD. His LFTs trended downwards. A PICC line
was placed and he will continue antibiotics as instructed via
homeinfusion.
.
#. Tachycardia: likely due to underlying infection and possibly
volume depletion. Pt remained intermittently in mild sinus tach
while in unit. Was hovering around 100 at time of call-out. Was
given IVF initially. Pressures stayed stable during ICU stay.
Telemetry was continued on the medical unit. Tachuycardia
resolved with resoumption of diet.
.
#. Diabetes Mellitus Type II: oral hypoglycemics were held and
pt was maintained on ISS. OHA resumed on discharge.
.
#. Cholangiocarcinoma: no acute issues st this time. Pt is
followed by Dr. [**Last Name (STitle) 6401**] and Dr. [**Last Name (STitle) **]. He is s/p chemo with
Gemcitabine and Cisplatin last dose on [**8-23**]. Pt will follow up
on this as outpt. Uric acid was mildly supressed at 1.7.
Medications on Admission:
Glucophage 1gm [**Hospital1 **]
Glimepirde 2gm daily
Discharge Medications:
1. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
2. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Ertapenem 1 gram Recon Soln Sig: One (1) gram Injection once
a day for 12 days: Last dose [**2175-9-29**].
Disp:*12 gram* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Cholangitis
ESBL E. Coli bacteremia
GI Bleeding post ERCP (ampullary bleed) s/p 3U PRBC
Cholangiocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with cholangitis and recurrent biliary
obstruction. You underwent ERCP with retrieval of previously
placed CBD stents on [**2175-9-13**]. This was complicated by ampullary
bleeding for which you recevied 3U PRBC and were observed in
ICU. You were subsequently found to have bacteremia with
extended spectrum beta lactam (ESBL) resistant E. Coli infection
for which Meropenem was initiated on [**2175-9-16**] after empiric
treatment with Vancomycin and Zosyn from [**9-13**] to [**9-16**]. This will
change to once daily Ertapenem on discharge and should continue
through [**2175-9-29**]. I have verbally updated your PCP office so that
they are aware, and will fax a copy of your discharge summary to
them.
Followup Instructions:
Follow up with ERCP team who will be in touch with you with
follow-up appointment information as needed.
|
[
"041.4",
"576.1",
"576.2",
"790.7",
"155.1",
"E878.8",
"998.11",
"427.89",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.84",
"97.05"
] |
icd9pcs
|
[
[
[]
]
] |
10318, 10401
|
6798, 9925
|
325, 412
|
10552, 10552
|
2252, 6775
|
11456, 11564
|
1686, 1757
|
10028, 10295
|
10422, 10531
|
9951, 10005
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10703, 11433
|
1772, 2233
|
276, 287
|
440, 1237
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10567, 10679
|
1259, 1370
|
1386, 1670
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,341
| 107,700
|
30888
|
Discharge summary
|
report
|
Admission Date: [**2144-1-20**] Discharge Date: [**2144-1-31**]
Date of Birth: [**2084-3-2**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Esophageal Cancer
Major Surgical or Invasive Procedure:
Minimally invasive esophagectomy, mediastinal
lymph node dissection.
History of Present Illness:
Patient is a 59 year old gentleman who was found to have severe
dysphagia and weight loss and was noted to have a near
obstructing distal esophageal cancer. This was treated with an
esophageal stent placement and then chemotherapy and radiation.
His restaging head CT appeared to show stable if not improved
disease and he presents for minimally invasive esophagectomy.
Past Medical History:
ONCOLOGIC HISTORY (taken from OMR - [**Doctor Last Name **] [**11-12**]): This
59-year-old gentleman initially presented in [**11/2142**] due to
dysphagia and weight loss. At that time, he had a barium
swallow, which showed a pinpoint narrowing of his distal
esophagus. He had endoscopy and underwent dilatation of this
stricture. He did not have much improvement with the dilatation
and in [**Month (only) 116**] of this year underwent a second dilatation once again
with no improvement. He had motility tests, which were most
consistent with achalasia. In [**Month (only) **], he underwent a Botox
injection to the narrowing in order to help to release it. He
had a CT scan after this which showed a 1.5 cm gastrohepatic
lymph node. On [**2143-8-28**] he underwent an upper endoscopy on
which they saw distal esophageal narrowing. They also performed
multiple biopsies of the area of narrowing. Of note, they saw
some ulceration in the GE junction and a thick abnormal fold
concerning for esophageal or gastric cardia cancer. The biopsy
showed moderate to poorly differentiated adenocarcinoma. After
this he underwent endoscopic ultrasound, however, they were
unable to pass the ultrasound probe beyond the stricture. He has
had a port, g-tube, and esophageal stent placed. He started
treatement with 5-FU and Cisplatin on [**2143-10-10**] with concurrent
radiation therapy.
.
PMH:
1. Sinusitis status post 2 surgeries.
2. Hypertension.
Social History:
He originally moved from [**Country 6171**] 17 years ago. Married, 2
children. Teaches french and spanish. He used to smoke a pack a
day, but quit 15 years ago. He used to drink a couple of glasses
of wine with dinner each night, but not since diagnosis.
Family History:
He has a father with pancreatic cancer who died at the age of
70.
Physical Exam:
T: 98.1 HR: 91 BP: 104/58 RR: 20 O2sat: 99% (FM 0.4)
Gen: NAD, normal respiratory effort without stridor or stertor.
Symmetric facial movement.
Lungs: CTA b
Heart: RRR
Abd: Soft, NT, J tube in place
Ext: No CCE
Pertinent Results:
[**2144-1-20**] 09:41AM freeCa-1.07*
[**2144-1-20**] 09:41AM HGB-10.7* calcHCT-32
[**2144-1-20**] 09:41AM GLUCOSE-123* LACTATE-1.1 NA+-137 K+-3.4*
CL--103
[**2144-1-20**] 09:41AM TYPE-ART PO2-253* PCO2-41 PH-7.43 TOTAL
CO2-28 BASE XS-3
[**2144-1-20**] 02:41PM freeCa-1.04*
[**2144-1-20**] 02:41PM HGB-11.9* calcHCT-36
.
DIAGNOSIS:
I. Left peri-esophageal lymph node (A):
1. Anthracosis and hyperplasia.
2. No tumor.
II. Peri-esophageal tissue (B):
Fibroadipose tissue with one small lymph node: No tumor.
III. Esophagogastrectomy (C-AF):
1. Regional lymph nodes and adjacent tissue:
a. Metastatic adenocarcinoma in 4 of 6 perigastric lymph nodes
and separate foci of tumor in the adjacent adipose tissue.
b. No tumor in 10 peri-esophageal lymph nodes.
2. Extensive ulceration and fibrosis of the distal esophagus
with transmural tear, status-post chemoradiation.
3. There is no residual carcinoma in the esophagus.
4. The proximal squamous-lined esophagus and gastric fundic
portion are unremarkable.
Clinical: Esophageal cancer, post-chemoradiation.
.
RADIOLOGY Final Report
UGI SGL CONTRAST W/ KUB [**2144-1-24**] 10:11 AM
Reason: Assess anatomy for leak at anastamosis site. Please use
Thi
IMPRESSION: No evidence of leak at the cervical esophagectomy
anastomosis.
Surgical staples, drain, subclavian line and NG tube in
appropriate position.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2144-1-29**] 5:35 AM
Reason: reasses pneumothoraces
[**Hospital 93**] MEDICAL CONDITION:
59 year old man s/p esophagogastrectomy, s/p R chest tube
removal, stable R PTx on last CXR, now with slight increase SOB
REASON FOR THIS EXAMINATION:
reasses pneumothoraces
REASON FOR EXAMINATION: Followup of a patient after
esophagogastrectomy.
IMPRESSION: Overall stable appearance of post-surgical chest.
Decrease in free intraperitoneal air.
Brief Hospital Course:
Mr. [**Known lastname 73080**] operative course was prolonged as expected, but
uncomplicated. He was routinely observed in the PACU, and
transferred to the ICU for closer monitoring due to the
complexity/acuity of the surgery.
.
ICU [**Date range (1) 68315**]:He tolerated extubation. Both Left & Right CT's
were placed to 20cm of suction. [**1-22**]: hoarseness was noted with
speaking. ENT service was consulted, and patient noted to have
left vocal cord paralysis. Currently, no need for inpatient
intervention as pt stable; should follow-up with Dr. [**Last Name (STitle) **]
as outpt.
.
On [**1-23**], he was transferred to [**Hospital Ward Name 2978**] for routine post-op care.
He continued NPO with NGT to suction, and IV hydration. The
left cervical JP drain to bulb suction was intact with scant
serous output. Left and Right Chest tubes to 20cm of suction
with no evidence of leak; draining serosanguinous fluid. JTUBE
was patent draining green, bilious fluid to gravity bag. Foley
catheter was patent, and draining clear urine. His pain was
managed with IV Dilaudid. He reported adequate pain management,
[**6-13**]. He was assisted to chair.
.
On [**1-24**], Tube feeds were started at 10cc/h. Nutrition Team was
consulted for adequate caloric intake. Tube feed formula and
rate was modified per Nutrition recommendations throughout
admission. He underwent a Barium swallow which revealed NO LEAK.
His NGT was removed. He remained NPO. Social Work was consulted
for support, and Physical Therapy was consulted due to expected
prolonged hospitalization and recovery. He will likely require
REHAB.
.
On [**1-25**], his foley catheter was removed. He was able to urinate
independently. He was advanced to sips of clear liquids, and
tolerated well. He continued with tube feedings via JTUBE.
Medications were transitioned to PO/PJTUBE as tolerated,
including PO oxycodone which relieved pain adequately. CXR
revealed increased bilateral pneumothoraces. Chest tubes were
put back to 20cm of suction. Treated with IV Lasix.
.
On [**1-26**], CXR revealed resolving pneumothoraces. Bilateral chest
tubes were place to water seal. Treated with IV Lasix. He was
advanced to clear liquids, and tolerated well. He continued with
tube feedings via JTUBE. Blood sugars remain controlled, treated
with regular insulin sliding scale. Pain continued to be well
managed.
.
On [**1-27**], Chest xray improved, and Righ Chest Tube was removed.
Treated with IV Lasix. Respiratory status remained stable. His
diet was advanced to regular, dysphagia diet.
.
on [**1-29**], Chest xray stable, and Left Chest Tube removed.
Respiratory status remained stable. He was able to tolerate
adequate PO intake with regular food. Tube feedings were
discontinued. His weight has remained stable.
.
On [**1-30**],he has remained stable, awaiting Rehab placement. His
physical & surgical status has improved daily. He was
re-evaluated per physical therapy, and cleared for discharge
home with VNA & PT. He & his wife agreed with this plan. His
last bowel movement was Tuesday [**2144-1-30**]. He will be discharged
with oxycodone, colace, ativan, and albuterol. He will follow-up
with Dr. [**Last Name (STitle) **] in [**2-5**] weeks, JTUBE will be removed in office
at that time as indicated.
Medications on Admission:
Ativan 0.5 PRN, compazine 10 PRN, Zofran 4 PRN, Protonix 40'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 2 weeks.
Disp:*35 Tablet(s)* Refills:*0*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for sleep anxiety.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*1*
5. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-5**] Inhalation every
4-6 hours as needed for shortness of breath or wheezing: Use
with spacer chamber.
Disp:*1 * Refills:*1*
7. Spacer
Aerochamber spacer-to be used with albuterol inhaler as
directed.
Size: Large/Adult
Disp:1 Refill:1
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
Primary:
Esophageal cancer
.
Secondary:
sinusitis/sinus polyps, HTN, anxiety
Discharge Condition:
Stable
Tolerating Regular Consistency: Soft (dysphagia); Thin liquids
diet
Adequate pain control with oral medications
Discharge Instructions:
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
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 vomiting,
diarrhea or other reasons.
*Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Do not drive or operative heavy machinery while taking pain
medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
.
JTUBE care:
*Keep tube securely fastened to skin to avoid pulling.
*If tube falls out, apply dressing & pressure, and head to
closest Emergency Room.
Followup Instructions:
1. Follow up with Dr. [**Last Name (STitle) **] in [**2-5**] weeks. Please call his
office for an appointment ([**Telephone/Fax (1) 1483**].
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2144-2-20**] 11:30
3. Provider: [**Name10 (NameIs) 8111**] [**Name11 (NameIs) 8112**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2144-2-20**] 12:30
4. Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 36206**] [**Telephone/Fax (1) 73081**], in 1 week or as needed.
Completed by:[**2144-1-30**]
|
[
"300.00",
"478.31",
"473.8",
"401.9",
"196.2",
"151.0",
"512.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"40.3",
"42.41"
] |
icd9pcs
|
[
[
[]
]
] |
9062, 9153
|
4716, 7988
|
288, 359
|
9274, 9395
|
2829, 4307
|
11048, 11706
|
2511, 2579
|
8099, 9039
|
4344, 4466
|
9174, 9253
|
8014, 8076
|
9419, 9419
|
9434, 11025
|
2594, 2810
|
231, 250
|
4495, 4693
|
387, 759
|
781, 2222
|
2238, 2495
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,419
| 139,304
|
33685
|
Discharge summary
|
report
|
Admission Date: [**2132-2-5**] Discharge Date: [**2132-2-9**]
Date of Birth: [**2092-8-30**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
The pt is a 39 year-old right-handed M who presented with
confusion and agitation to [**Hospital3 **] today after an
apparent generalized seizure.
The pt was unable to offer a history at the time of my
encounter. Therefore, the following history is per the primary
team, the medical record, and the patient's wife, who witnessed
the primary event.
The patient's seizure history begins in [**2129-1-18**] when he had a
generalized seizure in mid-air to vacation in [**State 108**]. He was
seen to lose consciousness, foam at the mouth, then stiffen and
shake all over for 1-2 minutes, followed by an extended period
of confusion and drowsiness. He was briefly evaluated on arrival
and discharged with no anticonvulsant coverage, as per his wife,
he
was felt to have been dehydrated.
His next suspicious event was in [**2131-5-6**], when he was driving
home with his two young sons in the car, one 14yo. He hit two
parked cars and his son felt that he had had a seizure, though
details at this time are not further known.
He then saw a neurologist, Dr. [**Last Name (STitle) 37270**] ([**Telephone/Fax (1) 77974**]), but the
diagnosis of seizure was left uncertain and he was again not
treated.
In mid-[**Month (only) 956**], he had another unexplained car accident. This
event, like the others, was associated with amnesia for what had
happened on the part of the patient. This time, he was quite
agitated afterwards and was admitted to [**Hospital3 417**] and
started on dilantin. The day after discharge, his neurologist
discontinued dilantin and started him on a lamictal taper. He is
currently taking 50mg [**Hospital1 **] and no other anticonvulsants.
Today, he was doing some housework in the basement around
9:15am. Near 10ish, he walked upstairs and sat down on the
couch. His wife began speaking to him but he just stared back
blankly and for the first 5 minutes or so, she felt that he was
kidding around with her. He had no adventitious movements at
this time. He seemed "zoned out" and was moving his head around
aimlessly.
He then suddenly lost consciousness, began to foam at the mouth,
stiffened and shook, with no apparent focal onset of motor
activity. His wife called EMS.
On their arrival, seizure activity had ceased but he was
extremely agitated. He continued to be so on arrival to [**Hospital1 6591**] and he was given ativan 2mg IM x 3 to no effect, then
restrained and given a total of haldol 35mg IV, and then he was
paralyzed with succinylcholine and rocuronium, and intubated. He
was reportedly loaded with dilantin 2g IV. Head CT was negative.
Here, he has been sedated with [**Hospital1 **] but when lightened, he
rouses and moves all extremities equally.
Per his wife, he had a normal birth and developmental history,
with no other history of seizures, febrile or otherwise. He has
not reported auras to her of any kind.
The pt was unable to offer a review of systems but per his wife,
he has had no fever, chills, cough, sputum, chest pain, N/V/D,
edema, rashes. She says he has been sleeping well, taking his
prescribed meds.
Past Medical History:
Seizure disorder
h/o heavy drinking but no longer
Social History:
Married, worded in factory that made specialty labes, now works
in postal office. Quit heavy smoking, cutting back to quit 4
days ago. One drink night prior to admission (St. [**Doctor Last Name **]
day), otherwise has been very infrequent. No illicits.
Family History:
negative for seizures, though mother is uninvolved and they know
little about her. His cousin has MS.
Physical Exam:
VS 98.0 96-120 126/59 12 100%
Gen intubated, NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO
MS
[**First Name (Titles) **] [**Last Name (Titles) **] briefly, he opens his eyes to noxious stimuli. Does
not track or follow commands.
CN
Pupils 3 to 2mm. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages. Blinks to threat b/l. EOMI to
oculocephalic maneuver. Corneal reflex and nasal tickle present
bilaterally. No overt facial asymmetry. Gag reflex intact.
MOTOR
Normal bulk, tone throughout. Withdraws to noxious stimuli in
all
four extremities and makes purposeful movements throughout and
symmetrically. No adventitious movements noted. No asterixis
noted. No myoclonus noted.
SENSORY
Grimaces to noxious stimuli in all four extremities.
REFLEXES
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
Pertinent Results:
ABNORMALITY #1: Throughout the recording the background
consisted of
low voltage fast beta frequency activity. There were no areas of
prominent focal slowing. There were no epileptiform features.
BACKGROUND: As above.
HYPERVENTILATION: Could not be performed as this was a portable
study.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as this
was a
portable study.
SLEEP: No normal waking or sleeping morphologies were noted.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 60 beats per minute.
IMPRESSION: This is an abnormal portable EEG due to the abnormal
background consisting of low voltage fast beta frequency
activity. This
likely reflects medication effect from benzodiazepine or
barbiturate
administration. There were no areas of prominent focal slowing.
There
were no epileptiform features. No electrographic seizure
activity was
noted.
INTERPRETED BY: [**Last Name (LF) 96**],[**First Name3 (LF) 125**] H.
OSH: cbc unremarkable (wbc here 12.2)
chem 10 unremarkable, apart from CO2 14
tox negative
UA neg for UTI
INR 1.0
Imaging
NCHCT at OSH negative for mass, bleed, stroke
[**2132-2-9**] 10:05AM CK(CPK)-8933*
[**2132-2-9**] 06:40AM CK(CPK)-9523*
[**2132-2-8**] 07:30AM CK(CPK)-[**Numeric Identifier **]*
[**2132-2-7**] 07:20PM CK(CPK)-[**Numeric Identifier **]*
[**2132-2-7**] 08:10AM CK(CPK)-8083*
[**2132-2-7**] 12:04AM CK(CPK)-7253*
[**2132-2-6**] 12:25PM CK(CPK)-6435*
[**2132-2-6**] 02:20AM CK(CPK)-6295*
[**2132-2-5**] 09:31PM CK(CPK)-6340*
TSH-23*
Free T4-0.66*
[**2132-2-8**] 07:30AM Phenyto-8.3*
[**2132-2-7**] 12:04AM Phenyto-10.8
[**2132-2-6**] 02:20AM Phenyto-11.6
[**2132-2-5**] 09:31PM Phenyto-12.3
[**2132-2-7**] 07:20PM Albumin-4.1
Brief Hospital Course:
Mr. [**Known lastname 47097**] is a 39yo M with seizure disorder on subtherapeutic
doses of Lamictal started 4 weeks ago, who presented after an
apparent secondarily generalized seizure given the preceeding
period of decreased responsiveness. He was intubated and heavily
sedated with 35mg Haloperidol IM&IV prior to transfer to this
hospital.
Neurologic exam on arrival present was reassuring for minimal
sedation and intact brainstem reflexes and no asymmetry on exam.
The likely cause of his seizure was inadequate coverage with
anticonvulsants.
1) Seizure Disorder-
There were no signs of infection or other triggering event. The
patient was noted to have CK ~6,000 the evening of admission
with low grade temperature of 100.5. The patient underwent LP
that was unrevealing with 1 WBC, normal protein and glucose. The
patient was extubated in the neuro ICU the following day and had
a normal neurologic exam. Given the focal onset, he would
require MRI to investigate for a focal lesion. However this was
performed at another facility in [**2131-9-20**]. Report and
images were obtained and without evidence of abnormality.
Routine EEG with mini-sphenoidal electrodes was performed
showing generalized slowing with fast Beta, but no asymmetry or
epileptiform discharges. He was continued on dilantin and
started on Lamictal. He should remain on dilantin until
therapeutic levels are reached on lamictal. He is cleared to
return to work, but it was discussed at length he should not
perform any activities that would put himself or others in
danger should he lose consciousness. He should not drive or
operate machinery for at least 6months according to
[**State 350**] law. He will follow up with Dr. [**First Name8 (NamePattern2) 10378**] [**Last Name (NamePattern1) 14440**] and
Dr. [**First Name8 (NamePattern2) 9485**] [**Last Name (NamePattern1) **] in [**Hospital 878**] Clinic.
2) Elevated CK's-
Likely secondary to seizure and large (35mg) dose of haloperidol
given at outside hospital. Troponins were negative. His TSH was
also notably elevated to 23. He was aggressively hydrated for
goal UOP 200cc/hr. UA however was negative for myoglobin. CK's
were trending down at time of discharge to 8933 from a peak of >
12,000.
3) Elevated TSH-
Notably elevated to 23. Free T4 was 0.66. Etiology likely
Hashimoto's. Pt was continued on Thyroid replacement. He will
follow up with his PCP for further titration and repeat TFT's in
a few months.
Medications on Admission:
Lamictal 50mg [**Hospital1 **]
Chantix 1mg [**Hospital1 **] (started 4 days prior to admission)
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*2*
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lamictal 100 mg Tablet Sig: Please see below Tablet PO twice
a day: Please take [**11-21**] pill [**Hospital1 **] x 1 week, then [**11-21**] pill q
AM/1pill q PM x 1 week, then 1 pill [**Hospital1 **] x 1 week, then 1 pill q
AM/1.5 pill q PM x 1 week, then 1.5 pills [**Hospital1 **] x 1 week, then 1.5
pill q AM/2 pills q AM x 1 week, then 2 pills [**Hospital1 **] continuous.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
rhabdomyolysis
hypothyroidism
Discharge Condition:
stable
Discharge Instructions:
Please call your primary care physician or return to the
emergency room if you experience seizure, uncontrolled muscle
pain, chest, shortness of breath.
Please take your medication as prescribed. You will slowly be
increasing your doses of Lamictal over seven weeks. Once this
medication has reached an adequate level, the dilantin will be
titrated off. This will be done by Dr. [**Last Name (STitle) 14440**] in the neurology
clinic. Call him for any questions ([**Telephone/Fax (1) 5088**].
Followup Instructions:
Please make a follow up appointment to be seen by Dr. [**First Name8 (NamePattern2) 10378**]
[**Last Name (NamePattern1) 14440**] and Dr. [**Last Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 5088**] in the
neurology clinic in the next 2 weeks.
Please make an appointment to see your primary care physician in
the next 1-2 weeks.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"244.9",
"728.88",
"345.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10129, 10135
|
6865, 9320
|
322, 339
|
10217, 10226
|
5132, 6842
|
10772, 11236
|
3800, 3904
|
9466, 10106
|
10156, 10196
|
9346, 9443
|
10250, 10749
|
3919, 5113
|
275, 284
|
367, 3438
|
3460, 3512
|
3528, 3784
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,677
| 164,194
|
21154+57222
|
Discharge summary
|
report+addendum
|
Admission Date: [**2117-5-11**] Discharge Date: [**2117-5-24**]
Date of Birth: [**2060-5-1**] Sex: F
Service: MED
CHIEF COMPLAINT: Failure to thrive.
HISTORY OF PRESENT ILLNESS: 57-year-old female with a
recently diagnosed cirrhosis, presumed alcoholic in nature
recently diagnosed on a recent admission to [**Hospital1 **] on [**2117-4-6**],
history of hypertension, now having a generalized failure to
thrive. Apparently was admitted to [**Hospital1 **] on [**2117-4-27**] with
history of bilateral lower extremity edema, increased
abdominal girth with 20 pound weight gain. Had Doppler's of
the lower extremities which were negative for deep venous
thrombosis. Had an unremarkable chest x-ray both found with
increasing LFTs and pneumonia level. Was started on Lasix
and Spironolactone. Had abdominal CT during this admission
which demonstrated nodular liver consistent with cirrhosis,
an ultrasound was unable to assess portal flow but
enlargements of ascites that were unable to be drained on
several attempts on the floor. The patient was to be tapped
but left AMA. Now returns to the emergency department after
increased lethargy and abdominal pain over the last two
weeks. Per reports sister found the patient on sofa
extremely lethargic. The patient is a poor historian but
reports poor p.o. intake over the last several days. Denies
fever or chills. He reports increased one episode of emesis
over the past one week, also some diarrhea. Denies chest
pain. Also reports mild productive cough times one day.
Today in the emergency department the patient was found
hypothermic to 95 and slight tachycardiac but otherwise
hemodynamically stable. Chest x-ray showed questionable right
middle lobe, left lower lobe infiltrate. Ultrasound again
shows ascites and cholecystitis. The patient was found with
leukocytosis and given Vancomycin, Ceftriaxone and Flagyl.
There are several attempts by emergency department and
medicine house staff to drain fluid from her abdomen but were
unsuccessful despite having ultrasound marked ascitic fluid.
PAST MEDICAL HISTORY: Presumably new diagnosed alcoholic
cirrhosis.
Hypertension.
Status post tubal ligation.
ALLERGIES: Zestril with interstitial swelling.
MEDICATIONS:
1. Lasix 40 mg q day.
2. Spironolactone.
SOCIAL HISTORY: The patient has a history of alcohol abuse.
Per family report is still drinking at time of admission.
Reports no tobacco or intravenous drug abuse. Reportedly
lives alone.
FAMILY HISTORY: Coronary artery disease and diabetes.
Family contacts include sister [**Name (NI) **] [**Name (NI) 3827**], [**Telephone/Fax (1) 56098**]. Also Cell phone #[**Telephone/Fax (1) 56099**].
PHYSICAL EXAMINATION: Patient hypothermic at 95.2, blood
pressure 131/81, pulse 100's, respiratory rate 20, 94% on two
liters. In general she is an obese female sitting in bed, in
no acute distress. Oriented to [**Hospital1 **] and to the year. Head,
eyes, ears, nose and throat significant for icteric sclera.
Pupils reactive. Oropharynx: Positive dentures, dry mucous
membranes, no JVP. Mildly icteric sclera. Cardiovascular
examination: Tachycardiac and regular, 2/6 systolic ejection
murmur left sternal border. Pulmonary examination shows
decreased breath sounds throughout, poor inspiratory effort.
Abdominal examination was obese, protuberant, positive fluid
waves, mild diffuse tenderness, no rebounding. Extremities:
2+ lower extremity edema.
LABORATORY FINDINGS: On admission white count 17.3,
hematocrit 38.6, platelet count 217, chemistry is sodium 136,
potassium 3.7, chloride 100, bicarbonate 20, BUN 30,
creatinine 1, glucose 100, calcium and alkaline phosphatase
9.1, 2.2, 3.5. ALT 25, AST 58, alkaline phos 151, amylase
11, lipase 23, total bili 8.9, albumin 2.7, INR 2.2. urine
tox screen negative. She had a lactate 3.5. She had a CK
and troponin which was negative. She had a Hepatitis panel
from outside which was negative. AFP negative. She had a
TSH of 9.6, CA-125 elevated at 942. Blood cultures and urine
cultures are pending at time of admission.
Chest x-ray shows questionable right lower lobe infiltrate
and small left pleural effusions and atelectasis. UA SPECT
graft 1025, pH 5.5, urobilinuria 4, large blood leukocyte
esterase, proteins, ketones Ultrasound showed prominent
ascites. Gallstones with gallbladder distension. No
thickening, no intra-hepatic lesion, common bile duct normal.
She had abdominal and chest CT which shows nodular liver
consistent with cirrhosis, gallstones and moderate free fluid
and ascites. Her echocardiogram from last admission shows
ejection fraction of 65%, dilated left atrium, normal right
atrium, E to A is 1.0. Triple MR.
HOSPITAL COURSE: Neurological. The patient came in with
failure to thrive. She was empirically treated for a
questionable pneumonia and FPP with Ceftriaxone and Flagyl.
She had received Vancomycin in the emergency department.
Initially the patient was unable to be tapped for
paresthesias so was empirically treated for FFP. It was felt
that Ceftriaxone and Flagyl will also cover for possible
aspiration pneumonia. As time went on it was felt that a
majority of the patient's mental status changes was secondary
for encephalopathy. She was started on Lactulose. Her
hepatic encephalopathy was complicated by a trip to the MICU
for an upper gastrointestinal bleed with resulting erosive
esophagitis. Later during her hospital course she developed
an iliaus which made Lactulose extremely difficult. During
this period of her hospital course her encephalopathy
progressed to approximately Stage III. The patient did
receive p. r. Lactulose with minimal effect. As there was
evidence of her ilius improving she then received Lactulose
orally, and has shown some improvement in her mental status.
At time of dictation however, she is still quite lethargic
and minimally verbal at this point. She has also been
started on p.o. Flagyl for additional assistance in
management of possible hepatic encephalopathy. Other causes
for encephalopathy such as gastrointestinal bleed,
electrolyte abnormalities and infections have also been
evaluated and at this point there is no evidence of
infection. Her lytes remain stable and her crit has also
remained stable.
Cardiovascular: The patient has remained tachycardiac during
her hospital course with rates from 100 to 110's. It is felt
that this represents mild hypovolemia secondary to poor p.o.
intake. She has been grossly overloaded during her hospital
course but thought to be possibly intravascularly dry. Later
on during her hospital course she had some episodes of
hypertension which have responded to intravenous fluids. It
is felt at this time as mentioned above that the patient may
be slightly hypovolemic.
Pulmonary: As mentioned above the patient initially came in
and was treated empirically for questionable pneumonia with
Ceftriaxone and Flagyl. She has never had sputum cultures to
date. Later during her hospital course the patient's
leukocytosis did improve and the patient did not spike fevers
and her oxygen saturations did not decrease. It is felt at
this point that the patient likely has some significant
atelectasis and likely effusion secondary to generalized
anasarca and atelectasis. She is not currently being treated
for a pneumonia. As mentioned above, the patient is grossly
overloaded but from a respiratory standpoint has been stable
with only minimal O2 requirements.
Gastrointestinal: The patient admitted with failure to
thrive there was concern that the patient may be suffering
from spontaneous bacterial peritonitis. Since multiple
attempts to tap the belly were unsuccessful and suspicion was
high, the patient was empirically started on Ceftriaxone.
Later, during hospital course after several days on
Ceftriaxone the patient did end up undergoing paracentesis.
Ascitic fluid was remarkable for approximately 250
neutrophils. Gram stain did show one colony of rare
bacteria. Given the patient's initial tenuous course there
was concern that this bacteria represented possible treatment
failure for SBP. Consequently she was switched to
Vancomycin, Zosyn, and Ceftriaxone and Flagyl were
discontinued. Later on during hospital course it was felt
that this bacteria was a contamination. Again, the patient
has been afebrile without a leukocytosis, she has been
continued on p.o. Ciprofloxacin for spontaneous bacterial
peritonitis prophylaxis. Meanwhile early in her hospital
course she had an episode of coffee ground emesis that was
concerning for Upper gastrointestinal bleed. She was
evaluated in the MICU and underwent a semi-emergent
esophagogastroduodenoscopy which showed mild erosive
esophagitis and poor leukothropathy. No varices present.
She was placed on aggressive Proton pump inhibitor. Her
hematocrit remained stable during the remainder of her
hospital course. Her gastrointestinal course which was
further complicated by a poorly understood small bowel
obstruction verses ilius. She had been evaluated by surgery
when initial CT was concerning for possible obstruction.
Given her Class C status she is not a candidate to travel to
the O.R. and was basically left to conservative management
via nasogastric tube, NPO intravenous fluids. At the time of
this dictation the patient's ilius has shown signs of
improvement with decreased abdominal distension and now
having bowel movements on p.o. Lactulose. For the time being
she continues on TPN. Pending improvement and the patient's
status will need to revisit whether the patient will begin
p.o. feeds either via nasogastric tube or orally. Also with
respect to gastrointestinal, the patient has been followed by
Liver service and has been treated for presumed alcoholic
cirrhosis. She has been on Trental, is continued on
Thiamine, Folates, and PPI's.
As mentioned above, the patient has severe liver disease.
She is classified as Childs C at this point. Per discussions
with liver at this point the patient is likely not a liver
transplant patient candidate. She is not a surgical
candidate for evaluation of SBO/ilius. The patient's
condition at this point remains guarded and further
discussions will take place between primary team, liver and
family to determine final course of treatment. Also of note,
analysis of peritoneal fluid revealed question of malignant
cells. The patient is due to be re-tapped on [**2117-5-25**] for
evaluation of a potential malignancy.
Heme. The patient was evaluated at MICU for an upper
gastrointestinal bleed. Her hematocrit has actually remained
quite stable during her hospital course. Meanwhile the
patient has remained coagulopathic with elevated INRs thought
secondary to poor nutrition and also liver disease. In
addition she has developed an increasingly worsening
thrombocytopenia. Laboratory work revealed that she is HIB
antibody positive and she will need to abstain from all
heparin products. Felt that her worsening thrombocytopenia
was likely secondary to hypersplenism from her severe liver
disease. No treatment is planned for this point but
supportive care.
Infectious Disease: As mentioned above, the patient
initially empirically started on Ceftriaxone and Flagyl for
question of pneumonia and also SPT. Following analysis of
her initial peritoneal fluid and evidence of rare bacteria
there were initial concerns that the patient had treatment
failure for treatment with subcutaneous bacterial parameters
and she was treated briefly on Vancomycin and Zosyn. As the
patient has remained afebrile during our entire hospital
course to this point, with improved leukocytosis and blood
cultures and urine cultures have been negative to date,
antibiotics have eventually been discontinued. At current
time she is taking p.o. Flagyl and p.o. Ciprofloxacin for
treatment of hepatic encephalopathy and prophylaxis for
spontaneous bacterial peritonitis respectively.
Renal: The patient's initial hospital course was complicated
by poorly understood oliguric renal failure. Based upon
urinalysis and physical examination, it was felt that the
patient was likely severely hypovolemic. Given her severe
liver disease however, there was also concerns for
hepatorenal syndrome. Later on, with decreasing urine output
there were also concerns for ATN. The Renal Team was
consulted for further advice and management. The patient
essentially was trialed on continuous intravenous fluids and
eventually the patient's creatinine had improved to 0.6. She
was currently making over 5 to 600 cc's of urine at this
point and is no longer considered oliguric. She is still
receiving gentle intravenous fluids and receiving TPN at this
point. Care must be taken for the patient's fluid balance as
she is grossly overloaded but likely intravascularly
hypovolemic.
Access: The patient has left IJ triple lumen catheter that
was placed on [**2117-5-16**].
Code: Several discussions have taken place between house
staff and the patient's sister [**Name (NI) **] [**Name (NI) 3827**] underscoring
how severely ill this patient is. At current the patient
remains DNR/DNI. The family is aware of how sick the patient
is. They have advised the patient is not a surgical
candidate and likely not a transplant candidate. Further the
patient's family is aware that her DNR/DNI status may need to
be revisited if patient failed to show improvement or if
decompensates. Please see the patient's sister numbers in
the chart.
DISCHARGE DIAGNOSIS: Presumed alcoholic cirrhosis.
Coffee ground emesis, thought secondary to esophagitis.
Small bowel obstruction verses ilius, now resolving.
Question of spontaneous bacterial peritonitis.
E. Coli urinary tract infection pan sensitive.
Oliguric renal failure.
Thrombocytopenia, Heparin induced thrombocytopenia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 5825**]
Dictated By:[**Last Name (NamePattern1) 11267**]
MEDQUIST36
D: [**2117-5-24**] 19:40:24
T: [**2117-5-24**] 22:18:32
Job#: [**Job Number 56100**]
Name: [**Known lastname 10515**],[**Known firstname 3650**] Unit No: [**Numeric Identifier 10516**]
Admission Date: [**2117-5-11**] Discharge Date: [**2117-5-27**]
Date of Birth: [**2060-5-1**] Sex: F
Service: MED
Allergies:
Zestril
Attending:[**First Name3 (LF) 211**]
Chief Complaint:
Addendum:
Major Surgical or Invasive Procedure:
na
Brief Hospital Course:
[**2117-5-27**] am patient was unarousable and developed increased
oxygen requirements and had very labored breathing. She was also
very edematous. Chest x-ray and abdominal xray were performed
at this time which showed increased abdominal distention. ABG
was obtained which revealed a respiratory acidosis as well as a
metabolic acidosis. Blood cultures were obtained. Antibotics
were started and patients lasix increased. Full efforts were
being exercised. As the morning progressed the team spoke with
patient's son, [**First Name8 (NamePattern2) **] [**Known lastname **], about the status of his mother.
[**Name (NI) 10517**] measures only were agreed upon by son and antibiotics
and medications were discontinues. A morphine drip was started
at that time.
At 6:45 pm called to patient's bedside by nurse. The patient had
stopped breathing and had no pulse. [**Name (NI) **] son was at the
bedside. Pt was unresponsive to painful stimulus. She had no
heart or lung sounds and pupillary reflexes were absent. Pt was
pronouced dead shortly thereafter. Spoke with son regarding
[**Name2 (NI) 10518**] and he stayed with his mom for an hour.
Discharge Disposition:
Home
Facility:
n/a
Discharge Diagnosis:
Death
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**] MD [**MD Number(1) 225**]
Completed by:[**2117-5-27**]
|
[
"287.4",
"572.4",
"286.7",
"567.8",
"572.2",
"571.2",
"584.9",
"789.5",
"303.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"45.13",
"99.15",
"99.05",
"54.91",
"38.93",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
15700, 15721
|
14524, 15677
|
14497, 14501
|
15770, 15775
|
15827, 15987
|
2512, 2702
|
15742, 15749
|
4740, 13497
|
15799, 15804
|
2725, 4722
|
14448, 14459
|
202, 2085
|
2108, 2304
|
2321, 2495
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,272
| 188,605
|
25583
|
Discharge summary
|
report
|
Admission Date: [**2173-10-17**] Discharge Date: [**2173-11-5**]
Date of Birth: [**2102-9-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
altered mental status/fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 71 y/o male with PMH significant for plasma cell
leukemia/multiple myeloma dx in [**5-/2173**] after presenting with
diffuse bony pain in the setting of a recent MVA. He was
treated with velcade and decadron and has recently completed his
6th course about 2wk ago. His treatment has been complicated by
invasive aspergillosis treated with TIW ambisome and a recent
hospital admission on [**8-23**] for febrile neutropenia.
.
He presented to the ED on [**10-17**] with change in mental
status/lethargy along with chills/fever. He was noted to have
an elevated lactate and transferred to the [**Hospital Unit Name 153**] for presumptive
sepsis along with hypercalcemia. He had been in his usual state
of health prior to this episode and denied any sick contacts,
CP, SOB, abdominal pain, N/V, diarrhea, HA, weakness, or
palpatations.
.
In the [**Hospital Unit Name 153**], his Bcx grew MRSA and his port was d/c and replaced
w/ PIV. His mental status changes were thought to be more due
to his hypercalcemia than his infection but he has failed to
normalize completely despite correction of his hypercalcemia w/
pamidronate and treatment of his infection w/ IVF, vanco, and
ambisome.
.
He was called out to the floor where he was started on cefepime
for febrile neutropenia. He received an LP which was normal
other than demonstrating plasma cells in the CSF. His mental
status improved during his stay here and he was AAO x2 on the
day after call-out rather than AAO x1. On the day after
call-out, however, the patient was seen to be hypotensive to the
90s. He responded to a 1L bolus but then quickly became
hypotensive again. He was transfered back to the unit [**1-20**]
hemodynamic instability.
.
On [**10-22**], he was again called out to the floor by the [**Hospital Unit Name 153**].
During his stay in the ICU, his major problems included
infection for which he was continued on his antibiotics (vanco,
ambisome, flagyl, acyclovir, adn , coagulopathy requiring
product transfusion, continued hypotension complicated by
significant peripheral edema, and continued diffuse bony pain.
He remained well from a respiratory standpoint. His code status
was changed to DNR/DNI after discussion between his proxy and
Dr. [**First Name (STitle) 1557**].
.
Onc Hx:
Pt presented in [**2173-5-19**] for evaluation of diffuse bone
pain, at which time he was noted to have an increased BUN,
creatinine, and was hypercalcemic. Treated at this time with IV
fluids, steroids, Velcade and an injection of Pamidronate. Bone
marrow bx was done on [**6-9**], showing extensive involvement by
plasma cell myeloma with 80-90% cellularity. A skeletal survey
at that time showed probable multiple myeloma, and a Beta 2
microglobulin level was 22.0. He has a IgG kappa monoclonal
protein, and presented to Dr. [**First Name (STitle) 1557**] with stage IIIB
myeloma/plasma cell leukemia. He has been on the Velcade
protocol since [**7-21**].
Past Medical History:
1. Diabetes mellitus type 2
2. Multiple Myeloma: dx [**5-23**], treated w/ velcade; c/b
pancytopenia
3. hx of invasive aspergillosis dx in [**7-/2173**], on ongoing TIW
ambisome treatment
4. baseline creatinine since diagnosis 1.8-2.3
5. Hypertension
6. Hyperlipidemia
7. s/p MVA
8. s/p tonsillectomy at age 19
Social History:
Retired, previously worked as a florist. He lives with his
daughter [**Name (NI) 3968**] who is involved in his care. He has a history of
15 years of cigarette smoking, stopped 20 years ago. No
recreational drug use. Social alcohol.
Family History:
Sister with DM.
No family history of cancer or heart disease.
Physical Exam:
97.9, 102/50, 67, 19, 95%
Gen: Sedated minimally arousable AA man in NAD
HEENT: proptosis, pupils small, MMM, no LAD
Chest: Crackles at the bases
CV: RRR, S1/S2 intact, 2/6 systolic murmur at apex
Abd: +BS, soft, nontender, nondistended
Ext: 2+ DP, no edema, diffuse pain w/ any movement
.
CULTURES: STAPH AUREUS (BCx [**10-17**]); all others w/ NGTD
.
CT HEAD W/O CONTRAST [**10-17**]:
No mass effect or hemorrhage. Multiple lytic areas in the skull
likely secondary to patient's history of multiple myeloma.
.
CT CHEST W/O CONTRAST [**10-18**]:
1) Multiple new diffuse nodular opacities, with a dominant right
upper lobe cavitary lesion. Many previously evident areas of
consolidation have improved with evolving cystic cavities. New
lung findings most likely represent recurrence of known invasive
aspergillosis. A secondary infectious process, such as other
fungal organisms, septic emboli, Nocardia, or pseudomonas, is an
additional differential consideration.
2) Increasing mediastinal lymphadenopathy.
3) Small bilateral pleural effusions.
4) Diffuse osseous metastases, unchanged.
.
TTE [**10-19**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Trace aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is a small pericardial
effusion. There are no chocardiographic signs of tamponade. No
vegetation seen (cannot exclude).
.
CXR: [**10-19**]
New generalized, moderately severe interstitial abnormality
accompanied by increasing mediastinal vascular caliber and
interval enlargement of the cardiac silhouette is due to
pulmonary edema, which could be cardiac or volume related or
response to transfusion or even drug administration. There is
no appreciable pleural effusion or pneumothorax. Cavitary
consolidation in the right lung apex, which developed between
[**9-14**] and [**10-17**] is
partially obscured by the generalized lung process, and there
may be another focus of new consolidation in the right mid lung
laterally. Right subclavian catheter tip projects over the SVC.
tach at 101; nl axis; no ST t-wave changes.
.
CSF: SINGLE PROMINENT BAND SEEN IN GAMMA REGION WHICH
CORRESPONDS TO BAND SEEN IN SERUM NO OLIGOCLONAL BANDING SEEN
Pertinent Results:
[**2173-10-17**] 10:55AM BLOOD WBC-2.3* RBC-3.23* Hgb-9.5* Hct-27.2*
MCV-84 MCH-29.2 MCHC-34.7 RDW-16.0* Plt Ct-30*#
[**2173-10-28**] 12:00AM BLOOD WBC-0.6* RBC-3.35* Hgb-9.8* Hct-28.1*
MCV-84 MCH-29.3 MCHC-34.9 RDW-16.8* Plt Ct-19*
[**2173-10-17**] 10:55AM BLOOD Neuts-17* Bands-2 Lymphs-68* Monos-1*
Eos-1 Baso-0 Atyps-11* Metas-0 Myelos-0 NRBC-1*
[**2173-10-17**] 10:55AM BLOOD PT-16.5* PTT-32.1 INR(PT)-1.9
[**2173-10-17**] 10:55AM BLOOD Plt Ct-30*#
[**2173-10-28**] 12:00AM BLOOD PT-16.6* PTT-34.2 INR(PT)-1.9
[**2173-10-28**] 12:00AM BLOOD Plt Ct-19*
[**2173-10-18**] 03:37PM BLOOD Fibrino-396 D-Dimer-374
[**2173-10-19**] 05:13AM BLOOD Gran Ct-420*
[**2173-10-28**] 12:00AM BLOOD Gran Ct-100*
[**2173-10-17**] 10:55AM BLOOD Glucose-116* UreaN-35* Creat-2.5* Na-130*
K-5.0 Cl-102 HCO3-16* AnGap-17
[**2173-10-28**] 12:00AM BLOOD Glucose-158* UreaN-32* Creat-1.3* Na-147*
K-3.2* Cl-119* HCO3-18* AnGap-13
[**2173-10-17**] 10:55AM BLOOD ALT-54* AST-25 LD(LDH)-222 AlkPhos-190*
TotBili-0.6
[**2173-10-28**] 12:00AM BLOOD ALT-20 AST-12 LD(LDH)-209 AlkPhos-140*
TotBili-3.6*
[**2173-10-17**] 10:55AM BLOOD Albumin-2.4* Calcium-10.6* Phos-4.1
Mg-1.9 UricAcd-7.6*
[**2173-10-28**] 12:00AM BLOOD Albumin-2.3* Calcium-7.0* Phos-2.1*
Mg-1.7 UricAcd-5.3
[**2173-10-23**] 12:20AM BLOOD Hapto-269*
[**2173-10-17**] 10:55AM BLOOD Osmolal-301
[**2173-10-24**] 12:00AM BLOOD IgG-4422*
[**2173-10-20**] 05:03PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
Lymphs-40 Monos-0 Macroph-60
[**2173-10-20**] 05:03PM CEREBROSPINAL FLUID (CSF) TotProt-130*
Glucose-84 LD(LDH)-13
[**2173-10-20**] 05:03PM CEREBROSPINAL FLUID (CSF) CSF-PEP-SINGLE PRO
Brief Hospital Course:
A/P: 70 y/o man with multiple myeloma/plasma cell leukemia, HTN,
hypercholesterolemia, DM type 2, who was admitted with change in
mental status. Admitted to the [**Hospital Unit Name 153**] then called out to the
floor.
.
1. Change in mental status: On arrival to hospital, change in
mental status thought to be due to hypotension/sepsis given that
mental status improved markedly with fluids resuscitation. Pt
also w/ marked hypocalcemia on labs that was corrected. Pt was
then found to be altered with a normal BP after fluid
resuscitation so an LP was done which demonstrated plasma cells
in the CSF. The patient's family was informed of the diagnosis
of CNS plasma cell leukemia and decided to make the patient CMO.
HIs antibiotics were stopped and the patients mental status
cleared somewhat. He was able to participate in the planning of
his hospice care and remained happy with the plan.
.
2. Sepsis: Pt was admitted with hypotension and AMS. His
initial blood cx grew out MRSA and he was started on
vancomycin/cefepime and his line was removed. His LP and urine
did not show signs of infection. He was started on stress dose
steroids. He was given ambisome for CT findings demonstrating
likely worsening invasive aspergillosis and acyclovir for a
history of disseminated zoster. After the LP showed CNS
involvement of his plasma cell leukemia, the patient was made
CMO. His antibiotics and steroids were stopped and further
cultures/temperatures were not taken.
.
3. MM/plasma cell leukemia: His last dose of Velcade was on
[**2173-10-7**]. LP showed CNS involvement of his disease in the CNS.
His extremely poor prognosis was discussed with the family and
the decision was made to make the patient CMO. As the patient's
sensorium cleared, he became actively involved in his hospice
planning and the patient was eventually discharged home to
receive home hospice services. His pain was well controlled
with a lidocaine patch and prn morphine. His CBC was followed
and he was transfused prn until he was made cmo.
Medications on Admission:
1. Ambisome 320mg tiw (last dose on [**10-13**])
2. Allopurinol 100 mg qd
3. Prednisone 10mg qd
4. Omeprazole 20mg qd
5. Velcade (last treatment last week)
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
2. Ativan 4 mg/mL Syringe Sig: 0.5-2 mg Injection q2-4h as
needed for anxiety/restlessness/seizure.
Disp:*15 mL* Refills:*2*
3. Levsin/SL 0.125 mg Tablet, Sublingual Sig: 1-2 tablets
Sublingual every 4-6 hours as needed for congestion.
Disp:*30 tablets* Refills:*2*
4. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1-2h
as needed for pain.
Disp:*10 mL* Refills:*0*
5. AMICAR 25 % Syrup Sig: Ten (10) mL PO every four (4) hours as
needed for oral bleeding: swab mouth with solution to stop oral
bleeding.
