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46,619
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34451
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Discharge summary
|
report
|
Admission Date: [**2108-4-29**] Discharge Date: [**2108-5-3**]
Date of Birth: [**2039-6-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4373**]
Chief Complaint:
GIB
Major Surgical or Invasive Procedure:
port removed
History of Present Illness:
History from MICU admit note, OMR, MICU team and conversation
with pt and wife c translator present.
.
Per MICU admit note, confirmed c pt: "This is a 68 yo Vietnamese
speaking male with history of locally advanced pancreatic cancer
on home hospice who presents with 2 days of BRBPR. Patient had
one bright red BM the evening of [**4-27**]. The next am he had
another 4 BMs that he also describes as bright red and later in
the evening passed 5 more BMs which were darker and nearly
black. He denies any hematemasis. He did have some mild abd pain
yesterday and felt febrile with chills. No nausea or vomiting.
No CP or palpitations. Patient did feel lightheaded prior to
coming to the hospital today.
.
Notably, patient had GI bleed back in [**1-17**] while on vacation.
He reports less BRBPR than the present episode. He presented to
his oncologist a few days after bleeding with Hct of 19.8. He
underwent EGD [**2-19**] showing gastritis and colonoscopy at the same
time that was normal."
.
In the MICU pt had minimal bleeding and hct remained stable. NG
lavage had bilious return c resolution of abd pain so ngt left
in overnight to suction. Pt had brb on rectal exam. He was seen
by GI who are planning for EGD tomorrow to evaluate for erosion
of tumor into the duodenum which they believe is the most likely
etiology of bleeding.
.
ROS: Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, dysuria, hematuria.
Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
- GERD
- hyperlipidemia
- non-resectable pancreatic adenocarcinoma dx [**8-/2106**] by CT, s/p
gemcitabine, capecitabine and oxaliplatin as well as cyber
knife. Decision to pursue hospice [**2108-4-9**].
Social History:
Home with hospice since [**2108-4-9**]. No smoking tobacco or alcohol.
Lives with his wife and his son's family.
Family History:
noncontributory
Physical Exam:
Vitals - 97.9 136/80 66 20 98%RA
GENERAL: cachectic appearing male, resting comfortably, NAD
HEENT: NC/AT, pale conjunctiva, PERRL, MMM, NG tube in place
CARDIAC: s1/s2 present, no m/r/g
CHEST: L porta cath in place
LUNG: crackles at right base, otherwise clear
ABDOMEN: +BS, distended, no tenderness to palpation
EXT: no LE edema, 2+ distal pulses, extremities cool
NEURO: AOx3
DERM: no skin lesions
Pertinent Results:
[**2108-4-29**] 10:41PM WBC-5.1 RBC-3.31* HGB-10.2* HCT-28.8* MCV-87
MCH-30.9 MCHC-35.6* RDW-16.4*
[**2108-4-29**] 10:41PM PLT COUNT-175
[**2108-4-29**] 10:41PM PT-14.8* PTT-30.1 INR(PT)-1.3*
[**2108-4-29**] 05:06PM GLUCOSE-82 UREA N-11 CREAT-0.6 SODIUM-137
POTASSIUM-3.3 CHLORIDE-107 TOTAL CO2-21* ANION GAP-12
[**2108-4-29**] 05:06PM ALT(SGPT)-29 AST(SGOT)-40 LD(LDH)-173 ALK
PHOS-365* TOT BILI-3.0*
[**2108-4-29**] 05:06PM ALBUMIN-2.8* CALCIUM-7.2* PHOSPHATE-2.6*
MAGNESIUM-1.5*
[**2108-4-29**] 05:44PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2108-4-29**] 05:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
CT torso: IMPRESSION:
1. No evidence of bowel perforation or free intra-abdominal air.
2. Stable appearance of pancreatic head mass consistent with
history of
pancreatic adenocarcinoma. Stable encasement of superior
mesenteric artery
and occlusion of the superior mesenteric vein.
3. Mild intrahepatic biliary dilatation, improved since the
previous study.
4. Ascites has increased since the previous CT of [**2108-3-12**] and
probably also increased since the paracentesis ultrasound of
[**2108-4-25**].
b/l lower extremity u/s: IMPRESSION:
Complete thrombosis of the left peroneal vein with extension
into the
popliteal vein at which point the thrombus is nearly but not
entirely
occlusive.
L upper extremity ultrasound: IMPRESSION: Nonocclusive left
axillary vein thrombosis.
EGD: A metal stent was seen in the duodenum.
Friability in the duodenal bulb (thermal therapy)
Previous gastrojejunostomy of the stomach, 4mm non-bleeding
ulcer noted at anatomosis site.
Otherwise normal EGD to jejunum
Brief Hospital Course:
# GI Bleed: Pt recieved 4U prbcs on the day of admission, after
which time hct remained stable. Pt had normal [**Last Name (un) **] [**2-19**] and EGD
in [**2-19**] showing just gastritis. Pt had CT abd/pelvis which
showed a similar tumor burden. On EGD, a bleeding friable area
was found that seemed consistent with progression of tumor into
duodenum, which had been a concern during pt's prior GIB in
[**1-17**]. This area was cauterized. The possibility of further
intervention was discussed with IR who felt that this would be
inappropriate unless pt bleeds again (given risk of adverse
effects from embolization). However, pt's goals of care
transitioned increasingly towards comfort (see below) and pt did
not re-bleed. Also noted was a small stomach ulcer. Pt was
started on [**Hospital1 **] pantoprazole and h pylori antibody was checked
and was negative.
.
# L axillary clot: Pt noted to have swollen L arm and was found
to have L axillary clot, likely [**3-13**] port which had been in since
[**1-16**]. Port was dced on [**2108-5-2**].
.
# LLE DVT: Pt noted to have LLE edema and ultrasound showed DVT.
Discussed possibility of filter with family but they prefer to
not do any extra procedures given current goals of care.
.
# Abd Pain: Pt with abd pain and nausea on admission, no acute
pathology on abd CT. Pt reported feeling bloated which improved
after NGT on suction. NGT was discontinued on HD2 and pt did not
have recurrence of abd pain.
.
# Elevated INR: INR 1.5 on admission, he received 4 units FFP in
ED in the setting of active GIB. His INR remained in the 1.3-1.5
range throughout admission.
.
# Ascites: Likely [**3-13**] pancreatic ca. Pt gets regular outpt
paracentesis by IR. Pt had drain for ascites placed on [**2108-5-1**]
and 1L ascitic fluid removed at that time. Plan to drain prn for
comfort.
.
# Increased Alk Phos/Tbili: Likely [**3-13**] his cancer, trending down
from previous baseline. Notably, biliary ductal dilatation
mildly improved from CT [**3-21**].
.
# Pancreatic Cancer: Per discussion with outpt providers, there
is no more treatment available.
.
# Goals of care: Long family discussion today. Aim to orient
care for comfort. Pt did not like home hospice as does not want
to die at home. Please see note below for full account of
conversation. A note was posted to the electronic medical record
by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4151**] on [**2108-5-2**] regarding this meeting.
Medications on Admission:
Tylenol
Creon
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain: hold for sedation. rr<12.
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
4. Creon 12,000-38,000 -60,000 unit Capsule, Delayed
Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO
three times a day: with meals.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) 1495**] [**Hospital 11042**] Rehab in [**Location (un) 686**]
Discharge Diagnosis:
primary: pancreatic cancer, GI bleed, RLE DVT, L axillary DVT
Discharge Condition:
Mental Status: Confused - sometimes
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted for bleeding with your bowel movements. We
looked in your stomach and think that the bleeding was coming
from your tumor which has spread into your small intestines. We
discussed this with you and also discussed that there is no
further treatment that the oncologists are able to do for your
cancer. Given this information, you decided to pursue hospice
care. You also did not want to die at home since you have young
children at home. THus we arranged for you to go to [**First Name8 (NamePattern2) **] [**Doctor Last Name 11042**]
which is very near your home and you will be able to get hospice
care there.
While you were here we also noticed that you had a clot in your
leg. We offered to place a filter in your veins to prevent the
clot from going to your lungs, you decided that going through
this procedure was not worth the discomfort. We also noticed a
clot around your port. Since you don't need the port anymore, we
took it out. Lastly, we placed a drain so that you can have the
fluid in your belly drained without needing to come to the
hospital.
Followup Instructions:
You will be followed by the hospice nurses and doctors as [**Name5 (PTitle) **]
as the doctors [**First Name (Titles) **] [**First Name8 (NamePattern2) **] [**Name5 (PTitle) 11042**].
Completed by:[**2108-5-5**]
|
[
"197.4",
"453.40",
"272.4",
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"E879.8",
"996.74",
"157.0",
"285.1",
"578.9",
"789.51",
"453.83",
"530.81",
"534.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.05",
"44.43",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
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|
4487, 6952
|
317, 332
|
7709, 7709
|
2743, 4464
|
8962, 9176
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2289, 2306
|
7017, 7462
|
7624, 7688
|
6978, 6994
|
7859, 8939
|
2321, 2724
|
274, 279
|
360, 1882
|
7724, 7835
|
1904, 2143
|
2159, 2273
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,026
| 102,103
|
2980+2981+55427
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2153-6-6**] Discharge Date: [**2153-6-23**]
Date of Birth: [**2083-5-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
altered mental status/hepatic encephalopathy
Major Surgical or Invasive Procedure:
diagnostic paracentesis
therapeutic paracentesis
tunneled HD catheter
hemodialysis
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old man with ETOH cirrhosis complicated
by HCC s/p RFA, DM2, CAD, PVD and CRI admitted from clinic on
[**2153-6-6**] with general debility, hepatic encephalopathy, dyspnea
on exertion, abdominal ascites and peripheral edema. Patient was
seen by Dr. [**Last Name (STitle) 497**] who determined that he has slow onset
encephalopathy grade I based on the symptoms he has described
over the few days prior to admission. Patient stateed that he
has felt more confused for the week prior to admission, as well
as more argumentative. Also states that one of his children was
concerned about his driving. Reports very poor appetite because
"food does not taste good". He had a CT chest on [**2153-6-6**] which
showed bilateral upper lobe opacities concerning for infection.
REVIEW OF SYSTEMS: Positive per HPI. Also reports having
hemorrhoids with occasional bright red blood when he wipes after
a BM. Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. HCC: CT abdomen [**2151-9-23**] revealed a segment IV 2.2
x 2.2 cm enhancing lesion concerning for HCC. This was confirmed
by [**Year (4 digits) 950**] on [**2151-10-1**], demonstrating a segment IV
hypoechoic 2.3 x 1.7 x 2.6 cm, hypovascular mass. He underwent
RFA of this lesion on [**2151-10-27**] without complications. s/p RFA
[**2151-10-27**].
2. ETOH cirrhosis
3. DM2: was on oral hypoglycemics but these were discontinued
with no need for further intervention at this time.
4. CAD: Radionucleotide cardiac perfusion study done [**2151-12-23**]
demonstrating normal LV myocardial perfusion and LV systolic
function with LVEF of 61%
5. PVD with left iliac stenting and fem-fem bypass in [**Month (only) 116**] and
[**2150-8-25**]. These were infected and patient had two surgeries in
[**2150-11-24**] to remove the fem-fem bypass graft and had left
femoral angioplasties.
- hx of infected femoral graft for which he is on
dicloxacillin suppression
6. Hypertension.
7. Bell's palsy: unclear etiology; reports noting a tick on his
body after walking in the [**Doctor Last Name 6641**] while on [**Location (un) **] 2 months prior
to the onset of the Bell's Palsy; Lyme serologies were negative
at the time; no further manifestations of Lyme disease and near
resolution of the [**Name (NI) 14245**] ptosis from the Bell's.
8. CCY in [**2114**]
9. Cystoscopy in [**2148**] showed a bladder polyp that was
premalignant. This was removed and followup cystoscopy in
[**2150-1-25**] was negative.
Social History:
Previous significant alcohol use, but quit drinking in [**2149-6-24**]
after a GI bleed. He is a former smoker (reports that he quit in
the [**2120**]) and denies any illicit substance use. He works as a
computer facilities control person. He lives with his wife and
adult autistic son. [**Name (NI) **] 2 daughters.
Family History:
Liver disease in his grandfather, which was not thought to be
related to alcohol. He also reports multiple nieces and nephews
with cognitive issues without a clear diagnosis.
Physical Exam:
Physical Exam on Admission:
VS: 97.2, 113/51, 66, 20, 99%RA
GENERAL: NAD, tired appearing M who appears stated age
HEENT: Sclerae anicteric. PERRL, EOMI.
NECK: Supple, did not appreciate elevated JVP
CARDIAC: RRR, no M/R/G, nl S1, S2
LUNGS: CTAB, no crackles, wheezes or rhonchi. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use, moving air well and symmetrically.
ABDOMEN: obese, distended, soft, non-tender to palpation.
Dullness to percussion over dependent areas but tympanic
anteriorly. No HSM or tenderness. +fluid wave c/w ascites
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 3+
LE pitting edema bilaterally to knees. 1+ DP/PT pulses
bilaterally.
NEURO: A+O x 3, slow to respond to questions with somewhat
slurred speech, +asterixis, slight R-sided facial droop c/w
known Bell's palsy
.
Pertinent Results:
Labs on Admission:
[**2153-6-7**] 05:14AM BLOOD WBC-1.8* RBC-2.94* Hgb-9.9* Hct-30.0*
MCV-102* MCH-33.8* MCHC-33.2 RDW-16.9* Plt Ct-81*#
[**2153-6-7**] 05:14AM BLOOD PT-23.7* PTT-41.1* INR(PT)-2.3*
[**2153-6-7**] 05:14AM BLOOD Glucose-100 UreaN-44* Creat-2.2* Na-135
K-3.8 Cl-106 HCO3-23 AnGap-10
[**2153-6-7**] 05:14AM BLOOD ALT-37 AST-99* LD(LDH)-140 AlkPhos-118
TotBili-8.4* DirBili-5.6* IndBili-2.8
[**2153-6-7**] 05:14AM BLOOD Albumin-2.5* Calcium-8.0* Phos-3.6 Mg-1.9
[**2153-6-7**] 05:14AM BLOOD Ammonia-133*
[**2153-6-8**] 05:45AM BLOOD AFP-2.5
Peritoneal fluid
[**2153-6-6**] 11:47PM ASCITES TOT PROT-1.5 ALBUMIN-LESS THAN
[**2153-6-6**] 11:47PM ASCITES WBC-35* RBC-235* POLYS-8* LYMPHS-28*
MONOS-7* MACROPHAG-57*
[**2153-6-6**] 01:07PM CREAT-2.2*
Microbiology:
[**2153-6-6**] 11:47 pm PERITONEAL FLUID
**FINAL REPORT [**2153-6-13**]**
GRAM STAIN (Final [**2153-6-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2153-6-10**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2153-6-13**]): NO GROWTH.
[**2153-6-7**] 8:23 am [**Month/Day/Year 14246**] Source: CVS.
**FINAL REPORT [**2153-6-9**]**
[**Month/Day/Year 14246**] CULTURE (Final [**2153-6-9**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2153-6-9**] 10:00 pm [**Month/Day/Year 14246**] Source: CVS.
**FINAL REPORT [**2153-6-12**]**
[**Month/Day/Year 14246**] CULTURE (Final [**2153-6-12**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2153-6-13**] 3:11 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT [**2153-6-19**]**
GRAM STAIN (Final [**2153-6-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2153-6-16**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2153-6-19**]): NO GROWTH.
[**2153-6-13**] 3:11 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT [**2153-6-19**]**
Fluid Culture in Bottles (Final [**2153-6-19**]): NO GROWTH.
Imaging:
[**2153-6-6**] CT CHEST W/O CONTRAST
FINDINGS:
New consolidations in the posterior segment left upper lobe (4,
53), in the right upper lobe (4: 52, 91), are most likely
infectious in etiology. Pericardial opacities in the right
middle lobe could be atelectasis or infection. 1 mm right upper
lobe lung nodule (4, 35) is stable, 1 mm lung nodule in the
right middle lobe is also stable. Subpleural 3 mm lung nodule in
the right upper lobe is new (4, 95). There are scattered
calcified granulomas. Small right pleural effusion and adjacent
atelectasis is new. There are few calcified pleural plaques (4,
118).
There is gynecomastia. Mediastinal lymph nodes do not meet CT
criteria for pathologic enlargement. Dense calcifications are
again noted in all coronary arteries. Mild calcification of the
aortic valve is of unknown hemodynamic significance. Trace
pericardial effusion is unchanged and physiologic. Tiny
epicardiac lymph nodes are again noted. This examination is not
tailored for subdiaphragmatic evaluation. For a more detailed
description of abdominal findings, please refer to concurrent MR
of the abdomen. There are no bone findings of malignancy.
IMPRESSION:
1. Multifocal bilateral opacities mostly likely infectious in
etiology. Other tiny lung nodules are stable.
2. Coronary calcifications.
[**2153-6-6**] BONE SCAN
INTERPRETATION: Whole body images of the skeleton obtained in
anterior and posterior projections show no abnormal areas of
tracer uptake. On the anterior projection, there is reduced
uptake in the spine and kidneys, unchanged, secondary to large
volume ascites as seen on the MRI of the abdomen done today. The
kidneys and urinary bladder are visualized, the normal route of
tracer excretion.
IMPRESSION:
No evidence of osseous metastatic disease.
[**10/2152**] EGD
- One column of nonbleeding grade I varices were seen in the
lower esophagus.
- There was erythematous and nodular mucosa at the antrum. There
was no evidence of active bleeding. No ulcer was seen.
- Mild non-bleeding portal hypertensive gastropathy was seen in
the body of stomach. There was no gastric varices.
- The mucosa at the duodenal bulb appeared erythematous and
nodular. There was no evidence of active bleeding. There was no
evidence of varices.
- Otherwise normal EGD to third part of the duodenum.
MRI abd w/ and w/o contrast:
1. Nodular cirrhotic liver with evidence of portal hypertension
with splenomegaly, ascites, recanalization of paraumbilical
vein.
2. 12-mm focus of arterial enhancement with washout and T2
correlate, lateral to the previously ablated lesion within
segment [**Doctor First Name **], which is concerning for a focus of HCC. A 7 mm
nodule within segment II, which demonstrates arterial
enhancement and washout but without T2 correlate is also very
suspicious. Close surveillance of these lesions is recommended.
3. New multiple nodular foci within segment VI with arterial
enhancement, no T2 correlate or washout identified. These arhave
intermediate concern given nodular nature. Continued
surveillance recommended.
4. Simple bilateral renal cysts.
Renal US [**2153-6-9**]
1. No evidence of hydronephrosis. Right renal cysts,
characterized as simple on MR exam of [**2153-6-6**].
2. Large amount of ascites.
Urinalysis:
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2153-6-9**] 10:00PM [**Month/Day/Year 14246**] Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.015
[**2153-6-7**] 08:23AM [**Month/Day/Year 14246**] Color-AMBER Appear-Clear Sp [**Last Name (un) **]-1.014
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-NEG
[**2153-6-9**] 10:00PM [**Month/Day/Year 14246**] Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-NEG
[**2153-6-7**] 08:23AM [**Month/Day/Year 14246**] Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.5 Leuks-NEG
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] RBC-1 WBC-26* Bacteri-FEW Yeast-NONE
Epi-<1
[**2153-6-9**] 10:00PM [**Month/Day/Year 14246**] RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] CastGr-29* CastHy-28*
[**2153-6-9**] 10:00PM [**Month/Day/Year 14246**] CastHy-18*
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] Eos-NEGATIVE
Discharge Labs:
[**2153-6-23**] 05:20AM BLOOD WBC-1.5* RBC-2.56* Hgb-8.7* Hct-26.2*
MCV-102* MCH-34.2* MCHC-33.4 RDW-18.1* Plt Ct-84*
[**2153-6-23**] 05:20AM BLOOD PT-23.6* PTT-46.8* INR(PT)-2.3*
[**2153-6-23**] 05:20AM BLOOD Glucose-92 UreaN-38* Creat-3.2* Na-135
K-4.0 Cl-98 HCO3-27 AnGap-14
[**2153-6-23**] 05:20AM BLOOD ALT-27 AST-104* AlkPhos-99 TotBili-6.1*
[**2153-6-23**] 05:20AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.7 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname **] is a 70 year old man with ETOH cirrhosis complicated
by HCC s/p RFAk encephalopathy, ascites, grade I varices, DM2,
CAD, PVD and CRI admitted from clinic today with hepatic
encephalopathy and acute kidney injury.
.
# Hepatic Encephalopathy: Patient presented with increased
irritability for 1 week and determined to have slow onset grade
I encephalopathy. He was found to have community-acquired
pneumonia given bilateral upper lobe opacities seen on [**2153-6-6**]
CT chest. Diagnostic para ruled out SBP. U/A neg but [**Date Range **]
culture + proteus, treated CAP with levofloxacin, and proteus
was sensitive to that as well. Continued home lactulose 30mg PO
TID and 30mg PO Q4H and rifaximin 550mg [**Hospital1 **]. Encephalopathy
cleared on lactulose and rifamixin over the course of the
hospital stay.
.
# ETOH Cirrhosis: Complicated by hepatic encephalopathy,
ascites, portal hypertensive gastropathy and HCC s/p RFA. Was
found to have non-bleeding grade 1 varices on EGD 11/[**2151**]. Does
have what is concerning for HCC recurrence in several regions on
MRI abd. AFP 2.5. Patient was discussed and tumor board and was
approved to be placed on transplant list. Transplant surgery was
following. Initially, diuretics (lasix and spironolactone) were
held in setting of [**Last Name (un) **] as below. Continued home pantoprazole
40mg [**Hospital1 **]. Of note, had therapeutic para on [**6-13**], removed 3 L.
MELD of 36 at time of discharge.
.
# Community-acquired pneumonia: Patient had CT chest [**2153-6-6**]
which showed bilateral upper lobe opacities concerning for
infection. Denied any fever, cough, or increased sputum
production. However, given hepatic encephalopathy was likely
related to infection, treated for CAP with levofloxacin 750mg
Q48h x 5 days (last day [**6-11**])
.
# UTI: Patient with proteus on [**Month/Year (2) **] culture on admission
despite neg U/A. Asymptomatic. This was sensitive to
levofloxacin which was already being used to treat CAP as above.
Completed 7 day course for complicated UTI.
.
# Acute on chronic kidney injury: Patient has chronic renal
insufficiency with baseline Cr ~1.5-1.7. Presented with Cr 2.2,
initially thought it may be prerenal pre-renal given poor PO
intake. However, did not respond to albumin challenge x2 days,
Cr continued to rise. Renal US on [**6-9**] ruled out
hydronephrosis. Started ocreotide and midodrine for HRS on [**6-12**],
albumin was also given daily. However, renal function continued
to decrease. A suspected cellulitis developed on the LLE which
was started on vanco. It was thought that the cellulitis would
not resolve with LE edema and thus would not qualify patient for
transplant. Because the edema would not resolve with diuretics,
Lasix 80mg daily was started with the understanding that the
patient's renal function would likely deteriorate and HD would
be required. This was discussed with the patient and he agreed
on this plan despite the risk for HD. On [**6-18**] an HD catheter
was placed and dialysis was started on [**6-19**]. He was discharged
on HD on a T/TH/SA scheduled to be continued at an out patient
dialysis center.
.
# PVD/Chronic Infected Femoral Graft. Consulted vascular
surgery to comment on status of PVD and ability to tolerate
transplant. Noninvasive vascular studies showed patent
bilateral external iliac and common femoral arteries with
monophasic waveforms and no focal velocity step-up.
Dicloxacillin [**Hospital1 **] was continued for suppression. He will follow
up with Vascular surgery 1 mo post discharge.
.
# LLE Extremity cellulitis: The patient was found to have
erythema on distal LLE extremity. Initially, it was thought that
it might be a cellulitis. It was treated with vancomycin, dosed
by daily troughs, for 5 days. On [**6-18**], Dr. [**Last Name (STitle) 497**] recommended
discontinuing the vancomycin as cellulitis seemed less likely
once some of the LE edema resolved.
.
# Malnutrition: Patient reported very poor appetite at home and
appeared somewhat debilitated. Nutrition consulted, followed.
Pt had better appetite in house.
.
# DM2: Diet-controlled.
.
# Hypertension: Continued home carvedilol.
# CAD: Continued home carvedilol, rosuvastatin.
# PVD: Continued home Plavix.
.
TRANSITIONS OF CARE:
-will f/u with vascular surgery as outpatient
-with f/u with nephrology as outpt at dialysis center three
times per week T/TH/SA
-will be contact[**Name (NI) **] by [**Name (NI) 6177**] from Transplant center about
arranging follow up to clinic and out pt lab work that will need
to be completed
-CONTACT: patient, daughter ([**Name (NI) **], [**Telephone/Fax (1) 14247**])
Medications on Admission:
- allopurinol 300 mg Tablet daily
- carvedilol 12.5 mg Tablet twice a day
- clopidogrel [Plavix] 75 mg Tablet daily
- dicloxacillin 500 mg Capsule [**Hospital1 **]
- furosemide 40 mg Tablet daily
- pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]
- rifaximin [Xifaxan] 550 mg Tablet [**Hospital1 **]
- rosuvastatin [Crestor] 40 mg Tablet daily
- spironolactone 50 mg Tablet daily
- ferrous sulfate 325 mg (65 mg iron) Tablet, Delayed Release
(E.C.) 1 Tablet by mouth once a day
- multivitamin Capsule daily
- omega-3 fatty acids-fish oil [Fish Oil] 360 mg-1,200 mg
Capsule, Delayed Release(E.C.) daily
Discharge Medications:
1. Allopurinol 150 mg PO DAILY
RX *allopurinol 300 mg 0.5 (One half) Tablet(s) by mouth daily
Disp #*15 Tablet Refills:*1
2. Clopidogrel 75 mg PO DAILY
3. Clotrimazole 1 TROC PO 5X PER DAY
4. DiCLOXacillin 500 mg PO BID
5. Pantoprazole 40 mg PO Q12H
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 1 capsule by mouth three times a day
Disp #*90 Bottle Refills:*1
10. Multivitamins 1 TAB PO DAILY
11. Lanthanum 500 mg PO TID W/MEALS
RX *FOSRENOL 500 mg 1 Tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*1
12. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 Tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
13. Nephrocaps 1 CAP PO DAILY
RX *Nephrocaps 1 mg 1 Capsule(s) by mouth daily Disp #*30 Tablet
Refills:*1
14. Rifaximin 550 mg PO BID
RX *Xifaxan 550 mg 1 Tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Encephalopathy
Pneumonia
Urinary tract infection
Cellulitis
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital with confusion and a decline
in your kidney function. Your confusion was due to a pneumonia
and urinary tract infection, which we treated with antibiotics.
The poor kidney function was caused by worsening liver function.
We tried a number of treatments, but they did not improve your
kidney function and you were started on dialysis after
consultation with the kidney specialists.
Of note, when the kidney doctors examined your [**Name5 (PTitle) **] under the
microscope, they saw cells which can be seen with a bladder
lesion. Since you have had a bladder mass removed in the past,
you had a cystoscopy performed to look in the bladder. No signs
of cancer were found.
You also had an infection of your left leg which we treated with
antibiotics. During the admission, the vascular surgeons saw
you to evaluate the extent of your peripheral vascular disease
and your ability to withstand a liver transplant. They
recommended seeing you in clinic 1 month after discharge.
You are starting on dialysis as an outpatient. Your schedule is
Tuesday/Thursday/Saturday. It is very important that you don't
miss any sessions as it can lead to serious heart and kidney
problems. Please notify your kidney doctor if you will not be
able to make a session.
The following changes have been made to your medications:
STOP: Furosemide, Spironolactone, Carvedilol
DECREASE: Allopurinol to 150mg daily
START:
Lactulose and take enough to achieve [**2-25**] bowel movements per day
to prevent confusion
Lanthanum for your kidney disease
Nephrocaps for your kidney disease
Xifaxan for your liver disease
Please see below for follow up appointment information
Followup Instructions:
Please call to schedule follow up with Dr. [**Last Name (STitle) **] (Vascular
Surgery) 1 month after discharge for your peripheral vascular
disease at ([**Telephone/Fax (1) 2867**].
[**Location (un) 6177**] from the Liver Transplant Center will be in contact
with you on [**2153-6-25**] to set up a follow up appointment with you.
If you do not hear from her by the afternoon please give the
transplant center a call at ([**Telephone/Fax (1) 3618**].
You will have to continue Hemodialysis following discharge the
from hospital. Your hemodialysis will take place at:
[**Location (un) 14248**]Dialysis Center [**Street Address(2) 14249**] [**Location (un) 5871**], [**Numeric Identifier 12701**]
#[**Telephone/Fax (1) 14250**]. HD nephrologist Dr. [**Last Name (STitle) 14251**] [**Name (STitle) 14252**]
Dialysis Schedule: Tuesday, Thursday and Saturday. First
outpatient session is [**6-26**] @ 6am
Admission Date: [**2153-6-23**] Discharge Date: [**2153-7-18**]
Date of Birth: [**2083-5-16**] Sex: M
Service: SURGERY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Liver cirrhosis with grade I encephalopathy, ascites, edema
Major Surgical or Invasive Procedure:
[**2153-6-24**] ABO incompatible liver transplant
[**2153-7-14**] Left IJ tunnelled line
[**6-24**] - [**7-6**] : PLasmapheresis daily
CVVH/ Intermittent HD
History of Present Illness:
70yo M w/ hx of EtOH/HepC cirrhosis s/p RFA with hx of DM2, CAD
(LVEF 61%), PVD, and CKD originally presenting prior to ABO
incompatible liver transplant for preop plasmapheresis +/- CVVH.