Disp:*100 mL* Refills:*1*
6. supplies
one semi-electric bed
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Plasma cell leukemia - multiple myeloma
Discharge Condition:
stable
Discharge Instructions:
Please take your medications as directed
Followup Instructions:
Pt d/c home for hospice care - not to return to the hospital
Completed by:[**2173-11-5**]
|
[
"203.00",
"875.0",
"V09.0",
"117.3",
"995.92",
"250.00",
"790.92",
"038.11",
"275.42",
"287.4",
"584.9",
"785.52",
"996.62",
"276.2",
"276.1",
"V63.2",
"288.0",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04",
"03.31",
"99.05",
"86.05",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
11211, 11260
|
8199, 8435
|
344, 351
|
11344, 11353
|
6544, 8176
|
11442, 11534
|
3925, 3988
|
10441, 11188
|
11281, 11323
|
10261, 10418
|
11377, 11419
|
4003, 6525
|
277, 306
|
379, 3325
|
8450, 10235
|
3347, 3659
|
3675, 3909
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,892
| 110,999
|
11970+11971
|
Discharge summary
|
report+report
|
Admission Date: [**2196-12-3**] Discharge Date: [**2196-12-4**]
Date of Birth: [**2143-2-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 20128**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: 53 yo M with hx of bipolar d/o,
baseline mild dementia, was found down at [**Hospital3 **] in her
bathroom. She states that she did hit her head however she
states that she did not lose conciousness. The patient states
that she remembers everything. She said that she fell while she
was getting up from the toilet and using the handicap handles,
she slipped and did not grab the handles and fell backwards and
hit her lower back and her posterior.
.
In ED, expressed LBP, mild headache, no neck pain.
.
In the ED, initial vs were: 96.2, 80, 146/80, 16, 100%/8L. She
had left sided posterior head contusion. Labs significant for
Hct 31.9, MCV 105 (baseline), creatinine 2.8 (baseline) with BUN
50, Na 132, K 5.3. Tox screen was negative. UA showed [**3-4**] WBC,
neg nit, few bact, 25 protein. CXR showed low lung volumes and
crowding of bronchovascular space. T-spine and C-spine showed no
acute fx and CT head showed no acute ICH. L-spine limited but no
fracture. VS on transfer were: 97.3, 74, 138/74, 16, 97%. Noted
that cannot clear spine [**2-2**] pain with neck flexion so changed to
[**Location (un) 2848**] J collar.
.
After the patient was transferred to the floor she continued to
complain of lower back pain however no other symptoms. She did
not have any neck pain, weakness, paralysis, loss of sensation,
chest pain, shortness of breath, or abdominal pain.
Past Medical History:
- CKD Stage IV with renal osteodystrophy and anemia of chronic
disease: Etiology of her renal dysfunction is thought to be
caused by nephrogenic diabetes insipidus / lithium
nephrotoxicity. She was treated with Lithium [**2180**] through [**2184**]
for her bipolar disorder.
- Secondary hyperparathyroidism
- Noninsulin dependent diabetes mellitus
- Hypertension
- Hypothyroidism
- Right hemiparesis caused by a brachial plexus injury. Please
note that the patient did NOT have a stroke as is indicated in
other past medical records.
- SIB "a long time ago" including OD on pills and cutting
herself.
Social History:
Born in [**Location (un) 86**], lived here all her life. Worked in limited care
and family services until [**2187**]. Moved into [**Doctor Last Name **] House shortly
after her right hemiparesis secondary to a brachial plexus
injury. Parents are deceased, has a good relationship with her
brother. [**Name (NI) **] military or legal history, never been married.
Family History:
Patient denies family history of psychiatric illness. Denies any
family suicide attempts or completed suicides.
Physical Exam:
General: Alert, orientedx3, 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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: II-XII intact, 5/5 strength in 4 ext, normal gait,
negative romberg
Pertinent Results:
[**2196-12-3**] 11:36PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2196-12-3**] 11:36PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2196-12-3**] 11:36PM URINE RBC-<1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2196-12-3**] 11:36PM URINE MUCOUS-RARE
[**2196-12-3**] 04:00AM URINE HOURS-RANDOM
[**2196-12-3**] 04:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2196-12-3**] 02:00AM GLUCOSE-120* UREA N-50* CREAT-2.8*
SODIUM-132* POTASSIUM-5.3* CHLORIDE-99 TOTAL CO2-21* ANION
GAP-17
[**2196-12-3**] 02:00AM estGFR-Using this
[**2196-12-3**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-12-3**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-12-3**] 02:00AM URINE HOURS-RANDOM
[**2196-12-3**] 02:00AM URINE HOURS-RANDOM
[**2196-12-3**] 02:00AM URINE UHOLD-HOLD
[**2196-12-3**] 02:00AM URINE GR HOLD-HOLD
[**2196-12-3**] 02:00AM WBC-6.8 RBC-3.04* HGB-10.7* HCT-31.9*
MCV-105* MCH-35.2* MCHC-33.5 RDW-12.7
[**2196-12-3**] 02:00AM NEUTS-71.1* BANDS-0 LYMPHS-17.7* MONOS-6.7
EOS-3.9 BASOS-0.6
[**2196-12-3**] 02:00AM PLT COUNT-156
[**2196-12-3**] 02:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2196-12-3**] 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2196-12-3**] 02:00AM URINE RBC-0-2 WBC-[**3-4**] BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
Brief Hospital Course:
# Fall: The patient had a head CT which was negative. Otherwise
the patient also had a c-spine CT which did not reveal any
fractures or dislocations. The patient was assessed for her
mental status which was determined to be able to produce a
reliable history. She stated that at the time the only other
place of injury was [**4-9**] back pain. She was evaluated to not
have any distracting injuries. Her c-spine was palpated which
did not have any tenderness. She had her collar taken off and
her neck ranged without any pain or neurologic deficits. The
patient had plain films done of her T-L-S spine which were all
negative for fractures or malalignments. Otherwise the patient
gives very clear history that this was not a syncopal episode
and that she never lost conciousness. She states that she
grabbed the handlebars on her toilet incorrectly which is what
caused her to fall. Given this the patient did not have a
syncope work up but was rather cleared from a fall perspective.
The patient was evaluated by physical therapy which determined
that the patient was safe to be discharged home and would
require a visit from outpatient physical therapy to evaluate for
how well she ambulates with her walker. The patient was
monitored on tele without any evidence of any arrhythmias.
Otherwise the patient was discharged with follow up to her
primary care doctor
.
# Acute Renal Failure: The patient had a minor elevation of her
kidney function from 2.8 to 3.1. Given this she had a CK checked
which was in the normal range and therefore made rhabdomyolysis
less likely. She was given IV fluid hydration and discharged
again with follow up to her primary care doctor.
.
#. Fever: The patient had one isolated episode of a temperature.
She spiked a temp to 101.8 which subsequently was evaluated for
with blood cultures which were negative, urine analysis which
was negative and a chest x-ray which was negative. The patient
did not have any other temperatures above 100.
Medications on Admission:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO THREE
TIMES WEEKLY (). Capsule(s)
5. Sodium Bicarbonate 650 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day). Tablet(s)
6. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety/agitation.
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risperidone 1 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO BID (2 times a day).
12. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QHS (once
a day (at bedtime)).
13. Lorazepam 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
14. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
17. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed
Discharge Medications:
1. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO QMOWEFR
(Monday -Wednesday-Friday). Capsule(s)
5. sodium bicarbonate 650 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day).
6. lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. risperidone 1 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO BID (2 times a day).
10. quetiapine 200 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
11. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. lorazepam 0.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
14. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
16. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed Release (E.C.) PO HS (at bedtime).
17. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Fall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
How to Prevent Falling: Recommendations for Patients and Their
Caregivers
1. Make your environment safe:
?????? Make sure that you have good lighting in your home. A well
lit home will help you avoid tripping over objects that are not
easy to see. Put night lights in your bedroom, hallways, stairs
and bathrooms.
?????? Rugs should be firmly fastened to the floor or have nonskid
backing. Loose ends should be tacked down.
?????? Electrical cords should not be lying on the floor in walking
areas.
?????? Put hand rails in your bathroom for bath, shower and toilet
use.
?????? Have rails on both sides of your stairs for support.
?????? In the kitchen, make sure items are within easy reach. Don't
store things too high or too low. Then you won't have to use a
stepladder or a stool to reach them. It's also a good idea to
avoid storing things too low, so you won't have to bend down to
get them.
?????? Wear shoes with firm nonskid soles. Avoid wearing
loose-fitting slippers that could cause you to trip.
2. Avoid dangerous medications and alcohol:
?????? Sedatives and sleeping pills, including Alprazolam (Xanax),
Chlordiazepoxide (Librium), Diazepam (Valium), Oxazepam (Serax),
Triazolam (Halcion), Flurazepam (Dalmane), and Meprobamate
(Miltown, Equanil).
?????? Over-the-counter medications for sleep or colds that contain
Diphenhydramine (Benadryl), like Tylenol PM, Benylin, or Nytol.
?????? Tricyclic Antidepressants, including Amitriptyline (Elavil)
and Imipramine (Tofranil)
?????? Bring all of your medications to your Doctor and carefully
review them to be sure they are safe.
?????? Avoid drinking alcohol.
3. Take 1200-1500 mg Calcium and 800 Units of Vitamin D every
day.
?????? Look for a generic brand that contains 600 mg calcium
(carbonate or citrate) and 400 Units of Vitamin D3, and take one
twice a day.
?????? Examples: Caltrate 600 + Vitamin D3 (contains calcium
citrate, better absorbed, less constipating), or Calcarb 600 +
400 D (contains calcium carbonate, less expensive, take with
meals).
?????? There are chewable options for calcium, but take an 800 or
1000 Unit Vitamin D3 pill in addition every day. These options
include: Tums 600 (take [**2-3**] daily) and Viactiv or Adora
(chocolate-flavored, take 3 daily).
4. Exercise: Three types of exercise are important:
?????? Aerobic: Daily walking, swimming, or biking. Work up to
20-30 minutes daily, to the point that you break a sweat. Use
every opportunity to walk or climb stairs.
?????? Strengthening: Do leg-lifts at least 3 days a week. Start
with no weight or a small velcro weight wrapped around your
ankles. While sitting in a straight-backed chair, lift each leg
until it is straight at the knee. Keep it extended for a count
of 3. Do this at least 10 times for each leg. Repeat each set
of 10 leg- lifts two to three times at each session.
?????? Balance: Practice balance daily by standing with feet
together, one in front and to the side of the other, and one
directly in front of the other until you can hold each position
for 1 minute. Then, practice standing on one foot until you can
remain that way for at least 1 minute without holding on to
something. Be sure to do this next to something you can grab on
to if you lose your balance.
5. Assistive Devices and other interventions:
?????? Canes and walkers can prevent falls if they are used
properly. They should be prescribed, measured, and adjusted by
a physical therapist or physician. [**Name10 (NameIs) **] [**Name Initial (NameIs) **] cane on the good
(stronger) side. [**Male First Name (un) **]??????t be embarrassed about using these. It is
more embarrassing to fall, break a hip, and lose your
independence.
?????? Hearing aides, glasses, and cataract operations can also help
prevent falls by improving your sensory function. Ask your
Doctor if you should have your hearing or vision checked.
?????? Get a Life-Line Device or other emergency system, so you can
call for help by simply pressing a button if you fall and can
not reach a phone.
?????? Drink plenty of fluids (at least [**1-2**] quarts a day) to prevent
dehydration.
?????? Take care of your feet. Wash them daily and inspect them for
lesions. If you have sores or foot pain, see your Doctor.
?????? Have your Doctor check your blood pressure while you are
standing up to be sure it doesn??????t fall too low. Get out of bed
slowly and pump your feet before standing up in the morning to
avoid sudden drops in blood pressure.
6. Resources for more information:
?????? National Safety Council:
[**URL 37657**]
Click on the Falls Prevention Resources and Safe Steps Video.
This provides a useful guide to preventing injuries in your
home.
?????? National Center for Injury Prevention and Control:
[**URL 37658**] There is a good home safety
checklist at this site.
?????? National Institute on Aging:
[**Female First Name (un) 37659**]
This provides information in Spanish.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-1-23**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-4-24**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 20129**]
Admission Date: [**2196-12-4**] Discharge Date: [**2196-12-21**]
Date of Birth: [**2143-2-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 832**]
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 53 yo female with hx of bipolar d/o, baseline
mild dementia, who was recently admitted because she was found
down at [**Hospital3 **] in her bathroom. She states that she did
hit her head however she states that she did not lose
conciousness. The patient states that she remembers everything.
She said that she fell while she was getting up from the toilet
and using the handicap handles, she slipped and did not grab the
handles and fell backwards and hit her lower back and her
posterior. She was discharged on [**12-4**] however when she arrived
to the [**Hospital3 **] she was unable to stand up due to
weakness and was sent back.
.
In ED, expressed LBP, mild headache, no neck pain.
In the ED, initial vs were: 96.2, 80, 146/80, 16, 100%/8L. She
had left sided posterior head contusion. Labs significant for
Hct 31.9, MCV 105 (baseline), creatinine 2.8 (baseline) with BUN
50, Na 132, K 5.3. Tox screen was negative. UA showed [**3-4**] WBC,
neg nit, few bact, 25 protein. CXR showed low lung volumes and
crowding of bronchovascular space. T-spine and C-spine showed no
acute fx and CT head showed no acute ICH. L-spine limited but no
fracture. VS on transfer were: 97.3, 74, 138/74, 16, 97%. Noted
that cannot clear spine [**2-2**] pain with neck flexion so changed to
[**Location (un) 2848**] J collar.
.
On the floor she was noted to be febrile to 101 and rigoring.
She was able to answer questions appropriately but did note
having fevers and trembling for 2 days. She denied any cough,
abdominal pain, dysuria or neck stiffness.
Past Medical History:
- CKD Stage IV with renal osteodystrophy and anemia of chronic
disease: Etiology of her renal dysfunction is thought to be
caused by nephrogenic diabetes insipidus / lithium
nephrotoxicity. She was treated with Lithium [**2180**] through [**2184**]
for her bipolar disorder.
- Secondary hyperparathyroidism
- Noninsulin dependent diabetes mellitus
- Hypertension
- Hypothyroidism
- Right hemiparesis caused by a brachial plexus injury. Please
note that the patient did NOT have a stroke as is indicated in
other past medical records.
- SIB "a long time ago" including OD on pills and cutting
herself.
Social History:
Born in [**Location (un) 86**], lived here all her life. Worked in limited care
and family services until [**2187**]. Moved into [**Doctor Last Name **] House shortly
after her right hemiparesis secondary to a brachial plexus
injury. Parents are deceased, has a good relationship with her
brother. [**Name (NI) **] military or legal history, never been married.
Family History:
Patient denies family history of psychiatric illness. Denies any
family suicide attempts or completed suicides.
Physical Exam:
ADMISSION Physical Exam:
Vitals: T: 101.6 BP: 160/100 P: 96 O2: 98RA
General: Patient looked sick/diaphoretic, rigoring
HEENT: MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on Admission:
[**2196-12-3**] 02:00AM URINE RBC-0-2 WBC-[**3-4**] BACTERIA-FEW YEAST-NONE
EPI-0-2 TRANS EPI-0-2
[**2196-12-3**] 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2196-12-3**] 02:00AM WBC-6.8 RBC-3.04* HGB-10.7* HCT-31.9*
MCV-105* MCH-35.2* MCHC-33.5 RDW-12.7
[**2196-12-3**] 02:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2196-12-4**] 07:15AM WBC-5.1 RBC-3.08* HGB-11.2* HCT-32.7*
MCV-106* MCH-36.2* MCHC-34.1 RDW-12.9
[**2196-12-4**] 07:15AM GLUCOSE-90 UREA N-49* CREAT-3.1* SODIUM-141
POTASSIUM-5.1 CHLORIDE-106 TOTAL CO2-24 ANION GAP-16
[**2196-12-4**] 07:15AM CALCIUM-8.4 PHOSPHATE-5.4* MAGNESIUM-3.1*
[**2196-12-20**] 06:15 6.2 2.71* 9.2* 28.8* 106* 34.0* 32.1 14.6
411
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2196-12-20**] 06:15 6.2 2.71* 9.2* 28.8* 106* 34.0* 32.1 14.6
411
[**2196-12-19**] 05:40 7.4 2.67* 8.9* 28.2* 106* 33.3* 31.5 14.7
424
[**2196-12-18**] 04:28 9.7 2.82* 9.6* 29.9* 106* 34.0* 32.2 14.5
474*
[**2196-12-17**] 05:02 10.2 2.75* 9.3* 29.1* 106* 33.9* 32.0 14.2
517*
[**2196-12-16**] 02:53 10.7 2.52* 8.7* 26.4* 105* 34.6* 33.0 13.5
516*
[**2196-12-15**] 01:31 11.3* 2.73* 9.2* 28.4* 104* 33.8* 32.4 13.0
515*
ADDED DIFF 9:49AM
[**2196-12-14**] 03:43 9.7 2.58* 8.8* 26.8* 104* 34.2* 32.9 13.1
489*
Source: Line-piv
[**2196-12-13**] 03:49 9.5 2.50* 8.4* 25.8* 104* 33.7* 32.6 13.2
385
[**2196-12-12**] 13:50 9.4 2.52* 8.5* 26.0* 103* 33.9* 32.8 13.1
305
Random
[**2196-12-12**] 02:52 9.2 2.49* 8.3* 25.9* 104* 33.3* 32.0 13.0
300
Random
[**2196-12-11**] 03:11 8.6 2.30* 8.3* 24.2* 105* 35.9* 34.1 12.8
254
Source: Line-aline
[**2196-12-10**] 02:40 7.8 2.30* 8.0* 24.5* 107* 34.6* 32.5 12.8
211
Source: Line-a-line
[**2196-12-9**] 17:14 7.0 2.22* 7.7* 23.8* 108* 34.9* 32.5 13.0
185
Source: Line-aline
[**2196-12-9**] 03:51 6.7 2.26* 8.1* 24.0* 106* 35.8* 33.7 13.0
173
Source: Line-A-line
[**2196-12-8**] 22:52 23.9*
[**2196-12-8**] 16:35 7.8 2.25* 8.0* 23.9* 106* 35.7* 33.7 12.9
153
[**2196-12-8**] 11:03 9.4 2.41* 8.3* 25.1* 104* 34.5* 33.0 13.0
159
[**2196-12-8**] 05:50 11.1* 2.44* 8.9* 25.9* 106* 36.6* 34.6 12.9
176
[**2196-12-7**] 05:55 13.6* 2.78* 10.2* 28.8*1 104* 36.5* 35.3*
13.0 1802
[**2196-12-6**] 13:07 9.3 2.75* 9.7* 28.3* 103* 35.2* 34.1 12.2
129*
CAD ADDED 5:03PM
[**2196-12-6**] 07:15 8.63 2.80* 9.7* 30.0*4 105* 34.6* 35.1* 12.8
1673
ESR ADDED 11:33AM,SPECIMEN QNS FOR SED RATE, NOTIFIED [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 37660**] ON [**2196-12-6**] @ 12:47PM
[**2196-12-5**] 09:10 6.9 2.86* 10.2* 30.2* 106* 35.6* 33.7 12.6
144*
[**2196-12-4**] 07:15 5.1 3.08* 11.2* 32.7* 106* 36.2* 34.1 12.9
153
[**2196-12-3**] 02:00 6.8 3.04* 10.7* 31.9* 105* 35.2* 33.5 12.7
156
.
Imaging:
[**12-15**] ECG Atrial fibrillation with rapid ventricular response.
Probable left anterior fascicular block. Delayed R wave
progression with late precordial QRS transition is
non-diagnostic but cannot exclude possible prior anterior wall
myocardial infarction. Modest lateral lead ST-T wave changes are
non-specific. Since the previous tracing of [**2196-12-11**] the
ventricular rate is faster and axis appears more leftward but
there may be no significant change.
[**12-11**] CT Chest/Abd/pelvis 1. Extensive multifocal airspace
opacities in the lungs as described along with small bilateral
pleural effusions. Findings are suggestive of a multifocal
pneumonia. 2. Multiple enlarged mediastinal lymph nodes, likely
reactive. 3. Indeterminate 7 mm calculus in the abdomen, which
may be within the right renal pelvis or represent a vascular
calcification. Of note, there is no hydronephrosis.
[**12-11**] MRI L-spine 1. Multilevel lumbar spine spondylosis
without severe spinal canal or neural foraminal narrowing. 2. A
broad-based disc protrusion is present at the L4-L5 level with
minimal inferior migration resulting in mild spinal canal
narrowing and bilateral subarticular zone narrowing with
deformity on the L5 nerves. 3. Moderate bilateral neural
foraminal narrowing is present at the L5-S1 level due to facet
arthrosis with impingement on the L5 nerves. Study is limited
for abnormal enhancement due to lack of post Gado imaging, gado
could not eb given due to low eGFR.
[**12-7**] abd u/s This is a technically limited study showing a
normal size of the liver and spleen. No focal abnormality is
seen. Limited views of the kidneys show no hydronephrosis, but
assessment for focal renal lesions is suboptimal.
Date 6 Lab # Specimen Tests Ordered By
All [**2196-12-3**] [**2196-12-5**] [**2196-12-6**] [**2196-12-7**] [**2196-12-8**]
[**2196-12-9**] [**2196-12-10**] [**2196-12-11**] [**2196-12-12**] [**2196-12-13**] All
BLOOD CULTURE Blood (EBV) IMMUNOLOGY Immunology (CMV) Influenza
A/B by DFA MRSA SCREEN SEROLOGY/BLOOD STOOL THROAT FOR STREP
URINE All INPATIENT
[**2196-12-13**] IMMUNOLOGY HCV VIRAL LOAD-FINAL INPATIENT
[**2196-12-13**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
[**2196-12-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2196-12-13**] URINE URINE CULTURE-FINAL INPATIENT
[**2196-12-13**] Immunology (CMV) CMV Viral Load-FINAL
INPATIENT
[**2196-12-13**] SEROLOGY/BLOOD MONOSPOT-FINAL INPATIENT
[**2196-12-12**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2196-12-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2196-12-11**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL
Brief Hospital Course:
53 year old female with a PMH significant for bipolar d/o,
baseline mild dementia, CKD stage IV, HTN and DM who was
recently admitted ([**2196-12-3**]) after a fall and discharged on
[**2196-12-4**], readmitted w/ weakness, now w/ hypotension to 70's
systolic and altered mental status, as well as daily fevers
since admission.
For several days she had fevers as high as 103. Infectious work
up and extensive imaging was negative for cause of fever. On
[**12-7**] the patient developed hypotension with SBP in the 70s and
hypoxic to the 90s on 4L, a rapidly increasing creatinine and a
new transaminities so was transferred to the MICU.
.
In the MICU, patient continued to have daily fevers but further
infectious work up all negative. Patient's ABX initially held as
no source identified, however she spiked fever to 103 on [**12-10**]
and was re-started on vanc/cefepime. LENIs negative for DVT.
ECHO without evidence of endocarditis. She did have a CT Chest
that showed ground glass opacities that could have been
consistent with pneumonia, so it was felt that she should be
treated for HAP. Of note, despite the patient's fever and mental
status changes as well as complaint of neck pain, she did not
get an LP.
.
Given the negative infectious work up, a rheumatologic process
was considered. Labs were notable for ESR 142 Ferritin 3170, TRF
102, TIBC 133, negative [**Doctor First Name **] and ANCA. Rheumatology was consulted
and felt that her this was unlikely to be HLH or Adult still's
given her lack of constellation of symptoms, nor did they think
this was a vasculitis (more likely infectious pna).
.
The patient's altered mental status attributed to psych meds in
the setting of acute renal failure and transaminitis leading to
poor metabolism of meds. Her mental status rapidly improved
after holding her psych medications. Malignant hyperthermia and
seratonin syndrome were considered but CK was 97 on [**12-6**] (height
of temperature curve) and the patient had no clinical exam
findings consistent with seratonin syndome. However, after
holding the patient's psych medications she started to become
more aggitated. Psychiatry was consulted and the patient was
restarted on aripiprazole with PRN lorazepam and risperdal and
has since remained calm.
.
The patient's hypoxemia felt likely to be due to OSA and fluid
overload as well as possible pneumonia. The patient autodiuresed
and was treated with ABX and her hypoxia resolved resolved even
though patient did not wear her CPAP (refused). Of note, she was
briefly on Bipap but did not require intubation.
.
The patient's creatinine peaked at 4 on [**12-9**] and has since
trended down to 2.4. Nephrology was consuled and spun her urine
and saw a few hyaline casts, few muddy brown casts consistent
with hypoperfusion. Renal U/S showed chronic disease, no acute
changes so it was felt this was most likely due to poor renal
perfusion as it has been slowly improving.
.
The patient's AST/ALT/ALP peakined on [**12-12**] at [**Telephone/Fax (3) 37661**] and
has since been trending down slowly. Her lipase and LDH were
also mildly elevated. Hepatitis serologies were negative. Liver
was consulted who felt that her LFT abnormalities were due to
hypotension/sepsis on the background of a fatty liver.
.
Finally, the patient developed A fib with RVR that was very
difficult to control. She was given IV Dilt, IV metoprolol and
even started on digoxin at one point (though stopped given her
rapidly changing renal function). Cardiology was consulted who
was considering a TEE cardioversion. However, this morning the
patient converted back into sinus rhythm. She is currently on PO
Dilt and PO Metoprolol.
Problem [**Name (NI) **]:
.
#Altered mental status: The patient had altered mental status
and was intermittently somnolent, but oriented x 2. We suspected
this was mostly due to multiple psychiatric medications in the
context of decreased clearance due to acute on chronic renal
failure. Her psychiatric and anti-hypertensive meds were held
until her mental status improved.
.
#Fevers: She originally presented with low back pain/neck
pain/HA, and upon arrival to floor fever to 101. Pt had daily
fevers from time of admission. Pt was started initially on
Vancomycin, cefepime and flagyl. An extensive infectious work-up
including monospot, influenza, full rapid respiratory panel,
hepatitis serologies, blood cx, urine cx and echo to r/o
endocarditis were all negative. She had MRI L-spine given fever
w/ back pain, which showed no abscess. She defervesced and
remained afebrile at time of discharge
.
#Hypotension: On admission she was hypotensive to 70's systolic
for unclear reason. As noted above, infectious unremarkable.
Blood pressure stablized with volume resucitation.
.
#Hypoxic Respiratory Distress: Likely related to volume
overload. Improved with diuresis.
.
#Atrial Fibrillation: New onset Afib on [**12-11**]. Etiology likely
longstanding HTN. TSH normal. HR difficult to control. She
intially was continued on her home regimen of metoprolol 12.5
[**Hospital1 **]. When this did not control rate he was changed to diltiazem
90mg QID. Metoprolol was restarted along with the diltiazem and
titrated up to 25 TID. Possible that if this regimen does not
achieve rate control than she may require DCCV in the future.
.
# Neck pain: Likely strain [**2-2**] fall. The patient sustained a
fall after trying to arise from the toilet. CT of the c-spine
did not reveal any fractures or malalignments. Neck pain
improved throughout admission.
.
.
#Acute on chronic renal failure: Her creatinine on admission was
3.1 but climbed to 4 on [**12-9**]. This was likely due to prerenal
source as patient was quite dry on exam. Unclear etiology of the
ARF however thought likely to be from ATN. Her creatinine
improved back to 2.5 over the following few days which is her
baseline.
.
#Transaminitis: Etiology unclear though may have been related to
transient hypotension. Hepatitis serolgies negative, [**Doctor First Name **], AMA
all negative. CT abdomen unremarkable for any liver related
pathology. LFTs trending down at time of discharge.
.
# Bipolar Disorder: Her psych medications of seroquel,
risperidone, clozaril, lamotrigine, depakote and lorazepam were
held due to concern for elevated LFT's. Psych was consulted and
we spoke to her outpatient psychiatrist Dr [**First Name (STitle) **]. Per their
recommendations, she was initially started at 1mg Risperidone.
This was then increased. On [**12-14**] the patient became more
aggitated with evidence of psychosis and mania. Psychiatry
recommended starting abilify 30mg QHS w/ lorazepam 1-2mg MRx1
QHS + risperdal 1mg TID PRN which helped patient and helped her
sleep. Pt noted to acutely decompensate with manic episode;
section 12'ed; admitted to [**Hospital1 **] 4 for further psychiatric
evaluation/stabilization.
.
# Hypothyroidism - The patients TSH was 1.2. Her home med of
levothyroxine was continued.
.
# Elevated inflammatory markers: Unclear cause, Noted to have
ferritin >3000 and extremely high ESR/CRP's >100, but again
trended down. Rheumatology did not feel it was rheumatological.
No splenomegaly or cytopenias to imply HLH. Heme looked at smear
and no abnormalities.
Medications on Admission:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO THREE
TIMES WEEKLY (). Capsule(s)
5. Sodium Bicarbonate 650 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day). Tablet(s)
6. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. Lamotrigine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety/agitation.
10. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risperidone 1 mg Tablet, Rapid Dissolve Sig: Three (3)
Tablet, Rapid Dissolve PO BID (2 times a day).
12. Quetiapine 200 mg Tablet Sig: Three (3) Tablet PO QHS (once
a day (at bedtime)).
13. Lorazepam 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
14. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
17. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Four
(4) Tablet, Delayed
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR
(Monday -Wednesday-Friday).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain: Do not exceeed 2g/day given
recent transaminitis.
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for straining with stooling.
9. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of
breath/wheezing.
10. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. risperidone 1 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for agitation.
12. insulin regular human 100 unit/mL (3 mL) Insulin Pen Sig:
One (1) unit Subcutaneous four times a day: See attached sliding
scale. Adjust as needed.
13. metoprolol succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
15. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. lorazepam 1 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for aggitation or insomnia.
17. aripiprazole 10 mg Tablet Sig: Three(3) Tablet PO QHS (once
a day (at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Systemic Inflammatory Response Syndrome (SIRS)
Atrial fib - paroxysmal in setting of SIRS and volume overload
with reversible cause
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
How to Prevent Falling: Recommendations for Patients and Their
Caregivers
1. Make your environment safe:
?????? Make sure that you have good lighting in your home. A well
lit home will help you avoid tripping over objects that are not
easy to see. Put night lights in your bedroom, hallways, stairs
and bathrooms.
?????? Rugs should be firmly fastened to the floor or have nonskid
backing. Loose ends should be tacked down.
?????? Electrical cords should not be lying on the floor in walking
areas.
?????? Put hand rails in your bathroom for bath, shower and toilet
use.
?????? Have rails on both sides of your stairs for support.
?????? In the kitchen, make sure items are within easy reach. Don't
store things too high or too low. Then you won't have to use a
stepladder or a stool to reach them. It's also a good idea to
avoid storing things too low, so you won't have to bend down to
get them.
?????? Wear shoes with firm nonskid soles. Avoid wearing
loose-fitting slippers that could cause you to trip.
2. Avoid dangerous medications and alcohol:
?????? Sedatives and sleeping pills, including Alprazolam (Xanax),
Chlordiazepoxide (Librium), Diazepam (Valium), Oxazepam (Serax),
Triazolam (Halcion), Flurazepam (Dalmane), and Meprobamate
(Miltown, Equanil).
?????? Over-the-counter medications for sleep or colds that contain
Diphenhydramine (Benadryl), like Tylenol PM, Benylin, or Nytol.
?????? Tricyclic Antidepressants, including Amitriptyline (Elavil)
and Imipramine (Tofranil)
?????? Bring all of your medications to your Doctor and carefully
review them to be sure they are safe.
?????? Avoid drinking alcohol.
3. Take 1200-1500 mg Calcium and 800 Units of Vitamin D every
day.
?????? Look for a generic brand that contains 600 mg calcium
(carbonate or citrate) and 400 Units of Vitamin D3, and take one
twice a day.
?????? Examples: Caltrate 600 + Vitamin D3 (contains calcium
citrate, better absorbed, less constipating), or Calcarb 600 +
400 D (contains calcium carbonate, less expensive, take with
meals).
?????? There are chewable options for calcium, but take an 800 or
1000 Unit Vitamin D3 pill in addition every day. These options
include: Tums 600 (take [**2-3**] daily) and Viactiv or Adora
(chocolate-flavored, take 3 daily).
4. Exercise: Three types of exercise are important:
?????? Aerobic: Daily walking, swimming, or biking. Work up to
20-30 minutes daily, to the point that you break a sweat. Use
every opportunity to walk or climb stairs.
?????? Strengthening: Do leg-lifts at least 3 days a week. Start
with no weight or a small velcro weight wrapped around your
ankles. While sitting in a straight-backed chair, lift each leg
until it is straight at the knee. Keep it extended for a count
of 3. Do this at least 10 times for each leg. Repeat each set
of 10 leg- lifts two to three times at each session.
?????? Balance: Practice balance daily by standing with feet
together, one in front and to the side of the other, and one
directly in front of the other until you can hold each position
for 1 minute. Then, practice standing on one foot until you can
remain that way for at least 1 minute without holding on to
something. Be sure to do this next to something you can grab on
to if you lose your balance.
5. Assistive Devices and other interventions:
?????? Canes and walkers can prevent falls if they are used
properly. They should be prescribed, measured, and adjusted by
a physical therapist or physician. [**Name10 (NameIs) **] [**Name Initial (NameIs) **] cane on the good
(stronger) side. [**Male First Name (un) **]??????t be embarrassed about using these. It is
more embarrassing to fall, break a hip, and lose your
independence.
?????? Hearing aides, glasses, and cataract operations can also help
prevent falls by improving your sensory function. Ask your
Doctor if you should have your hearing or vision checked.
?????? Get a Life-Line Device or other emergency system, so you can
call for help by simply pressing a button if you fall and can
not reach a phone.
?????? Drink plenty of fluids (at least [**1-2**] quarts a day) to prevent
dehydration.
?????? Take care of your feet. Wash them daily and inspect them for
lesions. If you have sores or foot pain, see your Doctor.
?????? Have your Doctor check your blood pressure while you are
standing up to be sure it doesn??????t fall too low. Get out of bed
slowly and pump your feet before standing up in the morning to
avoid sudden drops in blood pressure.
6. Resources for more information:
?????? National Safety Council:
[**URL 37657**]
Click on the Falls Prevention Resources and Safe Steps Video.
This provides a useful guide to preventing injuries in your
home.
?????? National Center for Injury Prevention and Control:
[**URL 37658**] There is a good home safety
checklist at this site.
?????? National Institute on Aging:
[**Female First Name (un) 37659**]
This provides information in Spanish.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-1-23**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: WEST [**Hospital 2002**] CLINIC
When: MONDAY [**2197-4-24**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"518.82",
"571.8",
"486",
"E939.3",
"E884.6",
"253.5",
"922.31",
"342.80",
"584.5",
"588.81",
"588.0",
"353.0",
"285.21",
"296.44",
"570",
"244.9",
"847.0",
"038.9",
"327.23",
"E939.8",
"292.81",
"278.01",
"728.87",
"995.92",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
35702, 35747
|
25200, 28906
|
16293, 16299
|
35922, 35922
|
19582, 19587
|
41047, 41761
|
18922, 19037
|
33868, 35679
|
35768, 35901
|
32442, 33845
|
36073, 41024
|
19077, 19563
|
16245, 16255
|
16327, 17900
|
19602, 25177
|
35937, 36049
|
17922, 18525
|
18541, 18906
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,821
| 152,011
|
51024
|
Discharge summary
|
report
|
Admission Date: [**2126-9-21**] Discharge Date: [**2126-9-24**]
Date of Birth: [**2079-3-23**] Sex: F
Service: MEDICINE
Allergies:
Zoloft / Paxil / Lorazepam / Haldol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
MICU Admission: TCA Overdose
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
HPI: 47 year old female with stage IV breast cancer on
gemcitabine/herceptin and signficant psychiatric co-morbidity
presenting to the ED after TCA overdose. Patient was seen in
[**Hospital1 18**] ED on [**9-12**] for anxiety and shortness of breath. Evaluated
by psychiatry and was discharged with follow up. She had her
gemcitabine/herceptin infusion on [**2126-9-18**].
.
On the day of admission, the patient called the covering
heme/onc fellow reporting hopelessness but denying suicidality.
She then called EMS after ingesting 28 Amitriptyline 75 mg
tablets at 11 am. She vomited after the ingestion
(Self-report). The medication is not a prescription medication,
she bought the pills online. Per ED notes, patient reports
desire to die secondary to "inoperable breast cancer." To the
ED team she denied homicidal ideation or AVT hallucinations. She
denied nausea, vomiting, headache, or chest pain. She did
report feeling "jittery" and anxious.
.
In the ED, vitals were: 98.9, 119/69, 76, 16, 96% RA. Initially
the patient's hemodynamics and mental status were stable, but
she became delirious and agitated and was intubated for airway
protection. She developed sinus tachycardia but the QRS was
<100. She was started on a bicarbonate drip and was given 2
amps of bicarbonate at 3 pm an an additional amp at 4 pm prior
to transfer to MICU. The patient was hypertensive throughout
her ED course. She was given activated charcoal via ETT X1. The
patient was transferred to the MICU for further monitoring.
Past Medical History:
PMH:
1. Stage IV breast cancer: diagnosed [**10-17**] with IDC,
ER/PR/her-2-neu positive right breast cancer with metastases to
liver and bone. She was given three cycles of AC with good
response and transitioned to Femara/Lupron [**10-18**]. She had POD
and had a brief treatment with Tamoxifen. She was treated with
Herceptin/Navelbine from [**Date range (1) 105993**]. In [**10-19**] the patient
developed MS changes in the form of increasing "negativity and
depression." She had a brain MRI which demonstrated a linear
enhancement of the left cerebellum, but had a negative LP. She
has been followed by serial MRI only. She was on a Phase II
study drug HKI-272 from [**Date range (1) 70730**]. Subsequently the patient was
treated with gemcitabine/herceptin.
2. Psychiatric Illness (Personality d/o vs. schizophrenia vs.
bipolar d/o not fully characterized, strong paranoid component.
Multiple psychiatric hospitalizations w/ prior suicide attempts;
not currently taking any meds). Follows with Psychiatry,
Heme/Onc SW.
2. H/o PTSD
3. Ulcerative colitis s/p hemicolectomy
4. Melanoma, on back. 7 years ago. Completely resected.
5. Partial thyroidectomy for goiter
6. Port-a-cath placement [**2124-12-15**]
Social History:
SH: single, no tob, no alcohol, on SSI. poor social support
Family History:
No history of breast cancer or ovarian cancer. Father has
history of melanoma. Mother reportedly has psychiatric issues.
Physical Exam:
PE: 97.2, 144/95, 82, 14, 100% RA
General: intubated, sedated, not responding to commands, no
flushing
HEENT: Pupils 3 mm and minimally responsive to light
Neck: no JVD
Car: RRR no murmur
Resp: CTAB
Chest: no masses, no inflammatory changes of the breasts
Abd: s/nt/nd/nabs
Ext: no edema
Skin: cool on extremities, no flushing
Neuro: not following commands.
Pertinent Results:
[**2126-9-21**] 12:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
[**2126-9-21**] 12:55PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2126-9-21**] 01:48PM PT-12.3 PTT-26.6 INR(PT)-1.1
[**2126-9-21**] 01:48PM PLT COUNT-155
[**2126-9-21**] 01:48PM NEUTS-70.3* LYMPHS-24.9 MONOS-3.5 EOS-1.3
BASOS-0.1
[**2126-9-21**] 01:48PM WBC-3.4* RBC-3.62* HGB-11.5* HCT-33.1* MCV-92
MCH-31.8 MCHC-34.7 RDW-15.9*
[**2126-9-21**] 01:48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2126-9-21**] 01:48PM CALCIUM-10.1 PHOSPHATE-3.3 MAGNESIUM-2.0
[**2126-9-21**] 05:39PM GLUCOSE-122* UREA N-9 CREAT-0.8 SODIUM-149*
POTASSIUM-2.4* CHLORIDE-104 TOTAL CO2-35* ANION GAP-12
.
Studies:
1. pCXR: Status post intubation, with ET tube 3.6 cm above the
carina. Probable left small pleural effusion.
2. CT head: No intracranial hemorrhage or edema. Left
cerebellar lesion seen on previous MR is not well characterized
on non-contrast head CT.
.
ECG: NSR, QRS 110 ms
Brief Hospital Course:
A/P: 47 year old female with metastatic breast cancer and
psychiatric disease presenting after TCA overdose.
.
1. TCA overdose: Patient was give IV bicarbonate in attempt to
increase pH. EKGs were followed. Patient's QRS was never
longer than 110. No seizures or episodes of hypotension occured
while in the ICU. Pschyiatry was consulted regarding the
patient's overdose. She will be transfered to inpatient Pysch
unit here at [**Hospital1 18**] for futher treatment.
.
2. Respiratory failure: Patient intubated secondary to altered
mental status from TCA overdose. The sedation was weaned the
patient was extubated without complication on the 2nd day of
hosptial admission.
.
3. FEN: Potassium initially noted low in the setting of IV
bicarbonate therapy. She was repleted and electrolytes were
followed. On the day of discharge, the patient was noted to
have a calcium of 12. The calcium was rechecked and was normal.
.
4. Psych - Patient seen and evaluated by psych while in
intensive care unit. They will give further care and treatment
as an inpatient
.
5. Breast cancer: Patient on active chemotherapy. Onc team
aware of patient's admission and saw her as an inpatient. Her
chemo therapy will be held for this week. It will be continued
per her outpatient oncologist. She will also have a routine
follow up CT torso per the onc team.
Medications on Admission:
Allergies: zoloft, paxil, lorazepam, haldol.
.
Medications:
Klonopin 1 mg po tid prn
Lupron
Oxycodone 2.5-5 mg po qhs prn
Reglan 10 mg po prn
Herceptin
Gemcitabine
Discharge Medications:
1. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 69**] - [**Location (un) 86**]
Discharge Diagnosis:
Tricyclic Overdose
Breast Cancer
Discharge Condition:
Good. Patient will be transfered to inpatient psychiatric unit
at [**Hospital1 18**] for further evaluation and treatment.
Discharge Instructions:
You were seen in the hospital for a overdose of your medication.
You were treated in the intensive care unit. You were
discharged to the inpatient psychiatry unit at [**Hospital1 18**]. Please
follow up on their recommended treatment. Also, please follow
up with your oncologist and primary care physician after you are
discharged from the hospital.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2126-9-30**] 12:00
.
Provider: [**First Name8 (NamePattern2) 2295**] [**Last Name (NamePattern1) 10917**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2126-9-30**] 12:30
.
Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2126-10-31**] 1:00
.
Also, please follow up with any appointments recommended by the
psychiatric service.
Completed by:[**2126-9-24**]
|
[
"174.9",
"276.8",
"518.81",
"197.7",
"969.0",
"198.5",
"E950.3",
"V10.82",
"780.97"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6620, 6690
|
4857, 6213
|
325, 338
|
6767, 6893
|
3742, 4669
|
7295, 7899
|
3224, 3348
|
6427, 6597
|
6711, 6746
|
6239, 6404
|
6917, 7272
|
3363, 3723
|
257, 287
|
366, 1889
|
4678, 4834
|
1911, 3130
|
3146, 3208
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,657
| 135,103
|
10088
|
Discharge summary
|
report
|
Admission Date: [**2131-9-3**] Discharge Date: [**2131-9-29**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85 year-old
man with multiple medical problems who is admitted for mental
status changes, weakness and shortness of breath. The
patient is unable to provide a history and the history was
gathered from the chart in medical records. The patient
reportedly had increased weakness and shortness of breath
since the Thursday previous to admission. He also had loose
stools that were nonbloody. The patient also had fevers and
cough, but no nausea and vomiting. Of note the patient had
recently been hospitalized at the [**Hospital3 **] TCU for ninety
nine days. He had then been transferred to the [**Hospital6 33698**] and during that stay was treated for a right
lower lobe pneumonia and staph bacteremia.
In the Emergency Room the patient was noted to have a
temperature of 100 and a white blood cell count of 27.2.
Chest x-ray showed bilateral atelectasis with small
effusions. There was also redistribution of the pulmonary
vasculature in the upper zone. The CT angio was negative for
pulmonary embolus. The patient had urine sent for urinalysis
and culture, blood culture times two and was empirically
started on intravenous Levofloxacin.
PAST MEDICAL HISTORY: 1. Hospitalized at [**Hospital3 **] TCU
for right lower lobe pneumonia and staph bacteremia. 2.
Hypertension. 3. Osteoporosis. 4. Gastroesophageal reflux
disease. 5. Decubitus ulcer of the left hip. 6. History
of prostate cancer diagnosed in [**2122**]. 7. Status post pelvic
fracture [**2131-5-6**]. 8. Status post right arm fracture [**2131-6-5**]. 9. Status post back surgery in [**2119**]. 10. History of
anchylosing spondylitis.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: 1. Calcium carbonate. 2.
Beconase. 3. Claritin. 4. Miacalcin nasal spray. 5.
Celebrex. 6. Multi vitamin. 7. Prilosec. 8. Potassium
chloride. 9. Levofloxacin 500 mg q day. 10. Clindamycin
600 mg intravenous q 6. 11. Fosamax. 12. Vitamin C. 13.
Diltiazem. 14. Colace. 15. Cozaar. 16. Zoloft. 17.
Hytrin. 18. Casodex. 19. Miconazole powder. 20. Zinc.
LABORATORY DATA: White blood cell count 20, differential 92%
polys, 2% bands, 4% lymphocytes, 2% monocytes, hematocrit
28.5, platelets 296. Sodium 134, potassium 3.3, chloride 28,
bicarb 23, BUN 33, creatinine 0.9, glucose 151. Chest x-ray
as described in the history of present illness. Pelvic x-ray
showed no evidence of hip fracture and CT angiogram was
negative for PE, but showed bilateral large pleural effusions
with consolidation collapse of the right lower lobe and
partial collapse and consolidation of the left lower lobe.
PHYSICAL EXAMINATION: Temperature 97.4. Pulse 74. Blood
pressure 110/60. Respiratory rate 24. Head, eyes, ears,
nose and throat revealed no sclera icterus. No
lymphadenopathy. No erythema or exudates in the pharynx.
Heart had a 2/6 systolic murmur at the apex. Lungs had
decreased breath sounds at both bases with dullness and
bronchial breath sounds at the right base. The abdomen was
soft, nontender, nondistended with good bowel sounds. The
extremities revealed no edema and a cast on the right forearm
and two ulcers on the right hip with erythema and yellow
drainage and necrotic edges and a mid thoracic ulcer with
erythema and no drainage.
HOSPITAL COURSE: The patient had a complicated hospital
course due to the multiple sources of infection. In addition
to the sources noted in the history of present illness the
patient also was found to have multiple dental abscesses, the
decubitus ulcers noted and pneumonia and a Methacillin
sensitive staph aureus high grade bacteremia. He was treated
initially with broad spectrum antibiotics and the coverage
was later narrowed according to the sensitivities of the
organisms, which grew out in the culture. The patient failed
to progress on the floor and ultimately was transferred to
the Intensive Care Unit on [**9-7**] for respiratory failure
and was intubated and supported with mechanical ventilation.
The patient was found at that point to have large pleural
effusions bilaterally and thoracentesis, however, revealed no
active infection in the fluid.
The patient was also found on CT to have a new fracture on
the right iliac crest. The Orthopedic Service was consulted
and felt that no surgical treatment was warranted given the
patient's grave medical condition. The CT also revealed
fluid collection in the right gluteal area, which was drained
under CT guidance, however, this also did not reveal a source
for the patient's high grade bacteremia. Ultimately the
patient was extubated, however, his condition deteriorated
and on the morning of [**9-28**] the patient became acutely
hypotensive and his respirations became labored and the
patient's daughter was consulted who chose to make the
patient comfort measures only. He expired on [**9-28**] of
respiratory failure secondary to sepsis and hypotension.
DIAGNOSES AT DEATH:
1. Methicillin sensitive staph aureus bacteremia.
2. Dental abscesses.
3. Decubitus ulcer.
4. Pneumonia.
5. Iliac crest fracture.
6. Sepsis.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 10038**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2131-12-15**] 08:28
T: [**2131-12-17**] 06:35
JOB#: [**Job Number 33699**]
|
[
"428.0",
"808.43",
"038.11",
"V09.0",
"518.81",
"522.5",
"733.90",
"486",
"707.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.04",
"99.04",
"38.93",
"43.11",
"38.91",
"34.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
1820, 2743
|
3419, 5481
|
2766, 3401
|
110, 1279
|
1302, 1793
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,074
| 182,558
|
53615+59562
|
Discharge summary
|
report+addendum
|
Admission Date: [**2121-6-13**] Discharge Date: [**2121-6-14**]
Date of Birth: [**2047-2-20**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
74 y/o male with unclear [**Name (NI) 3262**] who presents with massive ICH.
Per report, seemed to be in USOH until this evening when he
developed an occipital HA with L sided weakness and nausea. He
called EMS, then developed left arm pain which concerned him for
an MI so he took aspirin. When EMS arrived, he was given 500ml
NS and zofran, then quickly decompensated. He was taken to
[**Hospital3 **] where he was intubated and had a head CT that
showed massive ICH. He was transferred to [**Hospital1 18**] for Nsurg
evaluation.
.
In the ED, initial VS were: 60, 16, 201/67, 100%vent. CT showed
CT head with 3.6 cm intraparenchymal hemorrhage around the left
basal ganglia. Also intraventricular hemorrhage and the lateral
ventricles, third ventricle and fourth ventricle. Extensive
subarachnoid hemorrhage filling the cisterns causing mass effect
in the mid brain and pons. 4 mm midline shift. Neurosurgery was
consulted who felt this was a massive ICH with no chance for
recovery and no intervention was indicated. He was admitted to
the MICU due to being intubated.
Past Medical History:
HTN
DM
"Heart Disease"
Social History:
Lived alone. Used to be ministry
Family History:
NC
Physical Exam:
General: intubated, not responsive
HEENT: pupils fixed
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Pupils fixed and dilated, no corneal reflex on left,
intermittent nonpurposeful twitches on right. No vestibuloocular
reflex. Intermittent Twitches of RLE. No response to nailbed
pressure or sternal rub. Is overbreathing vent.
Pertinent Results:
[**2121-6-13**] 08:57PM BLOOD WBC-9.2 RBC-3.93* Hgb-12.2* Hct-37.8*
MCV-96 MCH-31.1 MCHC-32.3 RDW-13.1 Plt Ct-221
[**2121-6-13**] 08:57PM BLOOD Neuts-88.0* Lymphs-6.3* Monos-3.5 Eos-1.8
Baso-0.4
[**2121-6-13**] 09:21PM BLOOD PT-13.3* PTT-28.7 INR(PT)-1.2*
[**2121-6-13**] 08:57PM BLOOD Glucose-166* UreaN-27* Creat-1.4* Na-144
K-3.4 Cl-107 HCO3-27 AnGap-13
[**2121-6-13**] 08:57PM BLOOD ALT-21 AST-33 AlkPhos-42 TotBili-0.6
[**2121-6-13**] 08:57PM BLOOD Albumin-4.1 Calcium-8.8 Phos-2.4* Mg-1.8
[**2121-6-13**] 09:10PM BLOOD Type-ART Rates-/16 Tidal V-500 FiO2-100
pO2-374* pCO2-42 pH-7.42 calTCO2-28 Base XS-3 AADO2-296 REQ
O2-56 Intubat-INTUBATED
[**2121-6-13**] 09:09PM BLOOD Lactate-1.5
Brief Hospital Course:
74 y/o male who presents with massive ICH.
.
# ICH - Catastrophic midbrain head bleed with midline shift.
Neurosurgery feels no intervention can be done given exam and CT
findings as this injury is irreversible and lethal. Neurosurgery
met family to discuss grim prognosis. Shortly thereafter, care
was redirect towards comfort. Patient passed away at 0225.
Medications on Admission:
unknown
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2121-6-14**] Name: [**Known lastname 18113**] SR.,[**Known firstname 520**] [**Last Name (NamePattern1) **] Unit No: [**Numeric Identifier 18114**]
Admission Date: [**2121-6-13**] Discharge Date: [**2121-6-14**]
Date of Birth: [**2047-2-20**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**Last Name (NamePattern4) 3776**]
Addendum:
Death was attributed to large left intraparenchymal hematoma
with resulting extensive cerebral edema that produced mass
effect with effacement of the basal cisterns. This degree of
edema and mass effect was felt to be incompatible with recovery.
Discharge Disposition:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**]
Completed by:[**0-0-0**]
|
[
"401.9",
"250.00",
"429.9",
"431",
"331.4",
"V10.83",
"430",
"348.5",
"530.81",
"V49.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
4254, 4430
|
2838, 3197
|
297, 309
|
3347, 3356
|
2123, 2815
|
3412, 4231
|
1531, 1535
|
3255, 3264
|
3317, 3326
|
3223, 3232
|
3380, 3389
|
1550, 2104
|
254, 259
|
337, 1419
|
1441, 1465
|
1481, 1515
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,486
| 167,624
|
44387
|
Discharge summary
|
report
|
Admission Date: [**2166-2-12**] Discharge Date: [**2166-2-13**]
Date of Birth: [**2089-10-16**] Sex: M
Service: MEDICINE
Allergies:
Clonidine
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Patient found unresponsive at home.
Major Surgical or Invasive Procedure:
Placement of right femoral catheter for hemodialysis
Central line placement
Arterial line placement
History of Present Illness:
76 yo M with a history of CAD, PVD, hypertension,
hyperlipidemia, diabetes mellitus II and chronic kidney disease
admitted after becoming unresponsive at home.
.
The patient complained to his family of fatigue for the past
week. On the evening prior to his event he developed chills. The
patient said to his family that he felt as if he was coming down
with an illnes ("the flu") and he went to bed early. At 6:30AM
on the day of admission, the patient descended the stairs to the
living room in his house where his wife witnessed him having
difficulty breathing, described as "raspy" by his wife. The
patient did not respond to repeated questioning by his wife
about how he was feeling. The patient sat down on the couch then
laid his head on the arm of the couch and became unresponsive.
His wife called her daughter and then 911. The patient was
unresponsive for up to 30 minutes by his wife's report prior to
CPR being initiated by EMS.
.
The patient was found to be asystolic by EMT. He received
atropine 1mg x3 and epinephrine 1mg with return of pulse in
rapid a fib and pressure 60/palp. He was intubated in the field
and started on peripheral dopamine. On arrival to the ED, pulse
96, bp 140/56.
.
In the ED, the patient was found to have hyperkalemia and severe
metabolic acidosis (pH 6.7). He received 2amps calcium
gluconate, insulin and D50, 2 amps sodium bicarb and kayexalate
as treatment for hyperkalemia. He was changed from a dopamine to
levophed gtt, started on a versed gtt and heparin gtt. He
underwent CTA which was negative for PE or aortic abnormality.
He received 3 amps sodium bicarb in D5 and mucomyst prophylaxis
in advance of possible cardiac cartheterization. Catheterization
was deferred in the setting of profound acidosis.
.
Review of systems is notable for no cardiac complaints with the
exception of his apparent shortness of breath. He had no CP,
N/V, dizziness, lightheadedness, presyncope, edema, orthopnea.
The family denies recent fevers or cough. His wife states that
the patient recently complained of gout-type symptoms in his big
toe. No report of dysarthria or gait disturbances, headache or
blurry vision.
Past Medical History:
1. PVD: had stents to distal aortia, bilateral common iliac
arteries, and left external iliac artery [**2163-4-12**]. Had abnormal
ABIs subsequently [**2163-5-25**] but further intervention was
deferred at that time because his symptoms had substantially
improved until 1 month ago (see HPI).
2. Renal artery stenosis: has 90% lesion on R, serial 80%
lesions on left. Followed by Dr. [**Last Name (STitle) **] in Renal - discussions
ongoing re: revascularization options. Baseline creatinine mid
2's-3.0 over past few months.
3. HTN
4. Hypercholesterolemia
5. Type 2 DM, insulin dependent
6. CAD
7. s/p ccy
8. retroperitoneal fibrosis s/p bilateral ureterolysis with
omental wrap, [**4-/2150**]. stable on serial CT scans, most recent [**2-25**]
Social History:
retired insurance appraiser. Lives with his wife in [**Name (NI) 2312**].
Smoked 4 ppd x 40s yrs, quit 14 years ago. No EtOH.
Family History:
mother died at 61 y/o of brain tumor. father died at 72 y/o of
MI. brother recently died at 65 y/o of cancer, unknown type.
has 2 children, ages 42 and 43, both healthy.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 93.1 73 118/60 on levophed 0.213mcg/kg/min, AC 550, RR 20,
PEEP 10, FiO2 0.8
Gen: Intubated and sedated. Cooling vest in place.
HEENT: 4cm fixed and dilated pupils bilaterally.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: CTA bilaterally.
Abd: Soft, nontender, no masses or organomegaly.
Ext: No edema. 1+ pulses bilateral DP.
Integumentary: No rashes or lesions.
Pertinent Results:
ADMISSION LABS:
[**2166-2-12**] 07:50AM BLOOD WBC-16.4*# RBC-4.84 Hgb-13.9* Hct-44.4
MCV-92 MCH-28.7 MCHC-31.3 RDW-13.1 Plt Ct-225
[**2166-2-12**] 12:38PM BLOOD Neuts-89.2* Bands-0 Lymphs-6.2* Monos-3.7
Eos-0.4 Baso-0.4
[**2166-2-12**] 07:50AM BLOOD PT-17.3* PTT-86.8* INR(PT)-1.6*
[**2166-2-12**] 12:38PM BLOOD Glucose-220* UreaN-48* Creat-3.6* Na-148*
K-5.7* Cl-111* HCO3-15* AnGap-28*
[**2166-2-12**] 12:38PM BLOOD ALT-1057* AST-1316* LD(LDH)-1736*
CK(CPK)-2105* AlkPhos-197* Amylase-306* TotBili-0.4
[**2166-2-12**] 12:38PM BLOOD Albumin-2.7* Calcium-8.1* Phos-6.9*#
Mg-2.1
[**2166-2-12**] 07:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2166-2-12**] 12:38PM BLOOD TSH-4.0
[**2166-2-12**] 08:03AM BLOOD freeCa-1.10*
CARDIAC ENZYMES:
[**2166-2-12**] 07:50AM BLOOD CK(CPK)-1225* Amylase-160*
[**2166-2-12**] 06:34PM BLOOD CK(CPK)-5121*
[**2166-2-12**] 07:50AM BLOOD CK-MB-28* MB Indx-2.3 cTropnT-0.37*
[**2166-2-12**] 12:38PM BLOOD CK-MB-84* MB Indx-4.0 cTropnT-0.83*
[**2166-2-12**] 06:34PM BLOOD CK-MB-243* MB Indx-4.7 cTropnT-2.34*
ABG's:
[**2166-2-12**] 08:03AM BLOOD Type-ART pH-6.78*
[**2166-2-12**] 10:36AM BLOOD Type-ART pO2-215* pCO2-52* pH-7.02*
calTCO2-14* Base XS--18
[**2166-2-12**] 08:03AM BLOOD Glucose-124* Lactate-10.4* Na-144 K-5.9*
Cl-108 calHCO3-13*
[**2166-2-12**] EKG: Sinus rhythm at a rate of 100, normal axis ,
normal intervals, q waves in III, right bundloid appearance in
precordial leads. Downgoing T's in the inferior leads and V4-6.
Downgoing ST depressions in V3-5. Deepening of inverted T's in
the inferior leads and more pronounced downsloping ST depression
in V3-5 compared to prior dated [**2165-3-21**].
[**2166-2-12**] TELEMETRY: In the field, paddle strip reveals likely PEA
or near asystole with return to sinus rhythm with ST elevations
after therapy.
[**2166-2-12**] CXR: Appropriate position of endotracheal tube.
Mild-to-moderate pulmonary edema.
[**2166-2-12**] CTA:
1. No pulmonary embolism. No acute aortic abnormalities
identified. 2. Severe atherosclerotic disease of the aorta,
with calcified plaque along the descending aorta. 3.
Mild-to-moderate pulmonary edema. 4. Patchy airspace opacity at
the left lung base may represent a small amount of aspiration.
Brief Hospital Course:
A/P: 76 yo M with a history of CAD, PVD, hypertension,
hyperlipidemia, diabetes mellitus II and chronic kidney disease
admitted after becoming unresponsive at home found to have a
cardiac arrest now with profound metabolic acidosis.
.
# Unresponsiveness/Arrest. Unclear of underlying etiology. The
patient was found in a cardiac arrest (PEA) successfully
resucitated. This seems unlikely to be of primary cardiac
etiology with non-diagnostic EKG changes and modest cardiac
enzyme elevations. Sepsis as a preceding etiology seems possible
given report of infectious-type symptoms including fatigue and
chills the evening prior to his event. Infection and relative
hypovolemia precipitating acute on chronic renal failure as an
etiology for uremia/acidosis and hyperkalemia is also possible.
A CVA is possible but unlikely. CTA negative for PE or aortic
abnormality. Prolonged period (30 minutes) unresponsive prior to
rescucitation and profound metabolic acidosis portend a poor
prognosis. Patient uderwent Cooling protocol and agressive BP
control.
Patient continued to deteriorate with hyperkalemia and
progressing renal failure, exhibiting signs of profound
neurologic impairment. Goal of care were re-adressed with
family, who reported patient's wishes were to not have dialysis
or life support. Patient was made comfort measures only in the
morning of [**2166-2-14**].
Patient was extubated with family at the bedside; time of death
12:50pm [**2166-2-14**].
Patient had tested positive for the Influenza Virus.
Medications on Admission:
Nifedipine 90mg Daily
Crestor 20mg Daily
Furosemide 120mg Daily
Cozaar 100mg Twice daily
Calcitriol 0.5mcg Daily
Metoprolol 200mg Twice Daily
Zetia 10mg Daily
Insulin Glargine 25U at bedtime, Aspart Sliding scale
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
[
"276.2",
"250.00",
"585.4",
"403.90",
"414.01",
"272.4",
"487.1",
"584.9",
"427.5",
"443.9",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71",
"38.91",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
8237, 8246
|
6414, 7933
|
306, 408
|
8306, 8324
|
4133, 4133
|
8388, 8407
|
3525, 3699
|
8197, 8214
|
8267, 8285
|
7959, 8174
|
8348, 8365
|
3714, 3724
|
3746, 4114
|
4908, 6391
|
231, 268
|
436, 2589
|
4149, 4891
|
2611, 3362
|
3378, 3509
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,287
| 183,100
|
6476
|
Discharge summary
|
report
|
Admission Date: [**2189-9-11**] Discharge Date: [**2189-9-17**]
Date of Birth: [**2122-11-30**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
pericardial tamponade
Major Surgical or Invasive Procedure:
cardiac cath with pericardiocentesis for pericardial
effusion/tamponade
pericardial window
History of Present Illness:
6yoF with Stage IV non-small cell lung ca metastatic to brain
s/p 2 cyberknife treatments and also with L pleurex and severe
Parkinson's disease presents s/p urgent pericardiocentesis after
echocardiogram showed tamponade. Patient had echo done this AM,
[**2189-9-11**], as ordered by his PCP for peripheral edema (as an
outpatient), which showed tamponade. Specifically, she had a
small-moderate pericardial effusion with RV diastolic collapse.
Via non-invasive measurement, she had a pulsus of 25mmHg at the
time, which was 45mmHg when measured invasively (with Aline in R
femoral). Right heart cath showed RAP 20mmHg, RVEDP 20mmHg, PAP
22mmHg, pericardial pressure 20mmHg.
.
Pericardiocentesis with micropuncture needle under echo guidance
was done with pt in upright position. RV was entered initially.
Ultimately, 120cc bloody pericardial fluid was drained and sent
for cytology/culture. RAP fell to 14mmhg, pericardial pressure
fell to 3mmHg, SBP increased from 100mmHg to 150mmHg, and pulsus
decreased to 17mmHg. Post-pericardiocentesis echocardiogram
showed no fluid and no signs of tamponade, and the patient was
admitted to the CCU. Pulsus immediately prior to transfer was
15mmHg.
.
Currently, pt asking to eat. She denies pain at the site of the
drain. She denies SOB/cough. Per her son, she had been
complaining of pleuritic pain over the past few weeks, for which
her oncologist prescribed cough suppressives.
.
On review of systems, she (and her family) denies any prior
history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. She denies
recent fevers, chills or rigors. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.
Past Medical History:
1) Parkinson's Disease
2) Osteoporosis
3) Hepatitis B
4) Stage IV non-small cell lung Ca
Social History:
SOCIAL HISTORY: Lives with Son in the US, but originally from
[**Country 5142**]. Had exposure to gasoline stoves her entire life. No
history of smoking, alcohol, or illicit drug use.
Family History:
FAMILY HISTORY: Significant for Colon cancer in her father.
Physical Exam:
ON ADMISSION:
GENERAL: Frail, thin, elderly Asian female, with choreiform
movements (appearing in distress from this alone), masked
facies
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Crackles throughout L>R
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema b/l. No femoral bruits. RLE DP and PT
pulse 2+
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
NEURO: Motor is [**5-7**] throughout.
Notable cogwheeling and rigidity on muscular exam with some
choreiform movements.
.
ON DISCHARGE:
VS: 97.6-98.2, 99-115/65-80, 89-96, 16-19, 97-99%RA
Pulsus 6mmHg
GENERAL: Frail, thin, elderly Asian female, with choreiform
movements (appearing in distress from this alone), masked facies
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Crackles throughout L>R
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema b/l. No femoral bruits. RLE DP and PT
pulse 2+
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
NEURO: Motor is [**5-7**] throughout.
Notable cogwheeling and rigidity on muscular exam with some
choreiform movements.
Pertinent Results:
LABS ON ADMISSION:
.
[**2189-9-11**] 01:08PM VoidSpec-CLOTTED SP
[**2189-9-11**] 12:45PM OTHER BODY FLUID TOT PROT-3.4 GLUCOSE-110
LD(LDH)-265 AMYLASE-581 ALBUMIN-2.1
[**2189-9-11**] 12:45PM OTHER BODY FLUID WBC-1700* HCT-4.5* POLYS-96*
LYMPHS-3* MONOS-1*
[**2189-9-11**] 12:15PM GLUCOSE-104* UREA N-26* CREAT-0.6 SODIUM-137
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-23 ANION GAP-14
[**2189-9-11**] 12:15PM estGFR-Using this
[**2189-9-11**] 12:15PM WBC-14.6*# RBC-4.20 HGB-13.4 HCT-38.9 MCV-93
MCH-31.9 MCHC-34.5 RDW-16.4*
[**2189-9-11**] 12:15PM PLT COUNT-171
[**2189-9-11**] 12:15PM PT-11.4 INR(PT)-1.0
[**2189-9-14**] 06:47AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-TR
[**2189-9-14**] 06:47AM URINE RBC->182* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
[**2189-9-11**] 12:45PM Pericardial FLUID TotProt-3.4 Glucose-110
LD(LDH)-265 Amylase-581 Albumin-2.1
[**2189-9-11**] 12:45PM Pericardial FLUID WBC-1700* Hct,Fl-4.5*
Polys-96* Lymphs-3* Monos-1*
.
STUDIES & IMAGING:
.
[**2189-9-11**]
cardiac cath:
INDICATIONS FOR CATHETERIZATION:
Pericardial tamponade
PROCEDURE: Pericardiocentesis via subcostal approach with
echocardiographic guidance.
CARDIAC CATH:
Hemodynamic Measurements (mmHg)
Baseline
Site Sys [**Last Name (un) 6043**] End Mean A Wave V Wave HR
RA 20 23 20 87
RV 34 17 20 84
PCW 28 30 32 69
PA 34 21 22 85
PP 20 81
Contrast Summary
Contrast Total (ml)
Omnipaque (300 mg/ml) 2
Radiology Summary
Total Cine Runs
Fluoro Time (minutes) 3.00
Total IRP Dosage (mGy) 27
Findings
ESTIMATED blood loss: <100 cc
Hemodynamics (see above): Blunted y descent. Preserved X
descent. Elevation and equalization of filling pressures.
Pulsus paradox of 45 mm hg all consistent with tamponade
physiology.
Interventional details
Accessed pericardial space with combination of echocardiography,
pressure and fluoroscopic guidance using a micropuncture needle.
Needle temporarily in the RV which was expected given small
nature of the pericardial effusion. Exchanged for an Amplatz
stiff wire and using a series of 5,6,7,8 French Dilators were
able to place an 8 French drainage catheter and remove 120 cc of
bloody fluid. Y descent returned. RA pressure fell to 14 mm
hg.
Pericardial pressure of 3 mm Hg. SBP increased to 150 mm Hg
and
the pulsus decreased to 17 mm Hg indicating relief of tamponade.
Post procedure ECHO demonstrated removal of all fluid.
.
[**2189-9-11**]
Echo
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity is unusually
small. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function appears grossly normal (LVEF 60%). The right
ventricular cavity is small. The aortic valve is not well seen.
There is no aortic valve stenosis. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is a small to moderate sized
pericardial effusion. There is marked right ventricular
diastolic collapse (primarily involving the infundibular
segment, but also to a lesser degree the anterior free wall),
consistent with impaired fillling/tamponade physiology.
Impression: small-to-moderate-sized pericardial effusion;
cardiac tamponade is present
.
[**2189-9-11**]
post cath echo:
prepericardiocentesis: small circumferential pericardial
effusion with right ventricular free wall diastolic collapse
postpericardiocentesis: no residual pericardial effusion; no
chamber collapse; improved ventricular filling
.
Micro:
[**2189-9-11**] 12:45 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final [**2189-9-11**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2189-9-14**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST CULTURE (Preliminary):
ACID FAST SMEAR (Final [**2189-9-12**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
LABS ON DISCHARGE:
.
[**2189-9-17**] 08:00AM BLOOD WBC-6.7 RBC-3.92* Hgb-12.3 Hct-36.9
MCV-94 MCH-31.5 MCHC-33.5 RDW-16.3* Plt Ct-189
[**2189-9-17**] 08:00AM BLOOD Glucose-114* UreaN-26* Creat-0.6 Na-138
K-4.1 Cl-105 HCO3-24 AnGap-13
[**2189-9-17**] 08:00AM BLOOD Albumin-3.1* Calcium-7.9* Phos-2.2*
Mg-2.3
Brief Hospital Course:
66yoF with stage IV metastatic nonsmall cell lung ca and severe
Parkinson's Disease p/w cardiac tamponade s/p pericardiocentesis
and drain placement.
.
# Tamponade: Patient was admitted from the ECHO lab after
routine imaging showed evidence of pericardial effusion of
tamponade physiology. Patient was sent directly to the cath lab
where a right heart catheterization confirmed the diagnosis of
tamponade with a Pulsus of 45 mg Hg. A transcutaneous drainage
procedure was preformed with 150 cc of serosanginous fluid
removal and decrease in the pulsus to 15 mg Hg. Patient was
later sent for difinitive pericardial window by CT surgery and
tolerated the procedure well. Per the surgical report patient
had -closely monitor pericardial fluid drainage.
# Metastatic NSCLC: patient was admitted with a known diagnosis
of stage IV NSCLC with metastatis to the brain, a large left
sided effusion vs collapse on CXR and was s/p cyberknife
therapy. Patient was seen while in the CCU by her oncologists
who began erlotinib for a EGFR mutation sensitive tumor. Patient
developed heavy output loose stools to this medication, but no
other side effects. Patient was continued on a dexamethasone
taper for her reccent cyberknife procedure.
.
# Hypoxic respiratory failure: Patient had known NSCLC and was
noted to be hypoxic to the low 90s on addmission though not on
home oxygen. CXR showed complete white out of the left lung
suggesting effusion vs. collapse and appeared worse from a prior
CXR in [**Month (only) **]. Patient had plurex catheter in on admisison and
IP was consulted who d/c'd the tube as it had not had any output
in several days. Patient was stable at the time of transfer.
# Parkinson's Disease: Patient with a known history of severe
parkinson's disease and noted to have writhing choreform
movements on admission. She was continued on her outpatient
regimen of Amantadine, pramipexole and simemet.
.
# Hep B: patient continued on home entecavir.
Transitional issues:
-cytology and pericardial biopsy were pending at time of
transfer
-pharmacy has raised concern that dexamethasone and erlotinib
have possible interactions and dex taper may need to be
shortened.
Medications on Admission:
ALENDRONATE - (Prescribed by Other Provider) - Dosage uncertain
AMANTADINE - 100 mg Capsule - 1 Capsule by mouth three times a
day
BENZONATATE - (Prescribed by Other Provider) - Dosage uncertain
CARBIDOPA-LEVODOPA - 25 mg-100 mg Tablet - 0.5 Tablets by mouth
five times a day
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - 1 tsp by mouth
every eight (8) hours as needed for cough
DEXAMETHASONE - (Dose adjustment - no new Rx) - 4 mg Tablet - 1
(One) Tablet(s) by mouth twice a day-Start 2 days prior to
Cyberknife treatments. Taper as follows: take 4 mg [**Hospital1 **] on
[**8-31**], take 4 mg QAM & 2 mg QPM on [**9-4**], take 4 mg daily
on
[**9-8**], take 2 mg daily on [**9-12**], take 2 mg every other
day
on [**9-24**], [**9-22**] & [**9-24**]. Stop taking Decadron after your
dose
on [**2189-9-24**].
ENTECAVIR [BARACLUDE] - 0.5 mg Tablet - 1 Tablet(s) by mouth
daily take medication 2 hours before and after meal
HOME SERVICES EVALUATION - - by Spring Well Company
LEVETIRACETAM - (Dose adjustment - no new Rx) - 500 mg Tablet -
1 (One) Tablet(s) by mouth twice a day-Start 2 days prior to
Cyberknife treatment. Continue taking Keppra as prescribed for 7
days after your CyberKnife treatment. Stop taking Keppra after
your evening dose on [**2189-9-9**].
PRAMIPEXOLE [MIRAPEX] - 0.5 mg Tablet - 1 Tablet by mouth five
times per day
RANITIDINE HCL - (Dose adjustment - no new Rx) - 150 mg Tablet
-
1 (One) Tablet(s) by mouth twice a day-Start 2 days prior to
Cyberknife treatment. Continue taking Zantac as prescribed as
long as [**Known firstname **] are taking Decadron. Stop taking Zantac after your
morning dose on [**2189-9-24**].
Discharge Medications:
1. amantadine 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. carbidopa-levodopa 25-100 mg Tablet Sig: 0.5 Tablet PO 5X/DAY
(5 Times a Day).
4. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. pramipexole 0.25 mg Tablet Sig: 0.5 Tablet PO 5x/Day ().
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. erlotinib 25 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
Multicultural [**Date Range 269**]
Discharge Diagnosis:
Cardiac Tamponade
Metastatic Lung Cancer
Parkinson's Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
[**Known firstname **] were admitted to the hospital because [**Known firstname **] were found to have
a dangerous amount of fluid around your heart that was
preventing your heart from squeezing. [**Known firstname **] had a procedure to
drain this fluid followed by a surgery to help prevent
reaccumulation of this fluid.
While [**Known firstname **] were in the hospital [**Known firstname **] were started on a
chemotherapy that [**Known firstname **] will need to take at home. Unfortunately
by the time [**Known firstname **] were discharged the pharmacy was closed. [**Known firstname **]
will have to pick up the prescription tomorrow from:
CarePlus Pharmacy
[**Hospital1 **]
[**Location (un) 86**], MA
We had physical therapy see and they recommended that [**Known firstname **] have
supervision while walking at home.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2189-9-22**] at 4:15 PM
With: [**Name6 (MD) 20**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2189-9-24**] at 2:20 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2189-9-29**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], 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: TUESDAY [**2189-9-29**] at 9:30 AM
With: DR. [**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2189-9-19**]
|
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icd9cm
|
[
[
[]
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] |
[
"38.91",
"37.21",
"37.12",
"37.0",
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icd9pcs
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[
[
[]
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] |
13390, 13455
|
8810, 10788
|
328, 420
|
13559, 13559
|
4339, 4344
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|
2681, 2726
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2479, 2649
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,785
| 162,884
|
10586
|
Discharge summary
|
report
|
Admission Date: [**2150-4-9**] Discharge Date: [**2150-4-20**]
Date of Birth: [**2093-3-23**] Sex: M
Service: OMED
HISTORY OF PRESENT ILLNESS: The patient is a 56-year-old
male with a history of coronary artery disease, status post
inferior wall myocardial infarction, chronic obstructive
pulmonary disease, and anal cell carcinoma, who was admitted
to the MICU for respiratory distress. The patient presented
on the day of admission to the [**Hospital6 2018**] electively for radiation treatment and was noted to be
very tachypneic in the 30s and was sent to the Emergency
Room.
In the Emergency Room, the patient's respiratory rate was
confirmed in the 30s with oxygen saturation about 80% to 100%
on non-rebreather. ABG on 8 L was 7.42, 30, and 43. Chest
x-ray showed ................. redistribution, but overall
was poor quality. The patient denied chest pain, cough,
fever or increasing lower extremity swelling.
Electrocardiogram revealed right bundle branch block, left
anterior descending Q-waves in inferior leads, which per Dr.
[**Last Name (STitle) **] was old. The patient received 40 mg intravenous Lasix
with 1 L diuresis and improvement in oxygen saturation 90% on
100% non-rebreather.
The patient underwent CT angiogram, given concerns for PE.
Exam revealed no PE, severe chronic obstructive pulmonary
disease and mild congestive heart failure. The patient was
sent to the Intensive Care Unit on 100% non-rebreather for
further care.
PAST MEDICAL HISTORY: ................. carcinoma, status
post local resection, status post chemotherapy and radiation.
Chronic obstructive pulmonary disease for which he takes
chronic steroids. Status post myocardial infarction. Right
below-the-knee amputation. He suffers from diabetes mellitus
and is Insulin dependent. Schizophrenia.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Prednisone 10 once a day, Aspirin
325 once a day, Zyprexa 5 q.h.s., Isosorbide Nitrate 30 mg 3
times a day, Metoprolol 50 mg 3 times a day, Prilosec 20
q.h.s., Zocor 40 once a day, Benadryl, Zocor 40 mg q.h.s.,
Atrovent, Colace, Serevent, Albuterol, Multivitamin.
SOCIAL HISTORY: The patient has a 40-year tobacco history.
He is a former drinker. He is a resident of the [**Hospital **]
Healthcare Center. He is a former accountant.
PHYSICAL EXAMINATION: General: The patient was a
middle-aged, heavy-set gentleman. He was tachypneic while
sitting up in the chair. Vital signs: Temperature 99.6??????,
blood pressure 105/60, heart rate 95-100, respirations 26-30,
oxygen saturation 88% to 90% non-rebreather. HEENT: Pupils
equal, round and reactive to light. No scleral icterus.
Oropharynx clear. Neck: Supple. Difficult to assess JVP.
Chest: Poor air movement. No wheezing. No crackles.
Distant heart sounds. Tachycardia. No murmur was
appreciated. Abdomen: Obese, soft, nontender and
nondistended. The patient had severe radiation changes of
the skin across the buttocks and scrotum. Extremities: Warm
with 1+ edema. Poor left pedal pulse.
LABORATORY DATA: Chest x-ray and CT angiogram as previously
described.
White count 8.5, hematocrit 49.4, platelet count 160,000;
CHEM7 unremarkable; ABG as described.
Electrocardiogram as described.
HOSPITAL COURSE: The patient was admitted to the MICU where
he was observed overnight. He did well on 100%
non-rebreather and was treated initially with high-dose
steroids for presumed chronic obstructive pulmonary disease
flare and was started on Levaquin. The patient was
transferred out to the floor on 16th. His hospital course
was notable for resolution of his obstructive component of
lung disease with steroids.
The patient initially continued radiation treatment, but
given his considerable skin changes and breakdown secondary
to radiation, it was held for one week to allow for healing.
On the 20th of the month, he was transferred to the Oncology
Service for continuation of his treatment of his anal
carcinoma. His course was unremarkable. He received 5FU and
Mitomycin. He continued to have resolution of his chronic
obstructive pulmonary disease flare, and a steroid taper was
begun. He was brought to his baseline oxygen requirement of
about 6 L/min by nasal cannula. With skin care, the scrotal
skin breakdown and erythema resolved, and the patient was
restarted on his radiation therapy on [**4-20**].
He was transferred back to this home on [**4-20**] in stable
condition with his chronic obstructive pulmonary disease
flare having resolved and with radiation treatment ensuing
for his anal carcinoma. He is now status post 5FU and
Mitomycin treatment and is doing well with no noticeable side
affects from the 5FU. He continued to eat well and had no
other difficulties.
Given the severity of his chronic obstructive pulmonary
disease and the flare, his beta-blocker was stopped and will
be restarted given the tenuousness of his pulmonary
condition.
DISCHARGE DIAGNOSIS:
1. Chronic obstructive pulmonary disease flare.
2. Anal cancer.
3. Coronary artery disease.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: He will be discharged to [**Hospital **] Healthcare
Center.
DISCHARGE MEDICATIONS: Colace 100 mg p.o. b.i.d., Lipitor 10
mg p.o. q.d., Zantac 150 mg p.o. b.i.d., Serevent MDI 3 puffs
twice a day, Levaquin 500 mg p.o. q.d. x 4 days, Aspirin 325
mg p.o. q.d., NPH Insulin 10 U q.a.m., regular Insulin
sliding scale fingerstick 160-200 4 U, 201-250 6 U, 251-300 8
U, 301-350 10 U, 355-400 12 U, over 400 14 U. He will
continue on subcue Heparin until he is ambulatory, 5000 U
subcue b.i.d., Multivitamin once a day. Continue his
Combivent MDI 2 puffs q.4-6 hours around the clock, Albuterol
MDI 2 puffs q.2-4 hours, as well as Prednisone, he will take
50 mg q.d. for a week, then 40 mg q.d., for a week, and then
30 mg q.d. for a week, then 20 mg q.d. q.week, and then
remain on 10 mg q.d.
DISCHARGE INSTRUCTIONS: The patient should have his groin
and buttocks treated with Nystatin powder and Lotrimin creme
with cleaning and reapplication of this twice a day, as well
as ................... He should have [**Last Name (un) **] baths twice a
day. He will remain on 6 L oxygen by nasal cannula trying to
keep the oxygen saturations between 80 and 90%. He will be
on [**First Name8 (NamePattern2) **] [**Doctor First Name **], 40 kcal diet.
FOLLOW-UP: He will follow-up with Dr. [**Last Name (STitle) **] regarding his
cancer, and with Dr. [**First Name (STitle) **] [**Name (STitle) 34816**]. The patient will
continue on with Radiation/Oncology. He should have his
treatments daily, to be arranged with the Radiation/Oncology
Division at [**Hospital1 **] Hospital.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 32151**]
MEDQUIST36
D: [**2150-4-20**] 12:11
T: [**2150-4-20**] 12:11
JOB#: [**Job Number 34817**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Doctor Last Name 34818**], [**Last Name (un) **], [**Numeric Identifier 34819**]
|
[
"250.01",
"428.0",
"491.21",
"154.3",
"295.70",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5202, 5909
|
4973, 5069
|
1891, 2158
|
3284, 4952
|
5934, 7077
|
2354, 3266
|
165, 1482
|
1505, 1864
|
2175, 2331
|
5094, 5178
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,679
| 184,687
|
3486
|
Discharge summary
|
report
|
Admission Date: [**2139-10-5**] Discharge Date: [**2139-11-4**]
Date of Birth: [**2081-5-31**] Sex: M
Service: CSU
Mr. [**Known lastname 16033**] is a postoperative admission.
CHIEF COMPLAINT: Follow up for ascending aortic dilatation
with no symptoms.
HISTORY OF PRESENT ILLNESS: Patient presented with a
complaint of flutter and palpitations. An echo showed that
the patient had enlarged aorta. CAT scan done following the
echo revealed a 5 cm ascending aortic aneurysm. MIBI in
[**9-/2138**] showed an ejection fraction of 40 percent with an
inferior myocardial infarction and no ischemia. Cardiac
catheterization showed an ejection fraction of 58 percent
with a large aortic aneurysm, distal right coronary artery
lesion of 70 percent, a D1 lesion of 40 percent, an LV EDP of
11.
PAST MEDICAL HISTORY: Significant for hypertension, diabetes
mellitus type 2, GERD, chronic sinusitis, CAD status post
myocardial infarction, obesity.
PAST SURGICAL HISTORY: Significant for hemorrhoidectomy in
[**2119**], appendectomy in [**2112**], tonsillectomy.
MEDICATIONS PRIOR TO ADMISSION:
1. Mavik 4 mg b.i.d.
2. Glucotrol, no dose
3. Prilosec, no dose
4. Flonase, no frequency
5. Zyrtec, no dose
6. Aspirin 81 mg once daily
ALLERGIES: Patient states no known drug allergies, although
he also states that he could not tolerate statins.
FAMILY HISTORY: Mother is alive and well at 81. Father died
of Alzheimer's at age 88.
SOCIAL HISTORY: Occupation: Maintenance manager. Lives
with wife. Remote tobacco history; quit in [**2116**]. Occasional
alcohol use; 1 beer per week. No other drug use.
CAT scan done in [**5-/2139**] showed 5 cm ascending aortic root.
The rest of the aorta was normal. Chest showed no
infiltrates or masses.
PHYSICAL EXAMINATION: VITAL SIGNS: Heart rate 84 and
regular, blood pressure 146/88, height 5 feet, 11 inches,
weight 239 pounds.
GENERAL: Obese, young man.
SKIN: No obvious lesions.
HEENT: Pupils equally round and reactive to light.
Extraocular movements intact; anicteric; not injected.
NECK: Supple with no bruits and no JVD.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm; S1, S2 with a IV/VI
systolic ejection murmur that does not radiate.
ABDOMEN: Obese, soft, nontender, with positive bowel sounds.
No hepatosplenomegaly.
EXTREMITIES: Warm and well perfused with no clubbing,
cyanosis, or edema. No varicosities, although he does have
mild spider veins bilateral lower extremities.
NEURO: Cranial nerves II-XII grossly intact and nonfocal
exam.
PULSES: Femoral 1 plus bilaterally, dorsalis pedis and
posterior tibial 2 plus bilaterally, radial 2 plus
bilaterally.
HOSPITAL COURSE: As stated previously, patient was a
postoperative admit. He was directly admitted to the
Operating Room on [**2139-10-5**], where he underwent an ascending
aortic root replacement, _________, with a hemiarch repair
using a 26 Gel weave, also a coronary artery bypass graft
times 2 with a saphenous vein graft to the RPL and RPDA
sequentially. His bypass time was 158 minutes with a cross-
clamp time of 102 minutes and circulatory arrest time of 14
minutes. The patient was transferred from the Operating Room
to the Cardiothoracic Intensive Care Unit in the sinus rhythm
at 68 beats per minute with mean arterial pressure of 67 and
a CVP of 11. He had Neo-Synephrine at 0.3 mcg/kg/minute and
propofol at 20 mcg/kg/minute.
Patient did well in the immediate postoperative period. He
was reversed from his anesthesia, weaned from the ventilator
and successfully extubated.
On postoperative day 1 he remained hemodynamically stable.
However, the patient did complain of increasing respiratory
distress and was experiencing decreasing urine output. At
that time a transthoracic echo was done that showed no
pericardial effusion; however, the echo was unable to
visualize the arch.
On postoperative day 2 the patient's creatinine was noted to
be elevated, and a Renal consult was called. Renal service
felt patient was in acute renal failure, and renal ultrasound
was done at that time that proved to be negative. The
patient also had increasing liver function tests and coags,
and at that time a General Surgery consult was called to
assess for causes of the elevated liver function test shock
liver. The patient had an MRI at that time to rule out a
descending dissection. Additionally, the patient was
reintubated on postoperative day 2, and a Pulmonary consult
was called due to poor gas exchange. Furthermore, the
patient experienced rapid atrial fibrillation and was
cardioverted with 200 Joules to sinus rhythm. At that time a
Cardiology consult was also called. Given the patient's
oliguric renal failure, the patient was also begun on CVVHD
on postoperative day 2.
On postoperative day 3 the patient continued to experience
elevated LFTs, coags, BUN, and creatinine. Additionally, the
patient had an elevated white blood cell count with a
decreased SVR, and Infectious Diseases consult was called.
Patient was started on broad spectrum antibiotics at that
time but continued to experience difficulty ventilating the
patient. He was fully sedated and, on postoperative day 4,
he was chemically paralyzed and put on pressure-control
ventilation.
Over the next 2 weeks the patient experienced severe multi-
organ failure with an AST that peaked at 11,759, an ALT that
peaked at 5874 with total bilirubin that peaked at 13.6.
Additionally, patient required pressure-control ventilation
with nitric oxide to further enhance gas exchange and CVVHD
to supplement his renal function. He continued to be
followed by the Hepatobiliary service, the Renal service, the
ID service, the Cardiology service, and the Critical Care
service, as well as the Pulmonary service. Ultimately, the
patient's paralytics were discontinued by postoperative day 9
with gradual weaning of the nitric, following that was
ultimately weaned by postoperative day 11 followed by a
gradual wean from sedation.
On postoperative day 14 he was finally able to be weaned from
pressure-control ventilation followed by a change to IMV
ventilation and ultimately to pressure-support ventilation by
postoperative day 15.
On postoperative day 18 the patient was finally extubated.
By this point the only intravenous medication the patient was
on, besides antibiotics, was nitroglycerin for blood pressure
control. Over the next week the patient's pulmonary status
was closely monitored. He remained in the Intensive Care
Unit for vigorous pulmonary toilet. He had an ENT consult
that ultimately showed bilateral vocal cord paralysis. He
was transitioned from intravenous medications to oral
medications, and on postoperative day 24 the patient was
transferred from the Intensive Care Unit to _____ floor for
continuing postoperative care and cardiac rehabilitation.
Once on the floor patient had an uneventful hospital course.
His activity was increased gradually with the assistance of
the nursing staff as well as Physical Therapy. His diet was
advanced. He had a repeat ENT consult and video stroboscopy.
On postoperative day 29 it was decided that the patient would
be stable and ready to be transferred to rehabilitation on
the following day. At the time of this dictation patient's
physical exam is as follows:
VITAL SIGNS: Temperature 98.2, heart rate 62, blood pressure
100/60, respiratory rate 18, O2 sat 96 percent on room air,
weight currently 101.4 kg, preoperatively 113.6 kg.
LABORATORY DATA: White count 7.2, hematocrit 30.5, platelets
147, sodium 135, potassium 4.3, chloride 102, CO2 24, BUN 18,
creatinine 0.7, glucose 99.
PHYSICAL EXAMINATION: NEURO: Alert and oriented times 3;
moves all extremities; follows commands; very weak, unable to
walk independently; able to finally pivot from bed to chair,
unassisted, the day prior to transfer.
CARDIOVASCULAR: Regular rate and rhythm; S1, S2 with a II/VI
systolic ejection murmur.
RESPIRATORY: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended, with positive bowel
sounds.
EXTREMITIES: Warm and well perfused with no edema.
SKIN: Sternum is stable. Incision healing well. Left
saphenous vein graft harvest site healing well. Incision
open to air, clean and dry.
DISCHARGE CONDITION: Good.
FINAL DIAGNOSES: Status post ascending aortic hemiarch
repair with a No. 26 gel weave
Coronary artery bypass graft times 2 with a saphenous vein
graft to the RPL, sequentially to the RPDA, complicated by
multi-organ failure and bilateral vocal cord paralysis.
Hypertension.
Diabetes mellitus type 2.
Gastroesophageal reflux disease.
Hypercholesterolemia.
DISPOSITION: The patient is to be discharged to
rehabilitation at [**Hospital3 7665**] Center in _________.
FOLLOW UP: He is to have follow up with Dr. [**First Name (STitle) **] _______ in
2 to 3 weeks following his discharge from rehabilitation.
Follow up with Dr. __________ of the [**Hospital **] Clinic in 1 week.
Fo[**Last Name (STitle) **]p with Dr. [**Last Name (Prefixes) **] in 4 weeks. Patient is to
call for the last 2 appointments.
DISCHARGE MEDICATIONS:
1. Aspirin 325 once daily
2. Heparin 5000 units subcutaneously t.i.d.
3. Norvasc 10 mg once daily
4. Labetalol 800 mg t.i.d.
5. Glipizide 5 mg b.i.d.
6. Trazodone 50 mg at bedtime p.r.n.
7. Amiodarone 200 mg once daily
8. Percocet 5/325, 1 to 2 tabs, q. 4-6 hours p.r.n.
9. Beclomethasone aerosol spray, 2 sprays, b.i.d. p.r.n.
10. Pantoprazole 40 mg b.i.d.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2139-11-3**] 20:42:35
T: [**2139-11-4**] 00:34:15
Job#: [**Job Number 16034**]
|
[
"414.01",
"584.9",
"707.0",
"518.82",
"997.5",
"996.62",
"570",
"997.1",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"96.71",
"36.12",
"38.93",
"96.6",
"99.07",
"99.05",
"38.45",
"96.04",
"88.72",
"39.95",
"89.61",
"99.02",
"89.64"
] |
icd9pcs
|
[
[
[]
]
] |
8293, 8300
|
1383, 1455
|
9137, 9758
|
2711, 7649
|
991, 1083
|
8318, 8772
|
8784, 9114
|
1115, 1366
|
7672, 8271
|
216, 277
|
306, 814
|
837, 967
|
1472, 1773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,228
| 197,376
|
54094
|
Discharge summary
|
report
|
Admission Date: [**2131-5-21**] Discharge Date: [**2131-6-2**]
Date of Birth: [**2052-1-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Passed out
Major Surgical or Invasive Procedure:
Pacemaker lead explantation
History of Present Illness:
79 yr old previously active and independent man s/p dual chamber
pacemaker placement in [**2128**] who was admitted to an OSH after
syncope on [**2131-5-15**]. At that time, he was found by EMS to have
a long QT with multiple PVCs (R on T) and long non-sustained
runs of Torsades lasting up to 3 seconds, and was thought to be
the cause of his syncope. Initiallly, the patient was placed on
amiodarone, and was ruled out for myocardial infarction. All
electrolytes were normal, and the only reported QT prolonging
med was Zofran.
.
The patient noted fevers, chills and rigors for preceding week
prior to the [**5-15**] event (febrile to 104 in the field by EMS). On
[**5-16**], the patient grew S. schleiferi in [**5-16**] bottles.
Surveillance blood cultures had been negative, and the patient
did not have a leukocytosis. The patient had a TEE that was
negative for a clear vegetation on pacemaker leads or valves,
but the wire could not be fully visualized. After a discussion
with [**Hospital1 18**] cardiologist(s) it was decided to transfer the
patient to [**Hospital1 18**] for removal of the pacemaker in the absence of
another source of high-grade bacteremia. He was started on a
regimen of IV cefazolin which will need to be continued for at
least 4 weeks.
.
By report of the outside cardiologist, it is unclear what the
initial indication for the patient's pacemaker was. It was
suspected to be high grade AV block, after the patient was V
paced 97% with an unreliable escape, althout he was apparently
seen to transiently conduct with a narrow QRS complex when he
initially presented on [**2131-5-15**].
.
At the OSH ([**Doctor Last Name 62565**] Hospital in NH), the patient was
hemodynamically stable by report. On [**2131-5-17**], his amiodarone was
stopped and transitioned to beta-blockers. He had the lower
pacing rate changed to 70 given long QT and Torsades. By report,
the patient was still having short runs of Torsades with a long
QT prior to transfer. He had a cardiac catheterization prior to
transfer which showed non-obstructive CAD.
.
On transfer, he feels well without complaints.
Past Medical History:
type II DM
HTN
hyperlipidemia
glaucoma
R-pectoral dual chamber pacemaker (St. [**Hospital 923**] Medical Victory XL
DR) implanted on [**2128-8-23**] at [**Hospital **] Hospital in [**State 1727**]
Social History:
Lives in [**State 1727**] with his wife, who has significant medical needs
that have worsened over the last 2 years. He has children and
grandchildren that help out. Retired welding engineer.
-Tobacco history: 1.5 ppd for 20 years, quit 20 years ago
-ETOH: social
-Illicit drugs: None
Family History:
Father - MI [**96**]
Mother - colon cancer 70s
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
GENERAL: fatigued, no apparent distress, depressed mood
HEENT: anicteric, moist mucus membranes, PERRL
NECK: supple, JVP not significantly elevated
CARDIAC: RRR, no murmurs/rubs/gallops
LUNGS: crackles at the bilateral bases
ABD: soft, non tender, non distended
EXT: no edema
SKIN: warm and dry, scattered varicose veins
PULSES: palpable bilateral DP and PT
Discharge:
VITALS: 97.8/97.8 BP: 137-172/64-76 HR: 80-88 RR 16 O2 sat 95%
on RA
GENERAL: more talkative, NAD, no pain, alert and oriented
HEENT: anicteric, moist mucus membranes
NECK: supple, JVP at 12 cm, ICD in place over right neck
CARDIAC: RRR, no murmurs/rubs/gallops
LUNGS: unlabored WOB, no accessory muscle use, no cough, lungs
CTAB.
ABD: soft, non tender, non distended
EXT: no edema, 2+ bilateral radial pulses, 1+ DP/PT bilateral
pulses
SKIN: warm and dry, scattered varicose veins. Left chest with
ICD site, minimal swelling and tenderness. Left chest with
dressing from external pacer, now removed.
Pertinent Results:
Admission:
[**2131-5-21**] 11:26PM BLOOD WBC-4.7 RBC-3.08* Hgb-9.6* Hct-30.9*
MCV-100* MCH-31.1 MCHC-31.0 RDW-13.5 Plt Ct-148*
[**2131-5-21**] 11:26PM BLOOD PT-12.0 PTT-25.8 INR(PT)-1.1
[**2131-5-23**] 05:45AM BLOOD ESR-20*
[**2131-5-21**] 11:26PM BLOOD Glucose-108* UreaN-15 Creat-0.6 Na-142
K-4.0 Cl-108 HCO3-30 AnGap-8
[**2131-5-21**] 11:26PM BLOOD ALT-21 AST-41* AlkPhos-57 TotBili-0.3
[**2131-5-21**] 11:26PM BLOOD Albumin-3.0* Calcium-8.1* Phos-3.4 Mg-2.2
[**2131-5-21**] 11:26PM BLOOD TSH-9.1*
[**2131-5-21**] 11:26PM BLOOD Free T4-1.3
[**2131-5-23**] 05:45AM BLOOD CRP-6.7*
Discharge:
[**2131-6-1**] 07:45AM BLOOD WBC-4.6 RBC-2.91* Hgb-9.4* Hct-31.0*
MCV-107* MCH-32.4* MCHC-30.4* RDW-15.1 Plt Ct-134*
[**2131-6-1**] 07:45AM BLOOD Glucose-143* UreaN-10 Creat-0.6 Na-140
K-3.8 Cl-104 HCO3-26 AnGap-14
[**2131-5-27**] 07:00AM BLOOD ALT-11 AST-24 AlkPhos-53 TotBili-0.3
Studies:
[**5-21**] CXR:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs: Dual-channel right PIC line ends outside the chest,
at the lateral aspect of the right first rib, roughly 13.5 cm
proximal to the low SVC. Transvenous right atrial pacer lead
loops close to the tricuspid valve, tip along the lateral aspect
of the mid portion of the atrial cavity. Transvenous right
ventricular pacer lead ends in the mid right ventricle,
angulated upward rather than along the floor as generally seen.
Alternatively, this lead could be in the coronary sinus, but
assessment would require a lateral projection. There is no
pneumothorax or pleural effusion. Geographic opacities
projecting over the lateral aspect of the left mid lung suggest
pleural calcifications, also warranting confirmation with
conventional PA and lateral chest films. There may be a tiny
right pleural effusion. Heart size is normal.
.
[**5-22**] TTE:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%). Tissue Doppler imaging suggests 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 no mitral valve
prolapse. Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension.
.
[**5-23**] CT abd/pel:
1. No fluid collection.
2. Moderate to large bilateral pleural effusion with associated
bibasilar atelectatic changes.
3. Normal position of the pacemaker wires ending in the right
atrium and ventricles.
4. Liver cirrhosis with small amount of ascites, portosystemic
collaterals/varices and splenomegaly.
5. Diverticulosis, but no diverticulitis.
.
[**5-23**] Ppm pocket u/s:
No fluid collection in pacemaker pocket.