He had recently been admitted to the transplant service [**1-25**]
grade 1 hepatic encephalopathy, peripheral edema, & ascites. Of
note, he receives dialysis Tues, Thurs, Sat and last had HD in
AM of [**2153-6-23**].
Past Medical History:
PMH:
- HCC s/p RFA [**2151-10-27**] without complications
- EtOH/HepC cirrhosis
- DM2
- CAD (LVEF of 61%, [**11/2151**])
- PVD with hx of infected femoral graft, on dicloxacillin
- Hypertension
- Bell's palsy
- Bladder polyp
PSH:
- left iliac stenting and fem-fem bypass in [**Month (only) 116**] and [**2150-8-25**]
- removal fem-fem bypass graft in [**2150-11-24**] and left femoral
angioplasties
- CCY in [**2114**]
- cystoscopy in [**2148**] s/p removal of premalignant bladder polyp
- repeat cysto in [**2150-1-25**] which was negative
Social History:
Hx of alcohol abuse with GI bleed, former smoker (reportedly
quit ~30 years ago), denied illicit drug use. Lives wih his
wife, has three children.
Family History:
Grandfather with liver disease, otherwise non-contributory.
Physical Exam:
T 98.9 HR 82 BP 109/62 RR 20 O2sat 98%RA
Gen: NAD, AOx3
HEENT: Sclerae anicteric. PERRL, EOMI.
CV: Regular rate / rhythm
Pulm: Clear to auscultation, bilaterally
Abd: Soft, distended, non-tender, +bowel sounds.
Ext: Warm, well-perfused, no clubbing or cyanosis.
Neuro: slight R-sided facial droop c/w known Bell's palsy
Pertinent Results:
On Admission: [**2153-6-22**]
WBC-1.7* RBC-2.51* Hgb-8.4* Hct-25.6* MCV-102* MCH-33.4*
MCHC-32.8 RDW-17.8* Plt Ct-85*
PT-24.8* PTT-50.2* INR(PT)-2.4*
Glucose-89 UreaN-31* Creat-3.1* Na-134 K-3.8 Cl-97 HCO3-29
AnGap-12
ALT-25 AST-99* AlkPhos-110 TotBili-5.5*
Albumin-3.4* Calcium-8.5 Phos-3.5# Mg-1.9
At Discharge: [**2153-7-18**]
WBC-10.7 RBC-2.92* Hgb-8.9* Hct-28.8* MCV-98 MCH-30.3 MCHC-30.8*
RDW-15.8* Plt Ct-1078*
PT-10.1 PTT-25.5 INR(PT)-0.9
Glucose-91 UreaN-70* Creat-2.4* Na-136 K-5.4* Cl-101 HCO3-24
AnGap-16
ALT-28 AST-12 AlkPhos-246* TotBili-0.2
Calcium-8.6 Phos-5.6* Mg-1.7 UricAcd-6.0 Albumin 3.2
tacroFK-9.3
Brief Hospital Course:
Mr. [**Known lastname **] was taken to the OR [**2153-6-24**] for orthotopic deceased
donor ABO incompatible liver transplant with splenectomy. Please
refer to Dr.[**Name (NI) 1369**] operative note
Post-operatively, he was in the surgical ICU until [**2153-7-11**],
course complicated by a prolonged inability to wean him from the
ventilator, remain successfully extubated and mental status
issues. He was transferred to the med-[**Doctor First Name **] floor on [**2153-7-11**]
with most of his care focused around improving his nutritional
status, hemodialysis and optimal titration of his
immunosuppression.
Pertinent details, by systems:
Neuro: He was initially sedated post-liver transplant with a
combination of fentanyl, versed and propofol. These medications
were ultimately weaned though required in varying doses to keep
him comfortable on the ventilator. His pain control was
initially managed with fentanyl, then morphine, then
oxycodone/tylenol when tolerating POs.
In between intubations, while extubated (see respiratory
section), he did demonstrate confusion and was not at his
baseline mental status. He ultimately cleared when weaned from
the sedation and narcotics. On the floor, he quickly returned
to AAOx3 and used minimal narcotics, his pain regimen consisting
of acetaminophen and oxycodone 2.5 mg Q4H PRN.
CV: He was weaned off his pressors on POD 1. He was otherwise
hemodynamically stable, though he intermittently required
levophed during the initial half of his ICU course while he was
receiving plasmapheresis and CRRT. During the latter days in
the ICU, his pressures were strong enough off of pressors to
allow him to tolerate HD instead of CRRT. On [**7-2**], he experienced
an episode of chest pain and cardiac markers were positive
(elev of Tn 0.5 and CK altho raised 10K but cardiac index 0.4).
Cardiology was consulted. Per cardiolgy, after review of data
(EKG, CEs, hx) it appeared that he may have had a peri-operative
myocardial infarction (anteroseptal MI vs subendocardial
ischemia) around [**6-28**] during stressors (reintubation...) rather
than single episode of chest pain. Recommendations for NSTEMI
were medical management to optimize/limit his infarct in case of
recurrence. Anti-coagulation or any other invasive procedures.
He had no further chest pain. He was placed on ASA and Plavix.
post-splenectomy thrombocytosis (900K)
Resp: His ICU course was characterized by multiple failed
extubations. Initially extubated on POD 1 and reintubated into
POD 2 due to tachypnea and worsening oxygen saturations. He was
again extubated on POD 3 and reintubated on POD 5. Each
extubation was characterized by tolerating minimal vent settings
prior to extubation as well as RSBI scores in the <60 range.
However, he quickly reaccumulated secretions and CXR
demonstrated collapsed lungs. He had multiple bronchoscopies
that cleared copious secretions. All BAL cultures were
negative. He was finally extubated with success on POD 9.
He received an liver from AB donor. His blood type was O.
Splenectomy was done for this reason to decrease antibodies
against donor. Plasmapheresis was done daily for 2 weeks for a
total of 14 treatments. AntiA and antiB antibody titters were
monitored daily. Immunosuppressive consisted of ATG x 4 doses,
Cellcept, steroid taper and Prograf. LFTs trended down. Liver
duplex demonstrated patent vasculature with good flows. Post
splenectomy vaccines were administered on [**7-16**] (Haemophilus and
pneumococcal) and Meningococcal (Menactra)on [**7-17**]. JP drains (
in hilar area and posterior to liver) were removed as non
bilious drainage diminished. The splenectomy resection bed JP
was left in place.
Abdominal CT ([**7-4**]) was done for rising WBC . This demonstrated
a 9cm heterogeneous fluid collection near the tail of the
pancreas consistent with clot. He remained afebrile despite
elevated WBC. On [**7-7**], a liver duplex was done for decrease in
HCT.
Vasculature was patent. Adjacent collection was increased to 12
cm. On [**7-10**], under CT guidance, a 12 Fr pigtail drain was placed
in LUQ near splenic bed. Drainage was bloody. He continued on
broad spectrum antibiotics. Drain fluid culture was negative.
This pigtail drain output average 70 - 120 cc each day and
continued to be bloody. The drain will remain in place upon
discharge
He required hemodialysis 3 times a week via left chest tunnelled
catheter. He tolerated dialysis well. On [**7-10**], tunnelled line
insertion site was red with greenish, purulent drainage.
Catheter was removed. On [**7-14**], a left IJ tunnelled line was
placed. [**Month/Year (2) **] output started to increase around [**7-13**].
Hemodialysis was done on [**7-14**] after tunnelled line was replaced
(on Left, IJ). Dialysis was held on [**7-16**] given [**Month/Year (2) **] output
increase to 1100 cc per day. Potassium increased though to 5.8
on [**7-17**] for which Kayexalate was administered.
Nephrology followed closely noting increased [**Month/Year (2) **] output. The
plan was to perform dialysis twice weekly. Should [**Month/Year (2) **] output
increase greater than 1 liter consistently with normal chemistry
labs, hemodialysis was to be discontinued. Of note on [**7-16**],
potasium had increased to 5.3 and on [**5-17**].8. EKG was
unchanged and Kayexalate was administered with potassium
decrease to 5.4. Two gram potassium diet was ordered and tube
feeds were switched to Nepro.
Given insufficient calorie intake, a post pyloric feeding tube
had been placed and tube feeds were started. This was eventually
cycled over 12 hours. Glucoses were managed with [**Hospital1 **] Lantus (20
units) and sliding scale humalog. He did experience frequent
loose stool. C. difficile DNA amplification assay was negative
on [**7-13**].
Physical therapy worked with him extensively noting
debilitation. Rehab was recommended.
Given h/o left leg bypass graft infection, he was continued on
preop med, Dicloxacillin for prophylactic suppression coverage.
This was resuned on [**7-16**]. Prior to this had been covered by
Vancomycin x 17 days. He also received Zosyn x 7 days while in
ICU to cover presumed pneumonia.
Medications on Admission:
1. Allopurinol 150 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Clotrimazole 1 TROC PO 5X PER DAY
4. DiCLOXacillin 500 mg PO BID
5. Pantoprazole 40 mg PO Q12H
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Lactulose 30 mL PO TID
10. Multivitamins 1 TAB PO DAILY
11. Lanthanum 500 mg PO TID W/MEALS
12. Midodrine 10 mg PO TID
13. Nephrocaps 1 CAP PO DAILY
14. Rifaximin 550 mg PO BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Aspirin 325 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Clopidogrel 75 mg PO DAILY
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. DiCLOXacillin 500 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Fluconazole 200 mg PO Q24H
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Mycophenolate Mofetil 1000 mg PO BID
11. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
12. Pantoprazole 40 mg PO DAILY
13. PredniSONE 17.5 mg PO DAILY
started [**7-14**]. Follow taper
14. Senna 1 TAB PO BID:PRN constipation
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
16. Metoprolol Tartrate 12.5 mg PO TID
Hold for SBP < 120 or HR < 60
17. Tacrolimus 7 mg PO Q12H
18. ValGANCIclovir 450 mg PO 2X/WEEK (MO,TH)
19. Outpatient Lab Work
Every Monday and Friday stat labs:
CBC, chem 10, ast, alt,alk phos, tbili, albumin and trough
Prograf level
Fax results to [**Hospital1 18**] Tranplant coordinator [**Telephone/Fax (1) 14253**]
ICD-9: V42.7
20. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
21. Outpatient Lab Work, Start Thursday [**7-19**]. Courier Prograf
level to [**Hospital1 18**]. Fax all other labs to transplant clinic
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] northeast hospital
Discharge Diagnosis:
Etoh cirrhosis
[**2153-6-24**]: ABO incompatible liver transplant & splenectomy
HRS, resolving
NSTEMI
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 will be transfering to [**Hospital **] Rehab in [**Location (un) 701**]
Please call the [**Hospital 1326**] clinic [**Telephone/Fax (1) 673**] if you develop
any of the following: temperature of 101 or greater, chills,
nausea, vomiting, jaundice, confusion, increased abdominal pain,
incision redness/bleeding/drainage, JP drain or LUQ pigtail
drain insertion site appears red or has draiange, output from
drains stops or increases significantly, increased [**Telephone/Fax (1) **] output
greater than 1 liter or [**Telephone/Fax (1) **] output decreases or stops
Drain and record JP drain and gravity bag drainage three times
daily and as needed. Send copy of output results to clinic with
patient. Please call if the drainage increases significantly,
stopps completely, turns green in color or develops a foul odor.
Please draw full labs on Thursday [**7-19**] to include CBC, Chem 10,
LFTs, trough prograf. Prograf levels are to be couriered to
[**Hospital1 18**] lab. Slips and labels are provided. Determination for need
for dialysis can be discussed with the transplant clinic at
[**Telephone/Fax (1) 673**] (coordinator [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] RN)
Blood should be drawn every other day after that for now to
evaluate electrolytes, additionally, draw CBC, trough Prograf
and LFTs on Monday and Thursday until further notice. This can
be decreased per transplant clinic recommendations to twice
weekly for transplant monitoring once kidney function stable
-tube feedings will continue, cycled
-hemodialysis will be evaluated on an as needed basis. For now
we do not think the patient will require dialysis. Left
tunnelled line is in place if need for dialysis arises.
Please do not change medications, discontinue or start
medications unless cleared by the transplant clinic.
Patient should not lift greater than 10 pounds.
Patient should avoid showering until HD catheter has been
removed due to infection risk
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2153-7-25**] 9:40. [**Last Name (NamePattern1) **], [**Hospital Unit Name **] [**Location (un) 3971**], [**Location (un) 86**], MA
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2153-7-25**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2153-8-1**] 10:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2153-7-18**] Name: [**Known lastname **],[**Known firstname **] E. Unit No: [**Numeric Identifier 2213**]
Admission Date: [**2153-6-23**] Discharge Date: [**2153-7-18**]
Date of Birth: [**2083-5-16**] Sex: M
Service: SURGERY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 48**]
Addendum:
Patient treated for elevated potassium with kayexalate on day of
discharge. Renal recommendations include starting PO Lasix 40 mg
[**Hospital1 **]. Medication was added to discharge list prior to transfer to
Rehab facility. Labs to be checked on Thursday [**7-19**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] northeast hospital
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2153-7-19**]
|
[
"303.90",
"789.59",
"410.71",
"585.6",
"997.31",
"V58.67",
"584.5",
"155.0",
"997.1",
"403.91",
"572.4",
"414.01",
"286.7",
"V45.11",
"276.69",
"572.2",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"96.71",
"41.5",
"39.95",
"96.6",
"00.93",
"99.71",
"33.24",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
36863, 37079
|
25090, 31267
|
22684, 22843
|
33250, 33250
|
24445, 24445
|
35418, 36840
|
24024, 24085
|
31770, 33019
|
33125, 33229
|
31293, 31747
|
33426, 35395
|
12568, 12987
|
24100, 24426
|
24759, 25067
|
1287, 1623
|
22585, 22646
|
22871, 23278
|
24459, 24745
|
33265, 33402
|
17300, 17677
|
23300, 23844
|
23860, 24008
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,243
| 133,040
|
14641+14642
|
Discharge summary
|
report+report
|
Admission Date: [**2166-9-2**] Discharge Date: [**2166-9-8**]
Date of Birth: [**2102-5-24**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Failed right femoral AT bypass graft.
HISTORY OF PRESENT ILLNESS: The patient was admitted after
undergoing an urgent angiogram, which demonstrated. The
aorta was with atherosclerosis. There were no pressure
gradients across the aorta to the right external iliac
artery. There was occlusion of the right superficial femoral
artery. There was reconstruction of the popliteal by
profunda collaterals. There was occlusion of the anterior
tibial peroneal trunk, posterior tibial at the origins,
posterior tibial reconstitutes bicollaterals distally. This
provides __________ to the plantar surface of the foot. The
distal AT fills run off to the dorsalis pedis. The patient
was then admitted for further evaluation and treatment.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Diabetes, coronary artery disease with
an myocardial infarction in [**2159**], chronic renal failure on
hemodialysis Monday, Wednesday and Friday. Hypertension,
hypercholesterolemia, history of atrial fibrillation, history
of supraventricular tachycardia with pulmonary edema.
PAST SURGICAL HISTORY: Coronary artery bypass grafts in
[**2158**], angioplasty of the right coronary artery in [**2164-7-10**], left AV fistula, right TMA in [**Month (only) 205**] of this year, right
femoral popliteal with nonreverse saphenous vein graft in
[**Month (only) 205**] of this year, right iliac angioplasty in [**Month (only) 205**] of this
year. Coronary artery bypass grafts included angioplasty
with stent placement of the LMT and the left circumflex,
which were patent. The left internal mammary coronary artery
to the diagonal was patent. The saphenous vein graft to the
obtuse marginal three was patent and the right coronary
artery was totally occluded.
MEDICATIONS: Glipizide XL 10 mg changed to 5 mg q.d., Toprol
XL 100 mg q.d., Losartan 50 mg b.i.d., Simvastatin 40 mg
q.d., Nephrocaps one q.d., Epogen 7500 at dialysis, Sevelamer
1600 mg with meals, Kefzol 500 mg t.i.d., aspirin 325 mg
q.d., Plavix 75 mg q.d.
PHYSICAL EXAMINATION: Blood pressure 116/50. He is alert,
apprehensive male. HEENT examination was unremarkable.
Pulse examination showed palpable carotids bilaterally with
bilateral bruits. The left greater then the right AV fistula
on the left with a very good thrill. Radial pulses were
palpable. Abdominal aorta was nonprominant. Femoral pulses
were palpable bilaterally with bilateral carotid bruits.
There were no palpable pulses below the femorals bilaterally.
The left posterior tibial was doppler signal only. Chest was
clear to auscultation bilaterally. Heart was regular rate
and rhythm with normal S1 and S2. No murmurs, rubs or
gallops. Abdominal examination was unremarkable. Limb
examination showed right heel with superficial skin changes
secondary to pressure. Right TMA lateral incision there is
pin point opening with ischemic changes, but no drainage.
Neurological examination was unremarkable.
LABORATORY: CBC white blood cell count of 6.9, hematocrit
47.5, platelets 256K, PT/INR/PTT were normal. BUN 34,
creatinine 6.3, K 4.8. Urinalysis patient did not void.
Chest x-ray was unremarkable.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service post arteriogram. He received dialysis the following
day. He was begun on Levofloxacin and Flagyl renal dosing.
[**Last Name (un) **] Service followed the patient during his
hospitalization and managed his diabetes. Renal Service
managed his hemodialysis. On [**9-3**] the patient underwent a
right common femoral artery to posterior tibial bypass graft
with PTFE and debridement of the right foot ulcerations. He
tolerated the procedure well. He had a dopplerable posterior
tibial pulse at the end of the procedure. He was transferred
to the VICU for continued monitoring and care. Immediately
postoperatively he was hemodynamically stable. His pulse
examination was unchanged. His hematocrit was 33.9. His K
was 5.6. CK 76, troponin less then .3. Calcium, magnesium
and phosphorus were normal. Chest x-ray was without
pneumothorax. Blood gases were 7.35, 37, 157. Because of
hyperkalemia the patient was transferred to the CICU for
continued care.
On postoperative day one he remained stable without any
arrhythmia problems. [**Name (NI) **] was dialyzed. His lines were
discontinued. He was started on aspirin and subQ heparin and
transferred to the VICU for continued monitoring and care.
The patient was transferred to the nursing floor on
postoperative day two. Case management was involved with
discharge planning. Physical therapy felt that the patient
would be a good rehab candidate. Ultimate decision on
disposition was discharge awaiting family decision. He will
be discharged to the appropriate institution or discharged to
home. Dressings to the heel were normal saline wet to dry
t.i.d. He has a healing sandal. He may ambulate essential
distances with partial weight bearing. Levofloxacin and
Flagyl will be continued until discharged. The remaining of
his hospital course was unremarkable.
DISCHARGE MEDICATIONS: Sevelamer 1600 mg with meals,
Levofloxacin 250 mg q 24 hours, Colace 100 mg b.i.d.,
Dulcolax suppositories or tabs 10 mg q.d. prn, Glipizide XL 5
mg q.d., Neurontin 300 mg q dialysis day, Acetaminophen 325
to 650 mg q 4 to 6 hours prn, Metoprolol XL 100 mg q.d.,
Losartan 50 mg b.i.d., simvastatin 40 mg q.d., enteric coated
aspirin 325 mg q.d., Nephrocaps one q.d., Plavix 75 mg q.d.,
Epogen 7500 units intravenous at dialysis, Percocet tablets
one to two q 4 to 6 hours prn for pain. Protonix 40 mg q.d.,
insulin sliding scale please see flow sheet. Senna tabs two
q.d.
DISCHARGE DIAGNOSES:
1. Failed graft status post right common femoral artery to
posterior tibial artery bypass graft with PTFE.
2. End stage renal disease on dialysis, stable.
3. Hyperkalemia, corrected.
4. Type 2 diabetes controlled.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2166-9-8**] 14:26
T: [**2166-9-8**] 14:55
JOB#: [**Job Number 43141**]
Admission Date: [**2166-9-2**] Discharge Date: [**2166-9-15**]
Date of Birth: [**2102-5-24**] Sex: M
Service:
Addendum:
The patient remained in house receiving wound care, dialysis
and did well. We continued his antibiotics of levofloxacin
and Flagyl which he will get a total of 14 days on discharge.
The patient is afebrile currently with no acute signs of
infection.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg once a day
2. Sorbitol 60 mg taken po
3. MiraLax 17 gm [**Hospital1 **] prn
4. Sevelamer 3200 mg with meals
5. Levofloxacin 250 every 2 hours for 14 days total
6. Colace 100 mg twice a day
7. Colace tablets 100 taken in the p.m. every day
8. Glipizide 2.5 mg once a day
9. Metamucil one packet 3x a day
10. Neurontin 350 mg at bedtime
11. Simvastatin 40 mg once a day
12. Nephrocaps once a day
13. Epogen 750 units at dialysis
14. Senna tablets 2 a day
15. Percocet for pain
16. Protonix 40 mg once a day
17. Tylenol as needed for pain
18. Flagyl 500 mg po tid for a total of 14 days
19. Wet to dry dressings once a day to the right lower
extremity x3 days and follow up with Dr. [**Last Name (STitle) **].
HOME MEDICATIONS:
1. Regranex gel application one a day to his wounds
2. Flagyl 5 mg po tid, 14 days
3. Levofloxacin 250 mg one tablet every two days for a total
of 14 days
4. Protonix 40 mg once a day
5. Percocet for pain
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2166-9-15**] 09:21
T: [**2166-9-15**] 09:36
JOB#: [**Job Number 42247**]
|
[
"997.69",
"250.70",
"V45.81",
"440.31",
"250.40",
"276.7",
"401.9",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"39.49",
"38.93",
"84.3",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
5831, 6727
|
6750, 7485
|
3325, 5211
|
1257, 2176
|
7503, 7984
|
2199, 3307
|
156, 195
|
224, 931
|
954, 1233
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,421
| 112,184
|
18219
|
Discharge summary
|
report
|
Admission Date: [**2103-10-1**] Discharge Date: [**2103-10-21**]
Date of Birth: [**2069-7-31**] Sex:
Service: Neurosurgery
DATE OF DEATH: [**2103-10-21**]
HISTORY OF PRESENT ILLNESS: This is a 34-year-old woman who
had sudden onset of severe headache accompanied by slurred
speech and confusion. She was brought to [**Hospital6 50324**] with a diagnosis of a subarachnoid hemorrhage. She
had several episodes of vomiting in [**Hospital1 498**] and was then
transferred to [**Hospital1 69**].
PAST MEDICAL HISTORY: Remarkable for diabetes.
Hypertension.
Breast cancer.
CURRENT MEDICATION ON ADMISSION: Meridia 30 mg q.d.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: She is legally separated, has 2 children,
and was not working. She does not have a history of smoking
or drug use. She does drink alcohol occasionally.
PHYSICAL EXAMINATION: Vital signs at the time of admission
were 195/101, 86, 22, and 10. Head, eyes, ears, nose, and
throat, her pupils to be equal, round, and reactive to light
and accommodation, 3 mm to 2.5 mm. EOMs were full. Lungs
were clear. Heart showed regular rate and rhythm, normal S1
and S2. Abdomen was obese, soft, and nondistended.
Extremities showed no edema. Neuro exam, she was awake,
alert, and oriented times 3. Did complain of headache.
Moving all extremities. Closes eyes at times, but opens to
voice. No drift. Cranial nerves II through XII are intact.
Strength was [**4-30**] bilaterally in biceps, triceps, iliopsoas,
anterior tibialis, and [**Last Name (un) 938**]. Pupils were equal, round, and
reactive to light and accommodation. Extraocular movements
were full. She had no meningeal signs. Deep tendon reflexes
were 1 plus bilaterally at biceps, 2 plus bilaterally at
knees.
LABORATORY DATA: On admission her sodium was 142, potassium
3.4, chloride 104, bicarb 25, BUN 12, creatinine 0.9, glucose
175, PT was 12, PTT 23.5, and INR 1.0. Her white blood cells
were 10.9, hematocrit 40.5, and platelets were 268,000. She
did have a CT of the head, which did show a subarachnoid
hemorrhage on the left with multiple clot in the suprasellar
cistern and Sylvian cistern, left greater than right. She
was admitted to the Neurointensive Care Unit with q.1h. neuro
checks. She obtained an A-line and the goal was to keep her
blood pressure less than 120 with Nipride as needed. She was
started on nimodipine 60 mg q.4 h., normal saline,
famotidine. She was to have her glucoses checked q.i.d. She
was preop for an angiogram in the morning. She was started
on Dilantin at 100 mg t.i.d.
HOSPITAL COURSE: She did undergo the angiogram and
postprocedure she was sleepy, but was easily awakened and
followed commands, and moved all extremities; however, was unable
to perform complex tasks. Pupils were 3 to 2 bilaterally.
She underwent an angiogram, which did show a left internal
carotid artery aneurysm and was then brought to the operating
room for clipping of her aneurysm. Then early in the morning
on [**2103-10-4**], the patient did have an increase in her
intracranial pressure. She had a stat head CT
at that time, which did show left frontal intraparenchymal
hemorrhage at the surgical site. She then underwent an
emergency craniectomy with bone flap placement in the
abdomen. Postoperatively, she returned to the intensive care
unit and was monitored closely. She was kept sedated and was
followed with CAT scans of the head. Her serum osmolality
was checked every 4 hours. Her INR was followed with the
goal of keeping less than 1.3 at all times. She was able to
move her left side spontaneously, but moved and localized in
the right upper extremity to deep pain only. Her brain flap
was tense. She did spike fevers and was pancultured. On
[**2103-10-14**], a repeat head CT did show an acute new hemorrhage
in the left frontal lobe with surrounding edema and
herniation. Ventricles were increased in size slightly.
ICPs had been reported as high as 33. A repeat CAT scan
again on [**2103-10-15**] showed a large left hemorrhage. Due to the
repeat hemorrhage, discussion was held with the patient's
cousin and significant other and she was made do not
resuscitate. On [**2103-10-21**], she did expire.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 50325**]
MEDQUIST36
D: [**2104-6-16**] 10:41:55
T: [**2104-6-16**] 15:07:29
Job#: [**Job Number 50326**]
|
[
"V10.3",
"707.0",
"250.00",
"276.3",
"430",
"780.39",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.51",
"38.91",
"01.25",
"96.04",
"31.1",
"96.72",
"88.41",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
2597, 4476
|
871, 2579
|
205, 517
|
631, 676
|
540, 616
|
693, 848
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,582
| 199,746
|
47800
|
Discharge summary
|
report
|
Admission Date: [**2105-11-17**] Discharge Date: [**2105-11-17**]
Date of Birth: [**2026-6-20**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Asthma attack
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This 79 female with h.o asthma who presents acute dyspnea
xseveral weeks. Pt reports acute worsening of dyspnea after
aspirin ingestion at home for a headache around 1am. Pt denies
f/c/URI/change in cough, has chronic cough productive of yellow
sputum, hemoptysis, CP, palpitations, orthopnea/PND. She reports
she had never been hospitalized for asthma in the past.
Currently, pt reports breathing much improved.
She also denies headache/LH/dizziness/blurred vision, abd
pain/n/v/d/c/melena/brbpr/dysuria/hematuria/joint
pain/paresthesias/weakness.
.
In the ED, EKG unrevealing, thought to be tight, sating well on
NRB. Given nebs, solumedrol, zofran. Per ED no indication for
ABG, speaking in full sentences. Pt would "like to go vote
tomorrow".
Past Medical History:
1. Appendectomy with intestinal obstruction, age 4.
2. Cholecystectomy in her 20's.
3. Rhinoplasty in her 20's.
4. Concussion after skiing in her 20's, no sequelae.
5. Asthma
6. Osteoporosis
Social History:
Lives alone. Former smoker, quit 20 yrs ago. Occasional ETOH/few
drinks per week, denies drug use.