Brief Hospital Course:
79 yo M with DMII, HTN, HL and pacemaker, admitted to OSH with
high grade staph bacteremia and multiple episodes of VT/torsade.
.
# Staph schleiferi bacteremia
Growing pansensitive Staph schleiferi out of 4 of 4 bottles at
outside hospital. He was started on cefazolin 2g q8h with plan
to continue treatment for about 6 weeks. The source is unknown,
but given his pacemaker it was felt this should be removed and
replaced. Surveillance cultures and white counts were monitored,
and these remained stable. ID consult will follow patient as an
outpatient. He will need weekly CMP, CBC w/ diff, and ESR/CRP.
All laboratory results should be faxed to the Infectious Disease
R.N.s at ([**Telephone/Fax (1) 4591**].
# Pacemaker
This was placed many years ago at another hospital, and given
the 97% V-pacing rate, it was felt to be related to complete
heart block. His timolol eye drops were stopped for 2 days, but
still had no conduction, confirming this suspicion. His
pacemaker was removed given his staph bacteremia, and a
temporary wire was placed. He then had his pacemaker replaced
and was discharged to rehab.
# VT/Torsades
Multiple episodes of VT and torsades while at OSH that were
totally asymptomatic. These were likely precipitated by systemic
illness. He was monitored while at [**Hospital1 18**] without recurrence of
these rhythms.
- monitor on tele
- consider placement of ICD when pacemaker is replaced
- replete lytes aggressively
# CAD
Cathed at OSH today showing non-occlusive disease. Continued
aspirin, metoprolol and losartan.
.
# Cardiomyopathy
LVEF of 40% on cath at OSH, with reportedly normal echos in the
past. Etiology includes ischemic, pacer induced, or septic
stunning. Continued aspirin, metoprolol and losartan.
.
# DMII
On metformin and glyburide at home (unclear doses). Using
glargine and ISS while in house.
TRANSITIONAL ISSUES
- Cirrhosis noted on CT abdomen/pelvis
Medications on Admission:
MEDS ON TRANSFER:
- Aspirin 81 mg daily
- Metoprolol 50mg [**Hospital1 **]
- Losartan 25mg daily
- Cefazolin 2gm IV Q8H x 4weeks
- Insulin: Detemir 8 units SQ QAM; novolog SSI QACHS
- Terazosin 5mg HS
- Lumigan 0.03, 1 drop each eye HS
- Trusopt 2%, 1 drop each eye [**Hospital1 **]
- Timolol maleate 0.5mg 1 drop each eye QAM
- Acetaminophen 650mg Q4H prn pain
- Colace 100mg [**Hospital1 **]
- Maalox 30ml PO Q4H prn indigestion
- Senna 8.6mg [**Hospital1 **]
- Glucagon, dextrose per hypoglycemia protocol
.
PCP MED LIST:
-- glyburide 2.5 mg po qam
-- terazosin 5 mg po qhs
-- cozaar 25 mg po qday
-- metformin [**2119**] mg po qpm meal
-- timoptic 0.5% ?1 drop each eye [**Hospital1 **]
-- Lumigan 0.03% 1 drop each eye qhs
-- aspirin 81 mg po qday
.
PHARMACY MED-LIST:
dorzolamie 2% solution 1 drop each eye [**Hospital1 **]
terazosin 5 mg po qhs
cozaar 25 mg po qday
metformin [**2119**] mg at dinner
lumigan 0.03% solution 1 drop each eye qhs
Discharge Medications:
1. 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.
2. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
3. terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hols SBP <100.
5. metformin 1,000 mg Tablet Extended Rel 24 hr Sig: Two (2)
Tablet Extended Rel 24 hr PO once a day: with dinner.
6. bimatoprost 0.03 % Drops Sig: One (1) drop Ophthalmic qHS ().
7. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain/fever.
12. cefazolin in 0.9% sod chloride 2 gram/100 mL Solution Sig:
One (1) bag Intravenous every eight (8) hours for 4 weeks: Last
day [**7-5**] for total of 6 weeks. .
13. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 81223**]Rehab
Discharge Diagnosis:
Sepsis
Torsades de Pointes
Diabetes Mellitus type 2
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**].
You had an infection in your blood that likely affected your
pacemaker and you were transferred to [**Hospital1 18**] to have the
pacemaker removed. A temporary pacemaker was placed until the
antibiotics worked and you will need to continue the antibiotics
until [**7-5**]. A PICC line was placed to get the antibiotics
after you are discharged. You will need to follow up in the
infectious disease clinic and have labs checked weekly.
You had fainting episodes that were caused by a heart rhythm
called torsades de pointes. A defibrillator was placed that will
shock you out of the rhythm if it lasts long enought that you
collapse. This may save your life. You will have the dressing on
until sunday, then you can take it off. No lifting more than 5
pounds by your left arm for 6 weeks.
.
WE made the following changes to your medicines:
1. Increase losartan to lower your blood pressure
2. Start potassium as your potassium level has been low
3. Start colace and senna to prevent constipation
4. Start tylenol for pain
5. Start aspirin to prevent a heart attack
Followup Instructions:
Cardiology:
[**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 80724**]
[**Location (un) 34004**] Cardiology Associates
12 Hospital Dr [**Last Name (STitle) **]
[**Location (un) **], [**Numeric Identifier 110871**]
([**Telephone/Fax (1) 83814**]
([**Telephone/Fax (1) 110872**] fax
Date/Time: Wed [**6-20**] at 2:30pm
.
[**Name6 (MD) 110873**] [**Name8 (MD) 110874**] RN for wound check at [**Hospital **] Hospital
[**Telephone/Fax (1) 8226**]
Friday [**6-8**] at 10:00am.
.
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2131-6-27**] at 10:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2131-6-13**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"998.12",
"038.19",
"414.01",
"571.5",
"458.29",
"996.61",
"600.00",
"365.9",
"272.4",
"V15.82",
"E878.8",
"250.00",
"276.52",
"995.91",
"V58.67",
"421.0",
"426.0",
"427.1",
"E942.6",
"425.4",
"E878.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.94",
"38.93",
"37.89",
"37.78",
"34.01",
"33.27",
"33.24",
"37.77"
] |
icd9pcs
|
[
[
[]
]
] |
11449, 11501
|
7249, 9154
|
313, 343
|
11624, 11624
|
4212, 7226
|
12955, 14105
|
3032, 3194
|
10154, 11426
|
11522, 11603
|
9180, 9180
|
11806, 12932
|
3209, 4193
|
263, 275
|
371, 2491
|
11639, 11782
|
2513, 2711
|
2727, 3016
|
9198, 10131
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,814
| 147,560
|
52775
|
Discharge summary
|
report
|
Admission Date: [**2159-2-28**] Discharge Date: [**2159-3-14**]
Date of Birth: [**2079-1-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
1. Cardioversion
2. Intubation
3. Catheterization
4. [**Company 1543**] virtuoso dual chamber ICD placement
5. CPR
6. Blood transfusion
History of Present Illness:
80M HTN, h/o CVA, h/o presyncope with known conduction system
disease, h/o SVT, recent admission in [**2159-1-15**] for afib and CHF
exacerbation. Was discharged on Toprol XL for rate control and
on coumadin with plan for 3 weeks of anticoagulation prior to
elective DCCV. Last seen in cardiology clinic on [**2-21**] and had
been doing well. Scheduled for elective DCCV this week.
.
On day of presentation, was walking to refrigerator. Syncope
witnessed by wife. [**Name (NI) **] that he knew he was going to faint [**2-17**]
seconds prior to losing consciousness and was able to brace fall
with arm, landing on his rear. Wife did not note any tonic
clonic movements. No bowel/bladder incontinence. No preceding
CP, SOB, n/v, diaphoresis, palps, or aura. Was out for several
seconds, followed by 15 seconds of filling "dizzy".
.
States symptoms are similar to prior episodes of presyncope,
except that this episode actually led to LOC, whereas prior
episodes had resolved without intervention.
.
In ED, non-contrast head CT negative for acute bleed.
Past Medical History:
BPH
Incidental R liver cyst
- stable since [**4-19**]
Diverticulosis
Basal cell CA of the nose
- removed [**2157-2-15**]
CVA [**2150**]
- resulting in dysesthesias R hand
- imaging consistent with lacunar hypodensity c/w lacunar
infarct, L cerebellar hypodensity c/w chronic infarct
Cervical spondylosis
Hypertension
varicose veins
Sleep apnea
Colon CA
- s/p chemo/xrt, resection [**9-19**]
Hx of presyncope
- CardioNet monitor in [**4-20**]: episodes of SVT in 130s with
termination after 5-10 beats, no bradyarrythmias
- Conduction system disease: right bundle branch block, left
anterior fascicular block, borderline PR interval
Social History:
lives in [**Location 745**] with wife [**Name (NI) **], one son, one daughter, 6
grandchildren, retired computer science professor, former heavy
cigar smoker, quit in [**2150**], [**2-17**] drinks per week
Family History:
Father died MI in 80s, Mother died PE in 80s, twin sister died
of colitis age 30s, no family h/o colon, breast, uterine, or
ovarian ca
Physical Exam:
VS - T 97.8, BP 120/66, HR 66, RR 18, O2 sat 99% RA, wt 78 kg
Gen - comfortable, NAD, speaking full sentences
HEENT - NCAT, PERRL, EOMI, OP clr, MMM, no LAD, JVP ~ 9-10cm
Chest - CTAB
CV - irreg, irreg, nl s1 s2, no m/r/g
Abd - NABS, soft, NT/ND, no g/r, no CVA tenderness
Back - nontender to palpation
Ext - chronic venous stasis, 1+ bilat edema
Pertinent Results:
studies:
[**2-27**] head ct:
NON-CONTRAST HEAD CT SCAN: There is no evidence of acute
intracranial hemorrhage or shift of the normally midline
structures. The ventricles and sulci are prominent, consistent
with involutional change. There is hypodensity of the cerebral
periventricular white matter, consistent with chronic
microvascular infarction. There are unchanged rounded
infarctions of the right thalamus and a small lacunar infarction
of the posterolateral left thalamus. Hypodensity of the left
cerebellar hemisphere is unchanged, consistent with prior
infarction. There are no CT findings to suggest acute
territorial infarction on today's exam. There are mucus
retention cysts in the floors of the maxillary antrum
bilaterally. Other visualized paranasal sinuses and mastoid air
cells are clear. Osseous and soft tissue structures are
unremarkable.
IMPRESSION: No evidence of acute intracranial hemorrhage.
Unchanged appearance of the brain compared to [**2158-2-15**]
.
cxr [**2-27**]: IMPRESSION: Stable radiographic examination with right
pleural effusion, cardiomegaly, and pulmonary arterial
hypertension, without acute superimposed consolidation.
.
carotid us [**2-28**]: IMPRESSION: Widely patent common and internal
carotid arteries bilaterally.
.
ruq us [**3-2**] IMPRESSION:
1. No apparent biliary or hepatic parenchymal abnormality to
explain hyperbilirubinemia.
2. Cholelithiasis without cholecystitis.
3. Unchanged subcentimeter right hepatic simple cyst.
.
[**2159-3-7**] cath:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
single vessel disease. The LMCA, LAD, and RCA had no obstructive
lesions. The LCX gave off a large OM1 with a hazy 90% lesion.
2. Left ventriculography revealed an ejection fraction of 30%
with
global hypokinesis and no mitral regurgitation.
3. LVEDP was elevated at 20mmHg.
4. During angiography of the left system, the patient had a
asystolic
arrest. As pacer pads were being placed, he transitioned to
complete
heart block with a ventricular escape in the 40s. He was
hypotensive
with SBP in the 40s to 60s. Venous access was obtained and a
transvenous
pacer was successfully placed.
5. Succesful PCI of CX using overlapping bare metal stents
(3.0x12mm
proximal to a 2.5x12mm).
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Systolic and diastolic dysfunction.
3. Successful bare metal stenting of the circumflex system
.
[**2159-3-8**] echo:
Conclusions:
The left and right atria are markedly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Overall left ventricular systolic function is moderately
depressed, with moderate global hypokinesis (EF 35%). The right
ventricular cavity is mildly dilated. There is mild global right
ventricular free wall hypokinesis. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. An
eccentric jet of moderate (2+) mitral regurgitation is seen.
There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
A pacemaker lead is seen entering the right atrium, then
traversing the interatrial septum and the mitral valve, with the
lead tip positioned in the trabeculations of the left
ventricular apex.
IMPRESSION: Pacemaker lead at the left ventricular apex.
Moderate global left ventricular systolic dysfunction. Mild
right ventricular systolic dysfunction. Moderate mitral
regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2159-1-23**],
pacemaker lead is new. The other findings appear similar
Brief Hospital Course:
Brief CCU course: The patient is a 80 year old man with h/o
atrial fibrillation, HTN, h/o CVA, h/o SVT, admitted with
presyncope, who had DCCV on [**2159-2-28**]. This lead to sinus
bradycardia and then Atrial tachycardia with 2:1 block. He was
started on dofetilide that night. He underwent DCCV on [**2159-3-1**].
At 2:55 am on [**2159-3-2**] noted to be in NSVT with long interval
pauses (WT 480 with long RR and PVC on tele). Pt found pulseless
and a code blue was called. The patient was shocked x 3 with
360 J for vtach. Given CPR and went in to PEA arrest. CPR
resumed, got a pulse at 3:08 am per CCU notes (epi x 3, atropine
x 2, bicarb x 2) He was intubated.
.
In the CCU, pt was extubated successfully. There was question of
anoxic brain injury as the patient was not responding when taken
off of propofol. However, he has continued to progress
neurologically. Neurology team did evaluate him on [**2159-3-2**].
Given his rapid improvement thought to be encourarging. However,
could not rule out milder hypoxic-ischemic injury. Noted to have
fevers with CXR consistent with a PNA. Started on vancomycin and
levaquin on [**2159-3-2**] in the am. The patient was stable and
tranferred to the floor. On the floor his SVT was treated with
a beta-blocker and his abx were stopped as he had no signs of
infection. He remained stable on the floor and then went to
cardiac catheterization which was interrupted by CHB and
ventricular asystole, revived with atropine and pacer wire
placement. He had 90% OM1 lesion stented with little other
disease. He was in the unit and remained stable and on [**3-8**] had
a virtuoso icd placed, he was stable only with a small chest
wall hematoma and was then transferred back to the medicine
floor.
.
Floor course:
1. CAD: The patient's cardiac cath on [**3-7**] demonstrated 90% L Cx
that occluded in cath lab, the lesion was stented with BMS x2,
with good post-stent result. He remained chest pain free and
was treated with aspirin, plavix, lisinopril and bb. His statin
was held given his hyperbilirubinemia, and should be restarted
at a later date.
.
2. Arrythmia (Atrial fibrillation/ventricular fibrillation and
CHB): The patient had initially been admitted with atrial
fibrillation. He was DCCV and doing well but with dofetilide
developed VT/VFib. He then went to cath and was noted to have
complete heart block. Given his VT/VFib/CHB he had [**Company **]
(virtuoso) dual chamber ICD placed. He had no further events
during his course and was treated post-ICD with prophylactic
vancomycin and close monitoring by EP. He had no complications
and will need close follow-up with the device clinic as an
outpatient. Given his underlying Atrial fibrillation, he will
need his coumadin restarted once cleared by EP. With the pacer
and beta-blocker he had no further telemetry events and was
stable for discharge.
.
3. CHF: The patient was overloaded on CXR and exam and his Vgram
was consistent with heart failure as well. He was aggressively
diuresed and was maintained on a beta-blocker and ace. As an
outpatient he will continue lasix, bb and ace and will need
close monitoring by his doctor for his fluid status.
.
4. Cough: The patient had a minimal cough throughout his course
and did not have CXR findings or fever, so antibiotics were not
used. His cough was likely due to CHF and he was treated with
nebs, cough syrup and lasix.
.
5. Hyperbilirubinemia since [**2159-1-29**]: Unclear etiology, his US
was negative and he remained asymptomatic. This was closely
followed and his statin was held. His Tbili gradually
downtrended and should continue to be followed as an outpatient.
The feeling is that this could have been secondary to shock
liver/stress.
.
5. anemia: The patient had a hematoma after icd placement, and
he was given a total of 3 units prbc. After this is hct was
stable and he required no further intervention.
.
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Toprol XL 200 mg PO once a day
3. Lisinopril 5 mg PO DAILY
4. Warfarin PO DAILY (2.5 M/W/F [**1-16**] tab all other days)
5. Lasix 80 mg [**Hospital1 **]
6. Amitriptyline 50 mg PO HS
7. Docusate Sodium 100 mg PO BID
8. Senna 2 Tablet PO BID
9. MVI
10. Flomax 0.4 daily
11. kdur 20 tid
.
Medications on transfer:
potassium chloride 40 meq po x1 0900
aspirin 325mg po qd
metoprolol 37.5mg po q6
coumadin 2.5mg po q M/W/F, 1.25mg po q T/T
multivitamins
tamsulosin 0.4mg po qd
amitriptyline 50mg po qhs
docusate [**Hospital1 **]
dofetilide 250mcg po q12 hours, last dose 2200
senna prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime): flomax.
6. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO three times a day.
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Senna 8.6 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
11. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): Please have your INR checked in 2 days from discharge.
Goal is [**2-17**].
Disp:*90 Tablet(s)* Refills:*2*
12. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
13. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 14
days.
Disp:*14 Tablet(s)* Refills:*0*
14. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO at bedtime
for 10 days: for pain.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Atrial fibrillation
2. CHF
3. Acute on chronic renal failure
4. Complete heart block
5. Ventricular tachycardia
6. Ventricular fibrillation
7. Hyperbilirubinemia
8. Anemia
Discharge Condition:
stable, tolerating medications
Discharge Instructions:
1. You were admitted with syncope and based on your abnormal
rhythm you were cardioverted and started on medication. You
also had an ICD placed for your arrythmia, and a catheterization
performed for your heart disease. Avoid lifting your left arm
more than 90 degrees for 6 weeks, or until advised by device
clinic.
.
2. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
3. Please attend all follow-up appointments
.
4. Return for fevers, chills, loss of consciousness, shortness
of breath and chest pain.
.
5. Please follow the new medication list we gave you
Followup Instructions:
1. Please make a follow-up appointment with Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] D. in 1 week. Call [**Telephone/Fax (1) 3329**] for an
appointment.
2. Please follow-up in device clinic in 1 week as advised. Call
([**Telephone/Fax (1) 8793**] or ([**Telephone/Fax (1) 5862**] for more information.
3. Please have your INR checked within 2 days from discharge.
Your goal INR is [**2-17**].
|
[
"414.01",
"427.31",
"584.9",
"427.5",
"585.9",
"426.0",
"424.0",
"998.12",
"427.1",
"V10.05",
"403.90",
"V58.61",
"507.0",
"427.41",
"428.0",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"99.60",
"37.94",
"88.53",
"96.71",
"88.55",
"00.46",
"00.40",
"99.62",
"36.06",
"96.04",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
12712, 12770
|
6751, 10653
|
339, 477
|
12989, 13022
|
2973, 2993
|
13686, 14097
|
2454, 2590
|
11316, 12689
|
12791, 12968
|
10679, 10996
|
5259, 6728
|
13046, 13663
|
2605, 2954
|
292, 301
|
505, 1558
|
3002, 5242
|
11021, 11293
|
1580, 2214
|
2230, 2438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,151
| 102,237
|
54824
|
Discharge summary
|
report
|
Admission Date: [**2157-6-21**] Discharge Date: [**2157-6-26**]
Date of Birth: [**2089-4-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
Aortic valve replacement 21mm tissue, coronary artery bypass
grafting times four (LIMA>LAD, SVG>PL, SVG>OM, SVG>D1) [**6-22**]
History of Present Illness:
68yoM with increasing exertional angina. Angina is described as
chest pressure which he experiences daily. Brought on by walking
200-400 feet, releived
with rest.
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes Mellitus
Chronic Obstructive Pulmonary Disease
Anxiety
Depression
Social History:
Lives with wife. Computer [**Name2 (NI) 112043**] at GE-[**Location (un) **]
40 pack-year quit [**2136**], ETOH quit 1 year ago
Family History:
Non-contributory
Physical Exam:
Discharge Exam
VS:T: 98.4 HR: 90-100 SR BP: 120-130/70 Sats: 95% RA Wt:
156 lbs
General: 68 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds otherwise clear
GI: abdomen soft, non-tender, non-distended
Extr: warm right tr edema, left 2+ edema
Incision: sternal and LLE clean dry intact no erythema, no
sternal click
Neuro: awake,alert oriented
Pertinent Results:
[**2157-6-26**] WBC-6.9 RBC-3.02* Hgb-9.3* Hct-27.4 Plt Ct-117*
[**2157-6-25**] WBC-5.9 RBC-2.88* Hgb-8.8* Hct-25.6 Plt Ct-98*
[**2157-6-23**] WBC-6.3 RBC-2.93* Hgb-8.8* Hct-25.3 Plt Ct-71*
[**2157-6-21**] WBC-8.1 RBC-2.31*# Hgb-6.6*# Hct-19.8*Plt Ct-178#
[**2157-6-26**] Glucose-151* UreaN-33* Creat-1.2 Na-135 K-4.4 Cl-99
HCO3-28
[**2157-6-21**] UreaN-18 Creat-0.8 Na-144 K-4.0 Cl-113* HCO3-22
AnGap-13
[**2157-6-21**] MRSA SCREEN (Final [**2157-6-24**]): No MRSA isolated.
CXR:
[**2157-6-25**]; The small left apical pneumothorax is unchanged.
Heart size and mediastinum are unchanged but there is interval
improvement of bibasal aeration with still present atelectasis
and small amount of pleural fluid.
Echocardiogram
[**2157-6-21**]: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Moderate AS (area 1.0-1.2cm2) Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. [**Male First Name (un) **] of the mitral chordae (normal
variant). No resting LVOT gradient. Eccentric MR jet. Moderate
(2+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be
underestimated (Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. There is moderate aortic valve
stenosis (valve area 1.2cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Two jets,
one being an eccentric, posteriorly directed jet of Moderate
(2+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Dr. [**Last Name (STitle) **] was notified in
person of the results.
POSTBYPASS
Biventricular systolic function is preserved. There is a well
seated, well functioning bioprosthesis in the aortic position.
No AI is visualized. The MR now appears to be decreased. Mild to
moderate ([**12-6**]+) with the eccentic jet appearing to be decreased.
The remaining study is unchanged from prebypass.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2157-6-21**] where the patient underwent Coronary
artery bypass grafting LIMA to LAD, SVG PL, SVG to OM, SVG to D1
and Aortic Valve Replacement with [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Aortic Porcine Valve
21 mm. 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 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. Initially his blood pressure while doing
stairs was 88/50 asymptomatic with quick recovery, repeat while
walking in halls was consistently 120/70. By the time of
discharge on POD5 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:
Preadmission medications listed are correct and complete.
Information was obtained from Patient outside report.
1. Simvastatin 20 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) [**12-6**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*60 Tablet Refills:*0
8. Metroprolol succinate 0.5 mg twice daily
8. Cyanocobalamin 50 mcg PO DAILY
9. Furosemide 40 mg PO DAILY Duration: 5 Days
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease
Hypertension
Hyperlipidemia
Diabetes Mellitus Type 2
COPD
anxiety/depression
renal insufficiency (baseline creat 1.1)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming, and look at your incisions
NO lotions, cream, powder, or ointments to incisions
Daily weights: keep a log please bring it with you to your
appointments.
Blood pressure: keep a daily log and bring it with you to your
appointments
No driving for approximately one month and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2157-7-5**] at
10:00AM
in the [**Hospital **] Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2157-8-10**] 1:30PM in the [**Hospital **]
Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist Dr. [**Last Name (STitle) 72502**] [**2157-7-6**] at 11:15
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 112044**],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 78021**] in [**3-10**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2157-6-26**]
|
[
"300.4",
"V15.82",
"414.01",
"458.29",
"424.1",
"280.0",
"250.00",
"518.0",
"403.90",
"286.9",
"411.1",
"496",
"272.4",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"35.21",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6810, 6859
|
4236, 5683
|
317, 446
|
7045, 7201
|
1458, 4213
|
7838, 8697
|
929, 947
|
6101, 6787
|
6880, 7024
|
5709, 6078
|
7225, 7815
|
962, 1439
|
271, 279
|
474, 639
|
661, 765
|
781, 913
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,184
| 164,766
|
34260
|
Discharge summary
|
report
|
Admission Date: [**2168-5-2**] Discharge Date: [**2168-5-3**]
Date of Birth: [**2104-10-11**] Sex: M
Service: MEDICINE
Allergies:
Rituxan / Shellfish Derived
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
transferred for ICU level care of sepsis in febrile neutropenia
Major Surgical or Invasive Procedure:
Central line placement
arterial line placement
History of Present Illness:
63M CLL dx'd [**12-4**] with last chemo a month ago p/w febrile
neutropenia (T102.3), shortness of breath, and hyponatremia on
[**4-27**] to NEBH. Levoflox started as outpt 1d PTA at NEBH for low
grade fevers and shaking chills. He was transferred to the ICU
on [**4-28**] for increasing shortness of breath and for initiation of
hypertonic saline. Work up (UCx and Bld Cx neg, stool neg for
Cdiff, CMV antigen neg, EBV IgG pos but IgM neg, HepB immune,
HepC neg) isolated only C albicans in stool and he was
empirically broadened to flagyl/cefepime. Pleural effusion on
HD3, got some lasix--BNP was normal, though. V/Q scan intermed
prob on HD4. No CTA [**1-30**] ARF.
.
By [**4-29**], anemia had worsened, Na down to 122
.
Morning of [**2168-5-2**], 7.25/34/61, 88%, on face mask + 5 liters. No
improvement after lasix 80mg IV and so intubated with size 8 ETT
and became hypotensive to 60s. Started peripheral neo and
propofol and transferred to [**Hospital1 18**]. Prior to departure from OSH,
on vent: 800x16, PEEP 5, FiO2 85% at 1:30 7.17/47/104; given 1
amp NaHCO3 prior to departure. En route had temperature to
103.5.
Past Medical History:
CLL dx'd [**12-4**] with massive HSM and WBC 500,000. treated with
chemo, last in [**3-5**] was fludarabine, prednisone, cytoxan.
Splenomegaly
Anemia
Neutropenia/Leukopenia
Gout
h/o GI bleed; guaiac pos at OSH, but no GI work-up
chronic laryngeal spasm
HSV
Social History:
quit smoking 5 months ago, occ/social alcohol. works as heating
company manager.
Family History:
NC
Physical Exam:
General Appearance: Well nourished, Diaphoretic
Eyes / Conjunctiva: PERRL, pupils 3->2
Head, Ears, Nose, Throat: Endotracheal tube
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Absent), (Left DP pulse:
Present), L radial a-line
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Bronchial: , Diminished: R base)
Abdominal: No(t) Bowel sounds present, massive liver and spleen
enlargement
Extremities: Right: 2+, Left: 2+
Skin: Warm, petechiae over shins
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
Pertinent Results:
Sputum gram stain and culture:
GRAM STAIN (Final [**2168-5-2**]):
[**10-22**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2168-5-10**]):
OROPHARYNGEAL FLORA ABSENT.
YEAST. HEAVY GROWTH.
ASPERGILLUS FUMIGATUS. RARE GROWTH.
.
.
All blood and urine cultures negative
.
.
Abdominal ultrasound:
1. Gallstones with gallbladder wall thickening and
pericholecystic fluid
raise the possibility of acute cholecystitis. However, no
significant
gallbladder distention is identified making this less likely.
These findings may also be seen with underlying liver disease.
2. Marked splenomegaly.
3. Marked enlargement of the right kidney, with no left kidney
visualized.
Possible congenitally absent left kidney, although correlation
with any
previous (outside) studies would be useful.
.
.
Brief Hospital Course:
The patient was thought to be in septic shock on admission. His
hemodynamics were monitored with a central venous catheter and
arterial line so that fluid managment and pressors could be
administered according to early goal directed therapy. He
required broad spectrum antiobiotics including antifungal, and
three pressors to maintain his MAPS at goal. The patient was
intubated for hypoxia, and required CVVH to manage his acute
renal failure. He developed DIC and received multiple units of
FFP and platelets. Based on an abdominal ultrasound, it was
thought that the source of his sepsis was cholecystitis. He
underwent percutaneous drainage of his gall bladder. Despite
all of the above medical management, he became progressively
more acidemic and developed ventricular arrythmias. Discussions
were held with his family and he was made comfort care only and
died within a few hours.
Medications on Admission:
allopurinol
iron supplements, multivitamin
Discharge Medications:
Patient died
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient died
Discharge Condition:
Patient died
Discharge Instructions:
Patient died
Followup Instructions:
Patient died
|
[
"518.81",
"575.0",
"584.9",
"995.92",
"276.7",
"276.1",
"780.6",
"276.2",
"038.9",
"785.52",
"204.10",
"288.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"38.95",
"39.95",
"51.02"
] |
icd9pcs
|
[
[
[]
]
] |
4720, 4729
|
3692, 4589
|
351, 399
|
4785, 4799
|
2763, 3669
|
4860, 4875
|
1950, 1954
|
4683, 4697
|
4750, 4764
|
4615, 4660
|
4823, 4837
|
1969, 2744
|
248, 313
|
427, 1555
|
1577, 1836
|
1852, 1934
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,774
| 152,690
|
41423
|
Discharge summary
|
report
|
Admission Date: [**2105-12-7**] Discharge Date: [**2105-12-11**]
Date of Birth: [**2027-1-11**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Primary Care Physician: [**Name10 (NameIs) 54468**],[**Name11 (NameIs) 54469**] [**Name Initial (NameIs) **]
.
Chief Complaint: fever and hypoxia
.
Reason for MICU transfer: septic shock
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
78 year old female with h/o meningioma c/b sroke and respiratory
failure who presents from NH with fever, leukocytosis,
tachycardia, and hypotension. She was diagnosed with a uti on
[**2105-12-1**] with proteus mirabilis on u cx (sensitivities below).
She was started on bactrim three days pta. She is nonverbal from
baseline so history was taken from medical record.
.
In the ED, initial VS were: 98.8 62 108/52 22 91% 4L Nasal
Cannula. She was found to have ?patchy infiltrates on CXR. She
was treated with azithromycin, ceftriaxone, and vancomycin in
the ED. She had two episodes of Afib with RVR which converted to
sinus rhythm; she did require diltiazem 10mg iv times one. She
was febrile to 102 in the ED and was given tylenol 1000mg PR.
Lactate was 2.2 and she was given 2L ifv.
.
On arrival to the MICU, vitals were hr 110, rr 18, sat 96 nrb,
90/74, tmax was 102. She was nonverbal. Her blood pressure
dropped to 70s systolic and came up to 80s after 500cc ivf.
After 500cc ivf, her saturation dipped to 86% and a scoop mask
was placed after which o2 increased to 93%.
.
Review of systems: unable to obtain
Past Medical History:
hypercholesterolemia, basal cell CA removal from Bilateral UE's,
bilateral cataract surgery, colon adenoma s/p biopsy, right
spenoid [**Doctor First Name 362**] meningioma s/p resection, s/p PEG tube placement
and trach placement (now s/p removal) now in persistent
vegetative state, seizure disorder
Social History:
She stopped smoking 35 years ago. She has not had alcohol in
years. She has 3 sons and a daughter. Lives at ECF, son is
involved and is HCP
Family History:
No Ca history
Physical Exam:
Physical Examination
afebrile, HR65, BP-120/85, 95% 3L NC
General Appearance: Thin
Eyes / Conjunctiva: PERRL
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
No(t) Bronchial: , Rhonchorous: coarse ronchi throughout), jvd
is difficult to appreciate
Abdominal: Soft, Non-tender, Bowel sounds present, gtube c/d/i
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed, opens eyes to voice; moves right hand and
leg; hemiparesis on left
Pertinent Results:
ADMISSION:
[**2105-12-7**] 03:00PM URINE HOURS-RANDOM
[**2105-12-7**] 03:00PM URINE UHOLD-HOLD
[**2105-12-7**] 03:00PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2105-12-7**] 03:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2105-12-7**] 03:00PM URINE RBC-8* WBC-97* BACTERIA-FEW YEAST-NONE
EPI-0
[**2105-12-7**] 03:00PM URINE MUCOUS-RARE
[**2105-12-7**] 02:30PM PO2-63* PCO2-39 PH-7.46* TOTAL CO2-29 BASE
XS-3 COMMENTS-ABG ADDED
[**2105-12-7**] 02:30PM LACTATE-2.2*
[**2105-12-7**] 02:20PM GLUCOSE-129* UREA N-95* CREAT-1.2*
SODIUM-150* POTASSIUM-5.1 CHLORIDE-111* TOTAL CO2-26 ANION
GAP-18
[**2105-12-7**] 02:20PM WBC-17.9*# RBC-3.96* HGB-10.7* HCT-33.2*
MCV-84 MCH-27.1 MCHC-32.3 RDW-16.5* NEUTS-78.3* LYMPHS-12.8*
MONOS-6.5 EOS-1.8 BASOS-0.6
[**2105-12-7**] 02:20PM PT-13.6* PTT-29.4 INR(PT)-1.3*
DISCHARGE:
[**2105-12-11**] 01:15PM BLOOD WBC-8.6# RBC-3.40* Hgb-9.1* Hct-28.0*
MCV-82 MCH-26.7* MCHC-32.4 RDW-16.0* Plt Ct-187#
[**2105-12-9**] 05:57AM BLOOD PT-13.1* PTT-30.0 INR(PT)-1.2*
[**2105-12-11**] 07:15AM BLOOD Glucose-114* UreaN-13 Creat-0.4 Na-143
K-4.1 Cl-108 HCO3-26 AnGap-13 Calcium-9.0 Phos-3.2 Mg-1.7
MICRO:
[**2105-12-7**] URINE Legionella Urinary Antigen -FINAL NEGATIVE
[**2105-12-7**] URINE URINE CULTURE-FINAL NEGATIVE
[**2105-12-7**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
[**2105-12-7**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY [**Hospital1 **]
REPORTS:
CHEST PORT. LINE PLACEMENT Study Date of [**2105-12-11**] 12:21 PM
1. PICC ends in the right atrium approximately 5 cm from the
atriocaval
junction.
2. Stable mild pulmonary edema and small bilateral pleural
effusions.
3. Possible left lower lobe pneumonia is unchanged.
CHEST (PORTABLE AP) Study Date of [**2105-12-7**] 2:45 PM
The examination is somewhat limited by motion. There may be mild
vascular congestion. Increased peribronchial cuffing on this
examination is suggestive of fluid overload. An ill-defined
opacity in the left perihilar region is incompletely evaluated
however could represent developing infection in the right
clinical context. Followup examination recommended. There is
mild cardiomegaly. No pneumothorax or significant pleural
effusion is seen.
ECG Study Date of [**2105-12-7**] 2:05:42 PM
Sinus tachycardia. Compared to the previous tracing of [**2105-10-8**]
the rate has increased.
Brief Hospital Course:
MICU Green Course
78 year old female with h/o meningioma c/b sroke and respiratory
failure in [**1-31**] who presents on [**2105-12-7**] from NH with UTI, HCAP,
[**Last Name (un) **], likely demand ischemia, c/w septic shock now resolved with
abx and fluids.
ACTIVE ISSUES:
#) Septic Shock: Septic shock was defined as sepsis, hypotension
and evidence of end-organ damage with [**Last Name (un) **] and small NSTEMI due
to demand. Possible etiologies of Ms [**Known lastname 90127**] septic shock
included HCAP given infiltrate on CXR and UTI. In the MICU, she
was treated and became hemodynamically stable on Vancomycin,
Levofloxacin and Cefepime (started on [**2105-12-7**]). She received
fluid resuscitation with MAP goal 55. No central line or
pressors were given per goals of care. Blood, cultures were
pending at the time of transfer to the medical [**Hospital1 **], urine
cultures showed no growth. No sputum was produced. No obvious
infected lines or decubitus ulcers or other sources of
infection. Evidence of end organ damage includes renal and
cardiac but improved during the course of her hospitalization.
Lactate levels were initially elevated to 2.3 but returned to
[**Location 213**] limits upon discharge.
Ms [**Name13 (STitle) 90128**] was subsequently transferred to the medical
floor on [**12-9**].12. Her vancomycin, cefepime and levoquin was
continued for an 8 day course for HCAP to end on [**2105-12-15**]. She
would then be converted to cefpodoxime (given the proteus was
also sensitive to ceftriaxone) for 6 more days (last dose
[**2105-12-21**]) to finish her 14 day complicated UTI treatment. Given a
negative urine legionella antigen test, her foley was
subsequently pulled.
#) Hypernatremia: During the course of her hospitalization, Ms.
[**Known lastname 46555**] developed hypernatremia. This was most likely
secondary to free water deprivation in setting of fevers and
insensible losses, and also possibly secondary to tube feed
interruptions. Ms. [**Known lastname 46555**] was volume repeleted via tube
feeds and her hypernatremia subsequently resolved.
#) Hypoactive delerium: Ms. [**Known lastname 46555**] was noted to be waxing
and [**Doctor Last Name 688**] on the morning of [**2105-12-11**] of her hospitalization. It
was unclear if this is her baseline or if this was secondary to
some toxic-metabolic etiology. After discussion with NH nursing,
this appears to be very close to her baseline mental status.
Also, her electrolytes, glucose, serum pCO2, were all
unremarkable. She revealed no focal neurologic defecits aside
from her known left-sided hemiparesis/hemineglect. Per [**Hospital1 18**]
nursing, patient was often made tired by keeping her up for a
few hours doing 4 different dressing changes every morning,
leading to PM drowsiness. Her vital signs remained stable, she
was able to protect her airway and was not making copious
sputum. She had normal sats and exam was significant for
rhonchi. She was monitored closely and given oral suction Q4H.
#) Hypoxemia: This was most likely a manifestation of multifocal
pneumonia/hcap and stabilized above 95% on [**12-25**] L NC. Ms
[**Known lastname 46555**] was given 10mg IV lasix piror to transfer to the
floor because of a CXR indicating some pulmonary edema in the
setting of fluid resucittation. During her hospitalization, the
hypoxemia resolved and she was satting between 92-95 on room
air. She did require Q4H superficial suction and oral care for
her secretions, but no deep suction in >48 hours.
#) [**Last Name (un) **]: Peak cr of 1.2. Most likely prerenal given brisk
improvement with IVF. Resolved to 0.4.
#) NSTEMI: Small troponin elevation, with peak troponin of 0.3,
thought to be [**12-24**] demand ischemia. Trended down to 0.11 without
intervention. EKGs were unchanged from baseline.
#) Trace peripheral edema: Likely secondary to being 8L
positive, but patient is 2.5L net negative since [**2105-12-10**] and
edema nearly resolved. Allowing for autodiuresis.
CHRONIC ISSUES:
#) Hypertension: Ms [**Known lastname 46555**] 's metoprolol was held
initially but then subsequently restarted and converted to a
long acting regimen. Lisinopril was held prior to discharge.
#) Seizure disorder: Continued levetiracetam 1000mg liquid per g
tube qAM, 1500mg qPM
#) Meningioma with stroke: Continued tube feeds
#) Atrial Fibrillation: Continued asa 325mg daily and restarted
metoprolol
#) GERD: Continued omeprazole
#) Goals of care: She was confirmed DNR/DNI by her HCP/son
[**Name (NI) 449**]. Palliative care confirmed her clear goals of care of no
pressors, lines, or any other extraordinary measures. I
explained to him given her bedbound status, 4 bed sores, and
poor mental status she was at high risk for readmission for
HCAP, urosepsis, or wound infection. We explored inpatient
hospice or DNH as a possible future decision. He was urged to
discuss this wish his facilities social worker and agreed to do
so.
TRANSITIONAL ISSUES:
Blood cultures were pending at the time of discharge.
Medications on Admission:
. lisinopril 10 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily).
2. levetiracetam 100 mg/mL Solution [**Name (NI) **]: Ten (10) PO QAM (once
a day (in the morning)).
3. levetiracetam 100 mg/mL Solution [**Name (NI) **]: Fifteen (15) PO QHS
(once a day (at bedtime)).
4. metoprolol tartrate 25 mg Tablet [**Name (NI) **]: One (1) Tablet PO TID
(3 times a day).
5. ascorbic acid 500 mg Tablet [**Name (NI) **]: One (1) Tablet PO once a
day.
6. aspirin 325 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Name (NI) **]: One (1)
PO DAILY (Daily).
8. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization [**Name (NI) **]: One (1) Inhalation every six (6) hours.
9. omeprazole 20 mg Tablet, Delayed Release (E.C.) [**Name (NI) **]: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
10. Lovenox 40 mg/0.4 mL Syringe [**Name (NI) **]: One (1) Subcutaneous once
a day.
11. bisacodyl 10 mg Suppository [**Name (NI) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
12. Milk of Magnesia 400 mg/5 mL Suspension [**Name (NI) **]: One (1) PO
once a day as needed for constipation.
13. Fleet Enema 19-7 gram/118 mL Enema [**Name (NI) **]: One (1) Rectal once
a day as needed for constipation.
14. mupirocin calcium 2 % Cream [**Name (NI) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
15. metronidazole 1 % Gel [**Hospital1 **]: One (1) Appl Topical DAILY
(Daily) for 5 days.
16. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day).
17. cephalexin 500 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
18. sulfamethoxazole-trimethoprim 800-160 mg Tablet [**Hospital1 **]: One (1)
Tablet PO BID (2 times a day) for 6 days.
.
Discharge Medications:
1. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. ipratropium bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
3. levetiracetam 500 mg Tablet [**Hospital1 **]: Three (3) Tablet PO QHS
(once a day (at bedtime)).
4. levetiracetam 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QAM (once
a day (in the morning)).
5. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours).
7. cefepime 2 gram Recon Soln [**Hospital1 **]: Two (2) GRAMS Injection Q12H
(every 12 hours): D1 = [**2105-12-7**], last dose [**2105-12-15**] for pneumonia.
8. levofloxacin in D5W 750 mg/150 mL Piggyback [**Month/Day/Year **]: One (1)
Intravenous Q24H (every 24 hours): D1 = [**2105-12-7**], last dose
[**2105-12-15**] for pneumonia.
9. cefpodoxime 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO every twelve
(12) hours: Please START on [**2105-12-15**], last dose on [**2105-12-21**] to
complete 2 week course for urosepsis.
10. lisinopril 10 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
11. ferrous sulfate 325 mg (65 mg iron) Tablet, Delayed Release
(E.C.) [**Date Range **]: One (1) Tablet, Delayed Release (E.C.) PO once a
day.
12. metoprolol succinate 50 mg Tablet Extended Release 24 hr
[**Date Range **]: 1.5 Tablet Extended Release 24 hrs PO once a day.
13. vancomycin 500 mg Recon Soln [**Date Range **]: Seven [**Age over 90 1230**]y (750)
mg Intravenous Q 12H (Every 12 Hours): D1 = [**2105-12-7**], last dose
[**2105-12-15**] for pneumonia.
.
14. 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.
15. heparin (porcine) 5,000 unit/mL Cartridge [**Month/Day/Year **]: 5000 (5000)
UNITS Injection three times a day: 5000 units subcutaneous TID.
Discharge Disposition:
Extended Care
Facility:
Roscommon on the Parkway - [**Location 1268**]
Discharge Diagnosis:
Septic shock
Complicated urinary tract infection
Hospital acquired pneumonia
Hypernatremia
Hypoxia
Non ST elevation myocardial infarction
Acute kidney injury
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mrs. [**Known lastname 46555**],
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted for a severe infection of your lungs (pneumonia) and
your urinary tract. You were critically ill, but fortunately,
you improved with lots of fluids and antibiotics. You also have
unfortunately developed multiple sores from being bedbound. We
have made dressing changes and will notify your extended care
facility to monitor these wounds closely.
We have made the following changes to your medications:
1) START vancomycin 1gm IV every 12 hours for an 8 day course
for pneumonia (last dose [**2105-12-15**])
2) START cefepime 2gm IV every 12 hours for an 8 day course for
pneumonia (last dose [**2105-12-15**])
3) START levofloxacin 750mg IV every 24 hours for an 8 day
course for pneumonia (last dose [**2105-12-15**])
4) START cefpodoxime 200mg by mouth every 12 hours on [**2105-12-15**] to
complete a 14 day total therapy for sepsis/UTI, with last dose
on [**2105-12-21**].
Please take all of your other medications as prescribed.
Followup Instructions:
Please follow up with your primary care doctor at your extended
care facility.
Completed by:[**2105-12-11**]
|
[
"401.9",
"276.2",
"V15.82",
"995.92",
"438.50",
"345.90",
"276.0",
"780.03",
"599.0",
"787.20",
"410.71",
"285.29",
"584.9",
"427.31",
"272.0",
"785.52",
"780.09",
"438.89",
"038.49",
"438.22",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
14386, 14459
|
5470, 5731
|
494, 516
|
14661, 14661
|
2980, 5447
|
15879, 15990
|
2163, 2178
|
12368, 14363
|
14480, 14640
|
10522, 12345
|
14795, 15292
|
2193, 2961
|
10441, 10496
|
15322, 15856
|
1644, 1663
|
395, 456
|
5747, 9463
|
544, 1624
|
14676, 14771
|
9480, 10419
|
1685, 1989
|
2005, 2147
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,130
| 192,386
|
49456
|
Discharge summary
|
report
|
Admission Date: [**2104-8-19**] Discharge Date: [**2104-8-28**]
Date of Birth: [**2026-3-19**] Sex: F
Service: GENERAL SURGERY BLUE
PRESENT ILLNESS: Ischemic colitis.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 12130**] is a 78-year-old
female with a prior medical history of coronary artery
disease status post CABG, atrial fibrillation, congestive
heart failure, hypertension, breast cancer status post
radiation treatment, irritable bowel syndrome,
hypothyroidism, psoriasis, and vertigo, and status post
appendicitis, who presented on [**8-19**] for an elective
partial colectomy for ischemic colitis. After medical
clearance by Anesthesia, consent was obtained. The patient
was transferred to the operating room for the colectomy by
Dr. [**Last Name (STitle) 957**]. Please refer to the previously dictated
operative note by Dr. [**Last Name (STitle) 957**] from [**8-19**] for details of
this surgery.
Postoperatively, the patient was transferred to the Surgical
Intensive Care Unit, where she stayed until postoperative day
#5. During this time, the patient required 3 units of packed
red blood cells for blood transfusions due to falling
hematocrits. In addition, patient's fluid status was
monitored with a cordis, and she was either diuresed or
bolused based on her central venous pressure and pulmonary
arterial pressures.
In the unit, the patient's diet was advanced as tolerated,
and by the time she was transferred to the floor on [**8-24**], the patient was ready for a soft solid diet and oral
medications.
The patient's time on the floor was unremarkable. She
tolerated her diet. She underwent Physical Therapy and was
out of bed and ambulating by the time she was discharged.
Physical Therapy recommended a rehab facility upon discharge,
and the patient was accepted at the [**Hospital6 459**] for
the aged, and she currently has a bed there starting this
afternoon.
Moreover, the patient was also followed by her cardiologist,
Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 103505**], who made recommendations on a daily basis
during this admission.
DISCHARGE CONDITION/DISPOSITION: The patient is being
discharged to a rehab center today in good condition.
DISCHARGE DIAGNOSES:
1. Ischemic colitis.
2. Status post partial colectomy.
3. Multiple blood transfusions following blood loss.
4. Atrial fibrillation.
5. Congestive heart failure.
DISCHARGE MEDICATIONS: All of her in-house medications.
1. Heparin 5,000 units subQ twice a day.
2. Amiodarone 200 mg po once a day.
3. Fexofenadine 60 mg po twice a day.
4. Synthroid 75 mg po once a day.
5. Zolpidem 5 mg po q hs as needed for sleep.
6. Nitroglycerin 3 mg sublingually as needed for pain.
7. Metoprolol 25 mg po twice a day.
8. Pepcid 20 mg po twice a day.
9. Isosorbide dinitrate 30 mg po 3x a day.
10. Pravastatin 40 mg po once a day.
11. Quinapril 5 mg po once a day.
12. Aspirin 325 mg po once a day.
13. Vicodin one tablet every 4-6 hours as needed for pain.
14. Glycerine suppositories, one suppository per rectum as
needed.
FOLLOW-UP INSTRUCTIONS: The patient will have a follow-up
appointment with Dr. [**Last Name (STitle) 957**] in about two weeks. Please
refer to the dictation papers for the actual schedule date.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2104-8-28**] 07:43
T: [**2104-8-28**] 07:48
JOB#: [**Job Number 103506**]
cc:[**First Name8 (NamePattern2) 103507**]
|
[
"V10.3",
"556.9",
"696.1",
"413.9",
"244.9",
"427.31",
"V45.81",
"428.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.75"
] |
icd9pcs
|
[
[
[]
]
] |
2264, 2426
|
2450, 3076
|
219, 2243
|
3101, 3560
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,166
| 178,515
|
7528
|
Discharge summary
|
report
|
Admission Date: [**2120-3-26**] Discharge Date: [**2120-4-2**]
Date of Birth: [**2051-1-17**] Sex: M
Service: Neurosrgery
HISTORY OF THE PRESENT ILLNESS: The patient is a 69-year-old
male with a left middle cerebral artery aneurysm. The
symptoms have included dizziness, tingling in his left
fingers and difficulty with speech. The patient denied chest
pain, shortness of breath, edema, dysuria, fever, chills,
cold symptoms.
PAST MEDICAL HISTORY:
1. Left transient ischemic attacks.
2. GERD.
3. Hypertension.
4. Emphysema.
6. Six TIAs, the last one six months ago.
HOME MEDICATIONS:
1. Atenolol 25 mg q.d.
2. Univasc 7.5 mg q.d.
3. Aggrenox 25 mg b.i.d.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Pulse 55,
blood pressure 153/74. General: The patient is a very
pleasant male, alert and oriented times three, in no acute
distress. HEENT: Normocephalic, atraumatic. Pupils equally
round and reactive to light. Extraocular movements intact.
Chest: Clear to auscultation bilaterally. Cardiac: Regular
rate and rhythm, no murmurs. Abdomen: Soft, nontender,
nondistended, no hepatosplenomegaly. Extremities: No edema.
Neurologic: Cranial nerves II through XII intact. Motor
[**5-20**], bilateral upper and lower extremities. Reflexes 2+ in
the bilateral upper and lower extremities. No Romberg sign.
No pronator sign.
HOSPITAL COURSE: The patient was admitted on [**2120-3-26**], taken
directly to the Operating Room where a craniotomy and
clipping of his left MCA aneurysm was performed. The patient
was sent to the Intensive Care Unit postoperatively for close
observation.
As the patient began to wake up it was evident that the
patient had developed a postoperative aphasia. The patient
was treated with dexamethasone as well as Dilantin
postoperatively. The patient did well postoperatively with
the exception of his aphasia for which the patient stayed in
the ICU for some time in an attempt to discern the cause and
be alert for other possible problems.
Over the course of the stay, the patient was placed on
high-dose intravenous fluids in order to increase his blood
pressure which subsequently improved his aphasia. It was,
therefore, determined that a higher blood pressure would aid
in maintaining better blood flow to his brain speech centers.
Once determined the patient was found to be stable and the
aphasia improving, the patient was discharged to the regular
Neurosurgical Floor where he continued to do well. During
the course of his stay, his mental status examination and
physical examination continued to be very good. His aphasia
continued to improve.
The patient was slowly weaned off of his IV fluids which he
tolerated well. Periodically, over the course of his
weaning, his blood pressure would become slightly lower. For
that reason, his blood pressure medication regimen was
altered such that he will only be taking only one-quarter of
his at-home Atenolol dose on discharge.
On [**2120-3-28**], the patient had an angiogram to ensure
appropriate patency of his cranial arteries which was
confirmed. The patient did have mild narrowing of his MCA,
although patency was evident.
It is now [**2120-4-2**], and the patient is doing quite well. He
is being discharged home. He will be sent home with Percocet
for pain, Colace for constipation. He will be sent home with
Dilantin 100 mg t.i.d. as well as Atenolol 6.25 mg once a
day. The patient is not to restart his home medications as
they include blood thinners and hypertensive medications. He
is to restrict himself to the medications that he is being
discharged on.
Before discharge, he will have his staples removed. He is to
follow-up with Dr. [**Last Name (STitle) 1132**] in one week. He may observe regular
activity, although he should not drive while on pain
medication. The patient may start showering tomorrow.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern4) 8358**]
MEDQUIST36
D: [**2120-4-2**] 04:52
T: [**2120-4-3**] 10:08
JOB#: [**Job Number 27520**]
|
[
"437.3",
"530.81",
"401.9",
"784.3",
"492.8",
"435.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.51"
] |
icd9pcs
|
[
[
[]
]
] |
1438, 4181
|
610, 760
|
775, 1420
|
468, 592
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,002
| 156,233
|
34498
|
Discharge summary
|
report
|
Admission Date: [**2102-8-2**] Discharge Date: [**2102-8-7**]
Date of Birth: [**2045-2-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
tracheal stenosis
Major Surgical or Invasive Procedure:
[**2102-8-3**] Rigid and Flexible Bronchoscopy with stent removal
History of Present Illness:
PMH: COPD (requires 2L NC at night), CHF (EF 25%), CAD, MI in
[**2-27**], s/p stenting x2, CRF (stage III), DM2, LLL nodule - now
resolved, per patient, [**Last Name (un) **] Syndrome, prostatic CA s/p
radiation tx, OSA (sleep study in [**5-30**]), tracheostomy in [**3-/2101**],
?syncope
Past Medical History:
COPD,(requires 2L NC at night tracheostomy in [**2100**]
Subglottic stenosis
OSA (sleep study in [**5-30**])
Congestive Heart Failure(EF 25%)
Coronary Artery Disease, MI in [**2-27**], s/p stenting x2
CRF (stage III)
Diabetes Mellitus Type 2
[**Last Name (un) **] Syndrome
Prostatic Cancer s/p radiation OSA (sleep study in [**5-30**])
Social History:
Lives in an [**Hospital3 **]
Tobacco: quit recently
ETOH: denies
Family History:
Mother - died at 75 of CVA
Father - not known
Siblings - brother and sister, both healthy
Physical Exam:
general: Obese african american male w/ upper airway stridor.
HEENT; airway stridor- baseline
Chest: inspir and expir wheezes. Use of accessory muscles with
,minimal activity.
COR: RRR S1, S2
ABD: obese, soft, +BS
extrem: no edema
neuro: intact.
Brief Hospital Course:
On [**8-1**], patient was unable to phonate and had shortness of
breath. A family member called 911 and he was taken to [**Hospital 79264**]
Medical Center ED. Dr. [**Last Name (STitle) 79265**] was notified, and performed a
rigid bronchoscopy in the ED, visualizing a displaced stent to
his vocal cords. The patient was nasally intubated and
transferred to [**Hospital1 18**] for further work up and treatment.
ON HD#2 pt was underwent a flexible and rigid bronchoscopy for
removal of silicone stent which appeared to have migrated.
Pt was observed over the ensuing days until the edema resloved.
He declined a surgical airway. He was d/c'd to home w/ oxygen as
prior to admission.
Medications on Admission:
Advair 500/50 [**Hospital1 **], Spiriva 18mcg Qdaily, Flomax 0.4mg qdaily,
plavix 75mg qdaily, Toprol XL 100mg, humalog SSI, Lasix 40mg
[**Hospital1 **], Lantus 34mg, prednisone 5mg, Imdur 30mg nitrastat prn,
crestor 5mg, liroxylin 2.5mg, xopenex prn, nasal spray,
singulair 10mg
Discharge Medications:
1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
5. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO 2xweek.
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
11. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Lantus 100 unit/mL Cartridge Sig: Thirty Four (34) Unit
Subcutaneous at bedtime.
15. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO once
a day.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
17. Oxygen
Home oxygen 2L at bedtime
18. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
19. humalog insulin sliding scale
Humalog Sliding Scale
61-140 mg/dL 0 Units
141-160 mg/dL 2 Units
161-180 mg/dL 4 Units
181-200 mg/dL 6 Units
201-220 mg/dL 8 Units
221-240 mg/dL 10 Units
241-260 mg/dL 12 Units
261-280 mg/dL 14 Units
281-300 mg/dL 16 Units
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
COPD 2LNC at night
Subglottic stenosis
OSA
Congestive Heart Failure EF 25%
Coronary Artery Disease, MI in [**2-27**], s/p stenting x 2
CRF (stage III)
Diabetes Mellitus type 2
[**Last Name (un) **] Syndrome
Prostatic Cancer s/p radiation
Discharge Condition:
stable
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] office [**Telephone/Fax (1) 10084**] if experience: increased
shortness of breath, cough or sputum production.
Continue insulin sliding
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] as directed [**Telephone/Fax (1) 10084**]
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 37713**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2102-9-5**]
|
[
"V10.46",
"996.59",
"428.20",
"414.01",
"519.19",
"E879.8",
"518.82",
"585.3",
"428.0",
"V45.82",
"496",
"478.74",
"327.23",
"560.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"98.15",
"31.42",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
4428, 4479
|
1558, 2243
|
336, 404
|
4761, 4770
|
4990, 5311
|
1181, 1273
|
2575, 4405
|
4500, 4740
|
2269, 2552
|
4794, 4967
|
1288, 1535
|
279, 298
|
432, 722
|
744, 1082
|
1098, 1165
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,657
| 162,533
|
46308
|
Discharge summary
|
report
|
Admission Date: [**2182-1-31**] Discharge Date: [**2182-2-22**]
Date of Birth: [**2119-4-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Codeine / Prednisone
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2182-2-8**] Redo Sternotomy, Tricuspid Valve Replacement(27mm Mosaic
Porcine) and Four Vessel Coronary Artery Bypass
Grafting(saphenous vein grafts to left anterior descending,
diagonal, obtuse marginal, and posterior descending artery)
Left and right heart Catheterization, coronary angiogram
[**2-20**]/ left thoracentesis
History of Present Illness:
This is a 62 year old female with past medical history
significant for coronary artery disease and prior porcine
tricuspid valve replacement(history of staph endocarditis) who
presents with chest pain, and worsening dyspnea on exertion. The
patient also complains of intermittent night sweats and fevers
for the past couple of months after dental surgery. Given the
concern for recurrent endocarditis, she was admitted for further
evaluation and treatment.
Past Medical History:
Hypertension
Hypercholesterolemia
coronary artery disease
s/p 4 stents at [**Hospital1 112**] in [**2161**]
gastroesophageal reflux
Depression/Anxiety
Uterine cancer in her 20s
h/o pulmonary embolism
h/o strokes with residual dysarthria and voice hoarseness
Social History:
Lives in [**Location **]. Retired hair dresser and real estate [**Doctor Last Name 360**].
Tobacco - Active tobacco, 3 per day for the last 5 years.
Reports only starting
smoking at age 56.
ETOH - 1 to 2 glasses wine per night.
Drugs - stopped smoking marijuana three weeks ago. Denies IVDA,
heroin, and cocaine.
Family History:
No premature coronary artery disease.
Physical Exam:
Admission:
BP: 124/92 Pulse: 94 Resp: 18 O2 sat: 99/2L
General: Alert and oriented x 3. Non-toxic.
Skin: Dry[x] intact[x]
HEENT: PERRLA [] EOMI[x]
Neck: Supple [] Full ROM[x]
Chest: Lungs clear bilaterally[x]
Heart: RRR [x] Irregular [] Murmur: III/VI @LLSB in diastole
Abdomen: Soft, non-distended, non-tender[x]
Extremities: Warm, well-perfused[x] Edema Varicosities: None []
Neuro: Grossly intact
Pulses:
Femoral Right: nd Left: nd
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: (+) Left: (-)
Pertinent Results:
[**2182-2-1**] Echocardiogram:
The left atrium is elongated. The right atrium is markedly
dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity is small. Left
ventricular systolic function is hyperdynamic (EF 80%). There is
no ventricular septal defect. The right ventricular cavity is
unusually small. with normal free wall contractility. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. A bioprosthetic tricuspid valve is
present. The gradients are higher than expected for this type of
prosthesis. The leaflets of the tricuspid prosthesis are
thickened. Moderate [2+] tricuspid regurgitation is seen. [Due
to acoustic shadowing, the severity of tricuspid regurgitation
may be significantly UNDERestimated.] There is no pericardial
effusion.
[**2182-2-8**] Intraop TEE:
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
The right atrium is markedly dilated.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion.
There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**11-24**]+) mitral regurgitation is seen.
A bioprosthetic tricuspid valve is present. The gradients are
higher than expected for this type of prosthesis. There is mild
pulmonary artery systolic hypertension.
There is no pericardial effusion.
Post-CPB:
A prosthetic tricuspid valve is in place. No TR. 1+ MR remains.
Aorta intact.
[**2182-2-21**] 04:57AM BLOOD WBC-12.6* RBC-3.35* Hgb-10.3* Hct-32.0*
MCV-96 MCH-30.8 MCHC-32.2 RDW-17.5* Plt Ct-300
[**2182-2-22**] 05:57AM BLOOD UreaN-33* Creat-1.3* K-3.7
Brief Hospital Course:
Mrs. [**Known lastname 12163**] was admitted to Cardiology where she ruled out for
myocardial infarction. Blood cultures were negative.
Echocardiogram was notable for bioprosthetic tricuspid valve
stenosis without evidence of vegetations. Given the above
findings, Cardiac Surgery was consulted. Further preoperative
evaluation included cardiac catheterization which revealed
severe three vessel coronary artery disease. She also required
dental clearance as well as vascular clearance as a preoperative
carotid ultrasound showed severe disease of the right internal
carotid artery. Given her carotid disease, she will follow up
with Dr. [**Last Name (STitle) **] as an outpatient for potential endarterectomy in
the near future. The preoperative course was also notable for
atrial tachycardias and possible urinary tract infection which
was treated appropriately with antibiotics. The atrial
tachycardia was attributed to her bioprosthetic tricuspid valve
stenosis. Overall, she remained stable on medical therapy and
was eventually cleared for surgery.
On [**2-8**], Dr. [**First Name (STitle) **] performed a redo sternotomy, tricuspid
valve replacement and four vessel coronary artery bypass
grafting(see operative note for details). Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring on Epinephrine, Neo Synephrine and Propofol
infusions. Vancomycin was used for surgical antibiotic
prophylaxis given the patient's penicillin allergy and inpatient
stay of greater than 24hours pre-operatively.
POD 1 found the patient extubated, alert, oriented and breathing
comfortably. She did develop a coagulopathy post-operatively
and received multiple blood products. The patient was
neurologically intact and hemodynamically stable and all drips
were weaned. She developed hypertension which was managed with
Clonidine and Hydralazine. CIWA scale was initiated for signs
of alcohol withdrawal, including delerium tremens. Atrial
fibrillation developed and the patient was started on an
amiodarone drip. Anxiety was managed with Ativan. The patient
developed severe agitation associated with respiratory distress
requiring reintubation on [**2-12**]. She was further diuresed, and
extubated on again on [**2-14**]. The patient had paroxysmal atrial
tachycardia and Wenckebach block post-operatively. EP was
consulted. Medications were titrated as tolerated. She
underwent DC cardioversion on [**2182-2-19**]. A TEE was performed
prior to cardioversion and revealed no clot. She was not given
Heparin or Coumadin due to fall risk and recent surgery. She
will take aspirin 325mg daily, as well as Amiodarone 400mg daily
x 2 weeks, then 200mg daily. Beta blocker was titrated 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 #14 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics.
The recommendation was made that she go to a rehabilitation
facility for a brief stay, however, she adamantly refused this
and wanted to go home. After multiple discussions with her and
husband refusal to take her home, she agreed to rehab.
Precautions, medications and followup are as listed elsewhere in
the chart.
Medications on Admission:
*Hydrochlorothiazide 25 Daily
*Pantoprazole 40 mg Daily
*Requip 0.5 mg Daily
*Cymbalta DR 30 mg Daily
*Cartia XT 120 mg Daily
*Lisinopril 10 mg Daily
*Premarin 0.3 mg Daily
*Simvastatin 10 mg Daily
*Metoprolol XL 150 mg Daily
*[**Location (un) 1725**] Aspirin 81 mg Daily
*Vitamin E
Discharge Medications:
1. Aspirin 325 mg Tablet [**Location (un) **]: One (1) Tablet PO DAILY (Daily).
2. Magnesium Hydroxide 400 mg/5 mL Suspension [**Location (un) **]: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. Docusate Sodium 100 mg Capsule [**Location (un) **]: One (1) Capsule PO BID (2
times a day).
4. Bisacodyl 10 mg Suppository [**Location (un) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
5. Acetaminophen 325 mg Tablet [**Location (un) **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
6. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Location (un) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Simvastatin 10 mg Tablet [**Location (un) **]: One (1) Tablet PO QHS (once a
day (at bedtime)).
8. Ropinirole 0.25 mg Tablet [**Location (un) **]: Two (2) Tablet PO QPM (once a
day (in the evening)).
9. Ipratropium Bromide 0.02 % Solution [**Location (un) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Location (un) **]: [**2-26**]
Puffs Inhalation Q6H (every 6 hours).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO twice a day.
13. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
14. Oxycodone-Acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
15. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
16. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily): 400mg daily x 2 weeks, then 200mg daily until further
instructed.
17. Ciprofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
18. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
19. Tramadol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every 4-6 hours
as needed for pain for 4 weeks.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Bioprosthetic Triscuspid Valve Stenosis s/p Redo TVR
Coronary Artery Disease s/p CABG
Postop Acute Respiratory Failure
Hypertension
Dyslipidemia
Carotid Disease, History of Stroke
Atrial Tachycardia
anxiety
alcohol withdrawal
Discharge Condition:
Alert and oriented x3 ,nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet prn
Alert and oriented x3 ,nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet prn
Alert and oriented x3 ,nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet prn
Alert and oriented x3 ,nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet prn
Alert and oriented x3 ,nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet prn
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**]
Please wear bra to reduce pulling on incision, avoid rubbing on
lower edge
Followup Instructions:
Dr. [**First Name (STitle) **] on [**2182-3-18**] at 2:30pm ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 33059**] ([**Telephone/Fax (1) 85509**]) in [**12-26**] weeks
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2182-3-18**] 1:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2182-3-19**] 10:15
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks, your nurse [**First Name (Titles) **] [**Last Name (Titles) **]
appointment ([**Telephone/Fax (1) 3071**])
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2182-2-22**]
|
[
"788.20",
"291.0",
"997.1",
"300.4",
"518.5",
"272.0",
"401.9",
"E878.2",
"427.89",
"530.81",
"286.9",
"V42.2",
"V17.3",
"V12.51",
"V10.42",
"443.9",
"424.2",
"414.01",
"433.10",
"627.9",
"426.13",
"V15.88",
"V45.82",
"424.0",
"438.13",
"305.1",
"333.94",
"511.9",
"427.31",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"37.23",
"34.91",
"36.14",
"88.56",
"38.93",
"88.72",
"99.61",
"39.61",
"96.04",
"35.27"
] |
icd9pcs
|
[
[
[]
]
] |
10749, 10764
|
4544, 8114
|
343, 674
|
11034, 11515
|
2489, 4521
|
12130, 12870
|
1795, 1834
|
8448, 10726
|
10785, 11013
|
8140, 8425
|
11539, 12107
|
1849, 2470
|
284, 305
|
702, 1161
|
1183, 1444
|
1460, 1779
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,144
| 170,786
|
51463
|
Discharge summary
|
report
|
Admission Date: [**2142-3-27**] Discharge Date: [**2142-3-30**]
Date of Birth: [**2071-3-7**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Ciprofloxacin / Propoxyphene
Attending:[**First Name3 (LF) 2972**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Aortic valvuloplasty
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old man with a history of CAD s/p CABG
in [**2130**], systolic CHF (EF 35% in [**11-15**]), severe COPD on 2L home
O2 and steroid-dependent, severe AS (0.8cm2) & AI, colon ca s/p
sigmoid colectomy with a residual large ventral hernia who was
admitted to [**Hospital1 18**] after being transferred from OSH for
respiratory failure.
.
History is obtained via his wife over the phone as the patient
is intubated on arrival. Per his wife, he was admitted at [**Hospital 7912**] from [**Date range (1) 106698**] for respiratory distress
complicated by intubation. He was treated for COPD exacerbation
and CHF with steroids, nebs and lasix. He was not discharged on
lasix but had been on it during a previous admission. The
evening of discharge he reports not feeling well with pain in
his sinuses. She states that he did not have chest pain but he
took nitro which makes her think that he may have but did not
tell her. He was recently prescribed Relexa as a sustritute for
nitroglycerin and he may have taken both. He stated that he
felt warm and felt warm to her but she did not take his
temperature. She took his blood pressure and it was in the 130s
systolic. He went to bed and in the morning he did not appear
well. He had shortness of breath after going to the bathroom
and took a nebulizer treatment as well as ativan. His wife
reports that his face and extremities turned purple and he was
short of breath. His wife then called EMS.
.
When EMS arrived, BP was 150/80, HR 134, RR16, O2 sats 94%.
They gave him O2 15L and 2 combivent nebulizer treatments. The
monitor showed sinus tach. He arrived in the [**Hospital3 **] ED
nonverbal requiring intubation on arrival. He was given
Etomidate and succinylcholine for intubation, ativan 1mg IV x 2,
then ativan 2mg IV. He was given combivent MDI via ETT, IV
morphine gtt for management of agitation and discomfort and
Lasix 20mg IV x 1. After discussion with the [**Hospital3 **] ICU
and cardiology teams, the decision was made to transfer him to
[**Hospital1 18**] ED for further management of his critical AS and
respiratory failure.
.
Of note, his wife states that he was intubated 3 times during
his prior admission. He has been in and out of the hospital
countless times over the past year, and is rarely home for more
than a few days between admissions. He has been intubated
frequently. She does not have his medication list on discharge
from [**Hospital3 **].
.
.
In the ED, he was given vancomycin and zosyn for possible PNA.
He was started on fentanyl and versed for sedation. He was put
on a small amount of levophed for hypotension which was turned
off on arrival to the ICU. On transport he was bradycardic to
the 40s but this resolved spontaneously.
.
In the ICU when sedation is stopped, he is alert, answers
questions appropriately and follows commands. He denies pain.
When asked, he states that he had 2 alcoholic drinks today
because he was feeling well, then started feeling poorly.
.
Prior discharge summary from [**Hospital3 **] reports that he was
admitted for COPD exacerbation complicated by respiratory
failure requiring intubation. He was ruled out for MI. He had
a small PTX after central line placement which resolved by
x-ray. He had a blood transfusion for a HCT of 25 which was
complicated by respiratory failure requiring intubation and
?TRALI but was extubated within 24 hours. No further blood
transfusions were attempted during the admission. Per the
discharge summary he was briefly on antibiotics for bilateral
infiltrates but these were stopped when the infiltrates
resolved. He was recommended for rehab during this admission
but refused. He was discharged on a prednisone taper 60mg daily
with a decrease by 5mg every 2 days.
Past Medical History:
- Dyslipidemia,
- Hypertension
- CABG:CABG '[**30**] (LIMA -> LAD, SVG -> D2, OM2, RCA; stent to RCA
graft '[**32**]). Has three vessel coronary disease
- drug eluting stents x2 to ostial and mid RCA [**2141-12-29**]
- severe AORTIC STENOSIS (mean gradient 47 mmHg, AV size 0.8-1cm
- PVD- h/o [**Name (NI) **] [**Doctor Last Name 27089**] (unclear when)
- Obstructive sleep apnea, pt unsure, does not use CPAP
- GERD
- Anxiety
- Colon cancer s/p sigmoid colectomy w/ colorectal anastomosis
'[**37**] and adjuvant Xeloda therapy
- B12 deficiency anemia
- Ascending aortic aneurysm (4.2x4.2 in [**4-13**])
- Anterior wall abdominal hernia
- COPD, uses 2 liters home oxygen, recently restarting tobacco
use
- Cholecystitis- biliary drain placed [**2142-1-8**]
Social History:
- Tobacco: quit for 12 days but asked for cigarette once home,
has 150 pack year smoking history
- Alcohol: former abuser but none currently
- Illicits: denies
Family History:
Muliple family members with [**Name2 (NI) **] under age of 60
Physical Exam:
General: Intubated but alert, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess due to body habitus, 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, distended with easily reducible
abdominal hernia
GU: no foley
Ext: cool hands and feet, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2142-3-27**] 05:40PM BLOOD WBC-12.8*# RBC-3.53* Hgb-11.0* Hct-33.2*
MCV-94 MCH-31.1 MCHC-33.1 RDW-15.9* Plt Ct-118*
[**2142-3-30**] 05:15AM BLOOD WBC-9.1 RBC-3.25* Hgb-10.6* Hct-30.1*
MCV-93 MCH-32.5* MCHC-35.0 RDW-16.4* Plt Ct-105*
[**2142-3-27**] 05:40PM BLOOD Neuts-96* Bands-0 Lymphs-3* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2142-3-27**] 05:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2142-3-28**] 02:07AM BLOOD PT-11.3 PTT-27.1 INR(PT)-0.9
[**2142-3-29**] 03:06AM BLOOD PT-12.6 PTT-35.4* INR(PT)-1.1
[**2142-3-27**] 05:40PM BLOOD Glucose-132* UreaN-27* Creat-1.2 Na-144
K-5.1 Cl-106 HCO3-27 AnGap-16
[**2142-3-30**] 05:15AM BLOOD Glucose-67* UreaN-26* Creat-1.1 Na-142
K-4.5 Cl-103 HCO3-33* AnGap-11
[**2142-3-27**] 06:52PM BLOOD CK(CPK)-42*
[**2142-3-28**] 02:07AM BLOOD CK(CPK)-30*
[**2142-3-27**] 06:52PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 22885**]*
[**2142-3-27**] 06:52PM BLOOD cTropnT-0.05*
[**2142-3-28**] 02:07AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2142-3-27**] 06:52PM BLOOD Calcium-8.1* Phos-5.1* Mg-1.9
[**2142-3-30**] 05:15AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1
[**2142-3-27**] 05:47PM BLOOD Lactate-1.8 K-5.1
[**2142-3-27**] 05:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.010
[**2142-3-27**] 05:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2142-3-28**] MRSA SCREEN MRSA SCREEN-FINAL
[**2142-3-27**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE};
Aerobic Bottle Gram Stain-FINAL
[**2142-3-27**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2142-3-27**] URINE URINE CULTURE-FINAL
Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-27**] 5:59
PM
SUPINE AP VIEW OF THE CHEST: The patient has been intubated with
an ET tube tip terminating approximately 6.5 cm from the carina.
The patient is status post median sternotomy and CABG. The heart
size is not enlarged. The aorta remains tortuous with vascular
calcifications redemonstrated. The left lateral chest is
excluded from the field of view. Otherwise, the lungs are clear.
There is no large pleural effusion on the right, and no
pneumothorax. The pulmonary vascularity is within normal limits.
Vascular calcifications are seen within the upper abdomen.
IMPRESSION: Endotracheal tube in standard position. No acute
cardiopulmonary abnormality; however, the left lateral chest
wall is excluded from the field of view.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT TTE [**2142-3-28**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.12 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aorta - Sinus Level: *3.7 cm <= 3.6 cm
Aortic Valve - Peak Velocity: *3.4 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *45 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 29 mm Hg
Aortic Valve - LVOT pk vel: 0.90 m/sec
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.8 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A ratio: 0.90
TR Gradient (+ RA = PASP): *21 to 41 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2141-12-28**].
LEFT ATRIUM: Mild LA enlargement.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic sinus.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild [1+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image qualityThe left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
inferior and distal septal/apical hypokinesis suggested. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are severely thickened/deformed. Severe AS is
suggested 9AVA 0.8 cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2141-12-28**],
the overall LVEF has probably improved.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2142-3-28**]
PORTABLE AP CHEST: Limited study with bilateral chest walls not
included in the field of view.
Endotracheal tube tip ends approximately 7.6 cm above the
carina, without
significant change compared to prior study. Post-median
sternotomy wires and CABG changes are noted. The
cardiomediastinal silhouette and hilar contours are normal. The
aorta is tortuous and calcified, unchanged. Lungs are clear,
without pneumothorax or effusion.
IMPRESSION:
1. No acute cardiopulmonary abnormality.
2. ET tube in unchanged position.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**2142-3-29**]
Results Measurements Normal Range
Aortic Valve - Peak Velocity: *3.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *38 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 20 mm Hg
Findings
This study was compared to the prior study of [**2142-3-28**].
LEFT VENTRICLE: LV not well seen.
RIGHT VENTRICLE: RV not well seen.
AORTIC VALVE: Significant AS is present (not quantified) Mild to
moderate ([**12-9**]+) AR.
The left ventricle is not well seen. Significant aortic stenosis
is present (not quantified). Mild to moderate ([**12-9**]+) aortic
regurgitation is seen.
Compared with the prior study (images reviewed) of [**2142-3-28**],
velocities across the aortic valve have decreased slightly.
Cardiology Report Cardiac Cath [**2142-3-29**]
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.04 m2
HEMOGLOBIN: 9.6 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 16/16/13
RIGHT VENTRICLE {s/ed} 51/4
PULMONARY WEDGE {a/v/m} 36/39/31
LEFT VENTRICLE {s/ed} 175/18
AORTA {s/d/m} 156/69/102
PERICARDIUM {m}
**CARDIAC OUTPUT
HEART RATE {beats/min} 77
RHYTHM S
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 30
CARD. OP/IND FICK {l/mn/m2} 8.5/4.2
CARD. OP/IND OTHER {l/mn/m2} 6.52/3.19
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 838
FICK
**VALVULAR STENOSIS
AORTIC VALVE GRADIENT {mmHg} 33.23
AORTIC VALVE AREA {sq-cm} 0.99
**PTCA RESULTS
AORTIC BALLOON VALVULOPLASTY
PTCA COMMENTS:
Initial baseline studies confirmed severe aortic stenosis with a
calculated valve area of 0.8mm2. We planned to perform aortic
balloon
valvuloplasty. Heparin was started prophylactically and a
therapeutic
ACT was confirmed. Access was obtained via the left common
femoral
artery under real time ultrasound guidence. Hemodynamic
measurments were then taken at baseline and on low dose
dobutamine. A 5
French balloon tipped transvenous pacing catheter was then
postitioned
in the RV apex. With moderate difficulty, the aortic valve was
crossed
using a straight 0.035in wire through a 4 French [**Doctor Last Name **]-1 catheter.
The
catheter was exchanged over a J wire for a 4 French Pigtail
catheter and
a gradient was measured. The pigtail catheter was then exchanged
out for
an Amplatz Super Stiff wire. During transient rapid ventricular
pacing,
aortic balloon valvuloplasty was performed using a 22mm x 6cm
Tyshak II
balloon. After bedside transthoracic echocardiography was
performed and
documented mild aortic regurgitation, aortic balloon
valvuloplasty was
repeated with the same balloon. Final hemodynamic measurments
demonstrated a significant reduction in the mean gradient to <
15mmHg
and a calculated aortic valve area of 1.2cm. The left common
femoral
arteriotomy was closed with a Perclose device achieving
hemostasis. The
patient left the lab hemodynamically stable.
COMMENTS:
1. Limited resting hemodynamics revealed severe Aortic Stenosis
with a
calculated valve area of 0.8mm2. There were elevated left and
right
sided filling pressures with a PCWP of 31mmHg and an RVEDP of
19. The
central aortic pressure was mildly elevated at 156/69 with a
mean of
102mmHg.
2. Successful aortic balloon valvuloplasty unsing a 22mm x 6cm
Tyshak II
balloon.
3. Following aortic balloon valvuloplasty, the mean gradient was
reduced to 15mmHg and the calculated valve area increased to
1.2cm2.
4. Aortic root aortography revealed mild aortic regurgitation
with a
mildly dilated ascending aorta.
FINAL DIAGNOSIS:
1. Severe aortic stenosis.
2. Elevated left and right sided filling pressures.
3. Successful aortic balloon valvuloplasty x 2.
4. Mild aortic regurgitation with a mildly dilated ascending
aorta.
Radiology Report CHEST (PORTABLE AP) [**2142-3-29**]
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Evidence of apical translucency suggestive of emphysema
or a bullous disease. No focal parenchymal opacity suggesting
pneumonia. Unchanged size of the cardiac silhouette, status post
sternotomy. In the interval, the nasogastric tube and the
endotracheal tube have been removed. No pleural effusions.
Brief Hospital Course:
# Critical Aortic Stenosis: The patient had known severe aortic
stenosis, which was confirmed with an echocardiogram
demonstrating an aortic valve area of 0.8cm2.
The cardiac surgery service was consulted to [**Month/Day/Year 4656**] the
patient for aortic valve replacement, however, he was felt to
not be a good candidate for the operation. He underwent a
balloon valvuloplasty on [**2142-3-29**] which resulted in mean gradient
reduction to 15mmHg and the calculated valve area increased to
1.2cm2 from 0.8cm2. He tolerated the procedure well and had no
compliations associated with the procedure.
.
# Respiratory Failure: The patient arrived to the MICU
intubated. His respiratory distress was thought to be
multifactorial due to decompensated heart failure in the setting
of critical aortic stenosis and possibly COPD exacerbation.
Cardiac enzymes were trended and were normal. There was no
evidence of pneumonia on imaging. For heart failure, he was
diuresed with lasix IV boluses with good effect. For COPD, he
was started on IV solumedrol, which was soon changed to oral
prednisone. He was extubated within 24 hours of arrival. He was
discharged with a prescription for a rapid prednisone taper.
.
# Hypotension: The patient transiently required vasopressor
support for hypotension in the Emergency Department. He was able
to be weaned off levophed by the time he arrived to the ICU. He
had no more issues with hypotension.
.
# Positive blood culture: Patient had one positive blood culture
growing Coag (-) staph that was thought to be a contaminant as
the patient had no signs or symptoms of infection.
.
# Coronary artery disease: He was continued on his home
ranolazine, aspirin, plavix, and simvastatin.
.
# GERD: He was continued on home dose ranitidine.
.
# Code: Patient was full code.
Medications on Admission:
Ranolazine 500mg PO BID
Ferrous Sulfate 300mg PO qday
Folic Acid 1mg PO qday
MVI 1 tab PO qday
Vit B12 50mcg PO qday
Omega-3 Fatty Acid 1 cap PO BID
Zocor 80mg PO qHS
Zantac 150mg PO BID
Seroquel 12.5mg PO BID
Pentoxifylline 400mg PO TID
Nitroglycerin 0.3mg PO q5min
Ativan 0.5mg PO TID
Metoprolol 25mg PO BID
Advair 250/50mcg inhaler
Plavix 75mg PO qday
Celexa 80mg PO qday
Aspirin 325mg PO qday
Amitriptyline 50mg PO qHS
Albuterol 2 puffs q4H
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO BID (2 times a day).
3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Vitamin B-12 50 mcg Tablet Sig: One (1) Tablet PO once a day.
7. Omega-3 Fatty Acids 1,000 mg Capsule Sig: One (1) Capsule PO
twice a day.
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Seroquel 25 mg Tablet Sig: 0.5 Tablet PO twice a day.
11. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual q 5 minutes as needed for chest pain.
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) IH Inhalation once a day.
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Citalopram 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
18. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at
bedtime.
19. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
20. Prednisone 10 mg Tablet Sig: 1-4 Tablets PO once a day for 7
days: Please take 4 tablets on [**3-31**], take 3 tablets on [**4-1**] and
[**4-2**], take 2 tablets on [**4-3**] and [**4-4**], take 1 tablet on [**4-5**] and
[**4-6**].
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
CHF exacerbation
Respiratory failure
Critcal AS
Secondary Diagnosis:
COPD
CAD
HTN
HL
GERD
PVD
OSA
Abdominal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were transfered to the [**Hospital1 18**] for management of your aortic
valve stenosis. You were initially admitted to the ICU where you
were quickly extubated and did well. You subsequently underwent
aortic valvuloplasty to open you aortic valve. You tolerated the
procedure well and had no complications. Your condition improved
after the procedure.
Medication Changes:
START: Prednisone taper 10 mg tablets; take 4 tablets on [**3-31**],
take 3 tablets on [**4-1**] and [**4-2**], take 2 tablets on [**4-3**] and
[**4-4**], take 1 tablet on [**4-5**] and [**4-6**].
No other changes were made to your medications
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-3**]
2:00
Please follow up with Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 2974**] [**2142-4-13**] at 12:00 pm
|
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,934
| 181,397
|
39615
|
Discharge summary
|
report
|
Admission Date: [**2189-11-14**] Discharge Date: [**2189-12-3**]
Date of Birth: [**2138-1-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
fevers, throat pain
Major Surgical or Invasive Procedure:
1. Large preverterbral space abscess s/p I&D
.
2. Soft tissue biopsy of right proximal humerus.
3. Irrigation and debridement of right shoulder deep
abscess
4. Removal of implant, deep right proximal humerus.
5. Bone biopsy, right proximal humerus
History of Present Illness:
History of Present Illness: 51F with hx of anterior cervical
MRSA abscess s/p drainage/ACDF, hx IVDU, hx BCa s/p L breast
mastectomy previously on tamoxifen, s/p R humeral ORIF, HCV
?cirrhosis who was transferred from [**Hospital3 2737**] for
management of anterior cervical abscess. Per report, the pt had
a PICC line in for 6 months conceivably for IV antibiotics which
she was most likely also using for IV drugs. 6 months ago she
noted significant erythema around the picc site and pulled out
the line. The site has subsequently been draining pus ever
since. Today she presented to OSH complaining of neck pain for 1
week. She thought she had irritated hardware in her spine while
lifting something. It continued to increase, and she started
developing difficulty swallowing off and on over the past week
as well. Yesterday, she began to feel as if her throat was
tight and breathing wasn't as easy. CT neck showed a 4.5 x 2 cm
retropharyngeal abscess. She was given a dose of Cefepime and
toradol and transferred to [**Hospital1 18**].
.
In the [**Hospital1 18**] ED she was 96.7 78 154/100 16 100%. NSG, ENT, and
Ortho were consulted. She got a CXR which was clear, and a
humeral xray which showed proximal humerus hardware and
extensive soft tissue swelling. She was given clinda/vanc,
dilaudid and taken emergently to the OR.
.
In the OR the pt was intubated for airway protection (reportedly
a difficulty airway). Neurosurgery debrided and found her to
have a paraesophageal abscess with significant purulent
drainage. They removed prevertebral hardware. They were unsure
if they fully evacuated the pus from both sides.
.
In the MICU the pt remained intubated and sedated. 95 156/100
121 9 99% intubated. The pt was noted to have a draining sinus
track on her right upper extremity that probed to bone. ID and
ortho were consulted.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-Breast cancer s/p L mastectomy on tamoxifen - managed by Dr.
[**First Name (STitle) **] Crop at [**Company 2860**]
-HCV diagnosed about 13 years ago, never treated. Radiographic
evidence of cirrhosis.
-Right femoral fracture s/p ORIF
-Shrapnel in head from remote h/o gunshot wound
-MRSA epidural abscesses at C4-C5 and C5-C6 s/p anterior
cervical exploration and abscess evacuation on [**2188-9-15**] with C4-6
fusion using VG2 allograft in each of the disk spaces and an EBI
VueLock plate over it and secured it with 6 screws in adequate
position. The pt had been planned for minimum 6wks Vancomycin tx
with indefinite oral suppressive therapy. Initially followed by
ID here, transitioned to care at [**Hospital1 **].
-neuropathy secondary to chemotherapy
Social History:
Lives in [**Location 5165**]. Smokes two cigarettes a day X many years.
Denies alcohol use, previous alcohol abuse but quit 25 years
ago. Denies current illicit drug use but abused drugs NOS until
7 years ago.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL:
General: intubated, sedated, nad
HEENT: Sclera anicteric
Neck: two drains in place
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: foley
Ext: RUE warm and swollen with scar from should to antecubital
fossa, mid upper extremity indented circle with purulent
drainage, probes to bone.
DISChARGE PHYSICAL:
VS: Tc 97.7 Tm 98.8 BP 125/66 (125-178/66/89) P 50-60 RR 18 O2
98% RA
I/O: 200/500
GEN: sitting in bed eating breakfast in bed in neck collar, NAD.
Anterior neck sutures visualized, c/d/i.
HEENT: NCAT, MMM
NECK: In C-collar (did not remove).
COR: +S1S2, no m/g/r.
PULM: CTAB over anterior & posterior fields, no c/w/r.
[**Last Name (un) **]: +NABS in 4Q. Soft, NTND
EXT: WWP, no c/c/e. R PICC in place, no erythema, swelling
noted. NEURO: AAO X3. Strength 4/5 in right interossei;
otherwise strength 5/5 in BL upper and lower extremities. CN
II-XII grossly intact.
Pertinent Results:
Shoulder Plain films
IMPRESSION:
1. Large amount of soft tissue swelling in the lateral upper
arm.
2. Intact-appearing hardware without hardware-related
complications.
3. No radiopaque foreign body.
.
Cervical MRI:
FINDINGS: There is confirmation of low T1 and elevated T2 signal
within the C6 and 7 vertebral bodies and minimally elevated T2
signal within the
intervening disc. There is also a spindle-shaped region of
contrast
enhancement in the anterior epidural space, with a hypointense
region
immediately posterior to the C6-7 disc space, the latter
centered to the right of midline. In light of the known
inflammatory process anterior to the spine extending from C4
through C7, discitis and osteomyelitis, as well as an epidural
abscess is the most likely diagnosis. There is also slight
enhancement of the posterior epidural space at this locale,
presumably infectious in origin, as well. There is no definite
spinal cord edema, although the cord is compressed over the
extent of this inflammatory process to a mild degree.
The prevertebral fluid collection is seen as an area of
hypointensity on the contrast-enhanced scan.
Finally, there are extensive secretions pooling within the nasal
and
oropharynx, extending into the supraglottic larynx. There is a
question of
coiling of a tube in the supraglottic larynx. The present images
are not
totally definitive, in this regard, as the axial scans
encompassing this
region do not reveal this structure completely, secondary to the
presence of an MR saturation band designed to reduce pulsation
artifacts. I have informed Dr. [**Last Name (STitle) **] of all of these findings,
including the issue of tube placement at the time of this
report.
CONCLUSION: Confirmation of suspected discitis, osteomyelitis
and epidural
abscess. Possible abnormal placement of a tube, as discussed
above.
MRI Neck ([**2189-11-15**]):
FINDINGS: Since the recent neck CT scan, there appears to be
evidence for drainage catheter which extends into what
presumably was the large prevertebral abscess cavity situated at
the cervicothoracic junction. Judging from the neck CT scan from
the outside facility, appears to be substantial reduction in the
extent of the fluid, perhaps only faintly visualized as a streak
of elevated T2 signal on axial image 3, series 7. It is to be
acknowledged that the present examination appears to only have
T1 weighted images in the sagittal plane. Thus, it is quite
difficult to evaluate the discs and vertebral bodies of
potential underlying inflammatory disease, although there is now
low T1 signal in the C6 and C7 vertebral bodies, and a concern
for possible epidural fluid or phlegmon posterior to this
region. It is also very difficult to evaluate for spinal cord
edema. A supplemental cervical spine MR scan would appear to be
an appropriate followup study.
.
CONCLUSION: Reduction in size of prevertebral fluid component.
However, concern for abnormalities of the cervical spine and
possible epidural space that deserve prompt followup imaging,
again with MRI scanning.
.
ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF 80%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve is not well seen. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion. If clinically
indicated, a transesophageal echocardiographic examination is
recommended.
IMPRESSION: Suboptimal image quality. No definite vegetations
seen but cannot be excluded on the basis of this study (TEE
recommended if clinically indicated)
Esophagus study
IMPRESSION: No pharyngeal or esophageal leak or narrowing
MICRO:
[**2189-11-15**] 3:22 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during prolonged
therapy with quinolones. Therefore, isolates that are initially
susceptible may become resistant within three to four days after
initiation of therapy. Testing of repeat isolates may be
warranted.
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-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2189-11-16**]):
GRAM POSITIVE COCCI IN CLUSTERS.
.
[**2189-11-14**] 8:50 am SWAB R ARM PICC LINE PURULENT DRAINAGE CULTURE
& GRAM STAIN. ABSCESS. ======> MRSA
.
[**2189-11-14**] 11:46 am SWAB ANTERIOR NECK ABCESS. ====> MRSA
.
[**2189-11-16**] 5:32 pm SWAB RIGHT HUMERUS. ====> MRSA
[**2189-11-14**] 08:25AM PLT COUNT-165
[**2189-11-14**] 08:25AM PLT COUNT-165
[**2189-11-14**] 08:25AM NEUTS-82.1* LYMPHS-13.2* MONOS-3.9 EOS-0.4
BASOS-0.4
[**2189-11-14**] 08:25AM WBC-6.8 RBC-4.75 HGB-12.7 HCT-39.1 MCV-82
MCH-26.7* MCHC-32.4 RDW-13.7
Brief Hospital Course:
51F with hx of anterior cervical MRSA abscess s/p drainage/ACDF,
hx IVDU, hx BCa s/p L breast mastectomy previously on tamoxifen,
s/p R humeral ORIF, HCV ?cirrhosis who was transferred from
[**Hospital3 2737**] for management of anterior cervical/para
esophageal abscess.
# Bacteremia, Cervical Osteo & MRSA Abscesses: The pt was
intubated to protect her airway. The neck abcess was debrided by
neurosurgery with removal of hardware in neck
and drains were placed. Ortho did a washout of the humerus. She
was initially covered with braod spectrum antibiotics with vanc,
cefepime and flagyl. Wound and blood cultures grew MRSA. She was
extubated without incident. A TTE was negative. Prior to
intiating her diet, she had a contrast study of her esopahgus
which was normal. A PICC was placed for long term antibiotics.
Per Infectious Disease recommendations, she was started on
Vancomycin 1000mg IV q12 hours x 8 weeks and Rifampin 600mg
daily x 12 weeks. She was followed by neurosurgery throughout
her stay, and they decided that they would not replace the
hardware in her neck as she did not have any focal neurologic
deficits other than slight weakness in her right hand which
correlates to C8-T1 (not C5-C7 where abscess was located).
Patient's pain was well controlled throughout her stay on the
floors and she She will follow up with orthopedics and
neurosurgery as an outpatient.
# History of IVDU: Social work was consulted and found patient
to be at high risk for relapse on discharge. They wrote a Page 3
referral for substance abuse treatment at her rehab facility and
gave her information and phone numbers for substance abuse care
and support groups as an outpatient.
.
# History Breast Cancer: Now s/p L mastectomy & prior tamoxifen
use. Not active during hospitalization.
.
# History of HCV with radiographic cirrhosis: LFTS wnl on this
admission. However, her viral load is 2,470,000 IU/mL. She was
scheduled for an appointment with her PCP and was advised to
discuss potential treatment for HCV in the future, should she
become symptomatic.
.
TRANSITION OF CARE:
-Patient has asymptomatic Hepatitis C with a viral load of
2,470,000.
-Patient has follow up appointments scheduled with her PCP and
with neurosurgery
-Will need labs drawn as outpatient (CBC, chem 7, ESR, CRP,
vanco trough) and faxed to her PCP. [**Name10 (NameIs) **] written.
Medications on Admission:
Neurontin 800mg [**Hospital1 **]
Discharge Medications:
1. Outpatient Lab Work
CBC with diff, Chem 7, vanco trough, ESR and CRP. Please fax
results to [**Telephone/Fax (1) 1419**], attention Dr. [**Last Name (STitle) **] [**Name (STitle) **].
Please draw weekly.
2. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous Q 12H (Every 12 Hours).
3. rifampin 300 mg Capsule Sig: Two (2) Capsule PO once a day.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
6. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis:
- MRSA abscesses (paracervical, epidural, right humerus)
- Cervical osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Worksheet-Discharge Instructions-Last Updated by:
[**Last Name (LF) **],[**First Name3 (LF) **] V., MD on [**12-3**] @ 1543
Ms. [**Known lastname 1007**], it was a pleasure to participate in your care while
you were at [**Hospital1 18**]. You came to the hospital because you were
very ill from infected collections in your neck & right arm.
Please continue to wear your neck brace every day until your
followup with Dr. [**Last Name (STitle) **] (neurosurgery) in 6 weeks.
Please schedule follow up appointments with Orthopedics in 2
weeks and Neurosurgery (Dr. [**Last Name (STitle) **] in 6 weeks. The phone
numbers for making these appointments are listed below. You will
also need to get an MRI on the same day as your appt with Dr.
[**Last Name (STitle) **]
We made the following changes to your medications:
STARTED:
1. Morphine SR 45mg one pill every 12 hours
2. Rifampin 600mg one pills daily for 8 weeks (last day =
[**2190-1-26**])
3. Vancomycin 1000mg IV every 12 hours for 8 weeks (last day =
[**2190-1-22**])
4. Docusate 100 mg twice daily
5. Senna 1 tab twice daily
6. Bisacodyl 10mg PO daily as needed for constipation
STOPPED:
1. Neurontin 600 mg three times per day
Followup Instructions:
Please follow up in 2 weeks at the [**Hospital 9696**] clinic at [**Hospital 61**] Hospital [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Center, [**Location (un) 551**]. Please
call [**Telephone/Fax (1) 1228**] to make an appointment.
Other appointments:
Name: [**Last Name (LF) 9328**],[**First Name8 (NamePattern2) 539**] [**Last Name (NamePattern1) 26**]
Location: [**Location (un) 87404**] INTENAL MEDICINE
Address: [**State **] STE A, [**Location (un) **],[**Numeric Identifier 22165**]
Phone: [**Telephone/Fax (1) 58182**]
**Please discuss with the staff at the facility the need for a
follow up appointment with your PCP when you are ready for
discharge**
Department: [**Hospital1 **] MRI (MOBILE)
When: TUESDAY [**2190-1-12**] at 8:45 AM
With: MRI [**Telephone/Fax (1) 327**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: TUESDAY [**2190-1-12**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 9151**], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"305.50",
"571.5",
"996.67",
"730.28",
"324.1",
"276.3",
"E878.1",
"998.6",
"070.70",
"041.12",
"V10.3",
"790.7",
"478.24",
"682.1",
"722.91",
"730.22",
"793.11",
"284.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"77.42",
"83.39",
"83.21",
"06.09",
"78.62",
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] |
icd9pcs
|
[
[
[]
]
] |
14118, 14191
|
10958, 13321
|
325, 578
|
14336, 14336
|
5099, 9259
|
15729, 16982
|
3945, 3963
|
13404, 14095
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14212, 14212
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13347, 13381
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14489, 15294
|
3978, 5080
|
9297, 10935
|
15324, 15706
|
2470, 2918
|
266, 287
|
634, 2451
|
14231, 14315
|
14351, 14463
|
2940, 3701
|
3717, 3929
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,500
| 119,532
|
6533
|
Discharge summary
|
report
|
Admission Date: [**2118-7-8**] Discharge Date: [**2118-7-12**]
Date of Birth: [**2041-5-17**] Sex: M
Service: MEDICINE
Allergies:
Tamiflu / Celebrex
Attending:[**First Name3 (LF) 8928**]
Chief Complaint:
Hypotension/anemia
Major Surgical or Invasive Procedure:
Upper endoscopy showing 2 [**Location (un) **] ulcers
History of Present Illness:
77 yo M with history of multiple ulcers, discharged on [**7-5**] for
an UGIB, presented to his PCP today complaining of "wooziness"
and found to be hypotensive. He had been constipated since
discharge from the hospital, without having any bowel movements.
Yesterday he began to feel very fatigued, and today he presented
to his PCP. [**Name10 (NameIs) **] noted his pulse to be fast at home. At his PCP's
office, he was hypotensive 80/40 right 70/35 left and was sent
to the ED.