Family History:
father-HD/MI
brother-asthma, [**Name2 (NI) 499**] cancer
Physical Exam:
gen-well appearing but anxious, NAD, able to speak in full
sentences, but noticeable prolonged expiratory phase,
intermittent wheezing during conversation.
vitals-T. 97.1, BP 118/62, HR 103, RR 22 sat 94%2L
HEENT-nc/at, PERRLA, EOMI, anicteric, MMM, no oropharyngeal
lesions/exudates
neck-no JVD, no LAD, supple
chest-b/l ae +scant expiratory wheezing, no c/r, good
airmovement except in bases.
heart-s1s2 rrr no m/r/g
abd-+bs, soft, NT,ND
ext-no C/C/E 2+pulses
neuro-aaox2, CN2-12 intact, non-focal
Pertinent Results:
[**2105-11-17**] 06:15AM BLOOD WBC-13.5*# RBC-4.53 Hgb-13.7 Hct-39.7
MCV-88 MCH-30.1 MCHC-34.4 RDW-12.2 Plt Ct-251
[**2105-11-17**] 02:33AM BLOOD Neuts-48.5* Lymphs-40.2 Monos-3.8
Eos-7.1* Baso-0.5
[**2105-11-17**] 02:33AM BLOOD PT-12.2 PTT-22.6 INR(PT)-1.0
[**2105-11-17**] 06:15AM BLOOD Glucose-163* UreaN-20 Creat-1.1 Na-136
K-3.5 Cl-100 HCO3-25 AnGap-15
[**2105-11-17**] 06:15AM BLOOD AlkPhos-64
[**2105-11-17**] 02:33AM BLOOD CK(CPK)-136
[**2105-11-17**] 02:33AM BLOOD cTropnT-<0.01
[**2105-11-17**] 06:15AM BLOOD Calcium-9.0 Phos-2.4* Mg-2.3
[**2105-11-17**] CXR PA portable- 1. Subtle increased linear opacity in
the medial aspect of the right lower lobe on this AP radiograph.
Recommend formal PA and Lateral radiographs to evaluate for
developing pneumonia as discussed with Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) **] the
day of examination at 8:07 AM.
2. Increased lung volumes suggesting obstructive lung disease.
Brief Hospital Course:
This is a 79 y.o female with a h/o asthma who presents with
dyspnea/hypoxia.
.
1. [**Name (NI) 19299**] Pt with dyspnea, decreased response to albuterol and
worsening SOB in the setting of recently ingesting an aspirin
and having exposure to construction work around her home. Thus,
he symptoms wer thought likely due to an asthma flare. Other
possibilities include infection, but clear chest x-ray/no white
count/no fever, PE however, wheezing on exam and seems to be c/w
asthma flare, unlikely to be MI given no CP/diaphoresis/or EKG
changes. S/P solumedrol, nebs in the ED. She was monitored
overnight in the ICU where she had stable vitals and O2 sat. She
was started on azithromycin and prednisone taper. Her inhaled
steroids were also switched from triamcinolone to fluticasone
[**Hospital1 **]. She will follow up both with pulmonology and her PCP. [**Name10 (NameIs) **]
was vaccinated for influenza and pneumonia.
.
2. Anxiety-Continued prn ativan.
Medications on Admission:
albuterol 2 puffs QID prn
diazepam 2mg 1 daily prn
fluticasone 50mcg 2 sprasy each nostril daily
triamcinolone acetonide 100mcg 2 puffs [**Hospital1 **]
calcium +D
Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 doses.
Disp:*4 Tablet(s)* Refills:*0*
2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 11 days: Please take 2 pills daily for 3 days (starting on
Wednesday), 1 pill daily for 4 days then half a pill daily for 4
days.
Disp:*12 Tablet(s)* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
4. Diazepam 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays in each nostril Nasal once a day.
6. CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Asthma exacerbation
Discharge Condition:
Good. Ambulating without desaturation.
Discharge Instructions:
You were admitted with an asthma exacerbation. This could have
been caused by exposure to fumes from construction near your
home or from your use of aspirin. We are sending you home on
antibiotics to start on Wednesday to take for 4 days and
steroids which you will taper as prescribed over the next 11
days. We also switched your triamcinolone inhaler to a
fluticasone inhaler which we think will be a better steroid
inhaler for you. Please continue your fluticasone nasal spray
and your albuterol as needed.
.
We added prednisone and azithromycin to your medications.
We changed your inhaled triamcinolone to fluticasone.
.
Please keep your follow up appointments as below.
.
Please call your doctor or return to the ED if you have
increasing shortness of breath, headache, fever, chills, cough,
nausea, vomitting or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary doctor Dr. [**Last Name (STitle) 26894**] at 10:30 am
on Wednesday [**2105-10-18**].
.
Someone from the pulmonology clinic will contact you within 2
days with a follow up appointment.
Completed by:[**2105-11-17**]
|
[
"493.92",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5051, 5057
|
2997, 3956
|
284, 291
|
5140, 5181
|
2015, 2974
|
6079, 6330
|
1420, 1479
|
4171, 5028
|
5078, 5078
|
3982, 4148
|
5205, 6056
|
1494, 1996
|
231, 246
|
319, 1067
|
5097, 5119
|
1089, 1287
|
1303, 1404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,788
| 156,087
|
52736
|
Discharge summary
|
report
|
Admission Date: [**2104-11-2**] Discharge Date: [**2104-11-13**]
Date of Birth: [**2057-11-6**] Sex: M
Service: CARDIOLOGY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3234**] is 46-year-old
Spanish speaking male with a past medical history of
rheumatic heart disease who on admission was postoperative
day number 11, status post mitral valve replacement and
aortic valve replacement after having been ruled out for
infectious endocarditis. His postoperative course was
complicated by atrial fibrillation. This was first noticed
on postoperative day number one with rapid atrial
fibrillation at 140 with left bundle branch block and the
patient was started on amiodarone 400 mg po t.i.d. on that
day [**2104-10-23**]. The patient was then discharged to
home five days prior to admission, and then three days prior
to this admission, the patient presented to his primary care
physician complaining of palpitations and was directed to
decrease his amiodarone to 400 mg b.i.d. and increase his
Lopressor dose to 75 mg b.i.d. For the next two days until
the day of admission, the patient complained of feeling more
lethargic and not himself.
On the morning of admission, he became lightheaded, called
EMT and was found to be bradycardic with a heart rate in the
20s. EMTs suspected beta blocker overdose, gave glucagon
which resulted in stabilization of heart rate to the 60s.
The patient was then brought to [**Hospital6 2018**]. The patient had recently been admitted on [**2104-10-8**] for fevers and endocarditis was suspected. Blood
cultures were negative but erythrocyte sedimentation rate and
C reactive protein were high. The patient was presumptively
treated with antibiotics after being ruled out for
endocarditis by blood cultures and echocardiography, the
patient underwent aortic valve replacement and mitral valve
replacement. Catheterization results showed a calcific
valvulopathy and rare growth of coag negative Staph from the
aortic valve.
REVIEW OF SYSTEMS: The patient complained of subjective
fevers at night twice since his discharge on [**10-28**]
without cough, headache, chest pain, nausea, vomiting and he
denied noticing any blood and urine or stools.
PAST MEDICAL HISTORY: Rheumatic heart disease diagnosed at
age 15, status post aortic valve replacement, mitral valve
replacement on [**2104-10-22**]. Cardiac catheterization
on [**2104-10-17**] showed normal coronary arteries.
Echocardiogram Obtained [**2104-9-16**] in [**Male First Name (un) 1056**] showed
left ventricular function of 40-45% with diminished aortic
and mitral valve areas.
ALLERGIES: Patient has no known drug allergies.
MEDICATIONS ON ADMISSION: Amiodarone 400 mg b.i.d., Coumadin
and Lopressor 75 mg b.i.d.
SOCIAL HISTORY: The patient has a remote history of tobacco
use, stopped 23 years ago and a remote history of ethanol
use, stopped 20 years ago. Patient has recently moved from
[**Male First Name (un) 1056**] for his valve surgery and lives with his wife and
children. He is presently disabled.
PHYSICAL EXAM ON ADMISSION: He was afebrile. Temperature of
96.5. Pulse 57-60. Blood pressure 105/66. Respiratory rate
16, breathing 97% on two liters. In general, he appeared his
stated age, was in no apparent distress. His lungs were
clear to auscultation bilaterally. His jugular venous pulse
was at 5-6 cm. Carotids had no bruits. Heart was regular
rate and rhythm, metallic S1, decrescendo [**3-4**] murmur, did not
radiate, metallic S2. TMI was diffuse laterally displaced
and his chest wound was clean, dry and intact. Abdomen
exhibited normal active bowel sounds, soft, nontender,
nondistended, no hepatosplenomegaly. Extremities were
without edema. Radial pulses were 2+ bilaterally.
LABORATORIES ON ADMISSION: Remarkable for potassium 4.5,
creatinine 1.0, hematocrit of 28.3 with 6.4% eosinophils.
His INR was 4.3. Albumin was 3.2. His electrocardiogram on
admission was sinus rate at 63, PR interval was prolonged,
280-312 ms, QRS 176 ms. [**Name14 (STitle) **] 500 ms. Axis was slightly left
deviated at -33 with a left bundle branch block and marked
left atrial enlargement.
Echocardiography from [**2104-10-9**] showed left atrium
5.4 x 8 cm. Right atrium 6.6 cm. LV 6.0/4.5. Left
ventricular ejection fraction of 50-55%, a dilated left
ventricle, 2+ aortic regurgitation, 3+ mitral regurgitation,
mild to moderate aortic stenosis, 1+ tricuspid regurgitation.
Note that this echocardiogram was obtained prior to his
mitral valve replacement and aortic valve replacement.
HOSPITAL COURSE: The patient was admitted for observation of
his heart block and evaluation by the Electrophysiology
Service. For his cardiac issues number one was history of
atrial fibrillation. Patient was deemed to need to continue
treatment with amiodarone and beta blocker and thus it was
decided that he would need a DDD pacer since he was
exhibiting sensitivity to amiodarone and Lopressor in terms
of his AV node function. Once the patient's INR was less
than 1.5, the patient underwent pacemaker implantation on
[**2104-11-7**]. The patient tolerated the procedure
without event and his heart rate remained AV paced in the 70s
with blood pressures 100-110 systolic/50s-60s diastolic
throughout his admission. His other issue on admission was
complaint of subjective fevers with a history of rheumatic
heart disease and previously being ruled out for
endocarditis, so, it was decided to obtain three sets of
blood cultures 12 hours apart to again check for endocarditis
which were negative throughout his stay. He also received a
transesophageal echocardiogram which was negative for
valvular vegetations and negative for a valve leak.
Hematology: During the hospitalization, the patient
exhibited a hemolytic anemia with low haptoglobin, high LDH
and a reticulocyte index that suggested an inadequate marrow
response. There was no perivalvular leak which could explain
the hemolytic anemia and it is recommended that the patient's
hematocrit be followed and his anemia worked up as an
outpatient. The patient received two units of packed red
blood cells to keep his hematocrit above 25% during this
admission. The patient also was found during this admission
to have a right upper lobe friction rub. By chest x-ray,
there was no evidence of infiltrate or other abnormality and
it was suggested that this patient has post pericardotomy
syndrome with a pleural pericarditis that would explain the
friction rub, erythrocyte sedimentation rate, high C reactive
protein and intermittent subjective fevers. The patient was
briefly treated with Motrin 800 mg times two doses which
caused an elevation in his creatinine from 0.9 to 1.7. The
Motrin was held. The patient was given one liter of normal
saline intravenous fluids. Urinalysis was consistent with
non-steroidal anti-inflammatory drugs toxicity, positive for
eosinophils.
Following discontinuation of Motrin, the patient's creatinine
returned to baseline and was 1.0 on the day of discharge.
The [**Hospital 228**] hospital course was also complicated by
hematoma in the pacer pocket in the setting of heparin and
Coumadin. The hematoma was observed, immobilized with a
pressure dressing and stabilized on [**11-11**] with an INR of
2.3. The heparin was discontinued. The INR remained
therapeutic through the day of discharge [**11-13**] with an
INR of 3.0. Goal INR because of this patient's mechanical
valves is 2.5 to 3.5. It was also noted during this hospital
stay, that this patient's heart rate is extremely sensitive
to beta blockers and it is recommended that his Atenolol dose
not be increased above 25 mg po q.d. The patient remained in
normal sinus rhythm AV paced during his hospital stay with
no evidence of atrial fibrillation. He was discharged in
good condition with follow-up Monday, [**11-17**] at 12 noon
with the Pacemaker Device Clinic and with Dr. [**First Name (STitle) **] of [**Hospital6 6613**] East on [**11-27**], at 4 p.m.
DISCHARGE DIAGNOSES:
1. Heart block, status post pacemaker implantation.
2. Post pericardotomy, pleural pericarditis syndrome.
3 Rheumatic heart disease, status post aortic valve
replacement, mitral valve replacement.
4 Pacemaker pocket hematoma.
MEDICATIONS ON DISCHARGE:
1. Zestril 10 mg po per day.
2. Coumadin 3 mg po per day with target INR of 2.5 to 3.5.
3 Amiodarone 400 mg po per day.
4. Atenolol 25 mg po per day.
FOLLOW-UP: Patient will need follow-up with [**Hospital 197**] Clinic
and it was recommended that he have VNA visits for a few days
after discharge for medication teaching and pacer pocket
follow-up. Pressure dressing to stay in place until
appointment with the [**Hospital 19721**] Clinic on [**11-17**].
DISCHARGE STATUS: Full code.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**]
Dictated By:[**Name8 (MD) 4430**]
MEDQUIST36
D: [**2104-11-13**] 14:16
T: [**2104-11-13**] 14:16
JOB#: [**Job Number 94837**]
|
[
"398.90",
"426.11",
"429.4",
"283.9",
"E942.6",
"427.31",
"275.41",
"996.72",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.23",
"99.29",
"88.72",
"99.69",
"37.83",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
8018, 8251
|
8277, 9043
|
2684, 2747
|
4574, 7997
|
2008, 2211
|
169, 1988
|
3782, 4556
|
2234, 2657
|
2764, 3060
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,300
| 173,418
|
30886
|
Discharge summary
|
report
|
Admission Date: [**2173-12-21**] Discharge Date: [**2173-12-26**]
Date of Birth: [**2123-10-7**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
kidney transplant recipient
History of Present Illness:
The pt is a 50yM with end-stage renal disease being maintained
on chronic hemodialysis secondary to hypertensive nephropathy.
His daughter was evaluated and found to be a suitable donor and
consented to a living related donor transplant. The patient
also has a history of multiple infected AV grafts with previous
excisions. He presents now for transplantation.
Past Medical History:
ESRD on HD
Hypertension
Lacunar changes on MRI brain
Social History:
Patient retired police officer from [**Location (un) 4708**]. Lives with wife
and kids. He denies prior tobacco or etoh. Denies prior IVDU,
Coccaine or other illicit drug use.
Family History:
Mother with DM and CHF, denies fh of CAD, HTN, CKD. Has 7
siblings who are healthy.
Physical Exam:
AVSS
GEN: NAD, NC/AT, AAOx3
CV: RRR, no murmurs
Pulm: CTA b/l
Abd: soft, NT, ND
Ext: scar RUE from previous AV fistula. trace edema, no
cyanosis
Pertinent Results:
AT ADMISSION:
wbc Hct Plts BUN Cr Na K Cl HCO3
7.6 36.3 161 30* 7.7* 140 3.8 95* 31
AT DISCHARGE:
wbc Hct Plts BUN Cr Na K Cl HCO3
6.1 33.0 155 38 1.8 139 4.5 112 19
TACRO LEVELS:
[**2173-12-24**] 3.1
[**2173-12-25**] 4
[**2173-12-26**] 11.5
Brief Hospital Course:
50yM admitted for planned transplant of living related kidney.
Went to the OR on [**2173-12-21**] and underwent a renal transplant from
his daughter. There were no intraoperative complications and
the patient tolerated the procedure well. He went to the floor
and followed the normal post-operative kidney transplant
pathway. He was making adequate UOP in the post-op period and
was being replaced cc:cc for his urine losses. On POD 1 he
became somewhat short of breath, his IVFs were stopped and he
was given 80mg IV lasix. He continued to be symptomatic and
dropped his sats into the 70s but came back up with oxygen. He
was given another 80mg lasix and transferred to the SICU for
further observation overnight. He received another dose of 80mg
Lasix overnight and his symptoms began improving. He was also
ruled out for MI, had a normal EKG and CXR. It was believed
that the reaction was secondary to volume overload and a
reaction to ATG. The ATG was discontinued but he did receive 2
of the three doses. On POD 2 he was transferred back to the
floor.
His UOP remained stable, his diet was advanced, and his foley
eventually removed. He received all of his immunosuppressive
medications including tacrolimus which was dosed daily base on
morning levels. Once his FK levels were stabilized it was
decided to send him home. His BP medications were adjuested
somewhat due to his hypertension and this was included in his
discharge instructions.
Medications on Admission:
amlodipine 10', metoprolol succinate 100'', valsartan 160',
nephrocaps, viagra
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: Four (4) Tablet PO BID
(2 times a day).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
11. Tacrolimus 1 mg Capsule Sig: Eight (8) Capsule PO Q12H
(every 12 hours) for 2 doses.
12. Outpatient Lab Work
Tacrolimus level to be drawn in the morning of [**2173-12-27**]
Discharge Disposition:
Home
Discharge Diagnosis:
liver related kidney transplant recipient
Discharge Condition:
good. tolerating diet, ambulating, pain controlled, tacrolimus
levels stable
Discharge Instructions:
please call the transplant office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
worsening abdominal pain, decreased urine output, weight gain of
3 pounds in a day, incision redness/bleeding/drainage
YOU MUST HAVE YOUR TACROLIMUS LEVEL DRAWN TOMORROW (monday
1/5/9)
Labs every Monday and Thursday
No heavy lifting
No driving if taking pain medications
[**Month (only) 116**] shower
**MAKE SURE YOU TAKE LOPRESSOR 200MG TWICE A DAY (initially
written as once a day) and CELLCEPT 1000MG TWICE A DAY
(initially written as 500mg twice a day). You also have a new
prescription for Norvasc and a pain medicine.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2173-12-30**] 9:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2174-1-11**] 2:30
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2174-1-11**] 3:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"285.21",
"E933.1",
"403.91",
"585.6",
"518.81",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.91",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
4344, 4350
|
1633, 3097
|
280, 310
|
4436, 4516
|
1257, 1389
|
5234, 5779
|
991, 1076
|
3227, 4321
|
4371, 4415
|
3123, 3204
|
4540, 5211
|
1091, 1238
|
1403, 1610
|
236, 242
|
338, 704
|
726, 781
|
797, 975
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,840
| 145,467
|
6525
|
Discharge summary
|
report
|
Admission Date: [**2106-8-6**] Discharge Date: [**2106-8-28**]
Date of Birth: [**2024-7-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Submental floor of mouth abscess.
Major Surgical or Invasive Procedure:
[**2106-8-8**]: Incision and drainage of deep neck and floor of mouth
abscess.
History of Present Illness:
This is an 82 year-old Russian male who presented to the ED on
[**2106-8-8**], the date of admission, with the chief complaint of
fever to 100.1, acute mental status change (from alert and
oriented to self to minimal orientation) and who fell without
loss of consciousness on [**2106-8-6**]. He was placed in a cervical
collar and admitted to the MICU on [**2106-8-8**]. After C-spine
clearance, it was noticed that the patient had significant left
facial swelling that had increased in extent quite rapidly. The
patient appeared agitated, but given his baseline mental status,
it was difficult to determine if he was in pain. There was no
purulent drainage from the parotid duct. His WBC was 13.0
initially and had risen to 21.5 when ENT was asked to evaluate
the patient's neck swelling. He was placed on Vancomycin,
Cefepime and Flagyl on [**2106-8-8**] for broad spectrum coverage of
a possible LLL PNA/infiltrate and for this likely neck
infection.
On initial exam, he had signficiant left facial swelling
anterior to the tragus and extending inferiorly to the region of
the masseter and submandibular gland, without submental
involvement. He had slight nonblanching erythema of the
overlying skin, without fluctuance. A CT neck was performed on
[**2106-8-8**] showing an extensive multiloculated rim-enhancing
fluid collection with foci of gas extending inferiorly from the
left parotid gland and parapharyngeal space into the sublingual
and bilateral submandubular space. The findings were highly
suspicious for abscess. Inflammatory changes extended inferiorly
to the level of the epiglottis with obliteration of the left
vallecula and with narrowing of the supraglottic airway.
The patient went to the OR on [**2106-8-8**] for incision and
drainage of a deep neck and floor of mouth abscess.
Past Medical History:
Parkinson's disease dementia, recurrent right inguinal hernia
s/p repair, Left orchiectomy in the distant past, "due to
infection" in [**2091**] complicating prostectomy, Urosepsis in
[**2-/2102**], colonic polyps, depression, glaucoma, HTN
Social History:
Lives with wife. Moved to the US in [**2094**] and was a former
engineer that worked with small doses of 'chemicals' but he is
unaware of toxicity. Denies alcohol use. Denies smoking use. No
illicit substance use.
Family History:
Non-contributory.
Physical Exam:
UPON DISCHARGE:
VITALS:
T - 96.5, HR - 61, BP - 125/72, R - 20, O2 Sat - 100% on RA
Neck: Incision clean/dry/intact, no mass, no fluctulance
CVS: RRR, S1, S2, No murmurs/rubs/gallops
RESP: Coarse breath sounds b/l
GI: bowel sounds present, soft
EXT: contracted
Pertinent Results:
On Admission:
[**2106-8-6**] 07:30AM BLOOD WBC-20.5*# RBC-4.44* Hgb-12.7* Hct-38.4*
MCV-87 MCH-28.6 MCHC-33.0 RDW-14.1 Plt Ct-336
[**2106-8-6**] 07:30AM BLOOD Neuts-87.8* Lymphs-7.3* Monos-4.4 Eos-0.2
Baso-0.4
[**2106-8-7**] 03:37AM BLOOD PT-15.3* PTT-33.7 INR(PT)-1.3*
[**2106-8-6**] 07:30AM BLOOD Glucose-137* UreaN-18 Creat-0.8 Na-141
K-3.5 Cl-102 HCO3-29 AnGap-14
[**2106-8-6**] 07:30AM BLOOD ALT-12 AST-21 LD(LDH)-226 AlkPhos-81
TotBili-1.0
[**2106-8-7**] 03:37AM BLOOD Calcium-7.4* Phos-2.2* Mg-2.0
[**2106-8-6**] 07:34AM BLOOD Glucose-139* Lactate-2.5* K-3.7
[**2106-8-10**] 07:04PM BLOOD freeCa-1.08*
On Discharge:
[**2106-8-28**] 05:32AM BLOOD WBC-10.7 RBC-3.54* Hgb-10.3* Hct-30.5*
MCV-86 MCH-29.0 MCHC-33.6 RDW-17.8* Plt Ct-264
[**2106-8-27**] 01:50PM BLOOD WBC-13.6* RBC-3.98* Hgb-11.3* Hct-34.7*
MCV-87 MCH-28.5 MCHC-32.7 RDW-17.6* Plt Ct-337
[**2106-8-26**] 04:12PM BLOOD WBC-11.6* RBC-3.83* Hgb-10.8* Hct-33.7*
MCV-88 MCH-28.3 MCHC-32.1 RDW-17.6* Plt Ct-300
[**2106-8-26**] 05:40AM BLOOD WBC-11.3* RBC-3.70* Hgb-10.5* Hct-32.7*
MCV-89 MCH-28.4 MCHC-32.1 RDW-17.5* Plt Ct-353
[**2106-8-26**] 04:12PM BLOOD Neuts-92.9* Lymphs-4.6* Monos-2.1 Eos-0.3
Baso-0.1
[**2106-8-28**] 05:32AM BLOOD Plt Ct-264
[**2106-8-28**] 05:32AM BLOOD PT-14.7* PTT-24.9 INR(PT)-1.3*
[**2106-8-28**] 05:32AM BLOOD Glucose-120* UreaN-21* Creat-0.6 Na-145
K-3.0* Cl-109* HCO3-29 AnGap-10
[**2106-8-27**] 01:50PM BLOOD Glucose-202* UreaN-20 Creat-0.8 Na-140
K-3.3 Cl-104 HCO3-27 AnGap-12
[**2106-8-28**] 05:32AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.0
[**2106-8-27**] 01:50PM BLOOD Calcium-8.3* Phos-2.7 Mg-2.0
Radiology:
[**8-6**] CXR:
IMPRESSION:
Retrocardiac opacity which may represent early left lower lobe
pneumonia.
CT C-Spine:
IMPRESSION: No sign of fracture or abnormal alignment.
Multiple-level DJD
with narrowing of vertebral foramen and neural foramen.
CT Neck [**8-8**]:
IMPRESSION:
1. Extensive multiloculated rim-enhancing fluid collection with
foci of gas extending inferiorly from the left parotid gland and
parapharyngeal space into the sublingual and bilateral
submandubular space. These findings are highly suspicious for
abscess. Inflammatory changes extend inferiorly to the level of
the epiglottis with obliteration of the left vallecula and
narrowing of the supraglottic airway.
2. Severe attenuation of the superior aspect of the jugular vein
with several
millimeters of non-enhancement suspicious for short segment
thrombosis.
Reconstitution of the jugular vein noted at the jugular
foramen/skull base.
3. Moderate bilateral pleural effusions.
Brief Hospital Course:
1) Parotid/submandibular abscess: s/p debridement by ENT who is
managing dressing changes. Pt was treated on course of Flagyl
500 mg Q8H, Cefepime 2g IV daily, vanco 1250 mg Q12h. As pt
still spiked a fever on these abx on [**2106-8-16**], ID c/s called and
followed patient. His Cefepine dose was increased to 2g IV q12.
Polymicrobial growth from abscess cultures and blood cultures
had no growth. Dental followed the patient as per recs of ENT,
however dental needed panorex to recommend teeth extraction but
were unable to do it because patient cannot stand. OMFS saw pt
on and did not feel his teeth that caused the abscess. He needs
to follow-up at with dental as an outpatient. He was discharged
with 1 week of Flagyl for a second brief elevation in his WBC
count near the end of his hospitalization which resolved with
flagyl.
.
2) Nutrition: He had a speech and swallow evaluation. He was
determined to be at risk for aspiration, but the family decided
he would not get a feeding tube and they understood the
aspiration risk. All medications except sublingual sinemet and
exelon were held due to the difficutly swallowing. By the end
of the hospitalization the patient was able to tolerate soft
solids. Please reconsider starting patient's other medications
when he is able to safely swallow them.
.
3)Parkinson's Disease/Dementia: The patient's symptoms acutely
worsened in the setting of infection and baseline dementia. Per
outpatient neurologist, we avoided anti psychotics. We
increased his dose of sinemet to two tabs 3 times per day. We
continued his exelon in liquid form. The patient's rigidity and
his demenia/delerium improved during the hospitalization.
Please avoid any psychoactive medications.
.
4) Respiratory failure: Mr. [**Name14 (STitle) 25024**] had respiratory failure
and needed to be intubated following his abscess drainage. The
failure was likely secondary to
likely [**2-16**] airway compromise from surgical edema. He was
intubated for several days. The swelling improved and he was
extubated and maintained good oxygen saturation on room air.
.
5) End of life/goals of care: Mr. [**Last Name (Titles) 25025**] family is very
involved. They chose to defer PEG tube placement at this time,
understanding the risk of aspiration.
Medications on Admission:
Xalatan 0.005 % 1 gtt OU QHS
Alphagan P 0.1 % 1gtt OU Q8
Seroquel 25 mg PO QAM, 50mg PO QHS
Celexa 30 mg PO daily
Rivastigmine 5 mg Oral Soln PO BID
Cosopt 2 %-0.5 % Eye Drops 1 gtt OU [**Hospital1 **]
Hydrochlorothiazide 12.5 mg Tab PO Daily
Trazodone 50 mg PO QHS
Sinemet CR 50 mg-200 mg Tab PO QHS
Sinemet 25 mg-100 mg Tab 2 tab QAM, 1 tab 2pm
Norvasc 5 mg PO Daily
Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H
(every 12 hours).
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
4. Carbidopa-Levodopa 25-100 mg Tablet, Rapid Dissolve Sig: Two
(2) Tablet, Rapid Dissolve PO TID (3 times a day).
5. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
6. Rivastigmine 2 mg/mL Solution Sig: 2.5 MLs PO BID (2 times a
day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for Groin itch.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
9. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
10. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 1 weeks: stop after
[**9-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
Neck Abcess
SECONDARY:
Parkinson's disease
[**Last Name (un) 309**] Body dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Last Name (Titles) 25024**].
You came to the hospital from your nursing home and were found
to have an infected abscess in your neck. The ENT surgeons
drained the abscess and you were treated with IV antibiotics.
You had difficulty breathing had to be intubated. You were
transferred to the ICU to help with your breathing and the
breathing tube was removed. You were transferred to the floor.
We continued treating your parkinson's disease. You were
evaluated by speech and swallow, who felt that you are at risk
for aspiration by eating. Your family decided that you would
not want a feeding tube and you started eating
We made the following changes to your medications:
1. We increased your dose of sinemet to 25-100 mg 2 tabs three
times per day
2. He are holding your seroquel, celexa, hydrochlorothiazide,
trazodone, and norvasc because you were having difficulty
swallowing. You may discuss re-starting these medications with
your primary doctor if your swallowing improves.
3. We are starting you on antibiotics (flagyl) which you should
continue for the next week.
Please see below for your follow-up appointments.
Followup Instructions:
You will follow-up with the doctor at your rehab facility.
Department: COGNITIVE NEUROLOGY UNIT
When: TUESDAY [**2106-10-5**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
|
[
"401.9",
"682.1",
"518.5",
"294.10",
"478.6",
"293.0",
"276.1",
"528.3",
"331.82",
"507.0",
"276.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"27.0",
"86.04",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
9340, 9410
|
5674, 7955
|
347, 427
|
9546, 9546
|
3090, 3090
|
10937, 11375
|
2773, 2792
|
8374, 9317
|
9431, 9525
|
7981, 8351
|
9726, 10429
|
2807, 2807
|
3715, 5651
|
10458, 10914
|
274, 309
|
2824, 3071
|
455, 2262
|
3105, 3701
|
9561, 9702
|
2284, 2526
|
2542, 2757
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,365
| 141,257
|
45966
|
Discharge summary
|
report
|
Admission Date: [**2134-2-22**] Discharge Date: [**2134-4-21**]
Date of Birth: [**2075-11-13**] Sex: F
Service: MEDICINE
Allergies:
Ribavirin
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Dyspnea, fever
Major Surgical or Invasive Procedure:
Central line insertion
Intubation
Paracentesis
History of Present Illness:
The pt is a 58F w/ HCV cirrhosis and HCC s/p Cyberknife who
initially presented to the ED on [**2-22**] w/ generalized malaise,
increasing DOE, and low-grade fever. Since then she has had a
complicated course including several MICU stays for SOB at times
requiring BiPAP, ultimately requiring urgent intubation on the
medical floor on [**3-31**] for resp failure and somnolence thought [**1-29**]
hypercarbic resp failure. Of note, she was also hypotensive
requiring levophed on [**4-19**]. The pt was extubated on [**4-5**]. She
has had multiple ID issues and has been followed by ID
consultants. She has been treated for MRSA PNA, Klebsiella UTI,
candidemia (c. dubliniensis) from bld cx on [**3-8**], Zoster
diagnosed [**3-29**]. The pt finished the last course of abx on [**4-6**]
and is now off all abx.
.
She was last called out of the MICU on [**4-8**] and has since
developed hypernatremia. She complained of some shortness of
breath beyond her baseline the evening of [**4-9**]; her ABG was
7.4/45/95. This evening she again complained of shortness of
breath although she was noted by the floor night float residents
to be appearing somewhat more alert and in less distress than on
[**4-9**]. Her ABG was 7.28/71/60. She had been started on IVF during
the day and the thought was that she may have had some fluid
overload. She was given Lasix 20mg IV x 1. Repeat ABG ~30-45
minutes later was 7.28/67/194 on 5L NC. She was transferred to
the MICU for further monitoring of her respiratory status.
.
Currently, she states she feels somewhat more short of breath.
She denies chest pain, chills, nausea, vomiting, abdominal pain.
She has a persistent productive but weak cough.
Past Medical History:
1. HCV cirrhosis - HCV dx [**2111**], s/p ifn & ribavirin (didn't
tolerate), now on copilot study, colchicine arm. On transplant
list.
2. HCC (2.3 x 3cm), discovered [**12/2132**], bx neg in [**1-/2133**], bx
positive [**8-/2133**], s/p cyberknife [**10/2133**]
3. Chronic inflammatory demyelinating polyneuropathy
4. s/p CCY c/b periumbilical hernias
5. Epilepsy as a child
6. Chronic bronchitis per patient, on fluticasone
Social History:
married, no children, no EtOH, Hx of IVDU
Family History:
noncontributory
Physical Exam:
HEENT: PERRL, EOMI, MM dry, OP clear,
Neck: supple, JVP flat
Chest: diffuse squeaks and rales, crusting erythematous rash on
R chest wall under R breast
CV: RR, tachycardic, s1 s2, no m/g/r
Abd: soft, protuberant, NT
Ext: 3+ pitting edema b/l up to the hips, w/w/p
Pertinent Results:
[**2134-2-22**] 07:22PM K+-4.9
[**2134-2-22**] 06:00PM URINE HOURS-RANDOM UREA N-865 CREAT-89
SODIUM-23
[**2134-2-22**] 06:00PM URINE OSMOLAL-472
[**2134-2-22**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2134-2-22**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2134-2-22**] 04:00PM GLUCOSE-88 UREA N-24* CREAT-1.2* SODIUM-125*
POTASSIUM-5.2* CHLORIDE-94* TOTAL CO2-24 ANION GAP-12
[**2134-2-22**] 04:00PM estGFR-Using this
[**2134-2-22**] 04:00PM ALT(SGPT)-68* AST(SGOT)-123* ALK PHOS-126*
AMYLASE-34 TOT BILI-2.4*
[**2134-2-22**] 04:00PM LIPASE-34
[**2134-2-22**] 04:00PM OSMOLAL-275
[**2134-2-22**] 04:00PM WBC-5.3# RBC-3.54* HGB-12.5 HCT-37.6 MCV-106*
MCH-35.2* MCHC-33.1 RDW-16.1*
[**2134-2-22**] 04:00PM NEUTS-82.1* BANDS-0 LYMPHS-8.8* MONOS-6.0
EOS-2.4 BASOS-0.6
[**2134-2-22**] 04:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2134-2-22**] 04:00PM PLT SMR-VERY LOW PLT COUNT-67*
Brief Hospital Course:
A/P: 58F with HCV cirrhosis, HCC, and COPD, admitted with
multifocal pneumonia, s/p multiple MICU stays, now going home
with hospice care.
.
## Respiratory distress, hypercarbia: Bilateral pleural
effusions likely contributing most to chronic dyspnea. ABG
indicates mostly compensated chronic respiratory acidosis,
likely from hypoventilation, especially given methadone. Given
her history of COPD, she may have been receiving more O2 than
necessary, further depressing her respiratory drive. Pt is
baseline tachypneic and is not in enough respiratory distress to
warrant intubation at this time. Bilateral pleural effusions
could also easily be hiding new pneumonia vs. tracheobronchitis.
Given junky lung exam, initial low pO2 may have been mucous
plugging. During her hospiotalization she was intubated three
times for respiratory distress. She had several bouts of
ventilator associated pneumonia and sepsis requiring pressors,
sputum positive for MRSA. A tracheostomy was considered. Final a
decision was made given overal poor prognosis to pursue hospice
care.
.
## Endstage liver disease - From hepatitis C. Now with
hepatocellular carcinoma. Not a transplant candidate. Going home
with hospice.
.
.
## h/o substance abuse
-- restart methadone slowly
.
Medications on Admission:
OUTPATIENT MEDS:
1. Lasix 40 mg tid
2. Aldactone 100 mg [**Hospital1 **]
3. Methadone 75.5 mg [**Hospital1 **]
4. Neurontin 300 mg tid
5. Lactulose 30 cc prn
6. Fluticasone [**Hospital1 **]
7. Colchicine 0.6 mg [**Hospital1 **]
8. Calcium carbonate 500 mg [**Hospital1 **]
9. Pantropazole 40 mg qd
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
Disp:*3600 ML(s)* Refills:*2*
2. Methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
3. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1h as
needed for pain: every hour as needed.
Disp:*50 ml* Refills:*0*
4. Lorazepam 2 mg/mL Concentrate Sig: 0.5-2 mg PO every [**4-2**]
hours as needed for aggitation, nausea.
Disp:*50 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
all care hospice
Discharge Diagnosis:
Liver failure
respiratory failure
MRSA pneumonia
Fungemia
Hepatocellular carcinoma
Discharge Condition:
Stable
Discharge Instructions:
Please call the hospice company wiht any concerns or questions.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2134-5-31**]
12:20
Completed by:[**2134-4-21**]
|
[
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"053.9",
"112.9",
"785.52",
"599.0",
"507.0",
"038.9",
"584.5",
"070.44",
"491.21",
"276.2",
"276.0",
"357.81",
"041.3",
"570",
"286.7",
"482.41",
"253.6",
"V09.0",
"789.5",
"155.2",
"511.9",
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icd9cm
|
[
[
[]
]
] |
[
"33.24",
"54.91",
"93.90",
"96.04",
"38.91",
"96.72",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6052, 6099
|
3984, 5248
|
285, 334
|
6226, 6235
|
2890, 3961
|
6347, 6536
|
2571, 2588
|
5597, 6029
|
6120, 6205
|
5274, 5574
|
6259, 6324
|
2604, 2871
|
231, 247
|
362, 2047
|
2069, 2496
|
2512, 2555
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,535
| 145,190
|
9131
|
Discharge summary
|
report
|
Admission Date: [**2134-5-24**] Discharge Date: [**2134-5-31**]
Service: MEDICINE
Allergies:
Prednisone / Cortisone
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
transfer for episode of neurologic deficit
Major Surgical or Invasive Procedure:
placement of right carotid stent
History of Present Illness:
Mr. [**Known lastname **] is an 83yo gentleman with h/o CAD, "ischemic and
valvular" cardiomyopathy with EF 15-20%, s/p BiV pacer without
ICD, paroxysmal AFib not on coumadin admitted to [**Hospital3 **] with subacute left-sided weakness and transferred to
[**Hospital1 18**] after episode of transient L upper extremity weakness and
dysarthria after using the commode.
Mr. [**Known lastname **] was initially admitted to [**Hospital3 **] with complaints
of weakness. He was found to have a digoxin level of 3.8, and
his digoxin was held. On the day of transfer to [**Hospital1 **], he
experienced transient dysarthria and left arm weakness after
using the commode. He was transferred to the neurology service
at [**Hospital1 18**]. His initial event was felt to be vagally mediated, and
the neurology service was further investigating whether the
patient would benefit from intervention of his known carotid
artery stenosis. He had been evaluated by Dr. [**First Name (STitle) **] in [**Month (only) 958**] of
[**2133**] and intervention was deferred in light of his multiple
co-morbidities.
During the patient's work-up, he had a similar episode on [**5-26**]
when he was on the commode and developed transient left-sided
weakness, at which point it was decided to pursue carotid stent.
Past Medical History:
# CAD: LAD 50-60% prox at first septal perf, 1st septal branch
60%; RCA 80% prox; RI 80% prox per cath in [**2125**].
# Cardiomyopathy with EF 15-20%, ?ischemic vs non-ischemic
# h/o moderate MR and severe TR--Echo [**2134-5-25**] showed trivial MR
and TR
# AFlutter and Paroxysmal AFib, remote h/o LV thrombus, on
amiodarone but not coumadin (developed macular degeneration
attributed to coumadin)
# BiV PPM with ICD placed [**2130**], ? ICD deactivated shortly
thereafter: BiV PPM [**Company 1543**] Insync III 8042; ICD component
removed later in [**2130**] to reflect code status
# HTN
# Hyperlipidemia
# Prostate Cancer metastatic to vertebrae, diagnosed [**2130**].
Followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
# h/o BOOP currently on steroid taper
# COPD--per records BUT PFTs from [**4-/2134**] showed mild decrease
FEV1 and FVC with normal ratio (RESTRICTIVE pattern)
# Psoriasis
# Iron deficiency anemia with hx GI bleed--baseline Hct 28-32
# CRI (baseline creatinine 2.0)
# Macular degeneration
# s/p left hip replacement
# Hypothyroidism
# Metastatic prostate cancer dx in [**4-22**]
# RUL lung opacity - unclear etiology, s/p unremarkable
bronchoscopy [**2-23**] with cytology negative for malignancy
ALLERGIES: ? Cortisone (although tolerates prednisone)
Cardiologist: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**]
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (has not seen him yet, was [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11180**])
Pulmonologist: Dr. [**Last Name (STitle) **]
Social History:
Patient was living at [**Last Name (un) 31463**] Pond independent living; he has a
significant other and several children in the area who have been
helping to care for him; after his [**Month (only) **] admission to [**Hospital1 18**], he
was discharged to rehab, where he has been until he was admitted
to [**Hospital3 **]. There was great concern that he would not be
able to care for himself at home. He has a wheeled walker and a
scooter.
Social history is significant for the absence of current tobacco
use; he has a 55 pack year history and stopped smoking 15 years
ago. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death; his father had an MI at age 63.
Physical Exam:
VS: T not avail. yet, BP 109/60, HR 111, RR 19, O2 100% on 3L on
dopamine at 5.
Gen: Elderly man lying calmly in bed in no acute distress, resp
or otherwise. Oriented. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. Pupils not reactive b/l and right
greater than left (stable as compared to note from 3/[**2133**]).
EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa.
Neck: Supple with no JVD. No bruits b/l.
CV: PMI located in 5th intercostal space, midclavicular line.
Borderline tachy with regular rhythm, somewhat distant heart
sounds. No S4, no S3. No murmur or rub.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi as appreciated anteriorly.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e. Significant bruising of arms b/l.
Skin: Mildly pale. No stasis dermatitis, ulcers, scars, or
xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+; 1+ DP
Neuro: Language intact, no slurred speech, alert and answering
questions appropriately. Good long term memory. CN III, IV, VI
intact. CN V intact--sensation intact b/l. CN VII--face
symmetric. CN VIII grossly intact. CN IX, X, XII tongue midline,
palate symmetric, gag intact. CN [**Doctor First Name 81**]--shrug intact b/l. Strength
[**3-22**] in UE both distal and proximal b/l. Strength 5/5 in LLE;
unable to test strength in RLE [**12-19**] to recent procedure.
pupils noted to be non-reactive vs sluggishly reactive and
unequal on presentation to the CCU. Although several notes
suggest that the patient has equal pupils, according to Neuro
note from [**2134-1-16**] in OMR: "Left pupil 4 to 2mm and brisk. R
pupil 5-->3mm (surgical)," which is similar to current exam.
Pertinent Results:
LABS on admission to CCU:
BUN/Cr 42/1.9
K 4.0
Mg 2.1
WBC 11
Hct 30
Plt 281
CKs negative x 3; troponin 0.11
ALT 49
AST 65
HDL 40
LDL 103
UA negative
UCx: fecal contamination
LABS during hospital course:
[**2134-5-26**] 06:10AM BLOOD WBC-11.0 RBC-3.29* Hgb-10.0* Hct-30.0*
MCV-91 MCH-30.4 MCHC-33.3 RDW-17.3* Plt Ct-281
[**2134-5-27**] 04:12AM BLOOD WBC-18.8*# RBC-3.08* Hgb-9.2* Hct-28.1*
MCV-91 MCH-29.9 MCHC-32.7 RDW-17.3* Plt Ct-324
[**2134-5-28**] 04:00AM BLOOD WBC-19.3* RBC-2.93* Hgb-8.8* Hct-25.6*
MCV-87 MCH-30.2 MCHC-34.5 RDW-17.9* Plt Ct-177
[**2134-5-31**] 09:30AM BLOOD WBC-27.5* RBC-3.13* Hgb-9.2* Hct-29.2*
MCV-93 MCH-29.4 MCHC-31.5 RDW-18.0* Plt Ct-159
[**2134-5-31**] 09:30AM BLOOD Neuts-87* Bands-0 Lymphs-10* Monos-2
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2134-5-26**] 10:30AM BLOOD PT-12.6 PTT-24.6 INR(PT)-1.1
[**2134-5-26**] 06:10AM BLOOD Glucose-124* UreaN-42* Creat-1.9* Na-140
K-4.0 Cl-106 HCO3-24 AnGap-14
[**2134-5-27**] 04:12AM BLOOD Glucose-228* UreaN-43* Creat-2.5* Na-136
K-3.8 Cl-92* HCO3-26 AnGap-22*
[**2134-5-29**] 05:42AM BLOOD Glucose-91 UreaN-56* Creat-4.6*# Na-136
K-5.0 Cl-100 HCO3-22 AnGap-19
[**2134-5-31**] 09:30AM BLOOD Glucose-80 UreaN-71* Creat-6.1* Na-134
K-5.9* Cl-100 HCO3-16* AnGap-24*
[**2134-5-25**] 09:30AM BLOOD CK(CPK)-52
[**2134-5-25**] 07:35PM BLOOD CK(CPK)-49
[**2134-5-27**] 04:12AM BLOOD ALT-48* AST-86*
[**2134-5-25**] 01:55AM BLOOD CK-MB-NotDone cTropnT-0.11*
[**2134-5-31**] 09:30AM BLOOD Calcium-8.4 Phos-10.3* Mg-2.7*
[**2134-5-26**] 06:10AM BLOOD %HbA1c-6.2*
[**2134-5-26**] 06:10AM BLOOD Triglyc-133 HDL-40 CHOL/HD-4.3
LDLcalc-103
[**2134-5-27**] 04:12AM BLOOD PSA-35.0*
[**2134-5-29**] 05:42AM BLOOD Digoxin-2.6*
[**2134-5-27**] 01:19PM BLOOD Lactate-3.3*
[**2134-5-30**] 11:27AM BLOOD Lactate-3.2* K-4.9
EKG demonstrated AV paced rhythm at 60 with no significant
change compared with prior dated [**2134-5-5**]. Upon arrival to the
CCU, EKG demonstrated regular wide complex tachycardia with LBBB
pattern, no visible pacing spikes. EKG from [**2-/2130**] (prior to
PPM) demonstrates LBBB with same morphology. Repeat EKG
demonstrated rate of 112 with same QRS morphology and visible
pacing spikes.
TELEMETRY demonstrated: Regular wide complex tachycardia at
about 100.
2D-ECHOCARDIOGRAM performed on [**2134-5-25**] demonstrated:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is severe global left
ventricular hypokinesis (LVEF = 15-20%). The right ventricular
free wall is hypertrophied. Right ventricular chamber size is
normal with borderline normal free wall function. The ascending
aorta is mildly dilated. The aortic valve leaflets are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened with trivial regurgitation. The
left ventricular inflow pattern suggests impaired relaxation.
There is an anterior space which most likely represents a fat
pad. Pulmonary artery pressures are indeterminate.
IMPRESSION: Suboptimal image quality. Severe left ventricular
hypokinesis. Mild right ventricular hypokinesis.
Compared with the prior report (images unavailable for review)
of [**2131-3-16**], the severity of mitral and tricuspid regurgitation
is lower.
FURTHER IMAGING STUDIES:
Carotid series [**2134-1-19**];
Duplex evaluation was performed of both carotid arteries.
Significant calcified plaques are identified on the right. Of
note, it extends fairly distally in the internal carotid artery
and somewhat tortuous vessel. The peak systolic over diastolic
velocity in the ICA is 550/195. In the remainder of the vessel,
the peak systolic velocities are 40, 304 in the CCA, ECA
respectively. The ICA to CCA ratio is 13. This is consistent
with an 80-99% stenosis.
On the left, peak systolic velocities are 78, 70, 113 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1. This
is consistent with less than 40% stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: On the right, there is significant calcified plaque
with an 80-99% carotid stenosis. This will fall to the higher
end of the range. In addition, it is fairly distal in the
internal carotid artery and somewhat tortuous vessel. On the
left, there is less than 40% carotid stenosis.
CT Head without contrast [**2134-5-25**]:
There is no evidence of acute intracranial hemorrhage, shift of
midline structures, or hydrocephalus. The [**Doctor Last Name 352**]-white matter
differentiation is preserved without evidence of major vascular
territorial infarct. Dense atherosclerotic calcifications are
noted on the carotid siphons. The paranasal sinuses and mastoid
air cells are unremarkable.
IMPRESSION: No acute intracranial process.
Carotid Series [**2134-5-25**]:
The sensitivity of the exam on the right is severely limited by
a
complex heavily calcified plaque that creates acoustic
shadowing. The
previously seen elevated velocities are not seen today, but the
distal
internal carotid artery waveform is quite dampened beyond this
area of
calcification. Suggest further correlative studies to better
evaluate.
IMPRESSION: Stable 1-39% left ICA stenosis.
CT Neck without contrast [**2134-5-25**]:
1. Marked atherosclerotic calcification involving the aortic
arch, great vessels, and carotid arteries which are suboptimally
evaluated without IV contrast. Apparent severe stenosis at the
origin of the right internal carotid artery.
2. Severe panlobular emphysema.
3. No significant change compared to [**2134-4-26**] chest CT in
blastic focus of the sternum, presumably a prostate metastasis.
4. Scarring and architectural distortion of the right upper
lobe, similar to the recent chest CT of [**2134-4-18**].
Carotid series [**2134-5-26**]:
Successful imaging of the elevated velocities seen previously in
the right internal carotid artery. Extremely elevated velocities
consistent with high-grade 80-99% stenosis in the distal right
ICA. This is consistent with the study from [**2134-1-16**].
Cath/Carotid Stent [**2134-5-26**]:
1. Access: Retro RFA with catheter to the RCCA/ICA.
2. Thoracic aorta: Aortagraphy revealed a Type II arch without
critical
lesions.
3. Carotid/vertebrals: The RCCA has origin calcificationwithout
critical
lesions. The ICA has heavy calcification with serial 80 and 90%
lesions
in the proximal and mid segments. The ICA fills the ipsilateral
ACA/MCA
with noted fetal origin PCA.
4. Successful PTA/stent to right ICA with a 6-8x40mm Protege
stent and
8.0x20mm stent more proximal. Excellent result with normal flow
down
vessel and no residual stenosis. Patient with hemodynamic
instablity at
end of procedure but was stable on transfer to CCU. No
neurological
sighns or symptoms at end of procedure.
FINAL DIAGNOSIS:
1. Severe stenosis of right ICA with heavy calcification
2. Successful PTA/stent to right ICA with 2 bare metal stents.
Cardiac Cath [**2134-5-27**]:
1. Resting hemodynamics on dopamine 12 mcg/kg/min demonstrated
initial
right and left heart filling pressures (RVEDP 5 mm Hg, PCW mean
7 mm
Hg), with markedly decreased pulmonary arterial oxygen
saturation of 33%
and a depressed cardiac index of 1.64 l/min/m2.
2. After the administration of 250 cc 0.9% saline and decreasing
dopamine to 6 mcg/kg/min, increase in pulmonary pressures and LV
filling
pressure were seen (PCW 11 mm Hg) with increased cardiac index
of 2.23
l/min/m2.
3. After further administration of 250 cc 0.9% saline (total 500
cc),
there was marked abnormal elevation of pulmonary pressure (mean
36 mm
Hg) and PCWP (mean 22 mm Hg), and a decrease in the cardiac
index to
2.01 l/min/m2.
FINAL DIAGNOSIS:
1. Decreased LV and RV filling pressures consistent with
hypovolemia.
2. Initial cardiogenic shock.
3. LV diastolic dysfunction.
CXR [**2134-5-27**]:
In comparison with the study of [**5-5**], the patient has taken a
much
better inspiration. The pacemaker/defibrillator remains in
place.
Specifically, no evidence of acute focal pneumonia at this time.
Renal Ultrasound [**2134-5-28**]:
No hydronephrosis and no cysts or solid masses identified.
Multiple non-obstructing small renal stones.
CXR [**2134-5-29**]:
There has been interval placement of a Swan-Ganz catheter with
distal lead tip in the distal right pulmonary artery. AICD with
leads within the right atrium and right ventricle is again seen.
There is unchanged cardiomegaly. There is streaky opacity seen
at the left base which may represent atelectasis or early
infiltrate. Attention to this area is recommended on subsequent
examinations to exclude underlying infiltrate. The right lung is
clear.
CXR [**2134-5-30**]:
The Swan-Ganz catheter, pacemaker is unchanged. There is again
seen some
vague density at the left CP angle, which may be secondary to
atelectasis or early infiltrate, but again this is unchanged
from prior. The rest of the lung fields are clear without overt
pulmonary edema.
Brief Hospital Course:
83yo gentleman with h/o CAD, chronic systolic heart failure with
EF 15%, AFib not on coumadin, s/p PPM admitted with recurrent
episodes of transient neurological deficits.
Patient's episodes were felt to be due to his significant
carotid stenosis. He had a carotid stent placed and was
transferred to the CCU for monitoring. The patient's blood
pressure was labile during his procedure and he required
dopamine to maintain his pressures upon transfer out of the cath
lab.
The CCU team placed a Swan Ganz catheter to assist with
management given the difficulty of clinically assessing his
volume status given his severely depressed systolic function and
underlying pulmonary disease. Swan ganz demonstrated that the
patient was dehydrated and he was given fluids for volume
resuscitation. He was also put on broad spectrum antibiotics in
case he was developing sepsis with hypotension. Dopamine was
weaned, but the patient developed acute renal failure on chronic
renal insufficiency. Renal was consulted and felt that the
patient would likely require hemodialysis if his renal function
did not improve soon.
After lengthy discussion with the patient and his family as well
as the patient's cardiologist and prior PCP, [**Name10 (NameIs) **] patient decided
that he would not want to be put on hemodialysis. He developed
uremic symptoms and expired on [**2134-5-31**] with his family at the
bedside.
# Paroxysmal Atrial Fibrillation s/p PPM:
Digoxin was held given recently elevated levels, but digoxin
levels trended up in the setting of his heart failure. He was
not on coumadin b/c of macular degeneration (per patient).
Although pt had wide complex tachycardia on presentation, his
baseline EKGs prior to PPM placement demonstrated LBBB. He was
felt to be in sinus tachycardia with aberrant conduction.
# Chronic BOOP:
Prednisone was stopped after discussing the matter with his
pulmonologist. prednisone taper
# [**Female First Name (un) 564**] esophagitis: Diagnosed in [**2134-4-18**], ? secondary to
prednisone.
He was continued on fluconazole, which was renally dosed.
# Metastatic prostate cancer:
Patient's oncologist (Dr. [**Last Name (STitle) **] made aware of patient's
admission and death.
# Hypothyroidism: continued levothyroxine
# Code: DNR/DNI
# Communication: with son [**Name (NI) **] [**Telephone/Fax (1) 31460**]
Patient expired on [**2134-5-31**] with his family at the bedside.
Medications on Admission:
Home Meds:
ASA 325 daily
Metoprolol succinate 25mg daily
Lisinopril 5mg daily
Digoxin 125mcg daily
Lasix 20mg daily
Levothyroxine 25mcg daily
Atorvastatin 10mg daily
Prednisone 5mg every other day vs daily
Fluconazole 200mg Q24H x 3 weeks ([**5-8**]- )
Omeprazole 20mg daily
Docusate
Senna
Ambien 5-10mg HS
Nitroglycerin SL
Atrovent neb Q6H PRN
Albuterol neb Q6H PRN
Meds on transfer to CCU:
ASA 325 daily
Metoprolol tartrate 12.5 daily
Lisinopril 2.5mg QAM
Lasix 20mg daily
Levothyroxine 25mcg daily
Prednisone 10mg daily
Fluconazole 100mg daily
Pantoprazole
Docusate
Ambien 5-10mg HS
Nitroglycerin SL
Tylenol
Heparin SubQ TID
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis: Carotid stenosis
Secondary Diagnoses: Chronic systolic heart failure,
dehydration, acute renal failure on chronic renal insufficiency,
uremia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2134-6-17**]
|
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icd9cm
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[]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,727
| 175,606
|
51921+59387
|
Discharge summary
|
report+addendum
|
Admission Date: [**2154-10-30**] Discharge Date: [**2154-11-5**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
GI BLEED
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57M with CAD s/p MI with LV hypokinesis, afib, CHF EF 30%, DM2,
HTN, ESRD on HD (last done on Saturday [**2154-10-26**]) who reported
weakness and fatigue at dialysis. Hct at that time was 12.
Patient has also had one week of intermittet melena with 2-3
stools ranging from black/tarry to BRB, associated with fatgue,
lightheadedness, DOE. Patient denies any fevers, chills, recent
EtOH use, ASA use, NSAID use, recent travel, uncooked foods.
Patient also denies any hematemesis, hemoptysis, dysphagia,
abdominal pain, abdominal cramping, tenesmus. Patient's GI bleed
is also temporally associated with chest pain, reported as a
[**5-23**] squeezing pain radiating to the L arm. CK: 133 MB: 6
Trop-T: 0.18. Baseline Tn is 0.16.
.
Patient did not go to dialysis as [**Month/Year (2) 1988**] on [**2154-10-29**] and also
has stopped taking all medications since [**2154-10-26**]. Patient
[**Year (2 digits) 18038**] crack cocaine on day PTA.
.
Multiple previous workups have included at least six
endoscopies, three colonoscopies, one enteroscopy, and a capsule
camera study, and all have been negative, except for small AVM's
in the duodenum
seen and cauterized on one study and minor jejunal erosions
noted
on the capsule camera study.
.
Most recent EGD was [**2154-8-29**] and was normal and last colonoscopy
was on [**2153-6-1**] that showed blood throughout the entire colon and
TI abd bleeding source was not identified.
.
In ED patient was hemodynamically stable with Hct of 12. GI and
Renal made aware. Patient did have some chest pain in the ED
with EKG was unchanged and initial enzymes were negative.
Past Medical History:
1. Type II diabetes mellitus
2. CAD s/p MI, MIBI in [**11-18**] showed reversible defects
inferior/latateral
3. CHF with EF 20-30% and severe global hypokinesis
4. Hypertension
5. Dyslipidemia
6. Atrial fibrillation
7. Hisrory of gastrointestinal bleed: Duodenal, jejunal, and
gastric AVMs, s/p thermal therapy; sigmoid diverticuli
8. Chronic pancreatitis
9. Hepatitis C
10. GERD
11. CRF, baseline 3.9-5.3
12. Gout, s/p arthroscopy with medial meniscectomy [**5-/2149**]
13. Depression, s/p multiple hospitalizations due to SI
14. Polysubstance abuse: crack cocaine, EtOH, tobacco
15. Erectile dysfunction, s/p inflatable penile prosthesis
[**5-/2148**]
Social History:
Smokes 3 cigs/day. Hx of alcohol abuse, with DTs and
detoxification. Active crack cocaine use.