In the ED, initial VS were 97.6 63 81/42 16 99% RA. His
hematocrit was found to be 21.9, after being discharged with a
hematocrit of 22-24. He was given IV fluids and a unit of PRBCs
and his symptoms improved. On transfer to MICU his vitals were
74 112/84 16 97% RA.
Past Medical History:
- hypertension
- sleep apnea on CPAP
- dx of seronegative rheumatoid arthritis, second opinion
rheumatologist suggested osteorthritis, recent Kenolog
injectionsin both knees, unsuccessful injection of hyaluronic
acid in ankles
- hyperlipidemia
- sprinal stenosis s/p X top procedure and laminectomy
- Recovered Prostate Cancer [**2105**] - s/p Brachytherapy. Followed
at [**Hospital1 112**] with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Also Dr. [**First Name4 (NamePattern1) 3403**] [**Last Name (NamePattern1) 20179**] of
urology at [**Hospital1 112**].
- s/p UGI bleed
- s/p Carpal Tunnel Syndrome
- h/o DVT, single episode
- h/o Gout
- h/o Lyme
- lower extremity edema
- Aortic stenosis
- radiation proctitis
- BCC AND AK; Followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. s/p 2 [**Initials (NamePattern4) 25054**] [**Last Name (NamePattern4) **]
and [**2112-9-2**]
Social History:
4 glasses of wine per night. Prior smoker, quit [**2093**]. Previously
had smoked 1.5 ppd X 35 years. Married to wife of 33 years, has
3 children from former wife, 8 grandchildren, 5 great
grandchildren.
The patient spends time between [**Location (un) 86**] and [**State 108**]. Formerly
worked as corporate attorney.
Family History:
Father had [**Name2 (NI) **] cancer, throat cancer died age 67
Mother died from lung CA age 78
Physical Exam:
PHYSCIAL EXAM ON ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to chin
CV: Regular rate and rhythm, holysystolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, slightly distended, bowel sounds present, mild
hepatomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
PHYSICAL EXAM AT DISCHARGE:
VS - Tc/Tm 98.3 134-161/66-76 86 20 97% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, MMM, OP clear
NECK - supple
LUNGS - faint crackles at bases b/l, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no systolic ejection murmur heard throughout
precordium
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ peripheral pulses (radials), 1+ pitting edema
b/l lower extremities, improved since yesterday
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, muscle strength 5/5 throughout, sensation
grossly intact throughout
Pertinent Results:
Labs on admission:
[**2118-7-8**] 02:45PM BLOOD WBC-10.1 RBC-2.08* Hgb-7.2* Hct-21.9*
MCV-106* MCH-34.5* MCHC-32.7 RDW-15.5 Plt Ct-244
[**2118-7-8**] 02:45PM BLOOD Neuts-64 Bands-0 Lymphs-23 Monos-8 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-3*
[**2118-7-8**] 02:45PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL
[**2118-7-8**] 02:45PM BLOOD PT-11.6 PTT-23.4* INR(PT)-1.1
[**2118-7-8**] 02:45PM BLOOD Ret Aut-5.7*
[**2118-7-8**] 02:45PM BLOOD Glucose-102* UreaN-36* Creat-1.3* Na-138
K-4.8 Cl-103 HCO3-26 AnGap-14
[**2118-7-8**] 02:45PM BLOOD LD(LDH)-281* TotBili-0.3 DirBili-0.1
IndBili-0.2
[**2118-7-8**] 02:45PM BLOOD Iron-44*
[**2118-7-8**] 02:45PM BLOOD calTIBC-290 Hapto-91 Ferritn-101 TRF-223
RELEVANT [**Hospital3 984**]
[**2118-7-9**] 04:00AM BLOOD WBC-8.4 RBC-2.19* Hgb-7.4* Hct-22.4*
MCV-102* MCH-33.7* MCHC-33.0 RDW-15.9* Plt Ct-230
[**2118-7-9**] 02:57PM BLOOD Hct-22.5*
[**2118-7-10**] 06:20AM BLOOD WBC-7.7 RBC-2.18* Hgb-7.4* Hct-23.0*
MCV-105* MCH-33.9* MCHC-32.2 RDW-15.8* Plt Ct-246
[**2118-7-10**] 06:40PM BLOOD WBC-8.1 RBC-2.88*# Hgb-9.6*# Hct-29.5*#
MCV-102* MCH-33.2* MCHC-32.5 RDW-16.6* Plt Ct-234
[**2118-7-11**] 11:45AM BLOOD WBC-7.3 RBC-2.88* Hgb-9.7* Hct-29.6*
MCV-103* MCH-33.6* MCHC-32.7 RDW-16.7* Plt Ct-257
[**2118-7-11**] 04:44PM BLOOD WBC-8.2 RBC-2.76* Hgb-9.3* Hct-28.1*
MCV-102* MCH-33.8* MCHC-33.1 RDW-16.2* Plt Ct-281
[**2118-7-11**] 08:55PM BLOOD WBC-8.6 RBC-2.82* Hgb-9.5* Hct-28.7*
MCV-102* MCH-33.8* MCHC-33.3 RDW-16.4* Plt Ct-297
[**2118-7-12**] 06:30AM BLOOD WBC-8.2 RBC-3.07* Hgb-10.1* Hct-30.8*
MCV-100* MCH-33.0* MCHC-32.9 RDW-16.2* Plt Ct-321
DISCHARGE LABS
[**2118-7-12**] 05:20PM BLOOD WBC-9.0 RBC-3.13* Hgb-10.3* Hct-32.1*
MCV-102* MCH-32.8* MCHC-32.0 RDW-16.2* Plt Ct-298
Brief Hospital Course:
77 yo M admitted for hypotension and anemia with history of
recent discharge for GIB related to [**Location (un) 3825**] ulcer, found to have
2 [**Location (un) 3825**] ulcers on repeat EGD.
ACTIVE ISSUES:
1. Anemia
GI bleed from 2 [**Location (un) 3825**] ulcers noted on EGD is likely cause,
given his history of melena; however, patient had episode of BRB
in the toilet bowl on the day of discharge so question of
possible other cause exists. The patient has a history of
radiation proctitis which may be responsible for this. He
required multiple transfusions -- first in ED/MICU (1unit) and
though he did not have an appropriate initial response, after
receiving 2 more units on the general medicine floor he
responded well. Hcts came up to high 20s (28-29) and eventually
increased to 32 upon discharge. Serial Hct were between 21-23.
He was seen by [**Location (un) **] who performed an EGD showing 2
[**Location (un) 3825**] ulcers within hiatal hernia sac; these were not actively
bleeding. He has been started on omeprazole and sucralfate and
will follow up with GI, as well as surgery as an outpatient for
possible repair of hiatal hernia.
2. [**Location (un) 3825**] Ulcers: Seen on repeat EGD as above; not actively
bleeding. Treated with omeprazole and sucralfate. The patient
will follow up with Dr. [**Last Name (STitle) 1940**] in GI in 3 weeks.
3. Hypotension at admission:
Most likely etiology was hypovolemia due constipation, poor PO
and continue use of diuretics, with possible contribution from
GI bleed although he was having melena and no hematochezia.
Blood pressure resolved in MICU with fluids and holding of
diuretics. On the general medicine floor he was normotensive;
home bumetanide was held for most of the admission and restarted
the day before discharge, when blood pressures were normal to
borderline high.
CHRONIC ISSUES:
1. Hypothyroidism: stable during this admission.
2. Hypertension: home antihypertensives -- lisinopril,
bumetanide and nadolol -- were held during this admission due to
hypotension when he came in. These were restarted upon
discharge as blood pressures were stable at normal to elevated
(130s-160s systolic range).
3. Pedal edema: Bumetanide held for most of admission but
restarted prior to discharge with significant diuresis and
decreased edema.
TRANSITIONAL ISSUES:
1. The patient will have his H/H checked in 1 week via his PCP
and these results should be communicated to Dr. [**Last Name (STitle) 1940**].
Medications on Admission:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
per pt, taken with pain medications
2. Bumetanide 2 mg PO QAM
3. Levothyroxine Sodium 50 mcg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN back pain
5. Pregabalin 25 mg PO BID
6. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
7. Diazepam 5 mg PO Q8H:PRN muscle spasm
8. Vesicare *NF* (solifenacin) 5 mg Oral daily
9. Omeprazole 40 mg PO BID
Please take 30 minutes before breakfast and 30 minutes before
dinner everyday.
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Bumetanide 2 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN back pain
5. Pregabalin 25 mg PO TID
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
7. Nadolol 80 mg PO DAILY
8. modafinil *NF* 200 mg Oral daily
9. Ascorbic Acid 250 mg PO DAILY
10. Cyanocobalamin 25 mcg PO DAILY
11. Diazepam 5 mg PO Q8H:PRN spasm
12. theanine (bulk) *NF* 99.1 % Miscellaneous prn supplement
13. thyroid, pork (bulk) *NF* 100 % Miscellaneous daily
14. Vitamin E 400 UNIT PO DAILY
15. Lisinopril 20 mg PO BID
16. Omeprazole 40 mg PO BID
17. Sucralfate 1 gm PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Anemia due to gastrointestinal bleeding
Secondary: Hypertension, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care at [**Hospital1 18**]. You came
to the hospital for anemia caused by acute blood loss. You were
given multiple blood tranfusions and monitored your blood
counts. You were seen by gastroentrology who did a study of
your bowel and found 2 [**Location (un) 25056**] ulcers within your stomach in
the area that is displaced in a hiatal hernia. They were not
actively bleeding. You were given medications to decrease the
acid in your stomach to treat the ulcers. Your blood counts
continued to remain stable and increase, and you were discharged
in stable condition with the plan to follow up with your GI
doctor as well as your surgeon as an outpatient. Please follow
up with your PCP [**Last Name (NamePattern4) **] 1 week to have your blood drawn to check
your blood counts.
Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2118-7-18**] at 10:30 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3879**] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: [**Location (un) 864**]
When: WEDNESDAY [**2118-8-3**] at 4:00 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: MONDAY [**2118-8-15**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8931**]
Completed by:[**2118-7-12**]
|
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"V45.4",
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"840.4",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9106, 9112
|
5432, 5624
|
297, 353
|
9246, 9246
|
3642, 3647
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2441, 2538
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8441, 9083
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9133, 9225
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7946, 8418
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9397, 10223
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2553, 2567
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3011, 3623
|
7777, 7920
|
239, 259
|
5639, 7286
|
381, 1131
|
3662, 5409
|
9261, 9373
|
7303, 7756
|
1153, 2088
|
2104, 2425
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,170
| 131,709
|
26414
|
Discharge summary
|
report
|
Admission Date: [**2162-12-27**] Discharge Date: [**2163-1-13**]
Date of Birth: [**2117-10-11**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt is a 45 year old man who had not been seen by his
neighbors for several days. Found down in his home. Transported
to OSH, where Pt was found to have L basal ganglia hemorrhage.
Received Ancef, loaded with Dilantin, intubated (Lidocaine,
Etomidate, Succinylcholine). Transferred to [**Hospital1 18**] for further
management.
In the [**Name (NI) **], Pt was bolused with Propofol then started on gtt for
sedation as Pt was agitated. Received Mannitol 50grams IV x1.
Neurosurgery service consulted, no intervention at this time.
Past Medical History:
CAD
CABG
Hypercholesterolemia
HTN
Social History:
Lives alone. Unknown Shx.
Family History:
Unknown.
Physical Exam:
Physical Exam (bolused w/propofol just prior to exam)
T 97.7 HR 70s BP 115/60 O2sat 100%
GEN Intubated, initially appears agitated, but then calm within
a few minutes. Intermittent movement of RUE, pulling against
restraints, turning head side to side.
HEENT lips dry, C-collar NOT in place, no clear head trauma
Chest coarse BS, no wheeze, no crackles
CVS RRR, no m/r/g
ABD soft, NT, ND, +hypoactive BS
EXT +bruising over RLE, early pressure ulcer posteriorly,
distal
pulses strong
Neuro
MS: Sedated w/propofol, not responsive to sternal rub.
CN: L pupil 2.5mm minimally reactive, R pupil 1.5mm nonreactive,
no blink to threat, optic discs not well visualized. Doll's eye
reflex absent. Corneals absent bilaterally. Any facial asymmetry
obscured by ETT, OGT, tape. +grimace to nasal tickle
bilaterally.
+gag.
Motor: Spontaneous movement greatest in RUE. Withdraws in all 4
extremities, more briskly on R. Slight increase in tone on L.
Reflex:
|[**Hospital1 **] |tri |bra |pat |[**Doctor First Name **] |toe |
L | 3 | 3 | 3 | 3 | 3 | dn |
R | 3 | 3 | 3 | 3 | 3 | dn |
[**Last Name (un) **]: withdraws to noxious time in all four extremities.
Pertinent Results:
.
OSH Labs:
21.3>54.6<331 90N 2L 7M
Na 147 K 4.1 Cl 101 CO2 14 BUN 82 Cr 1.4 Glu 117
Ca 9.1 Mg 3.5
SGOT 156 ALT 115 AlkP 89 [**Doctor First Name **] 67 Lip 41
PT 13.7 PTT 23.9 INR 1.1
CK 5018 Trop <0.1
U/A 150ket, lg blood, o/w neg
TSH 0.46
Serum and urine tox screens negative
.
Head CT: Large 5 x 4 x 2.5cm (~26cc) hemorrhage centered
primarily over the left basal ganglia/thalamus. Mild amount of
midline shift and moderate amount of mass effect on the adjacent
left brainstem, with a more focal hypodense area in the left
pons, concerning for focal infarction, chronicity indeterminate.
.
MR BRAIN WITHOUT AND WITH CONTRAST: The study is slightly
limited, as no pre- contrast T1-weighted axial images were
obtained.
As seen on the prior CT, in the left parietal lobe involving the
left basal ganglia and thalamus, is a large area of
susceptibility reflecting hemorrhage with a small amount of
surrounding edema, and a moderate amount of mass effect on the
adjacent ventricles. There is a mild amount of mass effect
exerted on the left anterior portion of the brainstem, which is
also unchanged. The post- contrast images demonstrate no
enhancing components of this lesion. On the T1-weighted images,
the lesion demonstrates peripheral increased signal, likely
representing methemoglobin conversion from deoxyhemoglobin.
Within the pons, seen on the FLAIR and T2-weighted images is a
focus of increased signal in the left pons with increased signal
seen on the diffusion- weighted images and without enhancement
on the post-contrast images. These findings could represent
so-called "T2 shine through", as from a subacute infarct.
Seen also on series 2, image 14 on the sagittal non-contrast
T1-weighted images, is a focus of increased signal in the mid
cerebellum, without enhancement on the post-contrast images;
this finding, as well, could represent a focus of hemorrhage.
MRA: 3D time-of-flight MR angiography was performed. There is
ectasia seen in both vertebral arteries as well as the basilar
artery. The major vessels of the circle of [**Location (un) 431**] and its
branches are patent. No cerebral aneurysms are identified.
IMPRESSION:
1. No enhancing masses identified. Left parietal lobe hemorrhage
as described above. Punctate focus of signal abnormality in the
cerebellum, likely a small focus of hemorrhage as well.
2. Pontine edema, which may be a subacute infarct, v. so-called
T2 shine through from edema surrounding the large hemorrhage,
which extends into the midbrain.
.
ECHO:
1. The left ventricular cavity size is normal. Regional left
ventricular wall
motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%).
2. The aortic valve leaflets (3) are mildly thickened. Trace
aortic
regurgitation is seen.
.
EEG:
FINDINGS:
ABNORMALITY #1: Background rhythms in the left hemisphere were
slow in
the mixed theta frequency range.
ABNORMALITY #2: There is a significant presence of left
posterior
temporal and parietal slowing. This was in the mixed delta and
theta
frequency range. No sharp features were associated with this
slowing.
This slowing persisted through the entire record.
BACKGROUND: Background rhythms on the right consisted of a [**9-4**]
Hz
posterior predominant rhythm. On the left, as stated above, they
were
slowed in the theta frequency range at approximately [**6-1**].
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: The patient progressed from wakefulness through
drowsiness but
did not enter into stage II sleep.
CARDIAC MONITOR: Showed a generally regular rate and rhythm.
IMPRESSION: This is an abnormal EEG due to the presence of focal
left
posterior quadrant slowing seen in the temporal and parietal
regions.
No epileptiform discharges were associated with this slowing. In
addition, slowed background rhythms were seen on the left as
compared to
the right. No electrographic seizures were recorded. These
findings
are consistent with a focal lesion in the left posterior
quadrant.
.
MRI SPINE:
FINDINGS: There is no evidence of abnormal cord signal or
morphology. There is no evidence of canal stenosis. There is no
evidence of focal disc protrusion. On the sagittal STIR
sequence, there is some increased signal in the subcutaneous
tissues in the mid cervical spine consistent with some edema.
This is somewhat remote from the interspinous ligaments. There
is no evidence of abnormal bone marrow signal. There is no
evidence of abnormal cord signal. There is abnormal signal
within the central pons consistent with the findings noted on
the patient's head MR study of [**12-27**].
IMPRESSION: No evidence of abnormality of the cervical cord. No
evidence of canal stenosis. Abnormal signal within the pons.
Please see the patient's head MR study. This may be responsible
for the temperature abnormality of the extremities.
.
MRA NECK VESSELS:
FINDINGS: There is no significant stenosis involving the common
carotid bifurcation on either side. The right vertebral artery
is dominant. Please note that the present study does noCT OF THE
CHEST WITH IV CONTRAST: There are coronary artery
calcifications. There is a nasogastric tube which terminates in
the stomach. The patient is status post coronary artery bypass
graft surgery. There is no axillary, hilar, or mediastinal
lymphadenopathy. There are no pleural or pericardial effusions.
Except for minimal nodular atelectasis at the left lung base,
the lungs are clear.
.
CT chest, abdomen, pelvis:
CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder,
pancreas, spleen, adrenal glands and kidneys are within normal
limits. The stomach, small and large bowel, are unremarkable.
There is no mesenteric or retroperitoneal lymphadenopathy, or
free air or fluid.
CT OF THE PELVIS WITH IV CONTRAST: There is a Foley catheter in
the bladder. The prostate, seminal vesicles, distal ureters,
bladder, sigmoid and rectum are unremarkable, and there is no
pelvic or inguinal lymphadenopathy. No ascites is present.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION: No evidence of significant abnormality.t include the
entire cervical course of the carotid and vertebral vasculature.
.
CT-sinus: IMPRESSION: Soft tissue thickening right-sided
sphenoid sinus and posterior ethmoid cells.
.
CXR [**1-7**]: IMPRESSION: Dobbhoff tube in good position. Left
basilar atelectasis.
.
MRV [**1-13**]: no sign of venous sinus thrombosis (prelimiary
results).
Brief Hospital Course:
The patient is a 45 yo man with unknown past medical history but
has scar from CABG, found down at home, intubated and brought
initially to OSH and transferred to [**Hospital1 18**] for further workup. He
was admitted to the neuro ICU for monitoring and further workup
and later transferred to the floor.
.
Neuro:
A head CT revealed deep left intracerebral hemorrhage - and a
follow up MRI/A showed large 5 x 4 x 2.5cm (~26cc) hemorrhage
centered primarily over the left basal ganglia/thalamus, mild
amount of midline shift and moderate amount of mass effect on
the adjacent left brainstem, with a more focal hypodense area in
the left pons, concerning for focal infarction, chronicity
indeterminate. MRI showed no obvious underlying mass, although
vascular malformation was still considered to be a possibility
(though none was seen, and this would not explain pontine
infarct).
Repeat CT on [**1-3**]/6 showed that the intracranial hemorrhage in
left thalmus was unchanged in size. Increased edema was
present, leading to a mild shift of midline structures and left
lateral ventricle compression. No new hemmorhagic foci were
found. C-Spine was cleared by MRI. Neurosurgery was consulted
upon admission and recommended conservative therapy. An EEG was
negative for seizures. Initial CPK was quite elevated by trended
down; this was felt to be related to being down for days. He was
dilantin loaded upon admission and was therapeutic within 24
hours of admission. Dilantin was discontinued on [**1-4**]/6 because
there had been no seizures during the hospital stay and there
was a potential for an allergic reaction against dilantin (i.e.
he had developed a rash).
His exam slowly improved. The pupil asymmetry at presentation
was though possibly related to pontine infarct; pupils became
more symmetric and were equally reactive within 48 hours of
admission. The patient is currently able to follow simple
commands, has full strength in his L-hemibody. He remains mute
however, with a dense right hemiparesis. His eyemovements are
disconjugate, but have improved significantly.
As his past medical history and risk factors are unknown, he
underwent a workup. Initial tox screen was negative, but cocaine
may not show up in tox screen several days after use. TTE was
negative. A TEE could not be done as the patient could not be
consented for this procedure. The patient was not diabetic (see
below). ASA was not started given the large intracranial
hemorrhage. MRV upon discharge was negative for venous sinus
thrombosis, ruling out a venous infarct.
.
CV:
Bloodpressure and heart rate remained well controled without any
medications.
.
Skin:
He had multiple skin lesions upon admission. These were treated
with cefazolin 1 gm IV q8hr for a possible skin infection, but
this was discontinued when a rash developed. He was followed by
the wound care and the lesions improved (see atttachment with
directions). An area that needs extra care is the L troch.
region. Cultures of the wounds showed Staphylococcus aureus and
enterococcus (sparse); no itervention was needed. Please
continue wound care (including airmattras, optimize nutritional
status).
Once the wounds on the back have healed, evaluation of a large
mole on the back with possible excision should be undertaken.
The patient developed a drug rash, either due to cefazolin or
dilantin. Both were discontinued and the rash improved. It was
symptomatically treated with benadryl.
.
ID:
Upon admission, the patient was treated with levaquin and flagyl
for a presumed aspiratoin pneumonia (very dark secretions,
fever). As repeated chest x-rays were negative this was
discontinued. At admission, three sets of blood cultures were
sent for workup of endocarditis with septic emboli; all were
negative. A TTE showed no valve vegetations or clots. A TEE
could not be performed as the patient could not consent for
himself and had no family to consent for him.
For temperature spikes several days into hospital course, two
more sets of blood cultures were also sent and were negative. A
CT of torso with contrast ([**2163-1-3**]) was negative for abscess
(as possible focus for the fevers) or mass, with small left base
nodular atelectasis. CXR on [**1-7**] shows L basilar atelectasis,
and RUQ US [**1-7**] (ALT 134(H), AST 109(H), Lipase 88(H), Amylase
94, Alb 3.4) showed no cholecystitis but distended gallbladder
secondary to being NPO.
WBC continued to be elevated (22K on [**1-7**]/6), and some atypical
cells were seen. A heamatology consult was called in. The
atypical cells were thought to be secondary to infection. If
these persist in [**1-28**] months, a further workup would be
indicated. For the last week, the patient has been afebrile.
A nasal swab showed sparse growth of staph aureus (MRSA) and the
patient needs to be on contact precautions.
C. diff stool cultures are pending upon discharge for diarrhea.
.
Endo:
TSH was checked because the patient has exophthalmos by exam.
This was within normal limits at 0.59. FSBS were normal and an
ISS was discontinued.
.
Resp:
The patient was extubated on [**12-29**]. Initially there was a question
of aspiration PNA. Currently the patient does not need
supplementary oxygen.
.
GI/FEN:
The patient failed a swallow study ("severe dysphagia.")
multiple times. A J-tube was placed [**1-7**]. Tube feeds were
tolerated well.
Lansoprazole Oral Suspension 30 mg NG daily should be continued.
.
Prophylaxis: Heparin 5000 UNIT SC TID
.
Social: The patient is alienated from family, lives alone. His
neighbor knows him best ([**Name (NI) 122**] [**Name (NI) **] [**Telephone/Fax (1) 65325**]). No power of
attorney or other decision maker (father's lawyer was [**Name (NI) **]
[**Name (NI) 65326**] [**Telephone/Fax (1) 65327**] but lawyer does not know patient). Mr.
[**Name13 (STitle) **] was willing to be temporary guardian, final court decision
pending.
.
Activity:
Activity as tolerated. Will need extensive PT/OT once ready.
Medications on Admission:
Unknown.
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
5. splints [**Last Name (STitle) **]: One (1) for each leg continuous: to prevent
foot drop.
6. woundcare [**Last Name (STitle) **]: One (1) as instructed: Please see enclosed
sheets for status of woundcare plus instructions per site.
7. Erythromycin 5 mg/g Ointment [**Last Name (STitle) **]: One (1) Ophthalmic QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab hospital
Discharge Diagnosis:
1. left subcortical hemorrhage
2. left pontine ischemic stroke
3. decubitus ulcers
4. medication related rash (dilantin or cefazolin)
5. aspiration pneumonia
6. MRSA positive nasal swab
7. dysphagia
Discharge Condition:
Stable: dense R-hemiparesis, mute but able to follow commands.
Discharge Instructions:
Please administer medications as instructed.
.
Areas of continued care:
-J-tube
-wound care to skin: please pay attention to L-tochanter ulcus.
Remaining sites are slowly healing.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital 4038**] Clinic, [**3-22**]
at 1pm.; [**Hospital Ward Name 23**] Building, [**Location (un) 858**].
.
Please follow up re. mole on L-back. [**Month (only) 116**] need excision once
patient more stable.
.
Please schedule an appointment with the Primary Care outpatient
clinic ([**Telephone/Fax (1) 250**]) to help set up appointment with Dr. [**First Name (STitle) **]
[**Name (STitle) 65328**], once discharged from rehab.
Completed by:[**2163-1-13**]
|
[
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"272.0",
"787.2",
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"401.9",
"780.6",
"507.0",
"693.0",
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"V45.81",
"276.51",
"342.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"44.32",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
15602, 15659
|
8769, 14716
|
329, 341
|
15902, 15967
|
2281, 2576
|
16195, 16719
|
1018, 1028
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|
279, 291
|
369, 900
|
2585, 8746
|
922, 958
|
974, 1002
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,193
| 167,255
|
22246
|
Discharge summary
|
report
|
Admission Date: [**2127-8-11**] Discharge Date: [**2127-8-13**]
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Hematoma s/p cardiac catherization
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
pt is 80 year old female with severe aortic stenosis (0.7 valve
area; mean grad 40.9), CAD s/p CABG '[**19**] (LIMA-LAD), SVG-ramus,
SVG-OM, SVG-RPL, SVG-PDA) presents with dyspnea and fatigue. Pt
decided to get AVR and referred for cath for pre-op assessment.
Cath revealed CI 2.6, PA 68%, LVEF 40%, LMCA-diffuse dx mild
stenosis; LAD - large patent diagnol, 70% mid; RCA diffuse dx
proximal with occlusion mid; SVG-PDA patent; SVG-RPL occluded;
SVG-OM and SVG-ramus patent; LIMA-LAD patent did not cross
midline; severe AS, +2MR; RA 10; PAP 57/26; PCWP 24.
Post cath complicated by large hematoma s/p sheath pull with SBP
decreased to 95 - tx with atropine, IV fluids, 2U PRBC - SBP
stabalized at 138 with no symptoms of CP/SOB. Pt Hct dropped
from 40 to 33. CT abd showed no evidence of RP hemorrhage;
hematoma within R groin extending along anterior aspect of R
thigh.
Past Medical History:
CABG [**2119**];
Appy;
[**First Name9 (NamePattern2) 30065**] [**Location (un) **];
Aortic Stenosis;
Immune hemolytic anemia;
small AAA;
hypothyroidism
Social History:
Lives in [**Location 2498**] with son; widowed
no etoh
no tobacco
Family History:
non-contributory
Physical Exam:
VS: afebrile P65 BP 134/60 O2Sat 100% 2L
Gen: NAD
Heent: Perrla, EOMI, oral mucosa clear
Resp: Clear to auscultation bilaterly
Cardio: Regular rate/rhythm S1/S2 grade III/VI systolic ejection
murmur
Abd: Obtunded, soft non-tender normal apparent bowel sounds
Groin: 5 x 2 inch hematoma in right thigh, tender to palpation
Ext: +2 edema bilaterly in lower extremities
Neuro: AAOx3
Pertinent Results:
[**2127-8-11**] 06:58PM WBC-14.6*# RBC-4.26 HGB-13.0 HCT-37.5 MCV-88
MCH-30.4 MCHC-34.6 RDW-14.0
[**2127-8-11**] 06:58PM PLT COUNT-176
[**2127-8-11**] 01:15PM WBC-8.2 RBC-3.83* HGB-11.6* HCT-33.5* MCV-87
MCH-30.2 MCHC-34.6 RDW-14.2
[**2127-8-11**] 01:15PM PLT COUNT-225
[**2127-8-11**] 12:24PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.048*
[**2127-8-11**] 12:24PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2127-8-11**] 12:00PM ALT(SGPT)-14 AST(SGOT)-18 ALK PHOS-53 TOT
BILI-0.6
[**2127-8-11**] 12:00PM ALBUMIN-3.4
[**2127-8-11**] 12:00PM PT-13.4* PTT-44.3* INR(PT)-1.2
EKG: ([**2127-8-5**]): Sinus 75; RBBB pattern
Brief Hospital Course:
1) Hematoma - Pt had CT abdomin/pelvis which was negative for
retroperotinal bleed, hematoma limited to anterior thigh. While
pt in hospital, serial Hct were checked and remained stable. Pt
hematoma slowly improved throughout hospital course. No bruits
were heard at site of catheter insertion.
2) AS - Pt admitted for severe AS with worsening symptoms of
dysnea and fatigue. Pt had echo on [**2127-8-12**] which revealed LVEF
45%, LA mod dilated, severe symmetric LVH, LV cavity size
normal, Ao root mild dilated, severe Ao valve stenosis, 1+ AoR.
3+ MR; aortic valve peak Gradient=87 mm Hg; mean gradient=55
mmHg; valve area = 0.6 cm2. Cardiac thoracic surgery offered
AVR, however due to possible mortality risk of surgery patient
declined surgery at present time.
3) CAD - Pt cardiac catherization showed extensive disease
(refer to HPI). While in hospital pt was continued on asprin,
lipitor, atenolol
4) Hypotension - After intial drop in blood pressure, pt never
had repeat incident of drop in blood pressure while in hospital.
Pt was continued on atenolol and BP remained stable.
5) Hypothyroidism - Pt was continued on outpatient dose of
levothyroxine while in hospital.
Medications on Admission:
Lovoxyl 0.112mg;
ASA 81 mg;
Atenolol 25mg;
Protonix 40mg;
Xanax 0.25mg;
Lipitor 40mg;
Nitro patch 0.4mcg/hr 8am to 8pm
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
3. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QD (once a day).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
7. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Discharge Disposition:
Home
Discharge Diagnosis:
Severe Aortic Stenosis
Post-Cath hematoma
Discharge Condition:
Good
Discharge Instructions:
Please make sure you call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8098**] and have a
repeat Hematocrit checked to make sure it is stable.
Followup Instructions:
1. Please follow up with PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] within one week.
Please call to schedule an appointment at [**Telephone/Fax (1) 58011**], you will
need to have your blood checked and report sent to Dr. [**Last Name (STitle) 8098**]
for evaluation.
|
[
"998.12",
"244.9",
"424.1",
"414.01",
"V45.81",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
4675, 4681
|
2684, 3878
|
317, 332
|
4767, 4773
|
1942, 2661
|
4984, 5319
|
1509, 1527
|
4047, 4652
|
4702, 4746
|
3904, 4024
|
4797, 4961
|
1542, 1923
|
243, 279
|
360, 1235
|
1257, 1410
|
1426, 1493
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,052
| 118,856
|
45357
|
Discharge summary
|
report
|
Admission Date: [**2195-10-23**] Discharge Date: [**2195-10-25**]
Date of Birth: [**2117-3-1**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: Seventy-eight-year-old male with
COPD, PVD, coronary artery disease, AS, who was admitted to
[**Hospital1 18**] [**10-1**] through [**10-2**] with chest tightness. The cath
showed 60% mid LAD, 60% D1, and severe aortic stenosis. He
had a CABG [**10-5**] with LIMA to LAD and reversed saphenous vein
graft to diagonal and AVR with porcine valve. Discharged
[**10-12**] to rehab. Presented to outside hospital on [**10-16**] in
AFib with RVR and was converted to normal sinus rhythm with
diltiazem.
Echo done at that time revealed EF 70%, no wall motion
abnormalities, small pericardial effusion without tamponade.
Questionable nonspecific EKG changes. Had dobutamine stress
echo which showed mild inferior ischemia. Patient was
asymptomatic and decision was made to continue his medical
treatment. Patient was transferred to [**Hospital1 18**] on [**2195-10-22**] for
further management.
PAST MEDICAL HISTORY:
1. Steroid dependent COPD.
2. PVD with claudication.
3. CAD status post CABG and AVR.
4. Anemia.
MEDICATIONS ON TRANSFER:
1. Lasix 20 [**Hospital1 **].
2. Colace.
3. Aspirin 325.
4. Combivent.
5. Paxil 20 q. day.
6. Advair.
7. Percocet.
8. Captopril 6.25 t.i.d.
9. Prednisone 20 b.i.d.
10. Digoxin 0.125 q. day.
11. Plavix.
12. Cardizem CD 240 mg q. day.
13. Coumadin 5 mg q. day.
14. Feosol 300 b.i.d.
15. Zithromax 250 q. day.
16. MDI Singulair.
17. Heparin drip.
18. Diltiazem drip 6 mg per hour.
ALLERGIES: Penicillin, reaction unknown.
SOCIAL HISTORY: Lives with wife. Greater than 80 pack
years, quit 15 years ago. Occasional alcohol.
PHYSICAL EXAMINATION: Temperature 97.7 F; BP 100/48; heart
rate 72; respiratory rate 20; sating 94% on two liters.
General: He was comfortable, in no acute distress. HEENT:
Anicteric, clear OP. Chest: Clear to auscultation
bilaterally. Heart: Regular rate and rhythm, 2-3/6 systolic
murmur heard throughout the precordium, loudest at the apex,
sternotomy scar healing well. Abdomen: Benign.
Extremities: No edema, incision in left lower extremity
healing well. Neuro: Alert and oriented times three.
Cranial nerves II through XII intact.
LABORATORY: CBC 11.3/30.0/427. BUN and creatinine 37 and
0.8. INR of 1.2. Cardiac enzymes negative.
Chest x-ray no edema, decreased left pleural effusion, stable
right effusion, question right atelectasis versus infiltrate.
EKG normal sinus rhythm, normal axis, LVH, T wave inversion
in I, aVL, V4-V6.
HOSPITAL COURSE:
1. AFib. The patient remained in sinus rhythm with good
rate control throughout his stay. He was weaned off the
diltiazem drip without incident and converted to stable
outpatient regimen, which included metoprolol for rate
control.
2. Coronary artery disease. The patient remained chest pain
free throughout admission. There was a question, report of
inferior ischemia by dobutamine echo at outside hospital.
However, given negative cardiac enzymes, lack of RCA disease
on recent cath, it was felt that there was no sufficient
reason to suspect ischemic etiology for causing patient's
AFib.
3. COPD. Patient's prednisone was tapered back to his home
regimen of 5 mg q. day and he was continued on his home MDIs.
His albuterol was changed to p.r.n. to avoid beta agonists in
the face of his AFib.
4. Patient was discharged home in stable condition. INR at
time of discharge was 2.0.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged home.
DISCHARGE DIAGNOSES:
1. Atrial fibrillation with rapid ventricular response.
2. Coronary artery disease status post coronary artery
bypass graft and aortic valve replacement.
3. Chronic obstructive pulmonary disease.
MEDICATIONS:
1. Paxil 20 mg q. day.
2. Singulair 10 mg q. day.
3. Iron 150 mg p.o. q. day.
4. Advair two puffs b.i.d.
5. Atrovent two puffs q.i.d.
6. Prednisone 5 mg q. day.
7. Metoprolol 50 mg b.i.d.
8. Lipitor 10 mg q. h.s.
9. Aspirin 81 mg p.o. q. day.
10. Albuterol two puffs q. four hours prn.
11. Coumadin 3 mg p.o. q. day.
FOLLOW UP: The patient was instructed to call his PCP for
close follow up of his PT INR after discharge. Patient also
to follow up with Dr. [**Last Name (STitle) 1270**] in two weeks. Patient was
also discharged home with VNA for INR checks, medication
teaching and post CABG wound and wound care, as well as home
PT and outpatient cardiac rehab.
[**First Name4 (NamePattern1) 1730**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2362**]
Dictated By:[**Last Name (NamePattern1) 8478**]
MEDQUIST36
D: [**2195-10-29**] 15:04
T: [**2195-10-31**] 20:38
JOB#: [**Job Number 96847**]
|
[
"496",
"997.1",
"V42.2",
"E878.2",
"V45.81",
"427.31",
"440.21",
"V58.83"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3648, 4188
|
2644, 3540
|
4200, 4817
|
1790, 2627
|
187, 1083
|
1232, 1663
|
1105, 1207
|
1680, 1767
|
3565, 3627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,996
| 120,940
|
21971
|
Discharge summary
|
report
|
Admission Date: [**2140-2-22**] Discharge Date: [**2140-2-27**]
Date of Birth: [**2060-6-28**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 4135**] is a 79-year-old
gentleman with a lifelong history of a heart murmur. Over the
past year he has had worsening fatigue and dyspnea on
exertion. An echocardiogram revealed progression of his
aortic valve disease. Cardiac catheterization revealed normal
coronaries, critical aortic stenosis, with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 1.0 cm2.
He presented for a surgical evaluation by Dr. [**Last Name (STitle) **] in
preparation for aortic valve replacement. On cardiac
catheterization on [**2139-8-25**] - prior to his admission -
his ejection fraction was also 59%. He had a peak gradient of
43 mm. TEE in [**2139-8-21**] showed trace MR, mild AS, 3+
AI, an ejection fraction of 55%, and an aortic root of 4.3
cm.
PAST MEDICAL HISTORY:
1. Elevated cholesterol.
2. Aortic stenosis.
3. Hypertension.
4. BPH.
PAST SURGICAL HISTORY: History of bilateral knee surgeries,
bilateral shoulder surgeries, and right carpal tunnel
surgery, as well as right eye cataract surgery.
MEDICATIONS PRIOR TO ADMISSION: Lipitor 5 mg p.o. once
daily, naproxen 500 mg p.o. p.r.n., hydralazine 10 mg p.o.
once daily, Flomax 0.4 mg p.o. once daily, aspirin 81 mg p.o.
once daily, multivitamin 1 tablet once daily, and a MDI
inhaler as needed.
ALLERGIES: He is allergic to IODINE.
HABITS: He had quit smoking cigars 25 years ago. Admitted to
1 drink per week.
PHYSICAL EXAMINATION ON ADMISSION: He was 5 feet 8 inches,
202 pounds, blood pressure of 113/80 on the right and 120/80
on the left, he was in sinus rhythm at 60. Of note, his
pupils were unequal with right greater than left. EOMs were
intact. He had anicteric sclerae. The neck was supple with no
JVD. His heart was regular in rate and rhythm with a grade
3/6 systolic ejection murmur and a grade [**11-26**] diastolic
murmur. His lungs were clear bilaterally. His abdomen was
soft, nontender, and nondistended with bowel sounds. He had
trace lower extremity edema. He had bilateral lower leg
varicosities. He was alert and oriented x 3 with no focal
deficits. He was moving all extremities with a normal gait
and 5/5 strength. He had 2+ bilateral femoral, DP, PT, and
radial pulses. He had a transmitted murmur in both carotids
versus a carotid bruit.
RADIOLOGIC STUDIES: Preoperative EKG showed an ectopic
atrial rhythm with left axis deviation and some LVH at a rate
of 56. Please refer to the official report dated [**2140-2-17**].
Preoperative chest x-ray showed no evidence of CHF or
pneumonia, but bibasilar linear atelectases.
PREOPERATIVE LABORATORY DATA: White count of 6.5, hematocrit
of 47.3, platelet count of 221,000. PT of 12.5, PTT of 28,
INR of 1.0. Urinalysis was negative. Sodium of 140, K of 4.4,
chloride of 101, bicarbonate of 28, BUN of 30, creatinine of
1.0, and blood sugar of 79. ALT of 19, AST of 28, alkaline
phosphatase of 66, total bilirubin of 0.7, total protein of
6.8, albumin of 4.2, globulin of 2.6. HbA1C of 5.2%.
HOSPITAL COURSE: On [**2140-2-22**] - the date of admission -
the patient underwent aortic valve replacement by Dr. [**Last Name (STitle) **]
with a 23-mm CE pericardial tissue valve. He was transferred
to cardiothoracic ICU in stable condition on a titrated
propofol drip and a Neo-Synephrine drip at 0.3 mcg/kg/min.
In the immediate postoperative period the patient went into
atrial fibrillation with a controlled ventricular response.
He was extubated successfully. The patient was switched over
to p.o. Percocet to pain control and was transferred out to
the floor later that afternoon. He was seen and evaluated by
case management, and on postoperative day 2 he had another
brief run of atrial fibrillation in the morning which
converted to a sinus rhythm with a blood pressure of 96/56.
He was saturating 94% on 2 liters. His creatinine was stable
at 1.1, white count was 12.2. He was restarted on his Flomax,
Lipitor, aspirin, and continued with Lasix diuresis. His beta
blockade was started with Lopressor. His chest tubes were
discontinued. His abdomen was slightly distended but
nontender with positive bowel sounds. Breath sounds were
greater on the right than the left with diminished sounds at
the bases. He was seen and evaluated by physical therapy to
begin his ambulation with the nurses. He was alert and
oriented.
On postoperative day 3, he had no complaints. He was
hemodynamically stable. He was alert and oriented. His chest
was stable. His incisions were clean, dry, and intact. His
Lopressor was increased to 25 twice a day. His pacing wires
were removed, and a rehab screen was begun.
On postoperative day 4, the patient had some atrial
tachycardia. He had been started on Coumadin for his atrial
fibrillation, and this was again discontinued. He was in no
apparent distress. His lungs were clear bilaterally. He
continued to be out of bed ambulating with the nurses and
physical therapist. He was switched over to Toprol XL 25 once
a day, and he continued to work on increasing his ambulation
status.
On postoperative day 5, the patient had some contact
dermatitis on his back and buttocks as well as a tape
reaction on his chest and abdomen. He remained in sinus
rhythm. His rash was noted to be macular and a little bit
pruritic; consistent with contact dermatitis. [**Name2 (NI) **] was
progressing well otherwise, and plans were made for him to be
discharged with VNA services.
DISCHARGE STATUS: The patient was discharged to home in
stable condition on [**2140-2-27**] with the following
discharge diagnoses.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement.
2. Hypercholesterolemia.
3. Hypertension.
4. Benign prostatic hyperplasia.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. once a day (for 7 days).
2. Potassium chloride 20 mEq p.o. once a day (for 7 days).
3. Colace 100 mg p.o. twice a day (x 1 month).
4. Enteric coated aspirin 81 mg p.o. once a day.
5. Percocet 5/325 1 to 2 tablets p.o. q.4-6h. p.r.n. (for
pain).
6. Lipitor 5 mg p.o. once daily.
7. Flomax 0.4 mg sustained release p.o. once daily at
bedtime.
8. Metoprolol sustained release 25 mg p.o. once daily.
9. Camphor menthol 0.5/0.5% lotion 1 application topically 4
times a day to rash areas with instructions not to apply
directly to any of his surgical incisions.
DISCHARGE INSTRUCTIONS: The patient was instructed to follow
up with Dr. [**Last Name (STitle) 20478**] (his primary care physician) in 1 to 2
weeks positive discharge, and to follow up with Dr. [**Last Name (STitle) **]
in the office for his postoperative surgical visit in 3 to 4
weeks post discharge, and to follow up with Dr. [**Last Name (STitle) 57534**] (his
cardiologist) in 2 to 3 weeks post discharge.
DISCHARGE DISPOSITION: He was discharged to home with VNA
services on [**2140-2-27**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2140-4-6**] 14:23:31
T: [**2140-4-8**] 09:10:58
Job#: [**Job Number 57535**]
|
[
"424.1",
"272.0",
"600.00",
"427.31",
"692.9",
"401.9",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"39.61",
"35.21",
"89.60"
] |
icd9pcs
|
[
[
[]
]
] |
6865, 7164
|
5691, 5810
|
5836, 6427
|
3141, 5670
|
6452, 6841
|
1052, 1192
|
1225, 1586
|
165, 934
|
1601, 3123
|
956, 1028
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,643
| 141,912
|
4426
|
Discharge summary
|
report
|
Admission Date: [**2107-3-1**] Discharge Date: [**2107-3-4**]
Date of Birth: [**2039-3-10**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
(From General Admission Note)
67 y/o M h/o CAD, COPD, GERD, and diverticulosis a/w painless
BRBPR. He was well until a recent hospitalization [**Date range (1) 19032**] for
COPD exacerbation and UTI treated with a prednisone taper and
broad-spectrum antibiotics (given his history of resistant
pathogens), respectively. The morning of admission, he awoke at
4 AM to have a bowel movement and felt a painless gush of bright
red blood after the passage of formed stool. He had 4 such bowel
movements. He denies ever seeing bleeding like this before. He
endorses a 20 lb. unintentional weight loss over the past year.
He denies fever, chills, dizziness, lightheadedness, chest pain,
change in his baseline cough/sputum production/dyspnea,
abdominal pain, nausea, vomiting, [**Date range (1) **], sick contacts, or
recent travel. A colonoscopy in [**11-12**] to workup GIB and weight
loss showed diverticulosis of the whole [**Date Range 499**] and Grade 1
internal hemorrhoids.
.
In the ED, initial V/S: T 98.3 HR 57 BP 115/71 RR 22 O2sat 93%
RA. BRB on rectal exam, no external hemorrhoids noted. WBC 17.9
Hct 33.2% plts 486K. Ninety minutes into his ED course his
automated BP was found to be 74/40, then 99/50 manually - the
patient was asymptomatic. He was given 2 L NS. After quickly
drinking a cup of water, he experienced midline abdominal pain
which resolved after being made NPO. He is currently
asymptomatic.
.
On the floor the patient had a couple of episodes of hypotension
to the 80s which was responsive to IVF. His Hct dropped from 33
to 23. He had an NG lavage that was negative. GI was consulted
and is planning on a c-scope in the am unless patient needs
tagged red cell scan.
Past Medical History:
CAD s/p NSTEMI in [**2101**] - [**4-10**] cath showed 10% LMCA stenosis, TTE
[**8-10**] showed mild RV enlargement and preserved BiV function
COPD on baseline 4L NC, nightly BiPAP 12/5
Iron-deficiency anemia b/l Hct ~30%
GERD
Diverticulosis
VRE and Pseudomonas UTI
HTN
Hyperlipidemia
Chronic low back pain s/p L1-L2 laminectomy
Bilateral cataract surgery
BPH s/p TURP
Social History:
The patient currently lives in [**Location 686**] with his wife. [**Name (NI) **] is
initially from [**Country 7936**], now retired but previously employed as a
mechanic for [**Company 19015**].
Tobacco: Patient quit 30 years ago, previous 20 pk-year history.
ETOH: Rare social use
Illicits: + Marijuana use up to 1 to 2 marijuana cigarettes
daily, quit
Family History:
Mother w/ asthma, Alzheimer's disease. Father w/ [**Name2 (NI) 499**] cancer.
Physical Exam:
Tmax: 37.1 ??????C (98.8 ??????F)
Tcurrent: 36.7 ??????C (98.1 ??????F)
HR: 88 (86 - 88) bpm
BP: 93/46(57) {93/46(57) - 108/51(64)} mmHg
RR: 14 (14 - 17) insp/min
SpO2: 91%
GEN: Comfortable NAD, jovial
HEENT: Sclera anicteric, edentulous, OP clear
NECK: No JVD
CV: reg rate distant S1S2 no m/r/g
PULM: pursed lipped breathing, scattered end-exp wheezes no
rales/rhonchi
ABD: soft NTND hyperactive BS
EXT: warm, dry no edema, ecchomosis
NEURO: converses appropriately
Pertinent Results:
[**2107-3-1**] 05:15AM WBC-17.9*# RBC-3.92* HGB-9.9* HCT-33.2*
MCV-85 MCH-25.3* MCHC-29.8* RDW-15.0
[**2107-3-1**] 05:15AM NEUTS-77.9* LYMPHS-15.4* MONOS-4.7 EOS-1.9
BASOS-0.2
[**2107-3-1**] 07:14PM HCT-23.9*
[**2107-3-2**] 06:04AM BLOOD Hct-30.2*
Imaging: [**2107-3-1**] CXR
PORTABLE CHEST UPRIGHT RADIOGRAPH: Comparison is made to
[**2107-2-16**] CT and radiograph. Exam is not significantly
changed from most with persistent bibasilar bronchiectasis and
more linear left lower lobe atelectasis with more medial right
lower lobe consolidative opacity. Cardiomediastinal silhouette
and hilar contours are within normal limits and unchanged in
appearance. The underlying emphysema is again noted.
IMPRESSION:
No significant interval change from most recent exam with
persistent bibasilar opacities.
.
[**2107-2-16**] CTA ABDOMEN
No focal hepatic lesion is identified. The gallbladder, spleen,
pancreas and adrenal glands appear normal. The kidneys enhance
symmetrically and excrete contrast normally without evidence of
hydronephrosis or hydroureter. A left renal cystic lesion is
unchanged. Intra-abdominal loops of large and small bowel are of
normal caliber. There is extensive colonic diverticulosis,
without evidence for acute diverticulitis. There is no
pneumoperitoneum or free fluid. Scattered mesenteric and
retroperitoneal lymph nodes are identified, none of which meet
CT criteria for pathologic enlargement. Atherosclerotic
calcifications involve the abdominal aorta though there is no
evidence for dissection. Minimal ectasis of the infrarenal
thoracic aortic measures 2.1 x 2.0 cm.
Bone windows reveal no worrisome lytic or sclerotic lesions.
Multilevel mild thoracolumbar degenerative changes are observed.
IMPRESSION:
1. Minimal ectasia of infrarenal aorta noted.
2. Extensive colonic diverticulosis without evidence for acute
diverticulitis.