Family History:
Father with alcoholism, cousin with [**Name2 (NI) 14165**] cell. Mother with
renal failure, d. 58. Twin brother and son with kidney disease.
Physical Exam:
Vitals - T 97.6 BP 131/77 HR 84 RR21 99%4L
GENERAL: laying in bed, NAD
SKIN: [**Last Name (un) **] extremities, warm and well perfused, no excoriations,
no rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pale conjunctiva,
MMM, no LAD, no JVD
CARDIAC: RRR, nl S1, S2
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, +hepatomegaly 7cm below costal margin
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 1+ DP pulses bilaterally
Pertinent Results:
[**2154-10-30**] 07:25PM CK(CPK)-104
[**2154-10-30**] 07:25PM CK-MB-6 cTropnT-0.18*
[**2154-10-30**] 07:25PM HCT-20.2*
[**2154-10-30**] 04:36PM GLUCOSE-317* UREA N-57* CREAT-5.8* SODIUM-136
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
[**2154-10-30**] 04:36PM CALCIUM-9.1 PHOSPHATE-5.0* MAGNESIUM-2.3
[**2154-10-30**] 04:36PM WBC-5.8 RBC-2.05* HGB-5.1* HCT-16.5* MCV-80*
MCH-24.7* MCHC-30.7* RDW-17.9*
[**2154-10-30**] 04:36PM NEUTS-76.7* BANDS-0 LYMPHS-15.0* MONOS-6.1
EOS-1.5 BASOS-0.6
[**2154-10-30**] 04:36PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ SCHISTOCY-1+
[**2154-10-30**] 04:36PM PLT COUNT-289
[**2154-10-30**] 04:36PM PT-13.4* PTT-26.6 INR(PT)-1.2*
[**2154-10-30**] 01:16PM WBC-6.4 RBC-1.87*# HGB-4.6*# HCT-14.9*#
MCV-80* MCH-24.5* MCHC-30.8* RDW-17.1*
[**2154-10-30**] 01:16PM NEUTS-82.7* BANDS-0 LYMPHS-11.1* MONOS-4.8
EOS-1.0 BASOS-0.4
[**2154-10-30**] 01:16PM PLT COUNT-372
[**2154-10-30**] 12:20PM GLUCOSE-276* UREA N-58* CREAT-5.7*#
SODIUM-137 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-24 ANION GAP-20
[**2154-10-30**] 12:20PM CK(CPK)-133
[**2154-10-30**] 12:20PM cTropnT-0.18*
[**2154-10-30**] 12:20PM CK-MB-6
[**2154-10-30**] 12:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-10-30**] 12:20PM PT-13.0 PTT-25.6 INR(PT)-1.1
CHEST (PORTABLE AP) [**2154-10-30**] 12:24 PM
CHEST (PORTABLE AP)
Reason: eval for ptx, chf
[**Hospital 93**] MEDICAL CONDITION:
57 year old man with chest pain at site of HD catheter
REASON FOR THIS EXAMINATION:
eval for ptx, chf
HISTORY: 57-year-old male with chest pain at the site of
hemodialysis catheter.
COMPARISON: Radiographs [**2154-10-9**].
SINGLE PORTABLE VIEW OF THE CHEST: A left subclavian large-bore
dual-lumen catheter reaches the high atrium. Cardiomegaly,
interstitial edema, and bilateral pleural effusions (right
greater than left), have not changed significantly since the
prior exam. The bony thorax is normal.
IMPRESSION: Overall no change since [**2154-10-9**]. Please
note that radiographic examination cannot address the site of
catheter insertion.
AV FITULOGRAM SCH [**2154-11-4**] 7:43 AM
AV FITULOGRAM SCH
Reason: Please eval fistula
Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
57 yo male with CAD, HTN, ESRD on HD. ? high pressures within
fistula per renal team.
REASON FOR THIS EXAMINATION:
Please eval fistula
INDICATION OF EXAM: This is a left AV fistulogram for a
59-year-old male with end-stage renal disease. High pressures
during dialysis.
RADIOLOGISTS: The procedure was performed by Drs. [**Last Name (STitle) 15785**] and
[**Name5 (PTitle) **], the attending radiologist, who was present and
supervising throughout the procedure.
PROCEDURE AND FINDINGS: After informed consent was obtained from
the patient explaining the risks and benefits of the procedure,
the patient was placed supine on the angiographic table, and the
left arm was prepped and draped in the standard sterile fashion.
Using palpatory technique and after injection of 1 cc of 1%
lidocaine, the AV fistula was accessed with a 21 gauge needle
pointing towards the venous outflow. A 0.018 guide wire was
placed. The needle was then exchanged for a 4.5 French
micropuncture sheath. The inner dilator and the wire were
removed, and hand injection of contrast demonstrates good
positioning of the micropuncture sheath within the left cephalic
vein. Serial venograms were performed at the level of the arm,
shoulder and chest, for possible venous outflow stenosis.
Diagnostic venograms demonstrate two areas of narrowing, one
within the fistula in the proximal cephalic vein, and proximal
to the level of the junction of the cephalic vein with the
axillary vein. Collateral formation/flow was identified. Based
on these diagnostic findings, it was decided that the patient
would benefit from balloon dilation of these lesions. The
micropuncture sheath was then exchanged for a 6 French vascular
sheath over a 0.035 [**Last Name (un) 7648**] wire. A roadmap venogram was
obtained, and a 6 mm balloon was advanced over the wire up to
the level of the narrowings, and several balloon dilations were
performed at dilations up to 15 ATM. A second area of narrowing
was dilated with a 7 mm balloon up to 10 ATM. The balloon was
removed. Followup venogram demonstrated partial angiographic
improvement of venous outflow after dilation.
Films were also obtained for evaluation of the arterial
anastomosis without any significant stenosis seen. The patient
tolerated the procedure well.
IMPRESSION:
1. Left AV fistulogram demonstrates two areas of venous
narrowing at the level of the proximal cephalic vein near the
fistula and near the junction of the cephalic vein with the
axillary vein.
2. Partial angiographic improvement after angioplasty with 7 and
6 mm balloons.
US EXTREMITY NONVASCULAR RIGHT [**2154-11-4**] 12:12 PM
US EXTREMITY NONVASCULAR RIGHT
Reason: R/O DVT, SWELLING
[**Hospital 93**] MEDICAL CONDITION:
58 year old man with right arm swelling
REASON FOR THIS EXAMINATION:
please rule out upper extremity DVT
INDICATION: Right upper extremity swelling.
COMPARISONS: None.
FINDINGS: [**Doctor Last Name **] scale, color and spectral Doppler ultrasound
images of right upper extremity veins were obtained.
Flow and compressibility is demonstrated within both internal
jugular veins.
Additionally, the right axillary, subclavian, brachial, basilic
and cephalic veins are patent and compressible. The right
axillary, subclavian, brachial, and basilic veins demonstrate
normal respiratory phasicity and response to distal
augmentation.
IMPRESSION: 1) No evidence of right upper extremity deep vein
thrombosis.
Brief Hospital Course:
#GI BLEED: Patient was intially admitted to the ICU for
management of his GI Bleed. His Hct was intially 15 but after 7
Units of prbcs, patients HCt had improved to 30 and remained
stable. Patient was seen by GI who felt that given the patients
extensive history of GI bleeds and multitude of studies that
have been done, there was no acute need for intervention. The
previous workups have included at least six endoscopies, three
colonoscopies, one enteroscopy, and a capsule camera study, and
all have been negative, except for small AVM's in the duodenum
seen and cauterized on one study and minor jejunal erosions
noted on the capsule camera study. Patients Hct was stable
once transferred to the floor. He was started on a PPI. Patient
was stable upon discharge.
.
#ESRD on HD: Patient with last HD on saturday prior to
admission. He received HD on first 2 days of admission given
extensive volume overload and then resumed on his regular
outpatient schedule. An AV fistulogram was done which showed
stenosis at the venous anastomosis and angioplasty was done x4
with partial resolution. Renal was aware of the results. He
remained in the hospital an additional day in order to make sure
the AV Fistula was functioning well.
.
#CAD: s/p MI - Pt has ruled out x3. ASA was initially held given
GI bleed but resumed on hospital day #4. Patient was continued
on his statin and labetolol. He remained chest pain free during
remaining stay. Of note, his Amlodipine, Isosorbide and
Lisinopril were held during hospitalization given his normal BP
and use of cocaine prior to admission. He was restarted on his
Lisinopril on the day of discharge given his slightly elevated
BP. His Amlodipine and Isosorbide were held upon discharge.
.
#DM: Patient continued his home insulin regimen.
.
#Depression/Delirium/Substance Abuse-The patient has a long
history of cocaine abuse. He had positive cocaine urine tox
screen while in the hospital. He admits to cocaine use on the
days prior to admission. In addition, the patient has a known
history of depression. He has poor follow up, however, with the
outpatient appointments made for him on prior hospitalizations.
Patient was seen by psychiatry during his stay for agitation and
delirium which occured during his initial ICU stay. It was felt
that the patients delirium was secondary to not being dialyzed
for over a week. THe patient received Seroquel for his
agitation. He also had a 1:1 sitter while in the ICU. The
patients mental status improved after he received dialysis. The
sitter was removed. The patient remained depressed but had no
suicidal ideation. He was evaluted by social work to make
further recommendations regarding his follow up. He will be
attending a partial hospitalization program at [**Hospital1 **] on Mondays,
Wednesdays, and Fridays the day after admission.
.
Medications on Admission:
Aspirin 325 mg Tablet
Amlodipine 5 mg Tablet
Atorvastatin 20 mg
Ferrous Sulfate 325 *
Pantoprazole 40 mg
Thiamine HCl 100 mg
Folic Acid 1 mg
Lisinopril 40 mg
Sevelamer 800 mg Tablet tid with meals
Labetalol 100 mg Tablet [**Hospital1 **]
Isosorbide Mononitrate 30 mg daily
NPH Insulin 30 qam / 20 units qpm
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
30Units qam Subcutaneous once a day: Please return to your home
regimen.
5. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: One (1)
20 Units qPM Subcutaneous at bedtime: Please resume your [**Last Name (un) **]
regimen.
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
7. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
GI Bleed
Discharge Condition:
Improved
Discharge Instructions:
You were admitted to the hospital for bloody stools and fatigue.
You had what is called a GI Bleed. You were admitted to the
intensive care unit for monitoring and treatment. You received
7 units of blood to improve your blood levels. In addition, you
had some blood tests to rule out any evidence of ischemia to
your heart. These were all negative.
In addition, you had a AV Fistulogram to evaluate the AV fistula
in your left arm. The vessels were re-opened by what is called
angioplasty.
It is crucially important to your health that you stop using
cocaine, as this can damage your already compromised heart
function.
Your next dialysis session is on Thursday and you will continue
to follow a Tuesday, Thursday, Saturday dialysis schedule.
We stopped 2 medications that you had previously been taking for
blood pressure. You will not take your Isosorbide Mononitrate
or your Amlodipine.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
You should return to the ED with fatigue, dizziness, black or
bloody stools, recurrent chest pain, shortness of breath,
fevers, chills, nausea, vomiting, or for any other problems that
concern you.
You will need to follow up with your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 216**] as below.
Followup Instructions:
You will be attending a partial hospitalization program at [**Hospital1 **]
on Mondays, Wednesdays, and Fridays starting tomorrow. You have
been given information about this program by the social worker.
You also should keep the following appointments:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2154-11-13**]
12:10
Dialysis Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON
BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-12-4**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2155-1-3**] 8:20
Name: [**Known lastname 17548**],[**Known firstname **] Unit No: [**Numeric Identifier 17549**]
Admission Date: [**2154-10-30**] Discharge Date: [**2154-11-5**]
Date of Birth: [**2096-11-3**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 1981**]
Addendum:
Pt had known history of CHF: Systolic dysfunction based on ECHO
done [**2154-10-8**]:
There is moderate to severe global left ventricular hypokinesis
(LVEF = 30 %). Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1983**] MD [**MD Number(2) 1984**]
Completed by:[**2154-12-9**]
|
[
"996.73",
"070.54",
"578.1",
"304.21",
"585.6",
"303.91",
"428.20",
"282.9",
"403.91",
"577.1",
"427.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.95",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
16230, 16393
|
9180, 12027
|
279, 285
|
13419, 13430
|
3430, 4895
|
14800, 16207
|
2733, 2875
|
12385, 13337
|
8449, 8489
|
13387, 13398
|
12053, 12362
|
13454, 14777
|
2890, 3411
|
231, 241
|
8518, 9157
|
313, 1925
|
1947, 2602
|
2618, 2717
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,588
| 137,869
|
10533
|
Discharge summary
|
report
|
Admission Date: [**2112-7-2**] Discharge Date: [**2112-8-11**]
Date of Birth: [**2045-12-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Fever, Hypotension
Major Surgical or Invasive Procedure:
[**2112-7-2**] Intubation
History of Present Illness:
Mr. [**Known lastname 34698**] is a 66 year old man with h/o POEMS syndrome, s/p
autoSCT [**12-15**], therapy-related MDS, recently hospitalized and
diagnosed with recurrence of POEMS syndrome, C1D18 of
Velcade/Dexamethasone, who was admitted with fever and
hypotension.
The patient was discharged 2 days prior to admission ([**2112-6-30**])
after hospitalization for febrile neutropenia, complicated by
ARF requiring HDx4 sessions and features of POEMS syndrome
relapse. At home, the patient had a low grade temp yesterday to
100.3 with chills and then another fever to 101.2 this
afternoon. The wife notes that he was complaining of increased
pain in his lower extremities (neuropathy) and had decreased PO
intake. He became increasingly lethargic and weak to the point
that they had difficulty getting him out of bed. His urine
output decreased from 1100cc the day before to 400cc over 24h.
Foley was in place since last Sunday (1 week). The wife called
the BMT fellow on call, who referred the patient to the ED.
In the field, the patient's BP was 60/40. EMS placed a
peripheral line and bolused him with IVF.
In the ED, initial VS were: T 101.2 HR 120 BP 184/132 RR 18
O2sat 100% NRB. BP then dropped to 50/30 about 10 minutes after
arrival. The patient was lethargic, but arousable to voice,
complaining of generalized body pains. Patient had brown, turbid
urine in his foley. CXR showed persistent L basilar
opacification. Labs notable for HCT 19.5, Plt 8, HCO3 18, Cr
3.7. The patient was started on Levophed, Vanc, and Cefepime.
Also given a dose of Hydrocortisone given recent steroid use.
Given 4L NS. He was intubated in the ED without difficulty using
the Bougie, despite h/o tracheal stenosis, and started on
Fent/Midaz for sedation. On transfer, Levophed was running at
0.42mcg. VS: T 100 HR 119 BP 114/51 RR 18 O2sat 99% on FiO250%
TV450 PEEP4.
On arrival to the MICU, patient's VS T 98.6 HR 106 BP 127/84 RR
16 O2sat 98% on AC TV 450 RR 18 FiO2 40% PEEP 5. The patient is
intubated and sedated on Fentanyl 100mcg/hr, Midazolam 4mg/hr,
Levophed 0.32mcg/kg/min.
Past Medical History:
ONCOLOGIC HISTORY:
POEMS syndrome manifested by polycythemia, polyneuropathy,
organomegaly, endocrinopathies including hypocalcemia,
hypothyroidism, hypogonadism and elevated PTH (diagnosed in
[**2099**]). In [**2101**] anasarca that eventually progressed to
respiratory failure, treated with plasmapheresis and prednisone
followed by 18 months of cyclophosphamide.
[**4-/2108**]/[**2108**]: Bortezomib (1.3 mg/m2 days 1,4,8,11 and
dexamethasone (20 mg days 1,2,4,5,8,9, 11, and 12) x three
cycles discontinued due to painful lower extremity neuropathy.
[**11/2108**] high dose cytoxan for stem cell mobilization ([**11/2108**])
[**12/2108**] high dose melphalan with stem cell rescue ([**2108-12-9**])
In remission since than.
[**4-/2112**]: bone marrow aspirate and biopsy showed dysplastic
basophilic and polychromatophilic erythroblasts, a marked left
shift and dysplastic myelopoiesis and abundant hyperchromic
megakaryocytes, which initially were felt to be consistent with
colchicine toxicity; however, chromosome studies performed on
that bone marrow material revealed an abnormal karyotype 15/16
studied cells showed a complex clone with the following
anomalies. He had deletion in the long arm of chromosome 5
between band 5q13 and 5q33, otherwise known as 5q minus. He had
monosomy 13, monosomy 17, monosomy 20, and addition of an
unidentified marker chromosome and [**2-12**] double minute
chromosomes. These were all consistent with a myeloid
abnormality since there were not an increased number of blasts
much more consistent with MDS.
OTHER PAST MEDICAL HISTORY:
1. POEMS syndrome: First diagnosed in [**2099**] with treatment
described above. His manifestations have been as follows:
A. Polyneuropathy - CIDP in [**2099-6-6**]; Painful lower extremity
sensory neuropathy and proprioception defects.
B. Organomegaly - Splenomegaly
C. Endocrinopathy - Hypothyroidism, hypogonadism, hypocalcemia
related to hypoparathyroidism
D. Monoclonal gammopathy
E. Skin and nail changes - now resolving.
F. Pulmonary hypertension and restrictive lung disease.
G. Chronic renal insufficiency (which has now resolved with
therapy)
H. Anasarca, now resolved.
I. Hyperuricemia and gout - now resolved
J. Polycythemia and thrombocythemia - now resolved
2. Vitamin B12 deficiency
3. S/p compound fracture, [**2103-8-7**]
4. S/p tracheostomy [**2101**]
5. prostate cancer s/p brachytherapy
6. gout
7. pulmonary HTN and restrictive lung disease
8. chronic kidney disease
9. C Dif ([**5-/2112**])
10. Acute angle glaucoma ([**2112-4-27**])
Social History:
Pt is a Ukrainian refugee who immigrated to the US in [**2049**]. He
lives with his wife and they have two sons. [**Name (NI) **] cigarettes, very
occasional alcohol. He works as a paint salesman for
[**Last Name (un) 34699**]-[**Location (un) 805**]. He is also a [**Country 3992**] veteran. Exposed to [**Doctor Last Name **]
[**Location (un) **], which he believes is the etiology of his POEMS.
Family History:
Mother is alive and has SLE, fibromyalgia. His father's medical
history is unknown. Half-sister with ovarian cancer.
Physical Exam:
ADMISSION EXAM
VS: Tm 98.7, Tc 98.7, P 98 (98-106), BP 117/70 (117/70 -
127/84), RR 16
SpO2: 98%, FiO2: 40%
Ventilator mode: CMV/ASSIST/AutoFlow, Vt: 450 mL, RR : 18, PEEP:
5 cmH2O
General: intubated, sedated
HEENT: Sclera anicteric, pupils minimally reactive to light, L>R
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation anteriorly with decreased breath
sounds at the bases
Abdomen: soft, non-distended, bowel sounds present
GU: foley with brown, turbid urine
Ext: Warm, well perfused, 2+ pulses, 2+ generalized
edema/anasarca
Neuro: sedated
Discharge Physical Exam:
98.1, 120/68, 74, 18, 98RA
General: AAOx3 in NAD, [**Last Name (un) 4969**] appearing male older than stated
age
HEENT: Pupils are asymmetric at baseline L>R
Neck: Previous scar from trach is well healed, no elevated JVP
no LAD
Lungs: CTAB moving good air bilaterally
CV: RRR, 2/6 systolic murmur heard best at hte LUSB not
radiating
Abd: mildly protuberant, normoactive bowel sounds, soft,
nontender, no palpable masses
Ext: Warm, well perfused, trace peripheral edema bilaterally
Skin: Two stage 1 ulcers. One located on the right buttock with
some underlying edema, and one located on the right posterior
posterior heel
Neuro: CN II-XII intact. Motor 3/6 strength in UE and LE
bilaterally. Decreased proximal strength biltaerally int he
lower extremiteis. Sensation grossly intact and symmetric.
Occasional intentional tremulous
Not orthostatic, patient is symptomatic upon standing but by
5min patients VS are stable.
Pertinent Results:
ADMISSION LABS
[**2112-7-2**] 08:40PM BLOOD WBC-3.4* RBC-2.16* Hgb-6.3*# Hct-19.5*
MCV-90 MCH-29.2 MCHC-32.4 RDW-15.1 Plt Ct-10*#
[**2112-7-2**] 08:40PM BLOOD Neuts-54 Bands-10* Lymphs-5* Monos-30*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2112-7-2**] 08:40PM BLOOD PT-13.5* PTT-22.8* INR(PT)-1.3*
[**2112-7-2**] 08:40PM BLOOD Glucose-71 UreaN-75* Creat-3.7*# Na-133
K-4.2 Cl-101 HCO3-18* AnGap-18
[**2112-7-2**] 08:40PM BLOOD ALT-47* AST-32 LD(LDH)-219 AlkPhos-272*
TotBili-1.1
[**2112-7-2**] 08:40PM BLOOD cTropnT-0.06*
[**2112-7-3**] 04:24AM BLOOD CK-MB-4 cTropnT-0.07*
[**2112-7-3**] 09:48AM BLOOD CK-MB-3 cTropnT-0.08*
[**2112-7-2**] 08:40PM BLOOD Albumin-2.8*
[**2112-7-3**] 04:24AM BLOOD Calcium-6.5* Phos-5.3*# Mg-1.5*
[**2112-7-2**] 09:08PM BLOOD Lactate-2.2*
MICRO
[**2112-7-2**] URINE CULTURE (Final [**2112-7-4**]): NO GROWTH.
[**2112-7-2**] Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS SPECIES.
Aerobic Bottle Gram Stain (Final [**2112-7-3**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2112-7-4**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2112-7-2**] Blood Culture, Routine (Pending):
[**2112-7-3**] SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2112-7-3**]):
[**12-1**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
RARE GROWTH Commensal Respiratory Flora.
[**2112-7-3**] Blood Culture: NEG
[**2112-7-4**] Blood Culture, NEG
[**2112-7-4**] Blood Culture, NEG
Urine Studies:
[**2112-7-20**] 06:05AM URINE CastHy-20* CastBr-2*
[**2112-7-9**] 02:09PM URINE HISTOPLASMA ANTIGEN-Test
[**2112-7-11**] 04:57PM URINE BK VIRUS BY PCR, URINE-Test
[**2112-7-11**] 06:23AM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
[**2112-7-27**] 09:13AM OTHER BODY FLUID WBC-650* RBC-[**Numeric Identifier **]* Polys-2*
Bands-1* Lymphs-12* Monos-26* Mesothe-1* Macro-58*
Urine:
[**2112-8-8**] 05:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2112-8-8**] 05:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2112-8-8**] 05:30PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-1
IMAGING
[**2112-7-2**] CHEST (PORTABLE AP): Persistent left basilar
opacification may represent atelectasis, pneumonia or
aspiration. Moderate-sized left and small right bilateral
pleural effusions. Possible mild pulmonary vascular congestion,
though evaluation is somewhat limited due to low lung volumes.
[**2112-7-4**] CHEST (PORTABLE AP): There is an endotracheal tube and
a feeding tube which are unchanged in position. There is also a
right-sided central venous line with the distal lead tip in the
cavoatrial junction, unchanged. There is unchanged
cardiomegaly. There is a left retrocardiac opacity and
left-sided pleural effusion which is stable. No overt pulmonary
edema is identified. Overall, there has been no significant
change.
[**2015-7-8**]: CT Abd/Pelvis: IMPRESSION:1. No new fluid collection or
source of intra-abdominal infection. 2. Stable bilateral small
to moderate partially loculated pleural effusions slightly
improved since [**2112-6-11**].
[**2112-7-11**]: RUQ U/S IMPRESSION: 1. No evidence of portal venous
thrombosis. 2. No hepatobiliary pathology. 3. Borderline
spleen size.
[**2112-7-17**]: CT Chest IMPRESSION: 1. Progression of left lower lobe
consolidation, and increase in size in bilateral loculated
pleural effusions with enhancing pleura, concerning for
pneumonia and/or empyema. 2. Cardiomegaly. 3. Heterogeneous
enhancement of the kidneys, bilateral, raises possibility of
pyelonephritis or infarct, recommend correlation with UA.
[**2112-7-27**]: Bronchial washing: Bronchial lavage: NEGATIVE FOR
MALIGNANT CELLS. Pulmonary macrophages and blood. No viral
cytopathic changes or fungal organisms are seen.
[**2112-7-29**]: Hip Xray:Views of both hips show minimal hypertrophic
spurring with slight narrowing of the joint spaces bilaterally.
Multiple metallic seeds are seen in the region of the prostate.
[**2112-8-2**]: Ultrasound right buttock: Persistent mild edema of the
soft tissue overlying the right buttock. No drainable
collection identified.
Discharge Labs
[**2112-8-11**] 12:00AM BLOOD WBC-2.3* RBC-2.37* Hgb-7.2* Hct-21.7*
MCV-92 MCH-30.3 MCHC-33.1 RDW-14.3 Plt Ct-40*
[**2112-8-11**] 12:00AM BLOOD Neuts-30* Bands-0 Lymphs-47* Monos-19*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-4*
[**2112-8-11**] 12:00AM BLOOD PT-10.3 PTT-22.7* INR(PT)-0.9
[**2112-8-11**] 12:00AM BLOOD Glucose-130* UreaN-37* Creat-0.6 Na-137
K-4.4 Cl-101 HCO3-28 AnGap-12
[**2112-8-11**] 12:00AM BLOOD ALT-52* AST-24 LD(LDH)-293* AlkPhos-391*
TotBili-0.4
[**2112-8-11**] 12:00AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.8
Brief Hospital Course:
Primary Reason for Admission: Mr. [**Known lastname 34698**] is a 66 year old man
with h/o POEMS syndrome, s/p autoSCT [**12-15**], therapy-related MDS,
recently hospitalized and diagnosed with recurrence of POEMS
syndrome, s/p Velcade/Dexamethasone, who was admitted with fever
and hypotension and requiring intubation initially who was found
to have B+glucan hemoptysis and multiple episodes of febrile
neutropenia requiring multiple ICU stays who is currently
hemodynamically stable and afebrile x 1 week still requiring
occasinal blood transfusions/platelet transfusions at the time
of discharge.
Active Issues:
#POEMS- Patient with recent diagnosis of POEMS syndrome relapse
Velcade/Dexameth (D1 [**6-16**]). During this admission he was
initially treated with high dose short course of steroids. His
pain was controlled with the addition of increased gabapentin,
addition of methadone and oxycodone. As his pain would worsen
when the steroids were weaned off, he was kepts on 3mg po
dexamethasone as a stable dose for one week prior to discharge.
While he was on a sliding scale due to being on steroids, he did
nto require any insulin and therefore this was stopped at the
time of discharge as he was on a stable regimen of steroids.
-Will require follow-up with Dr. [**Last Name (STitle) 410**] for ongoing care for
this
-Will continue dexamethasone 3mg po BID
#MDS- patient has history of therapy related MDS. His smear
during this hospitalization continued to show atypical cells.
During this hospitalization he required multiple blood
transfusiosn and platelet transfusions and for a period of time
was transfusion dependent. He had no adverse reactions to any
of his blood product transfusions. He was started on Revlimid
on [**8-2**] and tolerated this well. He will continue on this after
he leaves.
-Will require frequent lab work to determine if transfusions are
required
-Will continue revlimid 10mg po qday
#Dysuria- patient has significant dysruia and negative UA with
unclear source of the pain.
-continue methadone, oxycodone
-Continue oxybutinin, pyridium and urojets as needed for the
pain
-consider urology consult if persists
Neutropenic fevers- no clear source of his fevers. He was found
to have hemoptysis and was Bglucan positive so was started on
voricanozole and continues this at the time of discharge.He was
on IV Vancomycin and meropenem and these were weaned off in the
week prior to discharge and he was switched to ciprofloxacin
500mg po BID a few days prior to discharge and remained afebrile
with stable WBC.
-Continue voricanozole
-Continue ciprofloxacin
# Respiratory Failure: Patient was intubated in the ED to allow
for aggressive volume resuscitation. He was extubated without
problem and has no oxygen requiremnet at the time of discharge.
His lungs are clear on exam.
.
# Acute Kidney Injury: Patient had elevated Cr to 3.7 at the
beginning of his admission which was a combination of prerenal
and ATN. This responded to fluids and resolved prior to his
discharge.
.
# Elevated Troponin: Pt had three sets of elevated troponins
(0.06, 0.07, 0.08) but CK-MBs were normal. He also had some
initial EKG changes that resolved. He likely had some demand
ischemia in the setting of [**Last Name (un) **]. He was chest pain free
throughout his course
.
# Anemia: Patient is transfusion-dependent [**3-10**] to MDS. HCT 19.5
on admission, and was transfused 2 units pRBCs with an
appropriate bump in his HCT, which subsequently trended down. He
continued to require intermittent transfusions throughout his
course.
Last Platelet transfusion on [**2112-8-9**]
Last pRBC transfusion on [**2112-8-11**]
.
# Hyperbilirubinemia: T bili and direct bili were elevated. The
rest of his LFTs were unremarkable, demonstrating a cholestatic
picture. A right upper quadrant u/s was performed that showed
no evidence of cholestasis. His Alk phos continued to uptrend
during the end of his hosptial stay with no localizing symptoms.
-This will be monitored by Dr.[**Doctor Last Name **] office
# Volume overload: Secondary to new left ventricular dysfunction
and acute systolic heart failure as well as POEMS syndrome with
likely capillary leak, hypoalbuminemia, and initial aggressive
volume resuscitation. Patient was grossly volume overload after
his resuscitaion which had resolved at the time of discharge
without an elevated JVP or peripehral edema.
Transitional Issues:
-Patient to receive his own Revlimid while at rehab 10mg po qday
-Pain control- patient is currently on methadone and oxycodone,
please monitor for any changes needed
-[**Name (NI) 34700**] unclear source, on multiple medications
Medications on Admission:
([**2112-6-30**] d/c summary):
Levothyroxine 112mcg PO daily
Acyclovir 400mg PO qhs
Pyridoxine 100mg PO daily
Doxazosin 8mg PO daily
Vitamin B12 2000mcg PO daily
Thiamine 100mg PO daily
Oxycodone-Acetaminophen 5-325mg 1-2tabs PO q6h prn
Calcium carbonate 500mg PO BID
Allopurinol 100mg PO daily
Timolol maleate 0.5% 1gtt [**Hospital1 **]
Citalopram 10mg PO daily
Sulfamethoxazole-trimethoprim 400-80mg PO daily
Gabapentin 300mg PO q12h
Discharge Medications:
1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Vitamin B-12 2,000 mcg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO twice a day.
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
9. midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
11. methadone 5 mg Tablet Sig: [**2-8**] Tablet PO QAM (once a day (in
the morning)).
12. methadone 5 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)): give 12 hours after AM methadone dose.
13. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed for severe pain: hold for sedation or rr<10.
14. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days.
15. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
16. lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane TID
(3 times a day) as needed for penile pain.
17. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
18. REVLIMID 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily): Patient to take own medication.
19. voriconazole 200 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
20. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
21. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
22. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
23. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal DAILY
(Daily).
24. ondansetron 8 mg Film Sig: One (1) film PO every 4-6 hours
as needed for nausea.
25. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Primary: POEMS, Severe Sepsis, Respiratory Failure, MDS
Secondary: BPH, Type II Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 34698**],
You were admitted to the hospital because you were very short of
breath and having fevers. This required you to be in the ICU,
and after you improved you were transferred to the regular
oncology floor. Here we worked to help manage your pain and
treat your fungal pneumonia with IV antibiotics. On a couple of
occasions your blood pressure got low and you were feverish and
were treated in the ICU for this. As you were here for a
prolonged hospitalization you will require intensive rehab to
get your strength back and will do this at [**Hospital1 **]. While you
were here you received multiple blood and platlet transfusions
while your counts were low without problems.
Transitional Issues:
Pending labs/studies: None
Medications started:
Voricanozole (antifungal)
Ciprofloxacin (antibiotic)
Revlimid
Dexamethasone
Oxycodone (as needed pain medication)
Methadone (pain medication twice a day)
Senna
Colace
Oxybutinin (help with bladder spasm)
Terazosin (help with BPH)
Pyridium (help with pain on urinating)
urojet (numbing medicine for pain with urinatng)
midodrine- (for dizziness on standing)
Ondansetron- as needed for nausea
Medications changed:
INCREASED citalopram from 10mg once a day to 20mg once a day
INCREASED Gabapentin from 300mg to 600 mg
Medications stopped:
STOPPED allopurinol
STOPPED Doxazosin (on terazosin instead)
STOPPED Timolol eye drops (no longer needed)
STOPPED Percocets (on oxycodone and methadone instead)
Follow-up needed for:
1. Determine course of antibiotics and antifungals (Dr. [**Last Name (STitle) 410**]
2. Monitoring your blood counts and your liver function tests
3. You will need to follow-up with Dr. [**Last Name (STitle) **] to determine
if you need your glaucoma drops again
Followup Instructions:
Will we contact you with your appointment times and dates!
If you do not hear from us within 48hours please contact us
[**Telephone/Fax (1) 3241**]
|
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24,344
| 187,968
|
27328
|
Discharge summary
|
report
|
Admission Date: [**2130-4-23**] Discharge Date: [**2130-5-24**]
Date of Birth: [**2074-10-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Sulfa (Sulfonamides) / Ibuprofen /
Ginger / Amikacin
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Central Line Placement
Arterial Line Placement
Intubation
Mechanical Ventilation
Bronchoscopy
PICC line placement
Dobhoff tube placement
History of Present Illness:
Ms. [**Known lastname **] is a 55F from [**Hospital3 4298**] with history of
autoimmune hepatitis on azathioprine who is admitted to the MICU
for worsening SOB. Her symptoms of fevers, chills, cough, and
dyspnea began approximately one week prior to admission; she was
seen in the ER on [**4-18**] and given a prescription for levofloxacin
x5 days. Her symptoms failed to improve. Fevers were up to 102.5
at home. She represented to the OSH on [**4-22**]. Vitals there were
T101.3 P 96 BP 105/62 RR 18 O2 94% on room air. She was given
solumedrol 125mg IV, levofloxacin 750mg, lasix 40mg, and 500cc
of saline. CXR was concerning for a bilateral pna, and she was
subsequently transferred to [**Hospital1 18**] for further management as she
receives her hepatology care here.
On presentation to the ED at [**Hospital1 18**] her VS were 96.4 80 105/57,
90% on RA, 96-100 on 2L. She had oral thrush on exam as well as
an infected tooth. She had diffuse left sided crackles. WBC 1.4
(baseline [**12-27**]). Lactate 1.8. She was given 1g Vanco, 100mg
doxycycline, and gentamicin 375mg.
On the medical floor, she was continued on aztreonam,
vancomycin, and azithromycin. The morning of transfer, she was
found to be increasingly tachypneic with an increased O2
requirement. Her sats were 90-91% on 4L, at which time she was
placed on a non-rebreather. She is transferred to the MICU for
closer monitoring given concern for respiratory decompensation.
On review of systems, she reports left molar tooth pain. She has
some loose stools along with her respiratory symptoms. Denies
headache, nasal congestion, sore throat, myalgias/arthralgias,
dysuria, rash. Did have sick contact with "pneumonia" who is not
currently hospitalized. No travel. +mice at home.
Past Medical History:
Autoimmune hepatitis - cirrhosis by bx [**4-29**]; esophageal varices,
portal hypertensive gastropathy w/ h/o bleed
Esophageal candidiasis
Obesity
Asthma
Migraines
Restless leg syndrome
Social History:
Living Situation: Lives alone. She splits her time between RI
and [**Hospital3 4298**]. Disabled.
Pets- dog, cat and mice at MV home
Tobacco: denied
EtOH: denied
IVDU: denied
Family History:
Positive for diabetes and CAD. No history of liver disease.
Physical Exam:
ADMISSION PHYSICAL:
PE: T:100.1 BP:115/70 HR:91 RR:20 O2 97% 2L
Gen: NAD/ Comfortable/ not in ditress, ill-appearing, pleasant
HEENT: AT/NC, PERRLA, EOMI, anicteric, no conjuctival pallor,
dry MMM, +thrush, broken left lower molar, +tenderness,
NECK: supple, trachea midline, no LAD
LUNG: decreaed BS at bases L>R, +crackles and occasional rhonchi
on L, no wheeze
CV: S1&S2, RRR, II/VI SEM
ABD: obese soft/+BS/ NT/ ND/no rebound/ no guarding
EXT: No C/C/ trace edema
SKIN: No lesions, rashes, bruises on right forearm
NEURO: AAOx3
CN II-XII grossly intact and non-focal b/l
5/5 strength in upper and lower ext b/l
decreased sensation to light touch on left thigh
PHYSICAL UPON TRANSFER TO MICU:
Vitals 102 100 111/65 20's 99% NRB
General Obese woman sitting in bed, mildly tachypneic
HEENT Sclera white, conjunctiva pink, minimal thrush, no
lesions. has broken left molar, no purulence
Neck Large neck, supple
Pulm Lungs with left>right rales, and wheezing
CV Regular S1 S2 no m/r/g
Abd Obese nontender +bowel sounds
Extrem Warm tr bilateral pitting edema, no cords, palpable
pulses
Neuro Alert, oriented, moving all extremities without focal
deficits
Physical Exam on Floor:
PE: T:98.2 BP 118/68 HR 105 RR 24 O2 99-100% 3L O2 NC
Gen: Obese woman in NAD. Interactive and pleasant. Daughter at
bedside
HEENT: NCAT, PERRL EOMI, anicteric, MMM, broken left lower
molar, OP clear
NECK: supple, trachea midline, no LAD
LUNG: bibasilar crackles and occasional rhonchi on L, no wheezes
CV: S1&S2, RRR, II/VI SEM
ABD: obese, prominent striae, soft/+BS/ NT/ ND/no rebound/ no
guarding
EXT: pitting 2+ edema in lower extremities, warm, well-perfused.
Resolving ecchymoses on R shoulder, left arm w/ rash/ecchymosis
? from PIV
SKIN: No lesions, rashes, bruises on right forearm
NEURO: AOx2, CN II-XII grossly intact and non-focal b/l
4/5 strength in upper and lower ext b/l, decreased sensation to
light touch on left thigh
Pertinent Results:
ADMISSION LABS:
([**4-23**])
WBC-1.4*# RBC-2.99* HGB-10.0* HCT-31.0* MCV-104* MCH-33.6*
MCHC-32.4 RDW-19.3*
NEUTS-94* BANDS-0 LYMPHS-2* MONOS-4 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
PLT SMR-VERY LOW PLT COUNT-52*
PT-15.5* PTT-42.2* INR(PT)-1.4*
ALT(SGPT)-39 AST(SGOT)-82* CK(CPK)-364* ALK PHOS-247* TOT
BILI-0.9
LIPASE-29
ALBUMIN-3.0*
GLUCOSE-184* UREA N-14 CREAT-1.0 SODIUM-134 POTASSIUM-4.0
CHLORIDE-98 TOTAL CO2-27 ANION GAP-13
LACTATE-1.8
([**5-21**])
MICROBIOLOGY:
[**4-24**] CMV VL negative
[**4-24**] Cryptococcal angtiven negative
[**4-25**] Legionella negative
[**4-25**] Influenza A/B by DFA
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2130-4-25**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2130-4-25**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
Rapid Respiratory Viral Antigen Test (Final [**2130-4-25**]):
Respiratory viral antigens not detected.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
Refer to respiratory viral culture for further
information.
Respiratory Viral Culture (Final [**2130-4-27**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
[**4-30**] BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2130-4-30**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2130-5-2**]): NO GROWTH, <1000
CFU/ml.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2130-5-1**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary):
YEAST, PRESUMPTIVELY NOT C. ALBICANS.
ACID FAST SMEAR (Final [**2130-5-1**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
[**5-5**] Urine culture negative
[**5-6**] C. diff negative
[**5-7**] C. diff negative
[**5-7**] CMV VL negative
[**5-17**] Urine culture negative
[**5-21**] Urine culture negative
Tularemia pending
Adenovirus PCR negative
Aspergillus negative
Beta glucan negative
Blastomycosis negative
Coccidiomycosis negative
STUDIES:
[**4-23**] PA AND LATERAL CXR: IMPRESSION: Multiple new patchy
airspace opacities bilaterally, most
prominent in the left lower lung, consistent with multifocal
pneumonia.
Follow- up is recommended to ensure clearance
[**4-25**] TTE:
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast however images were suboptimal and patient was unable
to cooperate with maneuvers. No evidence of pulmonary AV
shunting identified by technically limited agitated saline
study. Left ventricular wall thicknesses are normal. 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 are moderately thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is borderline pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
No vegetation seen (cannot definitively exclude).
[**4-26**] CT CHEST:
CONCLUSION:
1. Extensive multifocal consolidation in both lungs which on
review of prior imaging has developed and progressed since the
radiograph of [**2130-4-23**]. These findings are most suggestive of
with multifocal pneumonia.
2. Incompletely assesed splenomegaly, perisplenic ascites and
inflammatory
change in the mesentry of the upper abdomen
[**4-30**] CT CHEST:
IMPRESSION:
1. Extensive patchy air space opacification scattered throughout
both lungs is similar in distribution and extent to CT performed
on [**2130-4-26**], but less dense in most locstions, compatible
with some improvement. The differential diagnosis for this
appearance is broad but includes resolving multifocal pneumonia
or edema.
2. Cirrhosis with splenomegaly and ascites.
[**5-2**] RENAL U/S:
FINDINGS: Study is slightly limited secondary to difficulties
with patient
positioning. The right kidney measures 10.4 cm. The left kidney
measures 11.8 cm. No stones, hydronephrosis, or solid masses are
identified. There appears to be a 1 cm simple-appearing cyst
within the lower pole of the right kidney.
IMPRESSION: No evidence of hydronephrosis
[**5-10**] PORTABLE CXR:
REASON FOR EXAMINATION: Followup of a patient with multifocal
pneumonia.
Portable AP chest radiograph was compared to [**2130-5-8**] and
[**5-7**], [**Numeric Identifier 66979**]. There is overall no change in the widespread
parenchymal opacities, although compared to more remote studies,
there is some degree of improvement. The NG tube tip is in the
stomach.
[**5-12**]: Swallow Study:
Reason for Exam: Concern for aspiration. A swallowing
videofluoroscopy study was done in conjunction with the speech
pathology service. Multiple consistencies of oral barium were
administered. Barium passed beyond the oropharynx without
evidence of obstruction. Upright swallows of thin liquids
resulted in aspiration and thereafter in spontaneous cough.
Further details are found in the online medical record, with the
speech pathologist note from [**2130-5-12**].
[**5-16**]: Diagnositc Paracentesis
Reason for Exam: Concern for SBP. Successful ultrasound-guided
paracentesis of 700 cc of yellow serosanguineous fluid. Negative
for SBP.
[**5-17**]: EEG
Reason for Exam: Altered Mental Status. This is an abnormal
routine EEG due to a slow and poorly modulated background
indicative of a mild encephalopathy. Medications, metabolic
disturbances, and infections are among the most common causes.
There were no areas of focal slowing although encephalopathies
can obscure focal findings. There was no evidence of
epileptiform discharges noted. Note is also made of a mild
tachycardia on cardiac telemetry.
[**5-20**] Abdominal CT:
Reason for Exam: Rule out recto/colovesicular fistula.
Cirrhosis, ascites, fluid-containing umbilical hernia. Varices.
Foley and rectal tube adequately placed. No evidence bowel
obstruction.
[**5-23**] Barium Enema: Reason for Exam: Rule out recto/colvesicular
fistula. No rectovesicular fistula.
Brief Hospital Course:
Pt is a 55 year old woman with autoimmune hepatitis on
azathioprine complicated by cirrhosis, portal gastropathy,
esophageal varices, transferred from [**Hospital6 **]
with multifocal PNA.
SUMMARY OF MICU COURSE:
- Multifocal pneumonia/Respiratory Failure: Patient was treated
for typical and atypical bacteria, including PCP (although this
was stopped after several negative BALs) and tularemia (s/p
doxycycline treatment). Viral studies were negative. She was
treated broadly with antibiotics per ID. PICC line was placed
for prolonged IV antibiotics. She had increased respiratory
distress on [**4-29**], failing bipap, and at that time, she and her
family decided to reverse her DNR/DNI to full code and thus, she
was intubated and mechanically ventilated. She continued on
mechanical ventilation until [**5-9**] when she was extubated
successfully. She remains on O2 supplementation via NC.
- Acute renal failure: Cr noted to increase to 1.6 and urine
studies were consistent with pre-renal state. She was given
IVFs with some improvement. Renal ultrasound negative for
hydronephrosis. Also ARF likely affected by amikacin; thus,
switched to aztreonam. Improved by transfer to floor.
- Leukopenia: Patient remained leukopenic during much of ICU
course. Heme-Onc was consulted for etiology of this leukopenia.
They felt this was likely secondary to azathioprine. Ig levels
were high; thus, no need for IVIG. She was given 1 dose of
Neupogen and no longer neutropenic.
- Autoimmune hepatitis: Hepatology input appreciated. Continued
on her rifaximin, lactulose. Mental status improved once NGT
placed and increased lactulose dose after extubation.
- Hypernatremia: Resolved with increased free water flushes via
NGT.
- Tooth infection: Patient with dental infection. While in ICU,
deferred further workup with Panorex.
The patient was tranferred to hepatology service on [**2130-5-11**].
Multifocal pneumonia: On transfer, the patient remained on
oxygen supplementation and was slowly weaned off. She remained
afebrile without further need for antibiotic therapy. Tuleremia
is still pending on discharge. This diagnosis is highly unlikely
but should be followed up.
Altered Mental Status: The patient's mental status continued to
wax and wane despite lactulose, which led to the conclusion that
it was not solely due to hepatic encephalopathy but delirium.
Another set of cultures (urine, blood) were sent but remained
negative. A CT head non-contrast was performed but showed no
acute processes. Neurology and Psychiatry were consulted to
further work up the patient's change in mental status. Both
consults felt the mental status change was secondary to a
multifactorial delirium. EEG was performed and showed no
evidence of epileptic activity. Without definitive intervention
the patient's mental status improved and is now at baseline per
daughter.
Autoimmune hepatitis: Over the course of admission, the
patient's LFTs slowly increased. Azathioprine was held on
admission (per above). Prednisone therapy was initiated and LFTs
improved on 20mg Prednisone. LFTs stabilized and Prednisone was
increased to 40mg to further decrease patient's Liver Function
Test.
Possible Rectovesicular Fistula: After transfer to the floor a
dark brown sediment was found in the foley catheter bag. On
examination this sediment appeared to be stool. Urinalysis and
urine cultures were negative for infection. CT of the abdomen
with PO contrast was non conclusive.
Hypernatremia: On the floor the patients hypernatremia
continued while she refused to eat or have a dobhoff tube
placed. 1/2NS IV fluid was started and after the patients mental
status improved and she began eating patient's hypernatremia
resolved.
Pancytopenia: Thought to be secondary to azathioprine, so
Azathioprine was held since admission. Pancytopenia has not
resovled since Azathioprine was held. Pancytopenia has been
stable. Leukopenia resolved after neupogen in the ICU. During
the stay B12, Folate, and reticulocyte count were all within
normal limits.
.
Asthma: Patient was placed on as needed albuterol/ipratropium
nebs and remained stable throughout the hospitalization.
Medications on Admission:
Home:
Albuterol inhaler PRN
Alprazolam 0.25mg PRN
Azathioprine 50 mg QD (alternating with 75 mg every other day)
Citalopram 20mg
Clotrimazole 10mg trouch QID prn
Flonase qhs
Furosemide 40 mg [**Hospital1 **]
Lactulose TID titrate to [**1-25**] BM
Nortriptyline 100 mg qhs
Oxycodone 5 mg tablet as needed
[**Month/Day (3) 66980**] 150 mg daily
Spironolactone 50 mg daily
Ursodiol 250 mg daily.
On transfer:
aztreonam 2g IV q8 (d1 = [**4-23**])
vancomycin 1g IV q12 (d1 = [**4-23**])
azithromycin 500mg PO daily (d1 = [**4-23**])
celexa 20mg daily
nortriptyline 100mg qhs
fluconazole 100mg daily
fluicasone nasal sprays daily
heparin 5000 tid
lactulose 30ml tid
ursodiol 250mg daily
albuterol nebs q4h prn
tessalon perles tid prn
guiafenesin/dextromethorpan prn
ativan hs prn, zofran prn
[**Month/Day (4) **] 150mg daily
colace, senna
Discharge Medications:
1. Rifaximin 200 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: One (1)
Injection TID (3 times a day).
3. Acetaminophen 325 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
4. Citalopram 20 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).
5. Prednisone 20 mg Tablet [**Month/Day (4) **]: Two (2) Tablet PO DAILY (Daily):
Please continue for 2 weeks. Liver Team will adjust dosing. .
6. Lactulose 10 gram/15 mL Syrup [**Month/Day (4) **]: Thirty (30) ML PO QID (4
times a day): Titrate to [**1-25**] bowel movements daily. .
7. Fluticasone 50 mcg/Actuation Spray, Suspension [**Month/Day (3) **]: Two (2)
Spray Nasal DAILY (Daily).
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (3) **]:
[**11-25**] Inhalation every 4-6 hours as needed for shortness of
breath or wheezing: 1-2 puffs as needed for shortness of breath.
.
9. Calcium 500 + D (D3) 500-125 mg-unit Tablet [**Month/Day (2) **]: One (1)
Tablet PO three times a day.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Humalog Insulin Sliding Scale
See Attached sliding scale.
12. Hydrocortisone Acetate 1 % Ointment [**Last Name (STitle) **]: One (1) Appl Rectal
[**Hospital1 **] (2 times a day).
13. Lasix 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
14. Aldactone 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
15. Clotrimazole 1 % Cream [**Hospital1 **]: One (1) Topical four times a
day as needed.
16. Ursodiol 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Multifocal pneumonia
Hepatic encephalopathy
Autoimmune hepatitis
Abdominal Hernia
Discharge Condition:
afebrile, hemodynamically stable, off oxygen supplementation
Discharge Instructions:
You were admitted to the hospital with multifocal pnemonia and
confusion. You were transferred to the intensive care unit where
you were intubated as you breathing was very labored. You were
treated with IV antibiotics for 2 weeks. After your time in the
intensive care unit you were confused and thinking was
disoriented. After a week your thinking cleared. You were also
found to have an umbilical hernia.
Please make sure to continue taking your medications daily. The
following changes were made to your regimen:
-alprazolam was stopped
-azathiprine was stopped
-Nortriptyline was stopped, this can be restarted under guidance
of your primary care physician
[**Name Initial (PRE) **] [**Name10 (NameIs) 66980**] was stopped
- Oxycodone was stopped
- Rifaximin was started at 400mg PO, three times daily
- Prednisone was started at 40mg Daily, This dosing will be
followed and adjusted by your liver doctor.
- Vit D/Calcium was started
- Lansoprazole was started at 30mg daily
- Furosemide was changed to 20mg daily
- Spironalactone was changed to 50mg daily
If you experience any chest pain, shortness of breath,
fevers/chills, abdominal pains, diarrhea or any other concerning
symptoms please call your doctor or return to the emergency
room. With a hernia if you ever have severe abdominal pain,
trouble moving your bowels, or blood in your stool you should
contact your doctor or go to the emergency room immediately.
Followup Instructions:
Please have patient follow up with primary care and Liver clinic
within one - two weeks.
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 66981**]
Liver clinic, ([**Telephone/Fax (1) 1582**]
|
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"493.90",
"596.1",
"518.81",
"284.1",
"112.0",
"278.00",
"572.2",
"289.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"54.91",
"96.04",
"38.91",
"38.93",
"96.07",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
18254, 18333
|
11391, 13589
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359, 497
|
18459, 18522
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4710, 4710
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2301, 2488
|
2504, 2680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,029
| 132,349
|
28145
|
Discharge summary
|
report
|
Admission Date: [**2139-9-22**] Discharge Date: [**2139-10-2**]
Date of Birth: [**2061-4-10**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
CT myelogram (spine)
ERCP with sphincterotomy and stone extraction
Attempted AV thrombectomy (by surgery and IR under contrast
guidance)
Hemodialysis
History of Present Illness:
78yo male transferred from OSH ([**Hospital3 **]) after unwitnessed
fall at NH. The patient is a poor historian and does not recall
the incident. Patient is CT head from OSH negative. No focal
neurologic symptoms. No localizing [**Last Name (un) 68421**] of infection. By
report, the patient had a C6 fracture. According to the
patient's son, the patient has had multiple falls in the last
1-2 years. Initially, his falls were thought to be related to a
cardiac etiology and "small heart attacks". He is seen by a
cardiologist in [**Location (un) 5503**] who sent him for defibrillator/pacer
placement a few months ago. He has continued to have falls since
then which are usually unwitnessed and thought to be secondary
to generalized weakness. The patient receives hemodialysis on
Mon, Wed, Fri and did receive his dialysis yesterday.
.
In the ED, the patient was found to have extensive DJD of the
cervical spine with resultant cord compression at C4-C7 and a
large lytic lesion in a throacic vertebral body. Pleural
effusion on the left side was noted on CXR.
.
ROS: not able to obtain, but patient denies any pain
.
PMH:
1. CKD, HD MWF, s/p L nephrectomy [**1-15**] renal ca??
2. A-fib
3. CASHD - h/o MI, EF 30%, s/p catheterization and AICD
placement
4. HTN
5. Crohn's disease (dx'd by biopsy in last year)
6. anemia
7. common bile duct stent
8. legally blind
9. h/o UTIs w/ delirium (multiple in the past 2 years)
10. h/o syncope, multiple falls
11. h/o prostate ca??
12. joint swelling - improved w/ fluid restriction, s/p
cortisone injections for knees
13. gout
14. chronic pulmonary effusions
.
MEDS
1. Metoprolol 25mg [**Hospital1 **]
2. Nephro liquid 120cc qD
3. Lisinopril 2.5 qD
4. Isoniazid 300mg qD
5. ASA 325mg qD
6. Simvistatin 40mg PO qD
7. Sevelamer 1600mg TID
.
ALL: NKDA
.
SHx: Lives at [**Hospital3 68422**] Nursing Home. No history of tobacco
use. Remote history of significant EtOH use.
.
FHx: Non-contributory.
.
Physical Exam:
VS: 100.4 --> 104.8 101-130s 140-170s/xx 20-25 94-97% 2LNC
GEN: somnolent, minimally responds to verbal commands or painful
stimuli
HEENT: L eye opaqu, R pupil responsive to stimuli; MM dry
Lungs: pt not able to comply with exam, tachypneic, rhonchorous
throughout
CV: tachycardic, RR, nl s1/s2, II/VI SEM loudest at LUSB
ABD: NABS, s/nt/nd
Ext: thrill in R AC fossa, no c/c/e, 2+ pulses
Neuro: squeezes hand after several requests, intermittent eye
opening; comprehensible, but inappropriate speech
.
LABS: see below
.
IMAGING:
[**2139-9-22**] P CXR (AM): Large left pleural effusion with associated
opacity presumed atelectasis. Small right pleural effusion.
.
[**2139-9-22**] T Spine: Mild L1 compression fracture of unknown
chronicity.
1.4 x 1.2 cm lytic lesion involving the T5 vertebral body for
which bone scan is recommended. Large left pleural effusion and
tiny right pleural effusion.
.
[**2139-9-22**] C Spine: Extensive degenerative changes with severe
spinal cord compression at multiple levels as described above,
presumed secondary to degenerative changes. Small well
corticated osseous fragment adjacent spinous process of C7 is
likely old trauma, much less likely acute avulsion injury.
There is no definite evidence for fracture.
.
[**2139-9-22**] P CXR (PM - after hypoxic episode): final read pending;
appears to have increased opacification of RLL
.
A/P: 78 yo M with MMP presents s/p fall at NH and change in
mental status.
#. Tachypnea - Patient became acutely tachypneic and hypoxic
upon transfer to the floor. He most likely experienced an
aspiration event related to post-tussive emesis. Other
etiologies include pneumonia versus fluid overload versus
pulmonary embolus. The patient stabilized with suction and a
short period on 100% NRB. His oxygen saturation has been stable
on 2L nasal cannula after this acute event.
- Monitor sats, titrate O2 as indicated
- CXR
- already on levaquin 250mg q24h for presumed UTI
- Vanco given hemodialysis, recent hospitalization, and exposure
to nursing home
- ABG - attempt to repeat if worsens clinically, venous pCO2 wnl
.
#. UTI - [**Month (only) 116**] be etiology for fever. Concern for bacteremia given
change in mental status, tachypnea, slightly elevated lactic
acid and degree of fever.
- renally dosed Levaquin x 7d
- UCx, BCx
- IVF at 100cc/hour
- place foley
.
#. Mental status changes - delirium, somnolence. UTI/infection
related vs hypoxia vs ICH s/p fall vs. hypercarbia vs. CASHD vs
metabolic. No sedating meds given recently. Not hypercarbic by
venous pCO2, no metabolic derarrangements indicated by labs.
- Head CT as OSH negative
- started on levaquin for UTI, vancomycin empirically
- ABG if O2 sats worsens
- TSH pending
.
#. Elevated cardiac markers - concern for ischemia given h/o
CASHD; LBBB on EKG; hemodynamically stable
- Repeat enzymes x 2
- Continue ASA, statin, B-blocker per home regimen
.
#. C4-7 cord compression - [**1-15**] severe DJD. Concern for lytic
lesions in T5 vertebral body. Pt has questionable history of
both renal and prostate ca.