[**3-2**] Colonoscopy:
Brief Hospital Course:
67 y/o M h/o CAD, O2-dependent COPD, GERD, and diverticulosis
a/w painless BRBPR, completed [**Month/Year (2) 499**] prep.
#GI bleed - Per pt's report, he had had multiple large BM
completely of bright red blood. Since admission, there was no
more [**Month/Year (2) **] bleeding, but one black stool, and persistent guaiac
positive stools. Pt had a negative NG lavage. Hct initially
dropped from 33 to 23, but bumped appropriately to 2U of pRBCs
and remained stable after that. Pt was prepped and scoped, which
showed extensive diverticulosis but no active bleeding source.
Pt was monitored transiently in the ICU, with frequent Hcts and
active type and screen. He did not require any furthur
transfusions. Surgery and IR were consultured for furthur
treatment if pt rebleeds and for furthur prophylactic surgical
options. Aspirin and BP meds were held and restarted prior to
discharge (except CCB as pt was persistently asymptomatically
hypotensive, at his baseline per pt).
#Leukocytosis ?????? WBC fluctuated but pt remained clinically
stable, afebrile and without localizing signs of infection. CXR
was negative, UA negative, cultures negative. He remained on his
stable dose of PO steroid and fluctuation was thought to be due
to stress response of bleeding and scoping.
#HTN - Pt's BP meds were held while hypotensive and ACEi
restarted prior to discharge. Verapamil was continued to be held
at discharge until reevaluation by PCP.
#COPD: Pt satted well on home O2, prednisone and inhaler
regimen.
#Glaucoma: Continued outpt eye gtts
Medications on Admission:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
Sunday).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
8. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
13. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Please resume this medication (your baseline prednisone
dose) tomorrow [**2-22**].
14. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day as needed for shortness of breath or
wheezing.
17. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
18. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
19. Verapamil 120 mg Tablet Sig: One (1) Tablet PO once a day.
20. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for diarrhea for 3 days.
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO every sunday.
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day.
3. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: Two (2)
Capsule PO once a day.
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
13. Prednisone 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
14. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Two (2) puffs Inhalation Q4H (every 4 hours)
as needed for SOB/wheezing.
17. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Diverticular bleed
Secondary: CAD, COPD, HTN, hyperlipidemia, GERD
Discharge Condition:
Stable, Hct 29.9
Discharge Instructions:
You were admitted for bleeding from your [**Hospital 499**], likely due to
diverticulosis. You had a colonoscopy which showed no active
bleeding and your blood counts stabilized.
We held your aspirin and blood pressure medications while you
were bleeding. You can restart the aspirin and lisinopril, but
do not start the verapamil until your see your doctor.
Please call your doctor or return to the hospital if you have
recurring blood in your stool, lightheadedness, weakness or
abdominal pain.
It was a pleasure taking care of you, we wish you the best!
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 8499**] in the next 1-2 weeks. You
could discuss surgical options with him to prevent recurrence of
this type of bleeding.
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2107-3-6**]
|
[
"455.0",
"496",
"V13.01",
"401.9",
"412",
"365.9",
"724.2",
"280.9",
"272.4",
"V58.65",
"530.81",
"562.12",
"414.01",
"V46.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
10397, 10455
|
5330, 6878
|
280, 293
|
10576, 10595
|
3403, 5307
|
11203, 11545
|
2809, 2888
|
8776, 10374
|
10476, 10555
|
6904, 8753
|
10619, 11180
|
2903, 3384
|
232, 242
|
321, 2018
|
2040, 2420
|
2436, 2793
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,513
| 143,746
|
1709
|
Discharge summary
|
report
|
Admission Date: [**2152-8-5**] Discharge Date: [**2152-8-6**]
Service: MEDICINE
Allergies:
Penicillins / Tylenol / Lipitor
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
falls and hypotension
Major Surgical or Invasive Procedure:
Right internal jugular central venous catheter placement
History of Present Illness:
[**Age over 90 **]F with CHF, CAD, DM2, AS, PAFib presents after 2 falls in 24
hours. Does not remember circumstances of fall this AM. Alert,
neuro intact.
.
According to her family--she lives in a duplex above her eldest
daughter--she has become progressively weaker over the past 6
months or so and recently can only walk ~10 feet with walker,
limited by SOB. The night before admission, her daughter found
her slumped out of a chair, and the morning of admission, she
fell while trying to get out of bed and used her lifeline. She
has ho history of falls. Pt does not recall events leading up to
either fall, saying only "I guess I'm showing my age." Daughter
says pt was normal when she found her, no incontinence, spasms,
or altered sensorium. Of note, pt reportedly says she hopes
she'll die almost daily.
.
Last week, she gained almost 5 lbs in 5 days; on Tuesday, her
PCP told her to increase her dose of lasix from 60mg daily to
80mg daily.
.
In ED, SBP 80s with pulse 50s, got 2L IVF and 1 unit PRBCs, SBP
still marginal, so placed RIJ. SBP up to 110s by the time
placement CXR was read, so did not start pressors. No infectious
source apparent; hypotension thought [**2-11**] volume status and
severe AS. Sats 96% on 3L NC after receiving volume.
Past Medical History:
1. HTN
2. CHF: (Ef= 30% by [**12-14**] TTE)
3. Severe AS, aortic valve area 0.6cm2
4. 3+MR, 2+ TR
5. CAD- single vessel disease, s/p drug eluting stent to LAD
[**2-15**].
6. Type 2 DM
7. Hyperlipidemia
8. S/P TAH/BSO
9. S/P appendectomy
10. Multinodular goiter- diagnosed [**9-11**]
11. Paroxysmal atrial fib
12.Chronic lower extremity edema
13.Chronic Renal insufficiency: basline Cr 1.5-1.7
Social History:
Lives alone in a [**Location (un) 1773**] apartment (daughter lives
downstairs). No etoh or tobacco.
Family History:
NA
Physical Exam:
95.0 130/96 63 23 99% 4L NC
GEN: frail elderly woman sitting upright, AAOx2
HEENT: NC/AT but TTP over L parietal bone, PERRL, EOMI
NECK: JVP 12-14cm but difficult to asses [**2-11**] RIJ
CHEST: fine crackles L base > R
CV: IV/VI high-pitched late systolic m, absent s2
ABD: firm, nontender. NABS. Guaiac negative.
EXT: massive ankle edema/3+ but with only mod pitting
SKIN: ecchymoses on R wrist and L arm
NEURO: CN II-XII intact
Pertinent Results:
[**2152-8-5**] 09:26AM WBC-4.3 RBC-2.77*# HGB-9.0*# HCT-25.4* MCV-92
MCH-32.5* MCHC-35.4* RDW-15.4
[**2152-8-5**] 09:26AM NEUTS-65 BANDS-0 LYMPHS-22 MONOS-10 EOS-3
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2152-8-5**] 09:26AM PLT COUNT-209
[**2152-8-5**] 09:26AM CK(CPK)-85
[**2152-8-5**] 09:26AM CK-MB-NotDone cTropnT-0.07*
[**2152-8-5**] 09:26AM GLUCOSE-119* UREA N-73* CREAT-2.0*
SODIUM-127* POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-26 ANION GAP-15
[**2152-8-5**] 10:34AM LACTATE-0.6
[**2152-8-5**] 12:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2152-8-5**] 12:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2152-8-5**] 09:46PM DIGOXIN-1.3
CXR: Single portable upright chest radiograph is reviewed and
compared to [**2152-5-18**]. Cardiomediastinal silhouette is unchanged,
with continued evidence of mild pulmonary vascular engorgement
and perihilar haziness, as well as unchanged small bilateral
pleural effusions. There is worsening atelectasis at the right
base. Left basilar atelectasis is unchanged.
IMPRESSION: Unchanged mild congestive heart failure, and small
bilateral pleural effusions, with slightly worse atelectasis at
the right base.
EKG: Sinus bradycardia. Occasional atrial premature beats. Left
axis deviation. Intraventricular conduction defect. Compared to
tracing of [**2152-5-18**] there is no significant diagnostic change.
RENAL ULTRASOUND: There are bilateral pleural effusions. The
right kidney measures 10.5 cm in length. The left kidney
measures 8.6 cm in length. There is no hydronephrosis or
nephrolithiasis. No renal mass or apparent renal fluid
collections are seen.
Brief Hospital Course:
[**Age over 90 **]F w/ CHF EF 30%, CAD, DM2, AS, paroxysmal Afib, CRI, presented
with 2 falls in 24hrs, found to be hypotensive to 80s in ED
.
# s/p falls - increasing weakness/deconditioning finally leading
to apparently mechanical falls, based on family report, but must
also consider syncope given severe AS.
.
# hypotension - based on reported exam in ED and response to
volume resuscitation, was likely hypovolemic and severe AS is
very pre-load dependent, causing hypotension. Normotensive on
arrival to unit, after 1 unit PRBCs and 2 liter NS in ED, but
became hypotensive to SBP 80s, requiring dopamine for
maintenance of blood pressure.
.
# CHF: ischemic cardiomyopathy/global LV HK with EF 30%, severe
AS and 3+ MR contributing as well. Close monitoring of fluid
status; appeared euvolemic on arrival to unit, but
decompensation morning of [**8-6**] have been due to fact that
she was initially over-resuscitated. Digoxin level 1.3, so no
additional doses digoxin administered. Patient was started on
dopamine to augment LV function. Held beta blocker given low
SBP. Attempted BiPAP for pulmonary edema and hypoxia, with some
effect.
.
# CAD - s/p DES in [**2151**], maintained on [**Last Name (LF) **], [**First Name3 (LF) **], statin
.
# PAF - amio/beta blocker/dig for rate control, not
anticoagulated per old notes
.
# CKD: recent baseline Cr 1.8. Held ACE inh since Cr elevated.
.
# anemia: baseline Hct 28-30, received 1 unit PRBCs because
anemic to 25 and hypotensive in ED. Guaiac neg/no source of
bleeding.
.
# hypothyroid: home dose levothyroxine
.
# DM2: not on any therapy currently; will monitor with AM lab
draw
.
# Ppx: heparin subcut. home ppi.
.
# Access - RIJ, PIV
.
# CODE: DNR/DNI, confirmed with son and daughter [**Name (NI) **] [**Name (NI) 9802**],
[**Telephone/Fax (1) 9803**]; after family meeting on [**2152-8-6**], patient was made
comfort measures only. Pressors were stopped and BiPAP
withdrawn, and the patient subsequently expired.
Medications on Admission:
1. HTN
2. CHF- (Ef= 30% by [**12-14**] TTE)
3. Severe AS, AoVA 0.6cm2/peak gradient 58mmHg
4. 3+MR, 2+ TR
5. CAD- single vessel disease, s/p drug eluting stent to LAD
[**2-15**].
6. Type 2 DM
7. Hyperlipidemia
8. S/P TAH/BSO
9. S/P appendectomy
10. Multinodular goiter- diagnosed [**9-11**]
11. Paroxysmal atrial fib
12. Chronic lower extremity edema
13. Chronic Renal insufficiency: baseline Cr 1.7
Discharge Medications:
N/a
Discharge Disposition:
Expired
Discharge Diagnosis:
1. congestive heart failure
2. aortic stenosis
3. coronary artery disease
4. hypertension
5. hyperlipidemia
6. paroxysmal atrial fibrillation
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"272.4",
"585.9",
"427.31",
"785.51",
"250.00",
"V45.82",
"403.90",
"398.91",
"397.0",
"396.2",
"414.01",
"244.9",
"E884.4",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6819, 6828
|
4365, 6340
|
259, 317
|
7013, 7022
|
2628, 4342
|
7074, 7080
|
2158, 2162
|
6791, 6796
|
6849, 6992
|
6366, 6768
|
7046, 7051
|
2177, 2609
|
198, 221
|
345, 1605
|
1627, 2022
|
2038, 2142
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,634
| 165,525
|
171
|
Discharge summary
|
report
|
Admission Date: [**2169-3-26**] Discharge Date: [**2169-4-9**]
Date of Birth: [**2090-12-5**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Right foot pain s/p stenting of right superficial femoral artery
Major Surgical or Invasive Procedure:
[**2169-3-30**] stenting of right superficial femoral artery
History of Present Illness:
78 y.o female s/p angio of the SFA with stent on [**2169-3-14**]
presents with RLE foot pain
Past Medical History:
Adrenal insufficiency
hx hypercaoguable state - but no clear h/o DVT/PE
hypercholestremia
? hx Dm2 - recent dx in setting of recent MTA
asthma
s/p cholecystectomy
PVD: on coumadin, s/p left metatarsal amputation '[**62**]
bilateral adrenal masses
cath [**4-18**]: clean coronary arteries
ECHO [**5-21**]: EF > 60%
Social History:
Lived alone prior to d/c [**3-25**] when she was d/c to rehabiltation
([**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **])Denies tobacco and ETOH useWorked as greenhouse
worker and babys[**Name (NI) 1786**] in the past6 kids (2 deceased), divorced,
her daughter [**Name (NI) 1787**] has been very involved w/ this
hospitalization and visits w/ patient daily
Family History:
no h/o PUD, pancreatic cancer or pancreatitis
+ h/o DM
Physical Exam:
Vital signs: 99.1-74-18 110/80 oxygen saturation 98% room air.
General: alert and oriented
HEENT: EOMI no caroitd bruits
Lungs: clear to ausculation
Heart: regular rate rythmn, no mumur, gallop or rubs
ABD: begnin
Pulses: femorals 2+ bilaterally, popliteals 1+ bilaterally,
pedal pulses monophasic dopperable signal bilaterally.
Pertinent Results:
[**2169-4-9**]
WBC-8.6 RBC-3.53* Hgb-9.5* Hct-30.4* MCV-86 MCH-26.9* MCHC-31.2
RDW-14.5 Plt Ct-119*
[**2169-4-9**]
PT-17.5* PTT-32.1 INR(PT)-1.9
[**2169-4-9**]
Glucose-102 UreaN-15 Creat-0.9 Na-137 K-4.7 Cl-99 HCO3-32*
AnGap-11
[**2169-4-9**]
Calcium-8.9 Phos-3.5 Mg-2.0
[**2169-4-5**] 2:26 PM
ART DUP LOW EXT RIGHT
FINDINGS:
Duplex evaluation of the right lower extremity arterial system
was performed which demonstrates a patent right common femoral,
superficial femoral, and popliteal artery. Velocity in the right
common femoral artery is 112 cm/sec, with velocities ranging
between 70 to 87 cm/sec between the common femoral, and the
trifurcation.
IMPRESSION:
No stenosis seen in common femoral, superficial femoral and
popliteal arteries on the right.
[**2169-3-11**].
CHEST, TWO VIEWS: The heart size is within normal limits.
Mediastinal and hilar contours unchanged in the interval. The
aorta is slightly tortuous, unchanged. No focal consolidations
are seen. Again, seen is linear scarring at the left base,
unchanged. There is eventration of the posterior hemidiaphragms
unchanged. There is DISH again seen.
IMPRESSION: No CHF or pneumonia.
[**2169-3-29**]
Sinus rhythm
Short PR interval
ST-T changes are nonspecific
Since previous tracing, T waves more upright in leads V5-V6
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 108 88 370/405.71 67 40 80
GENERAL URINE INFORMATION
Type Color Appear Sp [**Last Name (un) **]
Cath Straw Clear 1.015
Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
LG NEG NEG NEG NEG NEG NEG 7.0 NEG
MOD NEG NEG NEG NEG
RBC WBC Bacteri Yeast Epi
Brief Hospital Course:
Pt admitted on [**2169-3-26**]
[**2169-3-26**] - [**2169-3-29**]
Pt pre -oped for procedure on the [**2169-3-30**]. Pt was started on
heparin for anti-coagulation. A pre - op note was done on
[**2169-3-29**]. All results evxamined. Pt cleared for procedue on the
[**2169-3-30**].
[**2169-3-30**]
Pt underwent a right lower extremity arteriogram via left common
femoral artery approach, with angioplasty and stent placement in
the distal right SFA, for
peripheral vascular disease with right lower extremity rest pain
and hypercoagulable state.
Pt tolerated the procedure well. There were no complications.
After the procedure pt was transfered to the recovery room in
stable condition. When here ACT was around 180 her sheath was
pulled without complications. She remained on bedrest for 6 hour
after the sheath was pulled. After she recovered from anesthesia
she was transfered to the VICU in stable condition.
A post procedure check was done. It was found that the pt had a
hematome from the last admission. The pt was watched over the
next day.
[**2169-3-31**]
Pt still c/o foot pain post procedure. This coupled with the
hematoma an US was ordered. The results as were a atent right
superficial femoral artery through popliteal artery
angioplasty/stent. There is a large left groin hematoma with no
pseudoaneurysm or AV fistula.
Pt coumadin was started.
[**2169-4-1**]
Pt transfered from the VICU to the floor. Pt recieved a PICC
becaouse of poor access.
[**2169-4-2**] - [**2169-4-3**]
Pt anticoagulate with heparin and coumadin. She was mobilized,
her diet was advanced, her foley was removed. Pt responded with
good UO.
[**2169-4-4**]
Pt PLT count decreased from 200 to 89. Her heparin was DC'd a
HIT panel was sent. Pt still c/o toe pain. Because of the above
another ultrasound was done.
[**2169-4-5**]
The US revealed no stenosis seen in common femoral, superficial
femoral and popliteal arteries on the right.
A pain consult was obtained for the toe pain. The pain service
recommended nuerontin.
Pt responded to the medication.
A hematology consult was obtained for her decrease PLTS.
[**2169-4-6**]
Hematolgy saw the pt.
[**2169-4-7**] - [**2169-4-8**]
Pt PLT improved, foot pain improved with nuerontin.
Case mangement and PT were consulted. Recommended that the pt go
home with no sevices needed.
[**2169-4-9**]
Pt [**Name (NI) 1788**] home. PLT stable, toe pain much improved, pt taking PO,
urinating with BM, ambulating well, INR 2-3 range.
Medications on Admission:
albutrol
protonix
tylenol
oxycodone
predisone
coumadin
fludrocortizone
nuerontin
Discharge Medications:
1. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every
4 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
4. Morphine Sulfate 15 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
5. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO once a
day: You should have your INR checked on [**3-19**], and [**4-14**] at
the clinic of Dr. [**Last Name (STitle) 1789**] and coumadin dosed accordingly for goal
[**3-23**]. .
Disp:*30 Tablet(s)* Refills:*2*
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Outpatient Lab Work
Check INR (coags) and CBC on [**2169-4-10**], [**2169-4-12**], and [**2169-4-14**]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Peripheral Vascular Disease with stenosis of Right
superficial femoral artery
Secondary: Hypercoagulability, Asthma, Hyperlipidemia,
status-post Left transmetatarsal amputation
Discharge Condition:
Good
Discharge Instructions:
Please contact the office or come to the emergency with any
worsening bleeding from your groin or worsening coldness/pain in
your legs not improved with pain medications, or any questions.
You should follow-up with Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**] in the clinic on
[**2169-4-10**] between 8am and 2 pm to have your INR checked and
Coumadin dosed (as discussed with your daughter, [**Name (NI) 1791**], on
[**2169-4-9**]). Please call with any questions. You may address
questions related to adjusting your narcotic medications with
your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1789**].
Followup Instructions:
You should follow-up with Dr. [**First Name4 (NamePattern1) 1790**] [**Last Name (NamePattern1) 1789**] ([**Telephone/Fax (1) 1792**])
in the clinic on [**2169-4-10**], [**2169-4-12**], [**2169-4-14**] to have your INR
checked and Coumadin dosed (as discussed with your daughter,
[**Name (NI) 1791**], on [**2169-4-9**]).
Please contact the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (vascular
surgery) to set-up a follow-up appointment at a time of your
convenience within the next 2 weeks. [**Telephone/Fax (1) 1784**]
Completed by:[**2169-7-18**]
|
[
"440.22",
"V18.0",
"729.5",
"287.5",
"289.89",
"272.4",
"493.90",
"250.00",
"V49.73"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"39.90",
"39.50",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7126, 7132
|
3421, 5908
|
379, 442
|
7362, 7368
|
1734, 3398
|
8086, 8677
|
1314, 1370
|
6039, 7103
|
7153, 7341
|
5934, 6016
|
7392, 8063
|
1385, 1715
|
274, 341
|
470, 565
|
587, 903
|
919, 1298
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,313
| 156,864
|
44651
|
Discharge summary
|
report
|
Admission Date: [**2117-4-3**] Discharge Date: [**2117-4-4**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
transferred for management of upper GI bleeding and pneumonia
Major Surgical or Invasive Procedure:
placement of right internal jugular central venous line,
placement of right radial arterial line
History of Present Illness:
86 M h/o biliary cancer with metal duct stent (family thinks by
[**Doctor Last Name **], placed [**2115**]) had been c/o generalized malaise x2-3
days, and was found vomiting frank blood by wife this am.
Transported to OSH by EMS, resp distress er-route requiring BVM,
? aspirated vomitus, so intubated for airway protection at OSH.
Has coffee grounds from NGT, elevated trop 1.2, EKG at OSH
showing ? small STE in inf leads. Received protonix 40mg iv +
gtt at 8mg/hr and sent to [**Hospital1 18**].
In [**Hospital1 18**] ED, ETT was advanced 1cm. Hemodynamically stable. Hct
34, similar to OSH. VS: 98.8, 121/56, 100% on vent. Two #18 R
arm.
Past Medical History:
- cholangiocarcinoma being followed up by oncology
- coronary artery disease status post PTCA and 3 stent
placements
- hypertension
- h/o cholangitis [**2116-5-17**]
- ERCP in [**3-/2116**], [**4-/2116**], [**5-/2116**]
- osteoarthritis
- s/p colon resection
- depression
- bilateral total knee replacement
- benign prostatic hypertrophy
- Parkinson's disease
- REM behavior disorder
- obstructive sleep apnea
- periodic limb movements
- excessive daytime sleepiness
- Lumbar spinal stenosis - s/p verterbroplasty [**2-23**]
Social History:
no alcohol or drug use. He is a retired general contractor. He
used to smoke cigarettes many years ago and quit 15 years ago.
Family History:
there is no family history of any malignancy. His father died
of a coronary artery disease. His mother had a benign brain
tumor.
Physical Exam:
Flowsheet Data as of [**2117-4-4**] 03:14 AM
Vital Signs Hemodynamic monitoring Fluid Balance 24 hours Since
12 AM
Tmax: 35.9 ??????C (96.7 ??????F)
Tcurrent: 35.9 ??????C (96.7 ??????F)
HR: 70 (70 - 85) bpm
BP: 97/42(59) {86/42(59) - 118/64(82)} mmHg
RR: 21 (12 - 28) insp/min
SpO2: 92%
Heart rhythm: SR (Sinus Rhythm)
Height: 68 Inch
Respiratory
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 480 (480 - 550) mL
RR (Set): 28
RR (Spontaneous): 2
PEEP: 5 cmH2O
FiO2: 60%
PIP: 28 cmH2O Plateau: 21 cmH2O
Compliance: 42.5 cmH2O/mL
SpO2: 92%
ABG: 7.25/50/75/24/-5
Ve: 11 L/min
PaO2 / FiO2: 125
Physical Examination
General Appearance: Thin
Eyes / Conjunctiva: PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic, Poor dentition,
Endotracheal tube, NG tube
Lymphatic: No(t) Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal), No(t)
S3, No(t) S4, No(t) Rub, (Murmur: No(t) Systolic, No(t)
Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Diminished: )
Abdominal: Soft, Non-tender, Bowel sounds present, No(t)
Distended
Extremities: Right: Trace, Left: Trace, No(t) Cyanosis, No(t)
Clubbing
Musculoskeletal: Muscle wasting
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
Pertinent Results:
[**2117-4-3**] 04:30PM WBC-7.1 RBC-3.69* HGB-11.8* HCT-35.4* MCV-96
MCH-31.9 MCHC-33.2 RDW-16.7*
[**2117-4-3**] 04:30PM NEUTS-91.5* BANDS-0 LYMPHS-7.0* MONOS-1.2*
EOS-0.3 BASOS-0.1
[**2117-4-3**] 04:30PM PLT SMR-NORMAL PLT COUNT-253
[**2117-4-3**] 04:30PM GLUCOSE-162* UREA N-47* CREAT-1.0 SODIUM-141
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-29 ANION GAP-13
[**2117-4-3**] 04:30PM ALT(SGPT)-50* AST(SGOT)-116* CK(CPK)-48 ALK
PHOS-211*
[**2117-4-3**] 04:30PM LIPASE-24
[**2117-4-3**] 10:20PM TYPE-ART TEMP-36.1 PO2-266* PCO2-65* PH-7.24*
TOTAL CO2-29 BASE XS--1 INTUBATED-INTUBATED
[**2117-4-3**] 10:20PM LACTATE-3.1*
PORTABLE CXR FINDINGS: Consistent with the given history, an
endotracheal tube has been introduced with the distal tip
approximately 6.9 cm from the carina. A nasogastric tube has
also been placed with the distal tip just reaching the
gastroesophageal junction. Atherosclerotic disease of the aorta
is evident. The cardiac silhouette is within normal limits for
size. No definite consolidation or superimposed edema is
identified. Please note the right costophrenic angle has been
excluded from view. No effusion or pneumothorax is noted.
Limited imaging in the included upper abdomen reveals the tips
and numerous clips in the epigastric region. Bridging
osteophytes are noted throughout the thoracic spine.
IMPRESSION: Endotracheal tube in satisfactory position as
above. The nasogastric tube needs advancement by at least 15 cm.
No definite focal consolidation or infiltrate noted.
AP ABDOMEN 5:10 A.M. [**4-4**]
HISTORY: Cholangiocarcinoma, upper GI bleed, aspiration
pneumonia. Rising lactate and acidosis. Rule out perforation or
obstruction.
IMPRESSION: Supine view of the entire abdomen and upright
view of the upper abdomen show no evidence of intestinal
obstruction or perforation. A wide stent has replaced a biliary
drainage catheter since [**2116-6-25**]. There has been an
intervening cementoplasty in the lower lumbar spine. More spinal
degenerative osteophyte formation and mild derangement has
developed. A nasogastric tube is coiled in the upper stomach.
Brief Hospital Course:
86M w/ cholangiocarcinoma s/p metal biliary stenting, now with
hematemesis and likely aspiration pneumonia
.
# Acute blood loss anemia with upper GI source. Two large bore
peripheral IVs were placed, blood was typed and crossmatched but
pt did not require transfusion as serial Hct was stable. BP was
maintained with IVF with central venous pressure monitoring, and
once CVP >12, norepiphrine was administered to maintain MAP >65.
For the bleeding, octreotide and pantoprazole drips were
administered and gastroenterology was consulted for EGD.
However, pt's family declined invasive management of bleeding
(see further comments below).
# shock: hypovolemia from GI bleeding vs sepsis from asp
pneumonia. Broad spectrum antibiotics including coverage for
aspiration pneumonia were administered. Arterial line for BP
monitoring was placed and central venous line for CVP monitoring
and medication infusion was placed. Pt received volume
resuscitation with IVF to goal CVP 12 and then norepiphrine was
administered to keep MAP goal >65. A cosyntropin stim test
showed relative adrenal insufficiency, so stress dose
hydrocortisone was administered.
# Respiratory failure: history of developing respiratory failure
after hematemesis suggests aspiration of bloody gastric
contents, although admission cxr not impressive for pna.
Empirically treated for aspiration/community acquired pathogens
with vanc/levo/flagyl. Pt initially had acute respiratory
acidosis and a large A-a gradient; consistent with aspiration,
but during the 12 hour period after admission, lactic acidosis
developed and worsened despite treatment of septic shock. Minute
ventilation was increased to compensate, but PCO2 continued to
rise with falling pH despite these measures. Bicarb was
administered as a temporizing measure.
PE was considered, given the large A-a gradient, but the
patient's active GI bleeding precluded anticoagulation.
# CAD: positive troponins at OSH, negative when repeated here at
[**Hospital1 **]. Continue [**Last Name (LF) 95571**], [**First Name3 (LF) **] given h/o stents. Not on beta
blocker at home.
# HTN: hold spironolactone, lasix, given shock.
# Parkinson's disease: continue outpt sinemet
# Depression: continue home regimen of bupropion,
methylphenidate
# Goals of Care: DNR, discussed with daughter/HCP on admission.
As the patient's clinical status continued to deteriorate
despite aggressive medical supports, the family, after
consultation with the MICU team and the GI consult team, decided
that Mr [**Known lastname **] would prefer to be made comfortable rather to
undergo further invasive procedures with a low likelihood of
benefit in terms of survival and quality of life if he did
survive. Therefore, with his family gathered at the bedside, all
medications except analgesics and anxiolytics were stopped and
the ventilator was changed to a T-piece with humidified O2. The
patient expired on [**4-4**].
Medications on Admission:
Ezetimibe 10 mg
Aspirin 81 mg
Carbidopa-Levodopa 25-100 mg 1.5tab QAM/2 tab noon/1.5tab QPM
Spironolactone 25 mg
Methylphenidate 5 mg [**Hospital1 **] QAM and at 1300
Clonazepam 0.5 mg Tablet Sig: 1.5 Tablets PO QHS
Lasix 20 mg Tablet
Bupropion 200 mg Sustained Release [**Hospital1 **]
Zolpidem 5 mg qhs prn
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
acute blood loss anemia, upper gastrointestinal source
septic shock from aspiration pneumonia
cholangiocarcinoma
Parkinson's disease
Discharge Condition:
deceased
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"600.00",
"507.0",
"V43.65",
"038.9",
"995.92",
"327.23",
"156.1",
"785.52",
"401.9",
"414.01",
"V45.82",
"578.9",
"327.42",
"V45.89",
"715.90",
"276.2",
"276.52",
"311",
"518.81",
"332.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8833, 8842
|
5516, 8445
|
322, 421
|
9019, 9030
|
3382, 5493
|
9082, 9089
|
1804, 1936
|
8805, 8810
|
8863, 8998
|
8471, 8782
|
9054, 9059
|
1951, 3363
|
221, 284
|
449, 1094
|
1116, 1642
|
1658, 1788
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,615
| 141,400
|
54168
|
Discharge summary
|
report
|
Admission Date: [**2139-9-5**] Discharge Date: [**2139-9-22**]
Date of Birth: [**2059-4-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
80M with history of AS, HTN, and CAD who now has critical AS.
Major Surgical or Invasive Procedure:
[**2139-9-10**] Redo-sternotomy, Aortic Valve Replacment utilzing a [**Street Address(2) 111017**]. [**Male First Name (un) 923**] mechanical valve
History of Present Illness:
80 yo M with critical AS. Admitted for cath and heparin gtt
prior to surgery.
Past Medical History:
HTN
Gout
CAD-s/p CABGx4 19 yrs. ago
s/p prostatic seed implantation for ca
s/p CVA
Afib, s/p carotid stent 3 yrs ago
Family History:
NC
Physical Exam:
NAD 96.3 83 150/98 98% on RA
Lungs CTAB
RRR
abd soft/NT/ND
trace peripheral edema
Pertinent Results:
[**2139-9-22**] 06:30AM BLOOD WBC-7.5 RBC-2.77* Hgb-9.1* Hct-27.1*
MCV-98 MCH-32.7* MCHC-33.4 RDW-15.9* Plt Ct-218
[**2139-9-20**] 05:15AM BLOOD WBC-6.0 RBC-2.81* Hgb-9.1* Hct-27.1*
MCV-97 MCH-32.3* MCHC-33.4 RDW-15.7* Plt Ct-180
[**2139-9-22**] 06:30AM BLOOD Plt Ct-218
[**2139-9-22**] 06:30AM BLOOD PT-26.2* PTT-30.9 INR(PT)-2.7*
[**2139-9-21**] 06:50AM BLOOD PT-28.9* PTT-32.5 INR(PT)-3.0*
[**2139-9-20**] 05:15AM BLOOD PT-24.3* INR(PT)-2.4*
[**2139-9-19**] 05:00AM BLOOD PT-22.4* INR(PT)-2.2*
[**2139-9-21**] 06:50AM BLOOD UreaN-25* Creat-1.7* K-4.4
[**2139-9-20**] 05:15AM BLOOD Glucose-96 UreaN-25* Creat-1.8* Na-140
K-4.3 Cl-104 HCO3-29 AnGap-11
[**2139-9-19**] 05:00AM BLOOD UreaN-25* Creat-2.1* K-4.5
Brief Hospital Course:
He underwent a cardiac cath on [**2139-9-7**] which showed patent LIMA
and SVGs. He was taken to the operating room on [**2139-9-10**] where
he underwent a redo sternotomy with AVR (#23 St. [**Male First Name (un) 923**]
Mechanical). He was transferred to the SICU in critical but
stable condition on neo, epi and propofol. He was extubated that
same day. His vasoactive drips were weaned to off by POD #1. He
was transferred to the floor on POD #2. He was started on
heparin and coumadin for his mechanical valve and atrial
fibrilation. His creatinine continued to increase
postoperatively peaking at 2.1, his lasix dose was decreased,
and his creatinine began to return to baseline. On [**2139-9-18**] he
reported new onset right leg weakness and dysarthria. He was
seen in consultation by neurology who recommended a CT scan
which showed no acute bleed. An MRI showed several small acute
infarcts in the mid pons and both frontal lobes. His weakness
improved and he was ready for discharge on [**2139-9-22**].
Medications on Admission:
Atenolol 50 mg PO BID
Lasix 40 mg PO daily
Hytrin 10 mg PO daily
Vitorin 10/40 mg PO daily
Colchicine PRN
Allopurinol 300 mg PO daily
Coumadin 4.5 mg PO daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*14 Tablet(s)* Refills:*0*
9. Terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*2*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily):
Check INR [**9-24**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Location (un) 4047**]
Discharge Diagnosis:
Aortic Stenosis - s/p Aortic Valve Replacement, Coronary Artery
Disease with prior coronary artery bypass grafting surgery,
Hypertension, Hypercholesterolemia, History of Stroke in the
past, Atrial fibrillation, Prostate Cancer
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**4-22**] weeks - call for appt.
Local PCP [**Last Name (NamePattern4) **] [**2-20**] weeks - call for appt.
Dr. [**Last Name (STitle) 16618**] in [**2-20**] weeks - call for appt.
Completed by:[**2139-9-22**]
|
[
"428.0",
"427.31",
"401.9",
"434.11",
"585.9",
"496",
"V10.46",
"V45.81",
"416.8",
"424.1",
"V58.61",
"997.02",
"274.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"88.57",
"88.72",
"88.56",
"39.61",
"99.04",
"88.42",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
4296, 4364
|
1659, 2673
|
381, 531
|
4636, 4643
|
925, 1636
|
4961, 5224
|
794, 798
|
2883, 4273
|
4385, 4615
|
2699, 2860
|
4667, 4938
|
813, 897
|
280, 343
|
559, 638
|
660, 778
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,608
| 117,552
|
6422
|
Discharge summary
|
report
|
Admission Date: [**2159-4-25**] Discharge Date: [**2159-4-30**]
Date of Birth: [**2094-9-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Hypotension.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
History of Present Illness: 64-year-old man with pancreatic
cancer s/p recent Whipple ([**2159-1-31**]) now on adjuvant
chemotherapy (last dose per patient was two weeks prior to
this), diabetes type II, sCHF with EF 30%, CAD s/p MI, and
atrial fibrillation on coumadin who presented to the ED from
home with progressive lower extremity swelling and "not feeling
well." Family members at home, furthermore, felt that he did not
look right and decided to bring him to the emergency room. Of
note, patient was recently discharged from [**Hospital3 3583**] to
home with diagnosis of pneumonia. It is not clear what
antibiotics he was treated with - patient cannot remember.
.
In the ED, initial vital signs were T 97.6, HR 111, BP 86/56, RR
12, satting 94% RA. Labs notable for hct 29 (at baseline), trop
of 0.21 with normal CK (in setting of acute on chronic renal
failure with creatinine 2.0 from baseline ~1.3), and glucose of
38. Lactate was 1.6. EKG showed atrial fibrillation (rate of
107) with RBBB and RAD. There were no significant changes from a
preoperative EKG in [**Month (only) 958**]. CXR showed RLL infiltrate consistent
with pneumonia. UA was negative. Blood and urine cultures were
sent. Patient was given aspirin 325 mg, levofloxacin 750 mg,
vancomycin 1gm, and one amp of D50. He was given 1.5L NS (given
h/o sCHF) and admitted to the intensive care unit for persistant
hypotension.
.
Review of Systems: currently patient denies pain, shortness of
breath, chest pain or pressure, headache, nausea or vomiting
Past Medical History:
Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above
Social History:
Lives with his wife. Laid off from computer analyst position.
No tobacco. Occasional ETOH.
Family History:
Non-contributory.
Physical Exam:
Vitals: SBP 90s, HR 100-110, sat mid 90s on RA
General: pale-appearing elderly gentleman in no acute distress
HEENT: PERRLA, non-icteric sclera
Neck: JVP to ear lobe at 30 degrees
Cardiovascular: irregularly irregular
Pulmonary: bilateral crackles half way up lung fields
Abdominal: soft, non-tender, normal bowel sounds
Extremities: cold distally, non-diaphoretic, 2+ pitting edema to
above the knees bilaterally
Neurological: AAOx3, moving all extremities
Pertinent Results:
[**2159-4-25**] 01:18AM BLOOD WBC-10.0 RBC-3.26* Hgb-9.6* Hct-29.0*
MCV-89 MCH-29.5# MCHC-33.2 RDW-21.6* Plt Ct-359#
[**2159-4-25**] 09:05AM BLOOD WBC-11.8* RBC-3.20* Hgb-9.4* Hct-29.5*
MCV-92 MCH-29.4 MCHC-31.8 RDW-21.7* Plt Ct-347
[**2159-4-26**] 04:15AM BLOOD WBC-11.2* RBC-3.32* Hgb-9.6* Hct-29.6*
MCV-89 MCH-28.8 MCHC-32.3 RDW-21.4* Plt Ct-475*
[**2159-4-27**] 05:20AM BLOOD WBC-11.8* RBC-3.28* Hgb-9.6* Hct-29.2*
MCV-89 MCH-29.1 MCHC-32.7 RDW-21.4* Plt Ct-476*
[**2159-4-25**] 01:18AM BLOOD Neuts-79.2* Lymphs-12.2* Monos-6.9
Eos-1.4 Baso-0.2
[**2159-4-25**] 09:10AM BLOOD PT-35.7* PTT-51.0* INR(PT)-3.7*
[**2159-4-26**] 04:15AM BLOOD PT-27.4* PTT-42.7* INR(PT)-2.7*
[**2159-4-27**] 05:20AM BLOOD PT-25.3* PTT-42.0* INR(PT)-2.4*
[**2159-4-28**] 06:10AM BLOOD PT-28.2* PTT-42.0* INR(PT)-2.8*
[**2159-4-25**] 01:18AM BLOOD Glucose-39* UreaN-41* Creat-2.0* Na-143
K-3.9 Cl-108 HCO3-25 AnGap-14
[**2159-4-25**] 12:15PM BLOOD Glucose-94 UreaN-35* Creat-1.8* Na-144
K-3.6 Cl-110* HCO3-24 AnGap-14
[**2159-4-25**] 09:30PM BLOOD Glucose-177* UreaN-38* Creat-2.1* Na-141
K-4.0 Cl-107 HCO3-26 AnGap-12
[**2159-4-26**] 04:15AM BLOOD Glucose-182* UreaN-38* Creat-1.9* Na-141
K-4.1 Cl-107 HCO3-25 AnGap-13
[**2159-4-26**] 05:05PM BLOOD Creat-2.0* Na-138 K-4.2 Cl-105
[**2159-4-27**] 05:20AM BLOOD Glucose-137* UreaN-38* Creat-1.9* Na-140
K-3.7 Cl-105 HCO3-27 AnGap-12
[**2159-4-28**] 06:10AM BLOOD Glucose-97 UreaN-31* Creat-1.6* Na-140
K-3.8 Cl-105 HCO3-29 AnGap-10
[**2159-4-25**] 12:15PM BLOOD ALT-22 AST-35 LD(LDH)-269* CK(CPK)-101
AlkPhos-114 TotBili-0.8
[**2159-4-25**] 01:18AM BLOOD cTropnT-0.21*
[**2159-4-25**] 09:10AM BLOOD CK-MB-2 cTropnT-0.05*
[**2159-4-25**] 12:15PM BLOOD CK-MB-3 cTropnT-0.14*
[**2159-4-25**] 01:18AM BLOOD CK-MB-4 proBNP-[**Numeric Identifier 24733**]*
[**2159-4-25**] 01:18AM BLOOD CK(CPK)-142
[**2159-4-25**] 12:15PM BLOOD Albumin-2.2* Calcium-6.5* Phos-3.3
Mg-1.3*
[**2159-4-25**] 09:30PM BLOOD Calcium-7.4* Phos-3.6 Mg-1.8
[**2159-4-26**] 04:15AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.7
[**2159-4-27**] 05:20AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.8
[**2159-4-28**] 06:10AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.8
[**2159-4-25**] 09:10AM BLOOD Digoxin-<0.2*
[**2159-4-25**] 12:15PM BLOOD Digoxin-0.3*
[**2159-4-26**] 04:15AM BLOOD Digoxin-0.3*
[**2159-4-25**] 02:39AM BLOOD Lactate-1.6
[**2159-4-25**] 10:11AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2159-4-25**] 04:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2159-4-25**] 10:11AM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-4-25**] 04:25AM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-4-25**] 10:11AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2159-4-25**] 04:25AM URINE RBC-0 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2159-4-25**] 10:11AM URINE CastHy-[**1-26**]*
[**2159-4-25**] 10:11AM URINE Hours-RANDOM UreaN-831 Creat-116 Na-20
TTE [**2159-4-25**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The right atrial pressure is indeterminate.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with akinesis of
the inferior and inferolateral walls and apex and hypokinesis of
the basal and mid anterior, anterolateral, and inferoseptal
segments. Overall left ventricular systolic function is severely
depressed (LVEF= 25-30 %). Right ventricular chamber size is
dilated and free wall motion is normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is at least moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severely depressed left ventricular systolic
function with akinesis of the inferior and inferolateral walls
and apex and hypokinesis of the basal and mid anterior,
anterolateral, and inferoseptal segments. Mild aortic root and
ascending aortic diliatation. Moderate to severe mitral
regurgitation. Moderate to severe tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension.
Compared with the report of the prior study (images unavailable
for review) of [**2147-12-19**], the left ventricular ejection fraction
appears similar. The severity of mitral and tricuspid
regurgitation has increased.
ECG [**2159-5-2**]:
Atrial fibrillation with ventricular rate of 107. Complete right
bundle-branch block with QRS duration of 136 milliseconds. Q
waves in leads II, III and aVF. Poor R wave progression
laterally. Right axis deviation at plus 117 degrees. Compared to
the previous tracing of [**2159-2-6**] no diagnostic interval change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
107 0 136 348/430 0 117 -18
CXR:
Cardiac size is top normal. There has been reaccumulation of
bilateral
pleural effusions , more conspicuous in the current exam could
be due to
difference in positioning of the patient. Bibasilar
consolidations are
grossly unchanged. Right Port-A-Cath remains in place in
standard position.
There is no evidence of pneumothorax.
Brief Hospital Course:
64-year-old man with history of pancreatic cancer s/p Whipple on
chemotherapy, DM II, CAD, PVD, and sCHF now presents with
hypotension, and progressive lower extremity edema.
.
# Hypotension: Likely secondary to decompensated heart failure
with unclear trigger. [**Month (only) 116**] also have been secondary to poorly
controlled atrial fibrillation with RVR as patient had not been
taking his digoxin. Required short course of pressors and IV
fluids. Losartan was held. Digoxin and metoprolol were
initially held, but with stabilization of blood pressures,
digoxin was loaded and metoprolol was added on [**4-27**] with good
rate control. Now symptomatically improved with stable vital
signs.
.
# Acute on chronic sCHF: Likely secondary to ischemic
cardiomyopathy. On admission, patient had 3+ lower extremity
edema to the hip, and a BNP > [**Numeric Identifier 15362**]. His weight on admission
was 200#, up from his dry weight of 180#. He was intially
treated with lasix gtt with good urine output. On discharge he
was transitioned to furosemide 40mg IV bid. Weight on discharge
was 192#. He had improved, but persistent LE edema on
discharge. He will require continued diuresis and monitoring of
his edema. He was continued on aspirin, beta-blocker, statin.
.
# Acute on chronic renal failure: likely prerenal azotemia -
unclear if secondary to hypovolemia versus poor forward flow
from decompensated CHF. His creatinine gradually improved.
.
# Atrial fibrillation: Loaded with digoxin and restarted
metoprolol at 12.5mcg PO BID. He remained in atrial
fibrillation. He was continued on his home coumadin, and INR was
checked daily.
.
# Pneumonia: Treated at OSH. Afebrile while here with no new
respiratory complaints. Antibiotics were discontinued on [**4-25**].
Urine legionella negative.
.
# Pancreatic cancer s/p Whipple: patient is currently undergoing
adjuvant chemotherapy and work-up for possible cyberknife
therapy, both at outside centers closer to his home. Spoke with
Dr. [**First Name (STitle) 3443**] ([**Hospital3 **] Oncology), she will see him in clinic next
week to further plan his cancer treatment.
.
# Anemia: Stable and at recent baseline. Normal MCV suggests
anemia of chronic inflammation.
.
# Type II diabetes: on insulin as outpatient. His long-acting
insulin was held given renal failure and low sugars in ED. He
was covered with a humalog sliding scale, and restarted on his
home lantus 15 units PO daily on discharge.
Medications on Admission:
- toprol XL 50mg QD
- cozaar
- losartan 50mg PO daily
- lasix 20mg PO daily
- ecotrin 80mg PO daily
- lipitor 40mg PO daily
- protonix 30mg PO daily
- lantus 15 units qam
- levaquin 500mg PO daily X 5 days (just finished)
- coumadin 3mg PO daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for stomach pain.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
twice a day.
14. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous once a day.
15. Furosemide
Patient's dry weight is 180 lbs, weight on discharge 192 lbs.
Please perform daily weights. Obtain serum Na, K, Cl,
Bicarbonate, BUN, Creatinine, Glucose twice weekly and send to
rehab MD. Titrate down furosemide dose as lower extremity edema
resolves, and patient approaches dry weight. Goal dose of
furosemide is 40mg PO bid.
16. Electrolytes
Please replete K to 4.0, magnesium to 2.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Acute on Chronic Systolic Heart 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 for worsening of your heart failure. You were
treated with the diuretic furosemide, and your urine output
increased. You were restarted on digoxin for your atrial
fibrillation.
The following changes were made in your medications:
Your dose of furosemide was increased, and will be slowly
decreased while in rehab.
We stopped your Cozaar (losartan).
We restarted digoxin.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please arrange to see your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge
from rehab.
Dr. [**First Name (STitle) 3443**]
[**Hospital3 **] Oncology
Tuesday [**2159-5-8**] 12:00 pm
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
|
[
"427.31",
"V58.61",
"157.9",
"285.21",
"585.9",
"428.23",
"428.0",
"250.80",
"V58.67",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13116, 13188
|
8625, 11094
|
282, 289
|
13290, 13290
|
3053, 8602
|
13947, 14264
|
2540, 2559
|
11390, 13093
|
13209, 13269
|
11120, 11367
|
13441, 13924
|
2301, 2415
|
2574, 3034
|
1738, 1845
|
230, 244
|
345, 1719
|
13305, 13417
|
1889, 2278
|
2431, 2524
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,094
| 135,633
|
35765+58032
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-2-8**] Discharge Date: [**2182-3-4**]
Date of Birth: [**2126-10-22**] Sex: M
Service: SURGERY
Allergies:
Penicillin G / Codeine
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Left flank pain
Major Surgical or Invasive Procedure:
[**2182-2-9**]: Bedside drainage and washout of the left psoas abscess
[**2182-3-13**]: EGD
[**2182-2-11**]: CT-guided aspiration of right psoas collection.
[**2182-2-12**]: EGD
[**2182-2-14**]: Left lateral open drainage, left retroperitoneal
abscess.
[**2182-2-15**]: Successful placement of a right 10.2 French
internal/external percutaneous transhepatic biliary drain.
[**2182-2-20**]: Exchange of a right 10.2 French PTBD s/t obstruction.
[**2182-2-26**]: ERCP, two stents placed
History of Present Illness:
Patient is a 55 year old male with past medical history
significant for necrotizing pancreatitis secondary to [**Year/Month/Day **]
abuse s/p necrosectomy on [**2180-5-3**] followed by takedown of end
of the enterocutaneous fistula with small-bowel resection and
primary anastomosis on [**2180-5-25**]. Patient recently admitted on
[**2183-1-5**] for RUQ pain. MRCP at that time showed a filling
defect in the pancreatic duct concerning for a stone. Patient
agreed to have ERCP as an outpatient with Dr. [**Last Name (STitle) **] [**2182-2-14**].
Patient returns today with worsening [**10-28**] left flank pain. He
denies fevers, chills, nausea, vomiting and notes regular bowel
movements.
Past Medical History:
PMH: Hypertension, Ulcerative colitis s/p colectomy, J pouch,
Removal of nonmalignant brain tumor, [**Month/Year (2) **] abuse, Chronic
Methadone Maintenance for heroin abuse
Past Surgical History:
[**2157**]- colectomy
[**2161**] - brain tumor excision
[**2180-3-8**] Percutaneous tracheostomy. (Dr. [**Last Name (STitle) **]
[**2180-4-28**]
Percutaneous drainage of retroperitoneal
collection abscess of the pancreas x2 for infected
retroperitoneal fluid collection. (Dr. [**Last Name (STitle) **]
[**2180-5-3**]
1. Pancreatic necrosectomy (minimally-invasive.)
2. Replacement of percutaneous drains times 2 for a
peripancreatic retroperitoneal abscess. (Dr. [**Last Name (STitle) **], Dr.