- Neurosurg following
- Myelogram tomorrow, will coordinate with hemodialysis
- Check UPEP, SPEP, PSA
- bone scan as an outpatient
.
#. CKD - on hemodialysis, last treatment yesterday
- Renal consult --> no need for urgent HD
- Hemodialysis in AM
- okay to have myelogram tomorrow
.
# Biliary duct dilation s/p stent placement, abdominal exam
benign
- LFTs, pancreatic enzymes elevated
- Add flagyl to cover for cholecystitis given clinical status
- CT or U/S of abdomen as indicated for further evaluation
.
#. Anemia - unknown baseline, but stable for now
.
#. F/E/N - IVF for now given poor PO intake, pt is on thick
liquids at NH, NPO until improvement in mental status, replete
lytes as indicated
.
#. Prophylaxis - heparin SC
.
#. CODE STATUS: DNR/DNI
.
#. HCP: [**Name (NI) 1528**] [**Name (NI) 68423**], [**Name (NI) **] - [**Telephone/Fax (1) 68424**]
#. Nurse Manager at [**Company **]: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11923**] [**Telephone/Fax (1) 68425**]
#. PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] - [**Location (un) 5503**]
#. Cardiologist: Dr. [**First Name (STitle) 1169**] - [**Location (un) 5503**]
Past Medical History:
1) ESRD
- Hemodialysis MWF
- s/p left nephrectomy (? secondary to renal CA)
2) Atrial fibrillation
3) CAD
- History of MI; EF 30%; s/p catheterization and AICD placement
4) Hypertension
5) Crohn's disease (dx'd by biopsy in last year)
6) Anemia
7) Common bile duct stent
8) Legally blind
9) h/o UTIs w/ delirium (multiple in the past 2 years)
10) h/o Syncope, multiple falls
11) h/o Prostate cancer (unclear)
12) Joint swelling: Improved w/ fluid restriction, s/p cortisone
injections for knees
13) Gout
14) Chronic pulmonary effusions
Social History:
Lives at [**Hospital3 68422**] Nursing Home.
No history of tobacco use.
Remote history of significant EtOH use. Son is HCP.
Family History:
Non-contributory.
Physical Exam:
(on admission [**9-22**])
VS: 100.4 --> 104.8 101-130s 140-170s/xx 20-25 94-97% 2LNC
GEN: somnolent, minimally responds to verbal commands or painful
stimuli
HEENT: L eye opaqu, R pupil responsive to stimuli; MM dry
Lungs: pt not able to comply with exam, tachypneic, rhonchorous
throughout
CV: tachycardic, RR, nl s1/s2, II/VI SEM loudest at LUSB
ABD: NABS, s/nt/nd
Ext: thrill in R AC fossa, no c/c/e, 2+ pulses
Neuro: squeezes hand after several requests, intermittent eye
opening; comprehensible, but inappropriate speech
Pertinent Results:
CBC
[**2139-9-22**] BLOOD WBC-9.2 RBC-4.25* Hgb-13.8* Hct-40.4 MCV-95
MCH-32.6* MCHC-34.2 RDW-16.4* Plt Ct-223
[**2139-10-2**] BLOOD WBC-7.4 RBC-3.31* Hgb-10.3* Hct-32.6* MCV-99*
MCH-31.1 MCHC-31.5 RDW-17.3* Plt Ct-228
DIFFERENTIALS
[**2139-9-22**] 06:30AM BLOOD Neuts-87.1* Lymphs-5.6* Monos-6.9 Eos-0.2
Baso-0.2
RED CELL MORPHOLOGY
[**2139-9-22**] Hypochr-1+ Anisocy-1+ Poiklo-1+ Macrocy-1+
COAGS
[**2139-9-22**] BLOOD PT-12.9 PTT-29.5 INR(PT)-1.1
[**2139-9-22**] 06:30AM BLOOD Plt Ct-223
[**2139-10-2**] 06:00AM BLOOD PT-13.5* PTT-33.7 INR(PT)-1.2*
[**2139-10-2**] 06:00AM BLOOD Plt Ct-228
CHEMISTRY
[**2139-9-22**] 06:30AM BLOOD Glucose-110* UreaN-30* Creat-3.3* Na-141
K-3.9 Cl-101 HCO3-30 AnGap-14
[**2139-10-2**] 06:00AM BLOOD Glucose-62* UreaN-22* Creat-3.0* Na-140
K-4.5 Cl-107 HCO3-25 AnGap-13
ENZYMES/BILIRUBIN
[**2139-9-22**] 06:30AM BLOOD CK(CPK)-737*
[**2139-9-22**] 01:11PM BLOOD ALT-79* AST-417* CK(CPK)-928*
AlkPhos-540* Amylase-86 TotBili-4.7*
[**2139-9-29**] 05:35AM BLOOD ALT-21 AST-21 AlkPhos-187* Amylase-114*
TotBili-1.6*
[**2139-9-22**] 01:11PM BLOOD Lipase-26
[**2139-9-25**] 02:40AM BLOOD Lipase-17
CPK ENZYMES
[**2139-9-22**] 06:30AM BLOOD CK-MB-8 cTropnT-0.13*
[**2139-9-22**] 01:11PM BLOOD CK-MB-7 cTropnT-0.14*
[**2139-9-23**] 04:35AM BLOOD CK-MB-6 cTropnT-0.08*
OTHER CHEMISTRY
[**2139-9-22**] 06:30AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.1
[**2139-10-2**] 06:00AM BLOOD Calcium-8.0* Phos-4.6* Mg-1.8
OTHER HEME
[**2139-9-23**] 11:10AM BLOOD Hapto-192
PITUITARY
[**2139-9-23**] 04:35AM BLOOD TSH-0.88
IMMUNOLOGY
[**2139-9-23**] 04:35AM BLOOD PSA-14.0*
MISCELLANEOUS
[**2139-9-23**] 04:35AM BLOOD PEP-AT LEAST T IgG-1301 IgA-281 IgM-76
IFE-NO MONOCLO
BLOOD GAS
[**2139-9-23**] 12:09PM BLOOD Type-ART pO2-66* pCO2-30* pH-7.51*
calTCO2-25 Base XS-1
[**2139-9-23**] 12:09PM BLOOD Lactate-3.9*
[**2139-9-22**] 12:55PM BLOOD Lactate-2.4*
[**2139-9-22**] 12:55PM BLOOD Type-ART pO2-22* pCO2-60* pH-7.34*
calTCO2-34* Base XS-2
CXR ([**2139-9-22**]):
1. Large left pleural effusion with associated opacity presumed
atelectasis.
2. Small right pleural effusion.
.
T-Spine ([**2139-9-22**]):
1. Mild L1 compression fracture of unknown chronicity.
2. 1.4 x 1.2 cm lytic lesion involving the T5 vertebral body
3. Large left pleural effusion and tiny right pleural effusion.
C-Spine ([**2139-9-22**]):
Extensive degenerative changes with severe spinal cord
compression at multiple levels as described above, presumed
secondary to degenerative changes. Small well corticated osseous
fragment adjacent spinous process of C7 is likely old trauma,
much less likely acute avulsion injury. There is no definite
evidence for fracture.
**Multiple gallstones are seen. There is marked dilatation of
the common bile duct measuring approximately 2.3 cm and a high
density lesion measuring 2.5 cm at the pancreatic head, which
may represent an impacted stone. There is a biliary drain within
the pancreatic head and extending into the duodenum.
Head CT ([**2139-9-22**]):
1. Small bilateral simple fluid attenuation frontal subdural
collections representing hygromas or chronic subdural hematomas.
No acute hemorrhage is identified.
2. 4 cm right cerebellopontine angle cystic structure, likely an
arachnoid cyst.
Liver US ([**2139-9-23**]):
1. Choledocholithiasis causing massive CHD and CBD dilatation,
without intrahepatic duct dilatation. Biliary stent not
identified.
2. Cholelithiasis.
ERCP ([**2139-9-23**]):
1. A previously placed plastic stent was found in the major
papilla. The stent was pulled and sent for cytology.
2. Stone fragments and pus were noted to extrude from the major
papilla.
3. The CBD appeared dilated to 12 mm.
4. To aid biliary drainage, a 7cm by 10Fr Cotton [**Doctor Last Name **] biliary
stent was placed successfully in the CBD.
Echo ([**2139-9-24**]):
Left ventricular systolic function is severely depressed
(ejection fraction 20-30 percent) secondary to fibrosis and
akinesis of the anterior septum, and akinesis of the anterior
free wall and apex.
Mild aortic stenosis.
Mild (1+) aortic regurgitation is seen.
Moderate to severe (3+) mitral regurgitation.
Moderate to severe [3+] tricuspid regurgitation.
There is moderate pulmonary artery systolic hypertension.
Brief Hospital Course:
1) E.coli bacteremia. On [**9-22**] Mr. [**Known lastname 68423**] [**Last Name (Titles) 28316**] a temp to 104.
Blood cultures were drawn and later grew e.coli in [**1-15**] bottles.
Enterococcus species were found to grow in the following out in
the following week. He had a positive UA and cultures later grew
serratia and VRE. On [**9-23**], patient was dialyzed and
post-dialysis had a blood pressure of 50/P with tachycardia to
140's. He was started on levo/flagyl soon thereafter switched to
Vanc/Zosyn. Gent was added per ID recs.
The patient was transferred to ICU secondary to hypotension and
T 104.8. Blood cultures from this day grew e.coli in [**1-15**]
bottles (making it [**3-17**] total). Antibiotics included vancomycin,
zosyn, and gentamycin. Patient was noted to be dyspnic,
disoriented, and confused. Vitals were T 104.8; BP 90/48; HR
148; RR 24; Sa02 94% RA. Soon thereafter, vancomycin and zosyn
were D/C'ed per ID recs. Gantamicin was maintained, and therapy
will continue for 14 days (initiated [**9-23**]).
He was taken for urgent ERCP on [**9-23**] for presumed cholangitis.
Stone fragments and pus were noted to extrude from major
papilla. CBD was dilated to 12 mm. A biliary stent was placed.
Old stent was removed and sent for cytology.
In the ICU, he was transiently on pressors for hypotension - on
[**9-24**] dose of levophed was weaned down and off by [**9-25**]. On
transfer AST was 26; ALT 53; Amylase 66; Lipase 17. WBC was
14.4; creatinine was 4.5. Sepsis was improved and gentamycin was
maintained as sole antibiotic therapy. He was transferred to
floor on [**9-25**].
Follow-up blood cultures dran [**9-25**] remained negative for
bacterial growth. As noted, cultures from [**9-22**] later grew
enterococcus species that were sensitive to high dose
gentamicin. Follow-up blood cultures recommended after
gentamicin course has been finished.
2) Biliary duct dilation and stent placement, as per above.
Findings included:
- A previously placed plastic stent was found in the major
papilla. The stent was pulled and sent for cytology.
- Stone fragments and pus were noted to extrude from the major
papilla.
- The CBD appeared dilated to 12 mm.
- To aid biliary drainage, a 7cm by 10Fr Cotton [**Doctor Last Name **] biliary
stent was placed successfully in the CBD.
- LFTs prior to the procedure were elevated [**9-22**] to ALT 79; AST
417 and fell to normal levels following ERCP. Amylase levels
rose slightly in the days following, suggesting mild post-ERCP
pancreatitis.
3. UTI. Urine grew VRE and serratia [**9-23**] as noted previously.
Cultures of [**9-22**] were negative. Surveillance cultures 10/13 and
[**9-30**] proved negative. Foley catheter was D/C'ed without problem
[**9-28**].
4. Mental status. Mr. [**Known lastname 68423**] was oriented to "self." He was
oriented to "[**Location (un) 86**]" or "Hospital" and "[**2133-7-14**]." Toward the
end of his hospital course, he was oriented to "[**Hospital3 **]
Hospital."
5. CAD
Cardiac markers were elevated (0.13, 0.14, 0.08) from admission.
An echo showed ejection fraction of 20-30 percent. He was not
cathed. Beta blocker (metoprolol 25 mg [**Hospital1 **] po) was resumed on
[**9-26**], following transfer from ICU to the floor. Aspirin therapy
was maintained. He was successfully weaned from oxygen 2L by
nasal cannula to room air. Simvastatin (40 mg) was withheld
until discharge. SaO2 on [**9-29**] p.m. was 100% 2L.
6. Cord compression:
CT spine showed severe spinal cord compression at the C3-4
through C6-7 levels and 1.4 x 1.2 cm lytic lesion involving the
T5 vertebral body. PSA was elevated. Concern for metastatic
prostate cancer was raised. In addition, spinal stenosis and
cord compression were noted from C5 to C7. He was asymptomatic
for cord compression at these levels. Neurosurgery consultation
recommended CT myelogram, which was performed [**10-2**] and
confirmed cord compression. No surgical intervention, however,
was warranted. Outpatient bone scan is recommended.
7. ESRD on HD and fistula clot. Patient's AV fistula was noted
to be thrombosed. Transplant surgery attempted thrombectomy
resulted in rethrombosis after one hour. AV fistulogram [**9-29**]
revealed aneurysm and impatent AV fistula, and attempted
re-thrombectomy by IR was also unsuccessful. Instead, a right
internal jugular hemodialysis catheter was placed, through which
Mr. [**Known lastname 68423**] has also received his IV gentamicin. Hemodialysis was
performed according to renal recs (see accompanying
documentation) and will be resumed per patient's usual WMF
routine at the [**Location (un) 5503**] dialysis unit. [**Location (un) 5503**] will also
arrange for further AV fistula surgery.
8. Anemia. Found to be macrocytic with unknown baseline but
stable. Dialysis administered erythropoietin. Please follow-up
with outpatient evaluation.
10. HTN. Following patient's ICU course, his home dose of
lisinopril 2.5 mg PO daily was reinstated. Due to elevated blood
pressures (160s/80s), the dose was increased to 5 mg daily. He
was discharged with this new dose.
11. Afib. Patient remained in NSR during stay. On beta-blocker
and ASA.
12. Thrombocytopenia. Platelet count on [**9-25**] was found to be
88. While patient was not receiving heparin, his IV lines were
being flushed with heparin. This was D/C'ed and assay for anti
PF4 antibodies was sent. This later returned negative for HIT.
Platelet counts soon increased to the 180s and remained stable.
13. Other prophylaxis. DVT prophylaxis was maintained with
pneumoboots. Reflux prophylaxis was maintained with protonix.
CODE STATUS:
DNR/DNI, pressors okay
Medications on Admission:
1. Metoprolol 25mg [**Hospital1 **]
2. Nephro liquid 120cc daily
3. Lisinopril 2.5 daily
4. Isoniazid 300mg daily
5. ASA 325mg daily
6. Simvistatin 40mg PO daily
7. Sevelamer 1600mg TID
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
7. Gentamicin in Normal Saline 80 mg/50 mL Piggyback Sig: One
(1) Intravenous QM,W,F AFTER DIALYSIS () for 5 days.
8. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day:
maintain while on isoniazid.
9. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO once a day for
4 months: [**Month (only) 359**] is month five of nine months.
10. Outpatient Lab Work
Please have blood cultures drawn AFTER course of gentamycin has
been completed.
11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Outpatient Lab Work
Outpatient bone scan is recommended.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 68422**] Nursing Home - [**Location (un) 5503**]
Discharge Diagnosis:
E. coli bacteremia
Urinary tract infection (vancomycin resistenat enteroccocci and
serratia marcenscens)
Cervical spine cord stenosis
End stage renal disease
Hemodialysis AV fistula thrombosis
T5 lytic lesion
L1 compression fracture
Fall
Thrombocytopenia
----
Anemia
Hypertension
Coronary artery disease
Atrial fibrillation
Discharge Condition:
Stable; good
Discharge Instructions:
1. You were admitted and found to have an infection in your
blood. It will be very important for you to continue with your
antibiotics (dosed at dialysis).
2. Also, it will be important for you to follow-up with your PCP
and with your (nephrologist) kidney doctors.
3. If you experience fevers/chills, lightheadedness or have any
other concerns, please be sure to call your PCP or go to the
emergency room.
4 .Regarding your medications, you are being discharged on the
same medications as before, with an increased dose of lisinopril
(now 5mg daily), the addition of an antibiotic (gentamicin) and
pyrodixine (isoniazid has been resumed upon discharge).
5. Please have blood cultures drawn after you finish the course
of gentamicin.
6. Please follow-up with outpatient bone scan.
Followup Instructions:
[**Hospital 5503**] nursing home will arrange for hemodialysis and
surgical follow-up for AV fistula thrombectomy.
|
[
"996.73",
"453.8",
"599.0",
"428.0",
"403.91",
"721.1",
"041.4",
"427.31",
"518.82",
"576.1",
"785.52",
"287.5",
"574.51",
"238.0",
"585.6",
"511.9",
"293.0",
"038.0",
"V45.02",
"996.59",
"V10.46",
"V15.88",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.21",
"39.95",
"88.49",
"38.95",
"39.42",
"51.10",
"97.05",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
19355, 19443
|
12190, 17831
|
279, 431
|
19811, 19826
|
7936, 12167
|
20661, 20779
|
7355, 7374
|
18068, 19332
|
19464, 19790
|
17857, 18045
|
19850, 20638
|
7389, 7917
|
235, 241
|
459, 2398
|
6658, 7197
|
7213, 7339
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,076
| 199,195
|
5527+5528
|
Discharge summary
|
report+report
|
Admission Date: [**2149-12-29**] Discharge Date: [**2150-1-5**]
Date of Birth: [**2084-2-2**] Sex: F
Service: ICU
CHIEF COMPLAINT: Respiratory distress.
HISTORY OF THE PRESENT ILLNESS: This is a 65-year-old woman
with a history of breast cancer, and AML who was transferred
from [**Hospital3 537**] for fever and respiratory distress.
The patient is status post a long hospitalization at the [**Hospital 14852**] beginning in [**2149-7-10**] and ending
on [**Last Name (LF) 2974**], [**2149-12-26**], when she was transferred to the
[**Hospital3 537**]. The patient was initially diagnosed with AML
in [**2148-9-9**] while undergoing treatment for her Sezary
syndrome. She had a history of myelodysplasia which was
found to have converted to AML. She is status post three
courses of low-dose Ara-C and one does of high-dose Ara-C up
to [**2149-7-10**].
In [**2149-7-10**], she was admitted to the [**Hospital 8503**] for autologous bone marrow transplant. During
the course of her hospitalization she became unresponsive and
nonverbal. Over one week later she was diagnosed with
nonconvulsive status epilepticus and was transferred to the
ICU for intubation and treatment. Her family for unknown
reasons refused a phenobarbital coma. She was loaded
initially with Dilantin which was discontinued when it caused
leukopenia and then later with Depakote and Keppra.
She never remained responsiveness and remained nonverbal
throughout the course of her hospitalization up until [**2149-12-26**]. During this long hospitalization, she also was
readmitted to the Intensive Care Unit and intubated for an
MRSA pneumonia which was treated with linazolid.
At some point in the course, the patient was treated with
vancomycin and the family felt that this contributed to her
unresponsiveness and refused future doses of vancomycin.
In [**Month (only) 404**], while hospitalized at [**Hospital1 336**], a family meeting was
held in which the neurologist stated to the family that the
patient had no hope of functional recovery. The [**Hospital 228**]
health care proxy is her son, [**Name (NI) 6930**], and her daughter is
also involved in her care. At this time, the family was
reportedly angry at the [**Hospital 4415**] and felt
that [**Hospital1 336**] was responsible for their mother's decline. They
refused to make her DNR/DNI or CMO and insisted that she
remain full code.
She was transferred to [**Hospital3 537**] on [**2149-12-26**] in
the evening. At that time, she was not intubated but still
was not responsive or verbal.
On the morning of [**2149-12-28**], she was noted to be in
respiratory distress with an oxygen saturation of 80% on room
air and a temperature of 103.4. She was brought by ambulance
to the Emergency Room at the [**Hospital6 2018**]. Her daughter who works at the [**Hospital1 18**] in registration
discovered her mother there and subsequently refused to have
her transferred to the [**Hospital 4415**] as she felt
that the [**Hospital 4415**] caused her mother to be
so ill.
In the Emergency Department, she was in respiratory distress,
saturating 95% on 100% nonrebreather, blood pressure 130/80,
pulse 140s-150s. She was intubated for hypoxemia using
Etomidate, succinylcholine, and Ativan as the patient
clenched her jaw shut tight. Her systolic blood pressure
dropped immediately into the 70s and did not respond to
fluid. Dopamine GTT was initiated.
A chest x-ray demonstrated a left lower lobe pneumonia and a
white cell count was 20.2 with a left shift. It was felt
that she was in septic shock and dopamine was switched to
Neo-Synephrine at 60 micrograms per minute. Status post
intubation, she had suction of copious amounts of yellow
sputum.
In the Emergency Department, she was also noted to have poor
urine output and received 6 liters of IV fluids with 600 cc
of urine output over the next two hours. She received IV
doses of Clindamycin, levofloxacin, gentamicin, and
linazolid. She was sent to the ICU for further management.
PAST MEDICAL HISTORY:
1. Cervical cancer, diagnosed in [**2106**], status post total
abdominal hysterectomy.
2. Breast cancer times two, right breast DCIS, status post
mastectomy and lymph node dissection in [**2138**]; left breast
intraductal cancer, status post mastectomy and adjunctive
chemotherapy with four cycles of Cytoxan and Adriamycin in
[**2145-9-9**].
3. Sezary syndrome, status post photophoresis weekly up
until [**2148-9-9**].
4. Myelodysplasia converted to AML diagnosed in [**2148-9-9**], status post autologous bone marrow transplant at the
[**Hospital 4415**] in [**2149-7-10**], status post
four courses of Ara-C.
5. Hypertension.
6. Diabetes mellitus times nine years.
7. Hypercholesterolemia.
FAMILY HISTORY: Notable for a mother with hypertension and
breast cancer, father with diabetes.
SOCIAL HISTORY: No alcohol or tobacco.
ALLERGIES: Vancomycin, intravenous contrast (unclear
reaction), and nickel.
HEALTH CARE PROXY: Brother, [**Name (NI) 6930**], home phone number
[**Telephone/Fax (1) 22303**], work phone number [**Telephone/Fax (1) 22304**].
ONCOLOGIST AT [**Hospital6 **]: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
MEDICATIONS UPON ADMISSION FROM [**Hospital3 **]:
1. Keppra 1,000 mg b.i.d.
2. Augmentin 500 mg t.i.d.
3. Depakote 1,000 mg t.i.d.
4. Imodium 2 mg q.i.d.
5. Regular insulin sliding scale.
6. Prozac 20 mg q.d.
7. Prilosec 20 mg q.d.
8. Remeron.
9. Lantus 10 units subcutaneously q.h.s.
10. Jevity Plus tube feeds.
11. Free water boluses 250 cc q.d.
PHYSICAL EXAMINATION ON ADMISSION TO THE ICU: Blood pressure
stable, saturations 99% on assist control 20, 500, and 60%.
General: The patient was unresponsive but her eyes would
open to deep sternal rub. The pupils were downgoing and
conjugate gaze. Sclerae were anicteric. Neck: Without
thyromegaly. Heart: Regular rate and rhythm, II/VI systolic
murmur at the right upper sternal border, II/VI systolic
murmur at the left lower sternal border, and II/VI diastolic
murmur at the left sternal border. Lungs: Clear to
auscultation. Mastectomy scars were noted. Abdomen: J tube
in place. Soft, nontender, nondistended abdomen. Right
femoral A line in place (from ED). Extremities: Feet with
bandages. No edema.
LABORATORY DATA ON ADMISSION: White count 20, hematocrit 32,
creatinine 1.3 (last creatinine at this hospital was 0.7 in
[**2147-8-11**]). The differential included 45%
neutrophils, 21% bands, 15% lymphocytes, 12% metamyelocytes,
2% myelocytes. INR 1.2. Valproate level 45. The urinalysis
was notable for [**5-19**] white blood cells and occasional
bacteria. Blood gases were within normal limits at 7.40, 39,
70.
Chest x-ray demonstrated ETT 6 cm above carina, left
subclavian and left atrium, no effusions or infiltrate were
read on initial x-ray.
EKG was notably tachycardiac with ST depressions in V2 and
V3, mild left axis deviation and question of U wave.
Intervals were all within normal limits.
HOSPITAL COURSE: 1. CARDIAC: The patient was initially
felt to be in septic shock secondary to her left shift,
fever, and hypotension not responding to fluids; however, on
[**2149-12-30**], a Swan-Ganz catheter was placed which
demonstrated a cardiac index of 1.5, SVR 1,200, and pulmonary
capillary wedge pressure of 20. Her CK was in the 800s and
troponin 2.6. It was then felt that she suffered a cardiac
insult and was in cardiogenic shock. Her Levophed was
switched to dobutamine and Cardiology was consulted.
Cardiology felt that she was significantly fluid overloaded
and recommended not only diuresis but Captopril for afterload
reduction. An echocardiogram was performed which
demonstrated global decrease in LV and RV function and no
significant valve abnormalities. Her EF was about 20%. This
is in contrast to an echocardiogram from [**2149-7-10**] where
her EF was 55%. The patient's last dose of Adriamycin was
several years ago during her treatment for breast cancer.
Up to this date, the patient has been weaned off of
dobutamine (weaned entirely on [**2150-1-4**]) and
Captopril has been increased to 50 mg t.i.d. Repeat
echocardiogram should be performed within the next few days
to reevaluate cardiac function. It is likely that the
patient suffered a cardiac insult causing her decreased EF at
this point.
Of note, the Swan-Ganz catheter was removed on [**2150-1-5**] and changed to a triple-lumen catheter.
2. NEUROLOGY: The patient continued to be unresponsive and
nonverbal. She was also noted to be having upper extremity
clonic motions and clonus upon movement that would
generalize. An EEG was performed on [**2149-12-31**] which
demonstrated that the patient was in convulsive status
epilepticus. She was loaded with Depakote, phenobarbital was
added to her regimen and Keppra was continued.
Continuous EEG from [**2150-1-1**] to [**2150-1-5**]
demonstrated no further seizure activity, although the
patient had severe diffuse slowing. Neurology interpreted
this as severe toxic metabolic encephalopathy.
3. PULMONARY: The patient's ventilator dependency has
continued but she has remained on pressure support weaned
down on [**2150-1-5**] to 5 of pressure support and 5 of
PEEP, tolerating this well and with saturations in the high
90s. However, she continues to have large periods of apneic
events. She may require a tracheostomy if she is unable to
tolerate pressure support without having significant apneic
periods, may require tracheostomy for airway support. She
was switched over to IMV just to give her persistent breaths.
B. Pneumonia: The patient grew out MRSA from sputum. She
was continued on an eight day course of linazolid until
[**2150-1-5**] when it was discontinued as the patient has
been afebrile without worsening of her pneumonia, also with
thrombocytopenia and felt maybe contributed to linazolid.
4. GASTROINTESTINAL: The patient is status post G tube
placement in [**2149-10-10**] at the outside hospital. Tube
feeds initially held secondary to sepsis, on pressors, and
then started Criticare at 10 cc per hour for trophic feeds.
TPN was initiated on [**2149-12-29**] with insulin to cover
for elevated blood sugars. We have started to attempt to
increase tube feeds as tolerated and checking residuals
frequently. We will discontinue TPN if able to.
5. ONCOLOGY: Spoke to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the [**Hospital 8503**]. Dr. [**Last Name (STitle) **] states that further workup of Mrs.
[**Known lastname **]' AML demonstrated that she is in remission.
6. SKIN: The patient has a sacral decubitus ulcer and calf
decubitus ulcers, heel decubitus ulcers being treated with
wet-to-dry dressing changes.
7. ENDOCRINE: Apparent history of diabetes mellitus treated
with regular insulin sliding scale here. Insulin drip
started on [**2150-1-5**] to gain further control of sugars
now that the patient is off TPN.
B. Cosyntropin test on [**2149-12-30**] with an appropriate
bump in cortisol from 15-25 with Cosyntropin. Not adrenally
insufficient.
C. TSH elevated at 8.9 but T4 within normal limits and T3
slightly low demonstrating subclinical hypothyroidism. No
treatment initiated at this point.
8. RENAL: Creatinine clearance came down to 0.5 which is in
the patient's normal limits. No further issues with urine
output or creatinine.
9. INFECTIOUS DISEASE: Left lower lobe pneumonia, status
post three days of ceftazidime, Flagyl, and linazolid.
Ceftazidime and Flagyl were discontinued on [**2149-12-31**]
and linazolid was continued until [**2150-1-5**]. Have
discontinued all antibiotics at this point but will restart
if necessary. Linazolid for MRSA given the patient's history
of "allergy" to vancomycin. The patient was also having
yeast from urinalysis. We will discontinue Foley and repeat.
10. HEMATOLOGY: Thrombocytopenia, have held all heparin,
Swan discontinued on [**2150-1-5**] (Swan with
heparin-bonding). Linazolid discontinued on [**2150-1-5**]. We will review all medications to take off further
medications that may be causing thrombocytopenia. HIT
antibody pending.