[**Last Name (STitle) **]
[**2180-5-9**]
1. Retroperitoneal laparoscopy.
2. Replacement of percutaneous drains into retroperitoneal
abscess. (Dr. [**Last Name (STitle) **]
[**2180-5-25**]
1. Takedown of end of the enterocutaneous fistula with
small-bowel resection and primary anastomosis.
2. Extended adhesiolysis.
3. Repair of enterotomy.
4. G tube placement.
5. J-tube placement. (Dr. [**Last Name (STitle) **]
Social History:
Currently smokes one pack of cigarettes a day. Patient has a
long term history of [**Last Name (STitle) **] abuse and dependence. Typically
drinks 1 pint of [**Last Name (STitle) **] per day though he stopped drinking 6
weeks prior to admission.
Family History:
Father was an alcoholic
Physical Exam:
VS: T 98.0 80 131/84 18 98%
gen: NAD, AAO x 3
CV: RRR
pulm: Coarse BS BL
abdomen: + BS, thin, tender in midepigastric region,
incisional ventral hernia through the midline laparotomy
incision, reducible bowel contents, no rebound, Left flank with
bulge, tender to palpation, old drain site healed
extremities: no edema
Pertinent Results:
CBC: 12.3>10.4<619
138 95 22
------------<117
4.0 36 1.0
ALT: 56 AP: 813 Tbili: 2.7 Alb: 2.7
AST: 79 LDH: 100 Dbili: TProt:
[**Doctor First Name **]: Lip: 15
N:85.8 L:9.4 M:4.1 E:0.3 Bas:0.4
CT scan [**2182-2-8**]: 1. Interval worsening of psoas fluid
collections demonstrating rim enhancement since the examination
from [**2181-12-27**]. There is now a large left psoas fluid collection
measuring 13 x 7 x 3 cm that demonstrates a direct connection to
the cutaneous tissues of the left lateral abdominal wall. This
is either a primary fistula or has progressed through tract of a
drain placed in the interval, though history or imaging evidence
of such is not available here. In addition, there has been
interval enlargement of a right psoas fluid collection measuring
7 x 3 x 3 cm. 2. Associated mild hydronephrosis and hydroureter
of both kidneys
demonstrated to the level of these psoas fluid collections. 3.
Interval redevelopment of extensive small peripancreatic fluid
collections with air within them since the examination from
[**2181-12-27**] though present on prior examinations such as [**2180-6-22**].
4. Gallbladder sludge. 5. Calcific density within the proximal
aspect of the common bile duct can be correlated to an
intraluminal stone as noted on MRCP from [**2182-1-7**]. Additional
calcific densities within the pancreas compatible with chronic
pancreatitis. 6. Stable appearance of an atrophic pancreas, with
continued homogeneous enhancement of the remainder of the
parenchyma. Stable intra- and extra-hepatic biliary dilatation.
CT scan [**2182-3-1**]: 1. Interval decrease in the size of bilateral
psoas abscesses and peripancreatic pseudocyst. 2. 7-mm stone
noted in the pancreatic duct associated with pancreatic ductal
dilatation; additional probably parenchymal calcifications in
pancreatic head. Findings are consistent with changes of chronic
pancreatitis. 3. Diffuse intra- and extra-hepatic biliary
dilatation is essentially unchanged compared to the prior
examination.
[**2182-2-11**] 2:50 pm ABSCESS Site: ABDOMEN RT ABD.
DRAINAGE.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2182-2-19**]):
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
_________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
ANAEROBIC CULTURE (Final [**2182-2-15**]): NO ANAEROBES ISOLATED
[**2182-2-16**] 2:18 am BILE
FLUID CULTURE (Final [**2182-2-20**]):
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ =>16 R
Brief Hospital Course:
Mr. [**Known lastname **], a 55 year old male s/p pancreatic necrosectomy in
[**2180**] complicated by bilateral fluid collections who now presents
with increasing left sided flank pain. Labs on admission also
revealed a total bilirubin of 2.7 and alkaline phosphatase of
813, consistent with biliary obstruction. CT scan was obtained
and revealed a 12 mm CBD with a 5 mm intraluminal stone and
gallbladder sludge. It also demonstrated interval worsening of
the psoas fluid collections in comparison to the prior study on
[**2181-12-27**]. Psoas collection on the left measured 13 cm and
communicated with the left abdominal wall. Right psoas fluid
collection measured 7 cm. Pancreas appeared calcified and
atrophic, consistent with chronic pancreatitis. He was admitted,
made NPO and started on broad spectrum antibiotics, which were
eventually tailored to cefepime and flagyl.
On [**2182-2-9**] the patient underwent bedside drainage of the left
psoas abscess. 50cc's of fluid were expressed and a penrose
drain was left in the sinus tract. Cultures grew mixed bacterial
flora. The patient later underwent CT-guided aspiration of
right psoas collection, 30cc fluid aspirated which grew out
pseudomonas.
On [**2182-2-14**] the patient was brought to the OR for washout of the
left psoas abscess. He was bradycardic in pre-op holding,
diagnosed as a self-limited vagal episode by cardiology. No
further intervention recommended. Post-operatively Mr. [**Known lastname **]
failed to extubate and was transferred to the SICU where he
remained stable overnight. He was transfused a total of 3 units
of blood for low hematocrits and later transferred to the floor
in stable condition.
After several days of increasing nausea and abdominal distension
Mr. [**Known lastname **] went to IR for PTC drain evaluation which
demonstrated occlusion at the level of the CBD. A new 10 Fr
internal/external drain was placed. The drain was capped
post-procedure which he tolerated well. On [**2182-2-26**] he underwent
ERCP which showed a 1.5 cm distal CBD stricture with proximal
dilation. Two 7 cm 10 Fr Cotton-[**Doctor Last Name **] stents were placed in the
duct. Brushings taken during the procedure revealed reactive
epithelial cells without evidence of malignancy. CT scan was
obtained on [**2182-3-1**] and showed interval decrease in bilateral
fluid collection size. Pancreatic duct stone was still present
as were intrahepatic and extrahepatic ductal dilation.
Mr. [**Known lastname **] was started on TPN four days prior to discharge. At
this point he weighed 140 lbs and was approximately 35 lbs below
his usual weight. Toward the end of his hospitalization he was
meeting his [**2171**] kcal/day nutritional requirement and taking
nearly 100 grams of protein/day. He will be discharged with home
TPN to meet half of his daily caloric needs. He will also
continue cefepime and flagyl until his follow-up appointment
with Dr. [**Last Name (STitle) **] in approximately two weeks.
At the time of discharge, Mr. [**Known lastname **] was doing well, afebrile
with stable vital signs. He was tolerating a regular diet,
ambulating, voiding without assistance, and his pain was well
controlled. The patient received discharge teaching and
follow-up instructions with verbalized understanding and
agreement with the discharge plan.
Medications on Admission:
ASA, Celexa 20', Methadone 45', Klonopin 1 QHS, ibuprofen
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
3. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
heartburn.
7. 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*
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*66 Tablet(s)* Refills:*0*
9. cefepime 2 gram Recon Soln Sig: One (1) Intravenous every
twelve (12) hours.
Disp:*42 bags* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
1. Necrotizing pancreatitis
2. Bilateral retroperitoneal psoas abscesses
3. Sinus bradycardia
4. Hypercapnia s/p intubation
5. Chronic anemia
6. Biliary obstruction with LFTs elevation and leukocytosis
7. Malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-28**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Penrose drains Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container (ostomy
bag), please note color, consistency, and amount of fluid in the
drain. Call the doctor, nurse practitioner, or [**Month/Year (2) 269**] nurse if the
amount increases significantly or changes in character. Be sure
to empty the drain frequently. Record the output, if instructed
to do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
PTBD drain care: Keep capped. Please look at the site every day
for signs of infection (increased redness or pain, swelling,
odor, yellow or bloody discharge, warm to touch, fever).
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9406**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2182-3-13**]
3:00
.
Please call [**Telephone/Fax (1) 1231**] Dr.[**Name (NI) 2829**] office to schedule a
follow up appointment to see him. He would like to see you in 2
weeks.
Name: [**Known lastname 11884**],[**Known firstname 4049**] Unit No: [**Numeric Identifier 13040**]
Admission Date: [**2182-2-8**] Discharge Date: [**2182-3-4**]
Date of Birth: [**2126-10-22**] Sex: M
Service: SURGERY
Allergies:
Penicillin G / Codeine
Attending:[**First Name3 (LF) 2083**]
Addendum:
In addition to the events and plan mentioned above, patient was
discharged with insulin and insulin sliding scale following
diabetes management teaching on [**2182-3-3**]. He will be followed
closely by the VNA who will make necessary adjustments. Patient
was also prescribed and instructed to have TPN labs drawn
regularly. Home TPN, drain care and ostomy appliance care were
appropriately coordinated. Please note medication changes
included below.
Procedure: Prior to discharge the penrose draining the left
flank was drawn back approximately 1 inch at the bedside. The
patient was prepped and draped in the usual sterile fashion.
Ostomy appliance and skin suture removed. 1% lidocaine was used
to anesthetize the local area. The penrose drain was withdrawn
approximately 1 inch and a 3.0 ethilon suture placed to help
secure the penrose to the nearby skin.
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
2. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
3. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
heartburn.
7. 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*
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
Disp:*66 Tablet(s)* Refills:*0*
9. cefepime 2 gram Recon Soln Sig: One (1) Intravenous every
twelve (12) hours.
Disp:*42 bags* Refills:*0*
10. Outpatient Lab Work
please check chem 10, liver function tests, triglyceride level,
cbc with differential, pt, ptt, INR weekly. please fax results
to [**Last Name (NamePattern1) 13041**]/[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1180**] MD at [**Telephone/Fax (1) 13042**].
11. Klonopin 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
12. One Touch Ultra Test Strip Sig: One (1) Miscellaneous
four times a day.
Disp:*120 * Refills:*2*
13. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): please inject appropriate units
of insulin given prescribed sliding scale. .
Disp:*1 bottle* Refills:*2*
14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*1*
15. insulin sliding scale
Blood sugar 0-70 mg/dL: call your doctor
71-100 mg/dL: 0 units of insulin
101-150 mg/dL: 2 units of insulin
151-200 mg/dL: 4 units of insulin
201-250 mg/dL: 6 units of insulin
251-300 mg/dL: 8 units of insulin
301-350 mg/dL: 10 units of insulin
>350 mg/dL: call your doctor
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Home Therapies
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2084**] MD [**MD Number(2) 2085**]
Completed by:[**2182-3-4**]
|
[
"305.1",
"576.8",
"401.9",
"304.00",
"303.90",
"041.7",
"285.9",
"577.0",
"577.1",
"577.2",
"263.9",
"574.51",
"591",
"567.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"51.98",
"38.93",
"51.10",
"99.15",
"51.87",
"54.0"
] |
icd9pcs
|
[
[
[]
]
] |
17885, 18107
|
6512, 9850
|
296, 783
|
11239, 11239
|
3316, 6489
|
14130, 15637
|
2935, 2961
|
15660, 17862
|
10998, 11218
|
9876, 9935
|
11390, 14107
|
1728, 2655
|
2976, 3297
|
241, 258
|
811, 1507
|
11254, 11366
|
1529, 1705
|
2671, 2919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,806
| 165,376
|
6239
|
Discharge summary
|
report
|
Admission Date: [**2172-9-21**] Discharge Date: [**2172-9-28**]
Date of Birth: [**2119-7-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Nausea, Vomiting, Abdominal Pain
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **]
History of Present Illness:
53 y.o. Female w/ h.o. bipolar d.o., s/p recent hospitalization
for jaundice and found to have pancreatic mass causing
obstruction, s/p stent placement p/w recurrent nausea, vomiting,
abdominal pain. Pt states she noted the onset of nausea,
vomiting as well as new onset of jaundice 1 day PTA. Noted temp
of 100.3 at home. Pt reports also diarrhea and periumbilical
pain this AM to the ED, but on the floor denies diarrhea and
denies pain. She does report tea colored urine since yesterday.
Pt was noted to have jaundice during psych hospitalization
several weeks ago at OSH and had CT abd/pelvis and MR at OSH
notable for ? pancreatic head mass and biliary dilation and was
transferred to [**Hospital1 **] on [**2172-8-25**] for [**Date Range **]. [**Date Range **] showed a chain of
lakes with a beaded pattern in the main pancreatic duct c/w
chronic pancreatitis versus auto immune disease or malignancy.
Pt also found to have distal high grade stricture of the CBD and
dilated intra-hepatic ducts. Sphincterotomy was performed and
cytology samples sent from CBD which showed atypical cells. A
biliary stent was placed in CBD c plans to remove it the
following week. Stent was removed on [**9-3**] and sent for path which
also showed atypical cells. Pt also underwent abdominal CTA
given question of pancreatic head mass which showed "diffuse
hypoenhancement of pancreatic head and neck with upstream
dilation of pancreatic duct. No definite discrete mass
identified; findings may represent focal pancreatitis, however,
an underlying mass cannot be excluded."
Past Medical History:
Bipolar disorder
HTN
Asthma
Social History:
No smoking. Remote drinking.
Family History:
Father - leukemia
Mother - CAD
Physical Exam:
At Admission:
General: tachypneic, cachectic, dyspneic
HEENT: Sclera anicteric, dry mucous membranes
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, no m/g/r
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no clubbing, cyanosis or edema
MSK: tenderness to palpation over lateral hip and anterior hip.
tenderness with passive extension, passive internal and external
rotation. patient cannot atively move his hip joint.
Skin: multiple scars and excoriations on arms.
Pertinent Results:
Labs on admission
[**2172-9-21**] 08:20PM BLOOD WBC-17.7* RBC-4.16*# Hgb-13.7# Hct-40.2#
MCV-97 MCH-32.8* MCHC-34.0 RDW-16.1* Plt Ct-212
[**2172-9-21**] 08:20PM BLOOD Neuts-95.0* Lymphs-1.4* Monos-2.5 Eos-0.5
Baso-0.6
[**2172-9-21**] 08:20PM BLOOD PT-14.7* PTT-29.6 INR(PT)-1.3*
[**2172-9-21**] 08:20PM BLOOD Glucose-109* UreaN-16 Creat-1.1 Na-141
K-3.0* Cl-102 HCO3-23 AnGap-19
[**2172-9-21**] 08:20PM BLOOD Albumin-4.3 Calcium-8.9 Phos-1.3* Mg-1.6
[**2172-9-26**] 06:55AM BLOOD ALT-85* AST-36 AlkPhos-122*
[**2172-9-21**] 08:20PM BLOOD Lipase-15
[**2172-9-21**] 08:20PM BLOOD cTropnT-<0.01
[**2172-9-22**] 03:03AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2172-9-21**] 08:20PM BLOOD Lithium-0.4*
[**2172-9-21**] 08:29PM BLOOD Glucose-105 Lactate-3.6* Na-138 K-2.9*
[**2172-9-22**] 04:26AM BLOOD freeCa-0.91*
Labs on discharge:
[**2172-9-28**] WBC13.4* RBC3.90* Hgb12.7 HCT38.2
[**2172-9-28**] glc103 BUN14 Cr0.7 NA139 K+5.8 (hemolyzed) Cl103
bicarb23
[**2172-9-28**] ALT52 AST37 LDH444 AP115 Amy19 Tbili1.2
[**2172-9-22**]
Liver or Gallbladder U/S
FINDINGS: No previous ultrasound scan is available for
comparison. There is marked dilatation of the common hepatic
duct proximal to the biliary stent, with maximal transverse
diameter of 14 mm. Intrahepatic biliary duct dilatation is also
seen, most prominent in the left hepatic duct. No obvious focal
parenchymal lesion is identified in the liver. The gallbladder
is surgically removed. The body and tail of pancreas are not
fully visualized. No pancreatic duct dilatation is identified at
the head of the pancreas. Patent flow is identified in the
portal vein.
IMPRESSION:
Prominent dilatation of the common hepatic duct and intrahepatic
ducts
proximal to biliary stent. Findings are suggestive of
obstruction of biliary
stent.
[**2172-9-22**] [**Month/Day/Year **] report
[**Month/Day/Year **]: Scout images demonstrate cholecystectomy clips and a
plastic biliary
stent in the right upper quadrant. Subsequent images demonstrate
cannulation of the pancreatic duct with a beaded appearance.
Cannulation of the common bile duct reveals smooth tapering of
the distal CBD and post- obstructive dilatation of the proximal
CBD and intrahepatic bile ducts. A new plastic biliary stent was
placed. Please refer to the operative note for further details.
IMPRESSION:
1. Beaded pancreatic duct, suggestive of chronic pancreatitis.
2. Smooth distal CBD tapering, consistent with pancreatitis.
Portable CXR [**2172-9-22**]
FINDINGS: In comparison with the study of [**2171-11-14**], there has
been the
development of patchy opacification at the left base consistent
with
pneumonia. No vascular congestion or pleural effusion.
IMPRESSION: Left lower lung pneumonia.
[**2172-9-23**]
Chest PA and Lateral
HISTORY: Cholangitis. Increasing hypoxia and shortness of
breath.
IMPRESSION: PA and lateral chest compared to [**9-22**]:
The lung base is elevated at least by a moderate right pleural
effusion.
Although heart size is normal and unchanged, mediastinal and
pulmonary
vasculature is more pronounced and there is new septal
opacification in both lungs. The simplest explanation is volume
or cardiac related pulmonary edema.
[**2172-9-25**] Chest PA and Lateral
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate
increased patchy opacity in the right upper lobe which may
represent infection. Mild pulmonary vascular congestion and
small, right greater than left pleural effusions with
compressive atelectasis at the right lung base is unchanged. The
cardiomediastinal silhouette is within normal limits. There has
been placement of a right PICC with the tip at the cavoatrial
junction.
ECHO [**2172-9-24**]
The left atrium is dilated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormality seen. Moderate
pulmonary artery systolic hypertension
CT Chest without contrast [**2172-9-26**]
CT CHEST WITHOUT CONTRAST: There are multifocal infiltrate
involving all
major segments of the lungs, but predominantly in the right
upper lobe. The findings are compatible with multifocal
pneumonia. There is a partially consolidation versus collapse at
the base of the right lung. There is no discrete pulmonary
nodule, allowing the obscuration of the underlying infectious
process. There is no pneumothorax. Small bilateral pleural
effusions are noted, but no evidence of organized abscess.
The heart is within normal limit in size. There is no
pericardial effusion. A right subclavian central venous catheter
is seen with the tip at the cavoatrial junction. The great
mediastinal vessels are grossly intact, within the limits of
non-contrast study. The tracheobronchial tree is patent to the
subsegmental levels.
Assessment of lymphadenopathy in the thorax is limited. Two
subcentimeter
pericardial lymph nodes are noted, likely reactive to the
underlying
infectious process. There is no gross hilar, mediastinal or
axillary
lymphadenopathy by CT criteria.
The study is suboptimal to assess intraabdominal parenchymal
organs. Again
noted is moderate pneumobilia. Two biliary stents are noted in
the CBD,
unchanged. Surgical clips are seen at the empty gallbladder
fossa, compatible with prior cholecystectomy. There is probably
a pancreatic head mass, incompletely evaluated in this study,
grossly unchanged in appearance.
BONE WINDOW: There is no acute fracture or dislocation. No
suspicious lytic lesions are noted concerning for metastasis.
IMPRESSION:
1. Multifocal pneumonia, predominantly in the right upper lobe.
Partially
collapsed or consolidation right lung base.
2. Bilateral small pleural effusions.
3. No evidence of fluid collection to suggest abscess.
4. Unchanged pneumobilia, incompletely assessed.
Brief Hospital Course:
Patient was admitted to the MICU on [**9-21**] with nausea, vomiting,
and abdominal pain and was found to have cholangitis, sepsis, ?
PNA, and pleural effusion.
Obstructive jaundice/cholangitis
Patient initially presented with fevers, nausea, vomiting,
jaundice, leukocytosis and elevated LFT's and was admitted to
the ICU. Initial differential diagnosis included cholangitis,
cholecystitis or an auto-immune process. Pancreatitis was also
considered given history of pancreatitis in the past and [**Month/Year (2) **] x
2. She was started on vancomycin and zosyn. A RUQ-US was
performed which showed prominent dilatation of the common
hepatic duct and intrahepatic ducts proximal to biliary stent,
suggestive of biliary stent obstruction. [**Month/Year (2) **] was consulted and
an [**Month/Year (2) **] was performed revealing CBD obstruction with CBD
dilitation. Pancreatic and biliary stents were placed. Blood
cultures returned positive were positive for Klebsiella and
enterococcus. The jaundice, fevers, nausea, vomiting and
leukocytosis all continued to resolve upon transfer to the
floor.
Bacteremia
Patient's blood cultures were positive for klebsiella and
enterrococcus faecalis. Patient was started on daptomycin,
flagyl and cefepime which was narrowed to vancomycin (patient
allergic to ampicillin) and ciprofloxacin which was then changed
to vancomycin and levofloxacin for better lung penetration as
there was some suspicion that the patient might have a
coexistent pneumonia. Last dose of levofloxacin and vancomycin
are [**2172-10-5**]. Vanco dose increased to 1250mg po q8hrs on [**2172-9-28**]
for the mid-day dose. TTE was negative for vegetation given
enterococcal bacteremia.
Multifocal Pneumonia
When the patient was transferred to the floor, she had an oxygen
requirement of 2-3L with an oxygen saturation of >90%. Her exam
and chest x ray suggested fluid overload. She was diuresed with
good effect and was weaned off of oxygen completely without
feeling short of breath. A PICC was placed for her IV
antibiotics and the X ray was concerning for a right multifocal
pneumonia as well as a right-sided effusion. A chest CT was done
which revealed bilateral effusions which were too small to tap
and multifocal PNA. She should complete an 8 day course of
Hospital acquired PNA.
Pancreatic mass: in process of being worked up by Dr [**Last Name (STitle) **] as
outpt. Her path results were positive for atypical cells and Ca
[**81**]-9 was elevated. On further discussion with [**Year (2 digits) **], this could
be consistent with inflammation. She has follow up with GI on
[**2172-9-29**] at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**].
Bipolar disorder:
The patient has a history of BP d/o with recent psychiatric
hospitalization. Lithium, wellbutrin, and celexa were continued.
Her next dose of risperidone is due on [**2172-9-30**] per the patient.
An EKG was checked and her QTc was 432. This should be
rechecked at the rehab facility after her riperidone is given.
Hypertension
The patient was remained normotensive and home BP medications
were held.
Code: FULL CODE. The patient expressed her preference to be
DNR/DNI but we later found out that her cousins were in the
middle of getting guardianship. Thus the decision was made that
the patient should remain full code for the time being.
Medications on Admission:
Lisinopril 10 mg Daily
Bupropion HCl 300 mg Daily
Citalopram 80 mg Daily
Lithium Carbonate 600 mg qHS
Risperidone 37.5 mg IM q2 weeks
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Lithium Carbonate 300 mg Capsule Sig: Two (2) Capsule PO QHS
(once a day (at bedtime)).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
6. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Last dose on [**2172-10-5**] .
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for sob, wheezing.
9. 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.
10. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
12. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours).
13. Vancomycin 1,000 mg Recon Soln Sig: 1.25 (total 1250mg)
Intravenous q8hrs for 8 days: last dose evening of [**2172-10-5**].
14. [**2172-9-29**]
check vanco trough on [**2172-9-29**] goal 15-20, check ALT, LDH, WBC
15. Risperidone Microspheres 37.5 mg/2 mL Syringe Sig: One (1)
Intramuscular q 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
-cholangitis
-? pancreatic head mass
-sepsis
-bacteremia with klebsiella and enterococcus faecalis
-pneumonia
.
Secondary diagnosis:
-Bipolar d/o
-HTN
-asthma
Discharge Condition:
Stable. No abdominal pain. Satting well on room air. Non
icteric.
Discharge Instructions:
You were hospitalized because you presented to the ED with
concern for cholangitis. You were admitted to the intensive care
unit. An [**Location (un) **] was done and a stent was placed resulting in
resolution of your jaundice. They also found a lot of bacteria
in your blood. You were started on IV antibiotics and your
jaundice improved. One of your antibiotics was switched to an
oral antibiotic. You were also short of breath and required
oxygen but after fluid was taken off you were able breath much
more easily. There was a fluid collection seen on chest x-ray
but your CT scan showed it was too small to drain. It is very
important that you follow up with gastroenterology in regards to
the stents you've needed and the findings of your pancreas
biopsy.
.
You were started on the following new medications:
- Vancomycin 1250mg po q 8hrs (check next trough tomorrow
afternoon, goal 15-20) last dose on [**2172-10-5**]
- Levofloxacin 500 mg PO Q24H last dose on [**2172-10-5**]
-Albuterol 0.083% Neb Soln 1 NEB Inhaled every 6 hours as needed
for shortness of breath or wheeze
-colace and senna prn
-heparin sc 5000 units sc TID
.
You were continued on all your home psych medications.
.
Please seek immediate medical attention if you develop fevers,
chills, cough, abdominal pain, dizziness, inability to tolerate
food, yellow eyes, yellow skin, blood in the stool, diarrhea, or
any new concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2172-9-29**] 1:20
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2172-10-30**] 1:40
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2172-11-12**] 10:00
Completed by:[**2172-9-28**]
|
[
"401.9",
"296.80",
"996.79",
"790.7",
"E878.8",
"041.3",
"486",
"511.9",
"576.2",
"518.0",
"576.1",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.05",
"38.93",
"51.84"
] |
icd9pcs
|
[
[
[]
]
] |
14327, 14432
|
9110, 12475
|
333, 358
|
14654, 14722
|
2751, 3557
|
16190, 16555
|
2067, 2099
|
12660, 14304
|
14453, 14453
|
12501, 12637
|
14746, 16167
|
2114, 2732
|
261, 295
|
3576, 9087
|
386, 1952
|
14605, 14633
|
14472, 14584
|
1974, 2004
|
2020, 2051
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,314
| 121,485
|
30122
|
Discharge summary
|
report
|
Admission Date: [**2135-5-18**] Discharge Date: [**2135-5-30**]
Date of Birth: [**2089-2-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Chest tube placement x2
History of Present Illness:
This is a 46 y/o M with a PMHx of metastatic squamous cell CA
s/p WBXRT and palliative XRT of L/S spine, s/p 2 cycles of
carboplatin/taxol who initially presented to [**Hospital3 **] with c/o
SOB and was found to have a small PTX that was not treated at
the time. Over the past week, he developed progressive dyspnea
on exertion, SOB, and called EMS today. He was taken to [**Hospital **]; found to be hypoxic to 92%RA and in visible distress. A
CXR done at [**Hospital3 **] found a new hydropneumothorax and he was
transferred to [**Hospital1 18**] for further management.
.
In the ED, his initial VS were T 99.0, HR 114, BP 108/77, RR 38,
95%4L. His pulmonary status worsened and he was placed on a NRB
with sats improving to 95-100%. He had a chest tube placed by
thoracics surgery (after receiving 1 bag of platelets for plts
of 50K). This was initially not well positioned and a 2nd chest
tube was also placed. Both were draining serosanguinous fluid
and were placed to suction. He also recieved 1g of CTX IV and MS
4mg IV x2. He experienced transient hypotension to the 90s/50s
and was bolused 1L NS prior to arrival in the MICU.
Past Medical History:
1) Metastatic squamous cell carcinoma of the lung dx'ed in
[**12/2134**]; Received whole brain radiation, palliative radiation of
lumbrosacral spine in 04/[**2134**]. s/p 2 cycles of palliative
chemotherapy with carboplatin and taxol
2) Pulmonary embolism first dx'ed in [**3-12**]; on Lovenox
Social History:
The patient lives with his wife and daughter in [**Location (un) 5503**],
[**State 350**]. He has a 35-pack-year smoking history and quit in
[**2135-3-6**]. He works as a construction worker approximately 40
hours a week. He is originally from [**Country 6257**] and moved to the US
22 years ago. He denies any alcohol use.
Family History:
Brother diagnosed with leukemia at 54.
Physical Exam:
VS: Temp:96.2 BP:112/90 HR:103 RR:15 O2sat: 95% on RA
GEN: Appears in no acute distress, able to speak in full
sentences with a soft tone. Appears fatigued; cachetic.
HEENT: PERRL, EOMI, anicteric, MM dry, op with white plaques
NECK: Jugular veins flat
RESP: Shallow breaths throughout. Left Chest Tube insertion site
without erythema or tenderness
CV: Tachycardic, S1 and S2 wnl, no m/r/g
ABD: thin, NTND, +b/s, soft, no masses or hepatosplenomegaly
EXT: no edema.
SKIN: Petechiae present over bilat LE.
NEURO: AAOx3. Moves all ext spontaenously
Pertinent Results:
[**2135-5-18**] 11:45AM BLOOD WBC-16.1* RBC-4.22* Hgb-12.6* Hct-34.9*
MCV-83 MCH-29.8 MCHC-36.0* RDW-17.4* Plt Ct-54*
[**2135-5-18**] 11:45AM BLOOD Neuts-74* Bands-14* Lymphs-8* Monos-1*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-1* NRBC-1*
[**2135-5-18**] 11:45AM BLOOD Plt Smr-VERY LOW Plt Ct-54*
[**2135-5-18**] 09:09PM BLOOD Fibrino-342
[**2135-5-30**] 01:00AM BLOOD LMWH-0.78
[**2135-5-18**] 11:45AM BLOOD Glucose-88 UreaN-13 Creat-0.4* Na-130*
K-4.3 Cl-88* HCO3-29 AnGap-17
[**2135-5-18**] 11:45AM BLOOD CK(CPK)-130
[**2135-5-19**] 03:24AM BLOOD LD(LDH)-616*
[**2135-5-18**] 11:45AM BLOOD CK-MB-5 cTropnT-<0.01
[**2135-5-18**] 09:09PM BLOOD Calcium-7.3* Phos-4.7*# Mg-1.6
[**2135-5-20**] 05:06AM BLOOD Osmolal-260*
[**2135-5-18**] 09:33PM BLOOD Type-ART Temp-37 pO2-93 pCO2-49* pH-7.39
calTCO2-31* Base XS-3 Intubat-NOT INTUBA
[**2135-5-18**] 02:51PM BLOOD Lactate-2.1*
[**2135-5-18**] 09:33PM BLOOD O2 Sat-96
[**2135-5-18**] 09:33PM BLOOD freeCa-1.06*
[**2135-5-18**] 10:28PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
[**2135-5-18**] 10:28PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2135-5-20**] 07:32AM URINE Osmolal-599
[**2135-5-19**] 07:10AM PLEURAL TotProt-3.5 Glucose-1 LD(LDH)-1474
.
Chest x-ray [**2135-5-18**]-
1) New left chest tube does not lie within small apical
pneumothorax.
2) Known lung malignancy with possible asymmetric edema (or
lymphangitic carcinomatosis) at right lung base.
Chest x-ray [**2135-5-18**] - Moderate to large left hydropneumo- (or
hemopneumo-) thorax superimposed on right upper lobe mass and
bihilar and parenchymal metastatic disease.
.
EKG [**2135-5-18**] - Sinus tachycardia. Possible right atrial
abnormality. No previous tracing available for comparison.
Clinical correlation is suggested.
.
Cytology pleural fluid [**2135-5-18**] - NEGATIVE FOR MALIGNANT CELLS
.
LE dopplers [**2135-5-19**] -Multisited bilateral DVT in the lower
extremities as described. The major clot burden is on the right
side and the patent areas between the popliteal and femoral
bifurcation may represent evacuated areas following pulmonary
embolus.
.
Micro:
Plueral Cx - PLEURAL FLUID L PLEURAL. GRAM STAIN (Final
[**2135-5-18**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO
MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2135-5-21**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2135-5-24**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2135-5-19**]): NO FUNGAL
ELEMENTS SEEN.
.
Blood Cx - AEROBIC BOTTLE (Final [**2135-5-22**]):
REPORTED BY PHONE TO [**Name8 (MD) **] RN AT 1140 ON [**2135-5-19**].
VIRIDANS STREPTOCOCCI. ISOLATED FROM ONE SET ONLY.
GAMMA(I.E. NON-HEMOLYTIC) STREPTOCOCCUS.
ISOLATED FROM ONE SET ONLY.
STREPTOCOCCUS MILLERI GROUP. ISOLATED FROM ONE SET
ONLY.
ANAEROBIC BOTTLE (Final [**2135-5-25**]):
REPORTED BY PHONE TO VASCHES CASTILLIN AT 0855 ON [**2135-5-20**].
ANAEROBIC GRAM POSITIVE ROD(S). UNABLE TO FURTHER
IDENTIFY.
PRESUMPTIVE VEILLONELLA SPECIES. ISOLATED FROM ONE SET
ONLY.
.d
Blood Cx - AEROBIC BOTTLE (Final [**2135-5-24**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2135-5-24**]): NO GROWTH.
Brief Hospital Course:
46 y/o M with a PMHx of metastatic squamous cell CA s/p WBXRT
and palliative XRT of L/S spine admitted with respiratory
distress due to hemo/pneumothorax.
.
1. Hypoxemic Respiratory Failure
Pt had a known hx of a recently diagnosed pneumothorax 1 week
prior at [**Hospital6 **]. In the interim he developed
progressive worsening of respiratory distress and was admitted
for closer monitoring to the ICU. Respiratory decline was
thought to be likely multifactorial from PTX and known pulmonary
tumor burden as well as known thromboembolic disease burden. Two
chest tubes were placed. Re-expansion of lung fields was
visualized post-chest tube placement. Oxygen need continued to
decline and the apical chest tube was removed on HD#2. Thoracics
surgery decided to performe a Doxycycline pleurodeisis through
his chest tube to prevent further accumulation of his hydro/PTX.
Subsequently the second chest tube was removed. The pt continued
to improve in regards to his respiratory status and required no
more oxygen on discharge.
.
2. Pulmonary Embolism
LENIs done on HD#2 showed large burden of bilateral LE clot
despite being on Lovenox. This likely represented a
breakthrough clot despite anticoagulation and was most likely
due to his cancer. Oncology felt that placing an IVC filter was
not clinically indicated given his overall poor prognosis, and
after a discussion with the pt and family, he agreed not to
proceed with an IVC filter placement. Continued Lovenox 80mg SC
bid for treatment of PE/DVTs.
.
3. Metastatic Squamous Cell CA
Followed by thoracic oncologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. On
Carboplatin/Taxol as an outpatient, s/p 2 cycles. Given his
clinical picture, the tumor appears to be progressing despite
treatment. Hospice discussion was broached with pt in
discussions with oncology. Dexamethasone 4mg [**Hospital1 **] taper for
likely prevention of brain edema given mets was started with
Bactrim given for PCP prevention while on steroids. Family
initially considered placement in a rehabilitation facility but
given his continued worsening functional status, decided to have
the patient return home on hospice.
.
5. Hyponatremia
Profoundly dehydrated on admission, with Na 130, Cl 88. Tachy
to the 110s, BP stable. Given 1L NS in ED. s/p 8L NS hydration
on arrival to ICU. On HD#2, developed Na drop to 125. Serum
Osm 260, Uosm 600 which makes SIADH most likely. Likely due to
brain metastases as well as lung CA. Free water restrict given
SIADH and demeclocycline were started.
.
6. Thrombocytopenia
Due to chemo regimen; s/p 1u plts in ED prior to CT placement
.
7. Elevated WBC:
No evidence of PNA on CXR Likely due to chronic steroid
therapy. Bcx, urine cx and pleural fluid cx were all sterile,
except for 2 bottles on Bcx that showed mixed flora, which was
presumed to be a contaminant. Antibiotics were discontinued
after 1 dose given in the ED.
.
8. Code Status: DNR/DNI
Medications on Admission:
Morphine sulfate extended release 60 mg p.o. t.i.d.
morphine sulfate immediate release 15 mg p.o.q.1-2h. p.r.n. pain
Coumadin 5 mg p.o. daily
dexamethasone 4 mg p.o. q.8h.
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*1*
2. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*1*
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
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:*1*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*1*
7. Demeclocycline 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
8. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*1*
9. Megestrol 40 mg/mL Suspension Sig: One (1) PO BID (2 times a
day).
Disp:*600 ml * Refills:*1*
10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*30 cups* Refills:*1*
11. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-7**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
Disp:*1 inhaler* Refills:*0*
13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*1*
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-7**] Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*1*
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
16. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO four times a day as needed for nausea.
Disp:*120 Tablet, Rapid Dissolve(s)* Refills:*1*
17. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
dddddddddddddddddPrimary:
Metastatic squamous cell carcinoma of the lung
Hydropneumothorax
SIADH
Anemia/Thrombocytopenia
DVT/PE
Discharge Condition:
home with hospice, tolerating po intake, no oxygen requirement
Discharge Instructions:
You were treated in the hospital for fluid in your lung which is
a complication of your metastatic lung cancer.
.
Please return to the hospital if you have worsening shortness of
breath, high fevers or any other concerns.
Followup Instructions:
Please call Dr.[**Name (NI) 8949**] office to make an appointment in the
next 2 weeks and if you have any questions about adequacy of
pain management.
|
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4,787
| 109,022
|
2479
|
Discharge summary
|
report
|
Admission Date: [**2123-6-11**] Discharge Date: [**2123-6-23**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Acute on chronic renal failure
Major Surgical or Invasive Procedure:
Intubation, Extubation
Placement of nephrostomy tube on left and a stent of right
ureter
Irrigation and debridement of right wrist
History of Present Illness:
79yoM with h/o OSA, CAD s/p MI and CVA, diastolic CHF admitted
to [**Hospital1 18**] [**Date range (1) 12728**] with sepsis secondary to Klebsiella
bacteremia, admitted again on [**6-11**] to Urology service from rehab
with acute renal failure, transferred to MICU [**6-12**] with MRSA
bacteremia, ARF, and respiratory failure.
.
Patient was admitted [**Date range (1) 12728**] with sepsis due to Klebsiella
bacteremia. Source of Klebsiella infection was not known, but
was thought to be from pneumonia seen as retrocardiac opacity on
CXR. Urinalysis was negative at that time. He was intubated
during that admission for airway protection and hypercarbic
respiratory failure. Although he has OSA, he is not a CO2
retainer. He was discharged to [**Hospital3 **] to complete at
14day course of levofloxacin, to which the Klebsiella (from
culture at [**Hospital 4199**] Hospital) was sensitive. During his initial
presentation he did develop ARF with creatinine up to 2.8 from
baseline of 1.7-1.9. Creat returned to baseline during the
hospitalization. It rose to 2.0 prior to discharge after ACE-I
was restarted.
.
He was transferred to [**Hospital1 18**] ED [**2123-6-11**] after two days of
intermittent right sided abdominal pain, decreased urine output,
anorexia, and temp spike to 101. According to the patient's
wife, he did not feel himself soon after admission to rehab,
refusing to eat, being lethargic and unwilling to participate in
rehab activity. In the ED patient found to have ARF with creat
7.3, [K+] 5.1. CT showed right UVJ stone, right perinephric
stranding, left ureteral stone, and hydronephrosis. He was
admitted to Urology service and underwent left percutaneous
nephrostomy tube placement. He was also found to have UTI and
was started empirically on Vanc/Levo/Ceftriaxone. Urine culture
and blood cultures (4/4 [**6-11**]) grew MRSA, and CTX/Levo were
discontinued [**2123-6-13**]. Despite nephrostomy tube placement,
patient continued to have ongoing oliguric renal failure, which
renal felt was due to persistant obstruction vs ATN. He was not
hemodialyzed.
.
On [**2123-6-14**] he underwent right ureteral stent placement,
retrograde pyelography, and removal of stones. He remained
intubated post-operatively.
On [**2123-6-17**]- Pt also complained of right wrist pain/swelling and
subsequently was found to have septic wrist. This was irrigated
and debrided on [**6-17**]. Cultures positive for MRSA.
On [**2123-6-19**], pt was extubated.
On [**2123-6-20**], pt transferred to CC-7A. Reported feeling weak.
Denied HA, dizziness, chest pain,palpatations, SOB, cough,
abdominal pain, constipation, diarrhea, edema.
Past Medical History:
CVA - [**2117**] with residual right-sided weakness
post-concussive syndrome
OSA - on 2L NC during day and night; refused home CPAP
CAD - s/p MI in 3 yrs ago
CHF - diastolic dysfunction
Anemia - [**8-24**] EGD with gastritis, colonoscopy with
diverticulosis
Depression
s/p right shoulder surgery
s/p knee replacement
s/p bilateral nephrostomy tube placement
Social History:
He lives with his wife; daughter lives downstairs.
Tob: h/o cigarrette smoking, quit 22yrs ago
EtOH: denies
Family History:
h/o prostate cancer and hemorrhagic stroke
son d. MI at 50yrs
broth d. complications of TIIDM
Physical Exam:
VS T P BP RR O2 sat
Gen- Obese male, lethargic, nodding off during exam, NAD
HEENT- AT, NC, PERRLA, EOMI, sclera anicteric, MMM, oropharynx
clear
Neck- large neck, no JVD or LAD
Cor-RRR, no MGR
Lungs- coarse breath sounds-upper airways, posteriorly CTA B/L
Abd- obese, nontender, nondistended, + BS, no HSM or masses,
nephrostomy site-no erythema, induration or oozing from site
Extrem- right wrist wrapped in bandage-clean/dry/intact, no
edema of lower extremeties
neuro-CN grossly intact, sensation intact, strength diminished
on R side-both upper and lower [**3-24**].
Pertinent Results:
Imaging:
[**2123-6-19**] post-extub CXR: Endotracheal tube has been removed.
Feeding tube and left PICC line remain in place. Cardiac and
mediastinal contours are stable. Left lower lobe atelectasis is
slightly improved. Moderate left effusion is unchanged
[**2123-6-16**] echo: The left atrium is mildly dilated. The left
ventricular cavity size is normal.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal
(LVEF>55%). The right ventricle may be mildly dilated. Right
ventricular
systolic function is normal. The aortic valve leaflets (3) are
mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation
is seen. The mitral valve leaflets are mildly thickened. The
tricuspid valve
leaflets are mildly thickened. There is no pericardial effusion.
[**2123-6-13**] CT Abd/pelvis
1. Status post left nephrostomy. New 1.2-cm oval-shaped focal
density, which may be related to recent nephrostomy. Persistent
left ureteral stone and right obstructing UVJ stone, measuring 3
mm with hydronephrosis and hydroureter. No obstructing right
renal stones.
2. Heterogeneous density of the kidneys, especially on the
right, with 2.6 cm high-dense focal lesion. As suggested on the
prior study, these lesions can be further evaluated by
ultrasound.
3. Persistent fat stranding along the ascending colon, unchanged
compared to the prior study.
4. Limited study without intravenous contrast [**Doctor Last Name 360**]. Ectatic
appearance of iliac bifurcation.
Micro:
[**2123-6-19**] CATHETER TIP-IV Source: left SC TLC.
WOUND CULTURE (Preliminary): No significant growth.
[**2123-6-17**] 5:00 pm SWAB Site: ARM RIGHT WRIST WOUND.
GRAM STAIN (Final [**2123-6-17**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2123-6-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
[**6-15**] and [**6-16**]- blood cultures x 2 negative
[**2123-6-15**]
GRAM STAIN (Final [**2123-6-15**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2123-6-17**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12729**] [**2123-6-16**] AT 12PM.
STAPH AUREUS COAG +. SPARSE GROWTH.
[**6-11**] bld Cx positive for coag + staph
[**6-12**] urine Cx positive for coag + staph
[**6-12**] positive MRSA screen
Brief Hospital Course:
MICU course:
Pt was admitted to the MICU after he underwent R ureteral stent
placement, but became difficult to wean from the vent
post-operatively, and also was found to have MRSA bacteremia.
He also grew out MRSA from his urine as well, and also from his
R wrist. He was treated with vancomycin, dosed for level<15.
Plastic surgery was consulted for his R septic wrist, and he
went to the OR for washout of this joint. He had a TTE, which
was negative for vegetation. Surveillance cultures were
negative x 3 days. Pt continued to be in ARF, despite R
ureteral stent placement and L percutaneous nephrostomy. Renal
service was consulted, and pt was believed to have ARF secondary
to both recent obstructions as well as ATN. His diuretics were
held, and his Cr began to improve. He then progressed into the
post-obstructive diuresis phase, and renal service signed off.
His meds were renally dosed during this time. Pt was extubated
on [**2123-6-19**], and tolerated extubation well. Pt was restarted on
metoprolol and norvasc, but his ACEI and Lasix continued to be
held. He was continued on ASA and Plavix during his MICU stay.
He became hypertensive to 150's-160's during the end of his MICU
course, and his metoprolol was uptitrated. Pt was maintained
nutritionally by tube feeds while intubated, but began to have
thickened liquids after extubation. Pt had minor R leg pain
prior to leaving the ICU, but this pain resolved spontaneously.
RLE u/s was negative for DVT. Of note, pt repeatedly had his
NGT curled in his upper esophagus, despite repeated attempts at
replacement. This may suggest an abnormality in his upper
esophagus, which could be evaluated in the future.
.
.
1. Acute renal failure- The pt has a baseline creatinine of
1.7-1.9. On the last admission to the hospital on [**6-4**], pt had
creatinine rise to 2.8. This returned to 2.0 upon discharge to
rehab facility. On presentation for this hospitalization [**6-11**],
the pt was found to have a creatinine of 7.3 and K of 5.1. On CT
scan, pt found to have obstructing R UVJ stone and left ureteral
stone. He underwent left percutaneous nephrostomy and placement
of right stent. He was also found to have MRSA UTI and is being
treated with vancomycin. Despite nephrostomy tube placement and
stent, pt continued to have renal failure. This was thought to
be due to persistent obstruction and ATN. He was never dialyzed.
His creatinine has been trending down daily and is currently 3.8
and improving. He will need to follow-up with urology, Dr. [**Last Name (STitle) 4229**]
in [**12-21**] weeks.
.
2. MRSA [**Name (NI) 12007**] Pt is currently on day 9 of vancomycin.
.
3. MRSA bacteremia- positive blood cultures on [**6-11**].
Surveillance cultures on [**6-15**] and [**6-16**] were negative and [**6-17**]
blood cultures are negative to date. Given his septic wrist, he
needs to continue vancomycin for a total 4 week course(start
date [**2123-6-14**]) with daily vanc troughs checked given his ARF.
.
4. Septic wrist- S/P surgical irrigation and debridement. Wound
not erythematous or indurated. Cultured positive for MRSA. Last
wound Cx on [**6-17**] showed coag neg staph. [**6-19**] Wound catheter tip
negative. Pt needs to have 4 week course of vancomycin, start
date [**2123-6-14**]. Daily vanc troughs need to be checked with dosing
for levels<15.
.
5. Respiratory failure- pt intubated during surgery and could
not be extubated until [**2123-6-19**]. Tolerated extubation well.
Maintained on his home O2 dose of 2L continuous. )
.
6. [**Name (NI) 12730**] Pt usually wears CPAP at night, but was not very good
about using it at home. After intubation, he had CPAP 13 mm Hg
QHS.
.
7. CAD S/P MI 3 years ago and CVA in [**2117**] with residual R sided
weakness. No active issues currently. We continued ASA, Plavix,
Metoprolol, statin.
.
8. Diastolic CHF- Echo shows EF 55%. Pt has resolving left
pleural effusion. No JVD, crackles or LE edema on exam. CXR
showed mod left effusion is unchanged from previous studies
today. We did not need to give lasix as patient was in diuresis
phase of ATN. We continued betablocker and held aceI for ARF.
.
9. [**Name (NI) 3674**] Pt has history of iron deficiency anemia. Stools were
guaic negative. Crit stable throughout hospitalization, although
his Hct on discharge was at 24.6. He was given one unit of PRBC
for goal Hct>25, and needs to have a post-transfusion Hct drawn
tonight.
Medications on Admission:
Meds on Admission:
Levofloxacin 250mg po daily
Plavix 75mg daily
ASA 325mg daily
Fluoxetine 20mg daily
Zestril 5mg daily
Iron sulfate 325mg daily
Protonix 40mg daily
Multivitamin
Lopressor 50mg TID
Norvasc 5mg daily
.
Meds on Transfer:
Lasix 80mg iv BID
Propofol gtt
Metoprolol 50mg TID
Famotidine 20mg iv daily
Plavix 75mg daily
ASA 325mg daily
Fluoxetine 20mg daily
Fentanyl gtt
Heparin SC
Colace 100mg [**Hospital1 **]
Humalog insulin sliding scale
Haldol 3-4mg iv prn
Trazodone 25mg prn HS
Calcium gluconate prn
Albuterol prn
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Ten (10)
ML PO Q8H (every 8 hours).
7. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
12. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
15. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. Insulin
Continue insulin as detailed in the sliding scale sheet.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary - MRSA bacteremia, MRSA septic wrist, MRSA UTI, ARF
Secondary - CAD, CHF, Iron deficiency anemia, h/o CVA, h/o OSA
Discharge Condition:
Stable, afebrile and improving Cr
Discharge Instructions:
-continue all medications as prescribed
-please follow-up with appointments as listed below
-continue Vancomycin for a total of six weeks (start date [**6-14**])
-daily vancomycin troughs need to be checked, beginning tomorrow
-you need to have a post-transfusion hematocrit checked tonight,
as you received blood today
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] 2 weeks for follow-up.
Completed by:[**2123-6-29**]
|
[
"428.0",
"518.81",
"V09.0",
"041.11",
"038.11",
"592.1",
"591",
"711.03",
"995.92",
"285.9",
"428.30",
"599.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.42",
"55.03",
"96.72",
"87.74",
"82.21",
"38.93",
"59.8",
"96.6",
"56.0"
] |
icd9pcs
|
[
[
[]
]
] |
13263, 13333
|
6955, 11374
|
345, 477
|
13501, 13537
|
4392, 6029
|
13906, 14023
|
3690, 3785
|
11955, 13240
|
13354, 13480
|
11400, 11405
|
13561, 13883
|
3800, 4373
|
274, 307
|
6061, 6932
|
505, 3166
|
11419, 11618
|
3188, 3547
|
3563, 3674
|
11636, 11932
|
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