11. ACCESS: Right Cordis from [**2149-12-30**] to [**2150-1-5**] changed to a triple-lumen catheter Port-A-Cath since
previous admission at the [**Hospital 4415**].
Femoral A line placed by the Pulmonary Fellow in the
Emergency Department on [**2149-12-29**].
12. FAMILY: Spoke initially to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22305**] at the [**Hospital 14852**] who is the Hematology/Oncology Social
Worker at [**Telephone/Fax (1) 22306**]. [**Name2 (NI) **] offered pretty much
information on the patient's family and stated that the son
had been belligerent in the past and had threatened lawsuits
against [**Hospital1 336**]. Risk Management and Legal had been involved at
the [**Hospital 4415**]. A family meeting was held on
[**Last Name (LF) 2974**], [**2150-1-3**], at which the son and daughter were
told by Neurology that the patient likely has no hope of
functional recovery; however, that there have been patients
who have had similar periods of nonconvulsive status
epilepticus in the past that have had some functional
recovery. The son, who is the health care proxy, took this
as a sign of hope and stated "I am walking on air right now"
because he was given a shred of hope. The family decided to
keep her full code.
Of note, the patient's son, [**Name (NI) 6930**], refused to go in and
see his mother and stated that he has never seen her while
she has been sick in the hospital. [**Hospital1 6930**] was made the
health care proxy in [**2149-10-10**] during his mother's
hospitalization at the [**Hospital 4415**] and
according to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22305**] at the [**Hospital 10908**] while the patient was comatose. It was though the
decision of the family members to make him the health care
proxy.
An Ethics Consult has been ordered on [**347-1-6**] and
will discuss with Dr. [**Last Name (STitle) 4261**].
PLAN IN THE NEXT FEW DAYS: Neurology is requesting an MRI
when EEG leads are discontinued. Depakote and phenobarbital
levels should be followed-up on. Attempt to wean from
ventilation but may require tracheostomy for airway support.
Obtain better control of glucose. Family discussions and
meetings to continue.
DR.[**Last Name (STitle) 2437**],[**First Name3 (LF) **] 12-664
Dictated By:[**Last Name (NamePattern4) 22307**]
MEDQUIST36
D: [**2150-1-5**] 11:41
T: [**2150-1-5**] 12:53
JOB#: [**Job Number 22308**]
Admission Date: [**2149-12-29**] Discharge Date: [**2150-1-16**]
Date of Birth: [**2084-2-2**] Sex: F
Service:
ADDENDUM: This is an Addendum to the Discharge Summary
dictated on [**2150-1-5**].
Subjectively, since that time, the patient has remained the
same subjectively. She continues to be nonresponsive; only
opening eyes spontaneously. Her issues are as follows:
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. INFECTIOUS DISEASE ISSUES: The patient is currently
being treated with intravenous ciprofloxacin through [**2150-1-18**] for a positive line tip growing out gram-negative
rods which were not pseudomonal and not fermenting.
Of note, the patient is colonized with yeast in her urine;
although, she does have a negative urinalysis. She did
receive five days of oral fluconazole with no clearing of the
yeast. Due to the fact that the patient was afebrile, with
no signs of sepsis, and a stable white blood cell count, she
was not treated.
2. NEUROLOGIC ISSUES: The patient has had no seizure
activity on continuous electroencephalogram monitoring. She
is on valproic acid, Keppra, and phenobarbital. These doses
should be staggered and not given all at once because her
blood pressure does fall when they are administered
altogether.
3. CARDIOVASCULAR SYSTEM: The patient has a decreased
ejection fraction with a repeat echocardiogram showing an
ejection fraction of 20% to 30%. She was originally on 75 mg
p.o. captopril t.i.d.; however, her blood pressure has been
falling into the systolic range of 85 to 95 after admission.
She has been tapered down to 50 mg p.o. t.i.d. and may need
to be titrated down to 25 mg p.o. t.i.d.
There is no clear etiology for cardiomyopathy. It is thought
that it is either chemotherapy versus cardiac/coronary artery
disease in nature. The patient will need a repeat
echocardiogram in [**2150-4-9**].
4. PULMONARY SYSTEM: This is day eighteen of the
ventilator for the patient. She is day three of
tracheostomy.
5. ENDOCRINE SYSTEM: The patient is on a regular insulin
sliding-scale for her diabetes.
6. HEMATOLOGIC ISSUES: The patient has a history a
hematocrit that has been going up and down requiring
transfusions approximately every seven to ten days. The
patient's hemolysis laboratories are normal. Her stool is
guaiac-negative. A potential source may be in her lungs, as
we periodically suction blood clots. [**Month (only) 116**] have been an
irritation of the endotracheal tube. The most recent drop
may have been the tracheostomy procedure.
7. RENAL SYSTEM: Stable.
8. DERMATOLOGIC ISSUES: The patient with decubitus ulcers
on her feet and calves. She has been getting wet-to-dry
dressing changes once per day. She was to receive 14 days of
zinc and continuous vitamin C.
9. GASTROINTESTINAL SYSTEM: The patient with a
gastrojejunostomy tube in place. Continued gastrojejunostomy
tube. Elevated alkaline phosphatase has been stable. We
have been checking that once per week. No clear etiology.
Stool output has decreased with a change in tube feeds.
10. LINES: The patient with a Port-A-Cath in place.
11. PROPHYLAXIS: The patient is on a proton pump inhibitor
and pneumatic boots.
12. CODE STATUS: The patient is do not resuscitate, but we
will continue her on the ventilator.
13. COMMUNICATION ISSUES: The patient's son [**First Name8 (NamePattern2) **] [**Name (NI) **])
is the main contact. It has been stated that he his health
care proxy; however, this is not a form that was signed by
the patient before her decline. [**First Name8 (NamePattern2) **] [**Known lastname **] is basically
the designated speaker for the family. He can be difficult
to get hold of. I did fill out paperwork for him to be able
to be excused from work with the Family With Disability Act.
14. DISCHARGE DISPOSITION: The patient has been accepted at
[**Hospital **] Rehabilitation Center. We are waiting for
confirmation from Mr. [**Known lastname **] before her discharge.
MEDICATIONS ON DISCHARGE: (Discharge medications included)
1. Ciprofloxacin 400 intravenously q.12h. (through [**1-18**]).
2. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed.
3. Captopril 50 mg p.o. t.i.d. (hold for a systolic blood
pressure of less than 90).
4. Zinc sulfate 220 mg p.o. q.d. (through [**2150-1-23**]).
5. Valproic acid 1500 mg p.o. q.8h.
6. A regular insulin sliding-scale.
7. Phenobarbital 30 mg p.o. t.i.d.
8. Aspirin 325 mg p.o. q.d.
9. Levetiracetam 1000 mg p.o. b.i.d. (Keppra).
10. Lansoprazole oral solution 30 mg p.o. q.d.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE PROGNOSIS: Poor.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Last Name (NamePattern1) 22309**]
MEDQUIST36
D: [**2150-1-15**] 13:17
T: [**2150-1-15**] 14:19
JOB#: [**Job Number 22310**]
|
[
"287.5",
"996.62",
"518.81",
"785.51",
"205.01",
"410.91",
"202.20",
"482.41",
"V42.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"89.64",
"96.6",
"96.72",
"96.04",
"38.93",
"31.1",
"00.14"
] |
icd9pcs
|
[
[
[]
]
] |
18494, 18653
|
4763, 4844
|
18680, 19233
|
7034, 15039
|
15074, 18470
|
19248, 19591
|
152, 4022
|
6335, 7016
|
4044, 4746
|
4861, 6320
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,137
| 102,758
|
30241+57684
|
Discharge summary
|
report+addendum
|
Admission Date: [**2108-2-18**] Discharge Date: [**2108-2-20**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Productive cough.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
68yM s/p OLT [**2104**] with ESRD on HD who presented to an OSH
with a history of seizure. Per patientand records, he has a
remote history of seizure after receiving a liver transplant in
[**2104**] after which he was on Keppra for an unknown amount of time,
although patient thinks he was on Keppra for around a year. Pt
was taken to OSH where he was diagnosed with a pneumonia and
transferred to
[**Hospital1 **] for further care given his history of liver transplant and
recent GI bleed with admission to [**Hospital1 **]. Denies recent fevers,
V/D.
Notes new productive cough over the last 3 days. No CP/SOB/abd
pain, UTI symptoms.
Pt was recently admitted to the surgical service with an UGI
bleed. He had an EGD which identified a doudenal bulb ulcer
which was clipped and injected. He reports no blood per rectum
or hematemesis.
Past Medical History:
HCC, EtOH Cirrhosis s/p OLT, CAD, HTN, CHF/Cardiomyopathy (EF
25-30%) with frequent admissions for systolic heart failure,
Stage IV CKD (Baseline Cr 3.6), pancreatic insufficiency,
Anemia, Bronchitis, COPD, Tube feeds at home through G-tube,
COPD
Social History:
Married, lives at home with wife. Previously smoked 1PPD, now
trying to quit smoking. No current EtOH use for past 5 years.
Family History:
Father died of prostate cancer.
Physical Exam:
Vitals-WNL
Gen-AxOx3, NAD
CV-RRR, No MRG
[**Hospital1 **]-CTABL
Abd-Soft NT, ND
Ext-no C/D/E
Pertinent Results:
[**2108-2-18**] 08:37PM TYPE-ART PO2-146* PCO2-30* PH-7.52* TOTAL
CO2-25 BASE XS-2 INTUBATED-NOT INTUBA COMMENTS-O2 DELIVER
[**2108-2-18**] 08:25PM HCT-36.0*
[**2108-2-18**] 05:41PM TYPE-ART PO2-232* PCO2-35 PH-7.53* TOTAL
CO2-30 BASE XS-7
[**2108-2-18**] 05:28PM HCT-30.6*
[**2108-2-18**] 12:15PM VANCO-21.5*
[**2108-2-18**] 12:10PM STOOL BLOOD-NEGATIVE
[**2108-2-18**] 11:42AM GLUCOSE-109* UREA N-39* CREAT-3.5* SODIUM-136
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-32 ANION GAP-13
[**2108-2-18**] 11:42AM ALT(SGPT)-14 AST(SGOT)-47* CK(CPK)-63 ALK
PHOS-148* TOT BILI-0.4
[**2108-2-18**] 11:42AM CK-MB-1
[**2108-2-18**] 11:42AM ALBUMIN-2.8* CALCIUM-8.0* PHOSPHATE-2.3*
MAGNESIUM-1.5*
[**2108-2-18**] 11:42AM WBC-16.4* RBC-3.06*# HGB-8.8*# HCT-24.8*#
MCV-81* MCH-28.7 MCHC-35.4* RDW-15.5
[**2108-2-18**] 11:42AM PLT COUNT-143*
[**2108-2-18**] 11:42AM PT-13.9* PTT-32.1 INR(PT)-1.2*
[**2108-2-18**] 11:42AM FIBRINOGE-620*
[**2108-2-18**] 01:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2108-2-18**] 01:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
[**2108-2-18**] 01:30AM URINE RBC-[**4-14**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0-2
[**2108-2-18**] 01:20AM PT-13.9* PTT-33.6 INR(PT)-1.2*
[**2108-2-18**] 01:13AM LACTATE-0.8
[**2108-2-18**] 01:05AM GLUCOSE-101* UREA N-37* CREAT-3.2* SODIUM-133
POTASSIUM-4.2 CHLORIDE-91* TOTAL CO2-34* ANION GAP-12
[**2108-2-18**] 01:05AM ALT(SGPT)-13 AST(SGOT)-47* ALK PHOS-139* TOT
BILI-0.5
[**2108-2-18**] 01:05AM LIPASE-33
[**2108-2-18**] 01:05AM CALCIUM-8.2* PHOSPHATE-1.2*
[**2108-2-18**] 01:05AM WBC-17.3* RBC-2.19*# HGB-6.2*# HCT-17.8*#
MCV-81* MCH-28.3 MCHC-34.8 RDW-15.9*
[**2108-2-18**] 01:05AM NEUTS-30* BANDS-2 LYMPHS-28 MONOS-12* EOS-1
BASOS-1 ATYPS-0 METAS-0 MYELOS-0 BLASTS-11* NUC RBCS-6*
OTHER-15*
[**2108-2-18**] 01:05AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-1+
[**2108-2-18**] 01:05AM PLT SMR-LOW PLT COUNT-145*
Brief Hospital Course:
Pt was aditted via the ED on [**2108-2-18**] with complants of
productive cough. Pt was noted to have a Hct of 17.8 on
admission and due a history of recent GI bleed he was
transferred to the ICU and give blood transfusions with an
appropriate increase in his HCT to 30.0 which remained stable
throughout his hospital course. When he received this blood
transfusion he began to have respiratory compromise and he was
started on BiPAP in the ICU and he was dialysed and 3L offluid
was removed. This resolved his respiratory symptoms and he
subsequently was able to oxygenate without supplemental oxygen.
His Hct remained stable and he had no evidece of bleeding from
his GI tract and he was transferred out of the ICU. He did have
evidence of a possible continued pneumonia on a CXR and he was
continued on IV antibiotics while in the hospital. Because of
previous findings on blood work indicating a possible
myelodysplastic disorder of some type we discussed the
possibility of a bone marrow biopsy. However, on mulitple
occasions MR. [**Name13 (STitle) 68078**] refused to have this procedure done. On
HD 3 pt remained hemodynamically stable, tolerating a regular
diet with vital signs within the normal range. He was dischrged
home on a 10 days course of oral antibiotics.
Medications on Admission:
Carvedilol 3.125", Sirolimus 2g', prednisone 5', simvastatin
10', loperamide 2'prn diarrhea, tube feeds (vivonex@100/hr x
900cc at night), omeprazole 20", zofran 8'prn, mirtazapine 15',
testosterone 2.5mg patch', renal caps soft gel', creon 10'''
Discharge Medications:
1. sirolimus 1 mg/mL Solution Sig: One (1) PO DAILY (Daily).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO EVERY OTHER DAY (Every Other Day).
3. furosemide 80 mg Tablet Sig: Two (2) Tablet PO MWF
(Monday-Wednesday-Friday).
4. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
9. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO Q8H (every 8 hours).
10. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea.
11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
14. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Stable.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2108-2-29**] 1:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2108-2-29**] 2:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11058**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2108-2-29**]
2:40
Name: [**Known lastname 12047**],[**Known firstname **] H Unit No: [**Numeric Identifier 12048**]
Admission Date: [**2108-2-18**] Discharge Date: [**2108-2-20**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2800**]
Addendum:
Please note updated/corrected med list
sirolimus 1 mg/mL Solution Sig: One (1) PO DAILY (Daily).
sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO EVERY OTHER DAY (Every Other Day).
prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1)
Cap PO DAILY (Daily).
phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO Q8H (every 8 hours).
loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for diarrhea.
carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for
nausea.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
levofloxacin 500 mg Tablet Sig: One (1) Tablet PO every
other day for 10 days.
Disp:*5 Tablet(s)* Refills:*0*
Ritalin 5 mg Tablet Sig: [**2-12**] Tablet PO twice a day: 8 AM
and noontime.
omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO three times a day.
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 709**]
[**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**] MD [**MD Number(1) 401**]
Completed by:[**2108-2-20**]
|
[
"V42.7",
"305.1",
"432.1",
"428.0",
"276.8",
"532.90",
"428.22",
"285.21",
"780.39",
"238.75",
"783.7",
"799.4",
"V11.3",
"491.20",
"425.4",
"577.8",
"585.6",
"275.3",
"V85.0",
"403.91",
"414.01",
"V45.11",
"V10.07",
"486"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11434, 11657
|
3885, 5162
|
319, 327
|
7117, 7125
|
1792, 3862
|
9056, 11411
|
1631, 1664
|
5460, 6979
|
7084, 7096
|
5188, 5437
|
7276, 8254
|
1679, 1773
|
8286, 9033
|
262, 281
|
355, 1202
|
7140, 7252
|
1224, 1473
|
1489, 1615
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,053
| 198,713
|
41197
|
Discharge summary
|
report
|
Admission Date: [**2111-12-11**] Discharge Date: [**2111-12-29**]
Date of Birth: [**2032-11-16**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Intubation
Bronchoscopy
Rigid bronchoscopy
Bronchial artery embolization
History of Present Illness:
This is a 79 year old female with PMH history significant for TB
treated 20 years prior, bronchiectasis on 2L home oxygen, ASD
s/p surgical repair with resultant atrial fibrillation, history
of subdural hematoma and rectus sheath hematoma secondary to
coumadin and multiple TIAs off of anticoagulation, on dabigatran
for several weeks who presented initially to OSH for hemoptysis
and transferred to [**Hospital1 18**] for further evaluation.
Per report, patient with several coughing episodes last night
with hemoptysis of several teaspoons of bright red blood. She
went to bed without incident. On the day of admission, patient
developed massive amounts of hemoptysis (several cupfulls) at
1PM today, and was taken to an OSH. There, she was found to be
tachycardic to the 120s and hypoxic to 85% (on unclear amount of
oxygen) with stable hematocrit of 42.7 and an INR of 1.1. Other
labs notable for wbc of 15.3, dig level of 0.7, trop of 0.01,
CK: 51, sodium 126. She was intubated for airway protection.
Chest radiograph without acute process. Thoracic surgery team
performed bronchoscopy who found blood in the RLL; no
intervention was performed. NG tube was placed and drained
coffee ground material.
At [**Hospital1 18**] ED, initial vital signs were 130/80, 80, 16, 100%.
Repeat hct was 39.5 and INR was 1.3. NG lavage was clear.
Chest radiograph demonstrated opacities bilaterally concerning
for blood vs. aspiration. IP was consulted and patient was
taken emergently to OR for rigid bronchoscopy, which
demonstrated large clot in RLL with active oozing around the
clot. BAL was performed. Left lung was suctioned of blood.
Double lumen endotracheal tube was placed to protect the left
lung. Plan was for IR to evaluate patient for bronchial artery
embolization.
Past Medical History:
- atrial fibrillation, previously on coumadin but now on
dabigatran
- history of subdural bleed 3 years ago while on coumadin with
some dysarthria and right sided weakness
- history of multiple TIAs (most recently 2 weeks ago) while off
coumadin (restarted coumadin several years ago) -> stopped
definitively on 10/[**2110**]. Restarted dabigatran several weeks
ago.
- history of large rectus sheath hematoma in [**8-/2111**]
- HTN
- GERD
- history of TB treated 20 years ago
- bronchiectasis with home oxygen of 2L
- ASD s/p surgical repair 10 years prior with development of
atrial fibrillation after procedure
- chronic hyponatremia ? secondary to SIADH
Social History:
Lives with family in [**Location (un) **]. Prior 15 pack year smoking
history. No alcohol or other illicit drug use.
Family History:
NC
Physical Exam:
ADMISSION:
VS: Temp: BP: 126/61 HR: 74 RR: 25 O2sat, 100% on vent.
GEN: intubated
HEENT: pupils round, 3mm, and sluggishly reactive to light
RESP: lungs clear to auscultation from the anterior chest wall
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: soft, nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Intubated, pupil exam as above.
.
DISCHARGE:
VS: Temp: 96.4 BP: 144/78 HR: 64 RR: 18 O2sat: 98%2L NC
GA: AOx2, NAD
HEENT: MMM. no LAD. no JVD. neck supple.
Cards: irreg irreg, S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB, no wheezes or rhonchi
Abd: soft, NT, +BS. no g/rt. Palpable R periumbical subcutaneous
mass, non-tender, non-fluctuant
Extremities: wwp, no edema in LE bilaterally. DPs, PTs 2+.
Skin: dry, ecchymoses on UE bilaterally
Neuro/Psych: CNs II-XII grossly intact. 4/5 strength in U/L ext,
R<L. Sensation intact to LT. Gait deferred. Able to perform DOTW
forward.
Pertinent Results:
Admission labs:
[**2111-12-11**] 06:10PM GLUCOSE-108* UREA N-18 CREAT-0.5 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-31 ANION GAP-13
[**2111-12-11**] 06:10PM OSMOLAL-273*
[**2111-12-11**] 06:10PM WBC-10.7 RBC-4.16* HGB-12.8 HCT-39.5 MCV-95
MCH-30.8 MCHC-32.4 RDW-14.8
[**2111-12-11**] 06:10PM NEUTS-86.4* LYMPHS-10.0* MONOS-3.1 EOS-0.3
BASOS-0.3
[**2111-12-11**] 06:10PM PLT COUNT-231
[**2111-12-11**] 06:10PM PT-15.1* PTT-34.1 INR(PT)-1.3*
[**2111-12-16**] 03:08 Digoxin 0.8*
.
Discharge labs:
[**2111-12-29**] 05:47AM BLOOD WBC-6.2 RBC-3.27* Hgb-10.0* Hct-30.5*
MCV-93 MCH-30.6 MCHC-32.9 RDW-14.8 Plt Ct-545*
[**2111-12-29**] 05:47AM BLOOD Glucose-86 UreaN-15 Creat-0.5 Na-136
K-3.8 Cl-95* HCO3-34* AnGap-11
[**2111-12-29**] 05:47AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.2
.
Cardiac enzymes:
CK-MB cTropnT
[**2111-12-23**] 05:09 2 <0.011
[**2111-12-22**] 21:43 2 <0.011
[**2111-12-22**] 13:01 2 <0.011
[**2111-12-22**] 05:43 2 <0.011
[**2111-12-21**] 03:59 2 <0.011
.
Microbiology:
[**2111-12-24**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-NEG
[**2111-12-23**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-NEG
[**2111-12-17**] BLOOD CULTURE-NEG
[**2111-12-16**] Mini-BAL GRAM STAIN-GNRs; RESPIRATORY
CULTURE-PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML;
LEGIONELLA CULTURE-PRELIMINARY; FUNGAL CULTURE-NGTD; ACID FAST
SMEAR-NEG; ACID FAST CULTURE-NGTD
[**2111-12-15**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {PSEUDOMONAS AERUGINOSA, PSEUDOMONAS AERUGINOSA}
INPATIENT
[**2111-12-14**] URINE CULTURE-NEG
[**2111-12-14**] BLOOD CULTURE-NEG
[**2111-12-12**] URINE CULTURE-NEG
[**2111-12-11**] BRONCHIAL WASHINGS GRAM STAIN-NEG; RESPIRATORY
CULTURE- PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- 32 I 16 S
CEFEPIME-------------- 16 I 16 I
CEFTAZIDIME----------- 2 S 4 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM------------- 1 S 1 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ =>16 R =>16 R
ACID FAST SMEAR-NEG; ACID FAST CULTURE-PRELIMINARY; FUNGAL
CULTURE-NGTD; POTASSIUM HYDROXIDE PREPARATION-Cancelled;
LEGIONELLA CULTURE-NEG
[**2111-12-11**] MRSA SCREEN-NEG
.
Imaging:
Chest radiograph ([**2111-12-11**]):
1. ET tube 6 cm above carina.
2. Endogastric tube side port just at the GE junction, would
recommend
advancing approximately 5 more cm to ensure that it is within
the stomach.
3. Patchy opacities throughout the lungs may represent
aspiration or
hemorrhage in this patient with hemoptysis.
4. Prominent right apical opacity may be prominent assymetic
pleural
thickening. Recommend correlation with history of malignancy and
chest CT for further evaluation.
.
Bronch report ([**2111-12-11**]): large clot in RLL, actively oozing
around clot. Clot was not disturbed.
.
TTE ([**2111-12-12**]):
The left and right atria are moderately dilated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is dilated. Free wall
motion is low normal. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. Mild to moderate ([**11-29**]+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Pulmonary artery hypertension. Moderaet mitral
regurgitation. Mild aortic regurgitation.
.
Rigid bronch report ([**2111-12-12**]):
Once the patient was relaxed, the rigid bronchoscope was
introduced into the oral cavity and followed along the double
lumen endotracheal tube until the cords were visualized. At that
point in time, the tracheal cuff on the double lumen was
deflated and the tube was pulled back as the rigid scope
intubated the cords and was positioned in the trachea. Once in
good position, jet ventilation was started.
The flexible bronchoscope was then introduced through the rigid
barrel and complete airway surveillance was done to subsegmental
bronchi. Noted was a large amount of clot burden on the right
side, but no active bleeding. The left side was clear and some
minimal areas of secretions were all cleared
with the flexible scope. Large amounts of clot were removed from
the all segments of the right lower lobe, including the
posterior segment as well as the right middle lobe. There were
no signs of active bleeding. No endobronchial lesion visualized.
The flexible scope was then removed.
A Cook catheter was introduced through the rigid scope. The
rigid was removed and a single lumen a tracheal tube introduced
via direct visualization by Anesthesia. The tube was then
confirmed to be approximately 2 cm above the carina via
bronchoscopy. The bronchoscope was removed. The procedure was
ended with no complications.
Brief Hospital Course:
-please check CBC and CHEM 7 in 1 week to monitor for resolution
of isolated thrombocytosis, check renal function, potassium
after starting ACE-i
.
79F w/PMH significant for bronchiectasis, afib s/o IR guided
embolization for hemoptysis now called out from MICU for
continued medical management of VAP; episode of chest pain
during admission w/EKG changes, CEs negative x 3.
.
MICU COURSE [**2111-12-11**] - [**2111-12-21**]; Transferred to floor from [**2111-12-21**]
- [**2111-12-29**]
.
# Hemoptysis: Resolved s/p right bronchial artery embolization.
Initially unclear etiology, with broad differential including
bleeding in setting of bronchiectasis on dabigatran and
overlying infection. On admission to the MICU was s/p bronch
demonstrating large clot in RLL with oozing. Double lumen
endotracheal tube was in place to protect the left lung from
future bleeding and underwent emergent IR bronchial artery
embolization of right bronchial artery embolization using
300-500 mic embospheres -> enlarged hypertrophic arteries
suggestive of bleeding. 2 arteries supplying RLL, both
embolized. Subsequently the patient did well and was able to
have a regular ETT placed. She had a repeat bronch showing no
bleeding but copiuous secretions concerning for a VAP which was
treated as below. Her hematocrits remained stable and after
consultation with her PCP it was decided that she would no
longer be an anticoagulation candidate but could be restarted on
asprin 325mg daily for stroke prevention in setting of AFib with
recent TIAs. Pt was successfully extubated and weaned to home
baseline O2 requirement of 2L prior to discharge without
difficulty.
.
# Respiratory Failure/VAP. Intitially was intubated in the
setting of hemoptysis however once bleeding resolved she
continued to have RLL collapse on XRay concerning for another
process. A bronch revealed no bleeding but copious secretions
concerning for VAP. She was treated with Vanc and Zosyn until
sputum and BAL cultures grew out two strains GNRS and
antibiotics were broadened to Tobramycin. When speciation and
sensitivities grew out two strains of pseudomonas antibiotics
were weaned to Zosyn. ID was consulted who recommended
completing a 15 day course of zosyn (day 1 [**12-12**] to [**12-27**]). She
had a difficult time weaning from the vent and diuresis was
initiated in the hope of improving her respiratory status. She
was successfully extubated on [**2111-12-20**] and weaned to baseline O2
requirement without issues.
.
# Atrial fibrillation: Developed secondary to ASD surgical
repair. Patient with history of cerebral bleed on coumadin and
TIA without anticoagulation. Anticoagulation was held in the
setting of hemoptysis and as above after consultation with her
PCP she was restarted only on Aspirin 325mg daily for CVA ppx.
Her home rate controlling agents were initially held in the
setting of her bleed and slowly added back (metoprolol,
diltiazem, and digoxin). Had episodes of afib with RVR in ICU,
now resolved. Metoprolol titrated up to 150mg daily for improved
rate control. Patient was on short acting diltizem four times a
day as an inpatient; this was switched to long acting diltiazem
on discharge.
.
# Diarrhea: In setting of tube feeds via NGT while patient was
being cleared by speech and swallow. Resolved after stopping
tube feed. Denied abdominal pain, N/V, remained afebrile; C.
diff negative x 2 and no leukocytosis.
.
# Chest pain: 30 minute episode of L sided chest pressure [**4-1**]
days prior to discharge, resolved with SLNG x 1, dynamic EKG
changes notable for ST depressions in lateral leads, resolved
when chest pain free. CE negative x 3. Echo performed earlier
this admission w/dilated atria, intact systolic function.
[**Hospital 89732**] medical management by uptitrating beta blockage,
continuing ASA, and starting statin, ACE-i. Patient was on
atorvastatin 80mg as an inpatient, but switched to simvastatin
40mg on discharge in light of LDL of 119, lisinopril 5mg for
improved BP control, cardiac/renal protection.
.
# Thrombocytosis: Isolated thrombocytosis without elevated WBC,
fevers or other signs or symptoms of infection. Started to trend
downward prior to discharge.
.
# Bronchiectasis: Patient with baseline O2sats in the low 90s on
2L. She was continued on home nebulizers.
.
# GERD: continued on PPI.
.
# HTN: Held home antihypertensives initially in setting of
bleed. Metoprolol and diltiazem were later restarted.
Metoprolol increased as above, started lisinopril 5mg daily.
.
# Hyponatremia: Chronic per outside records, attributed to
SIADH. Sodium within known range, improved with 250cc NS bolus,
free water restriction to 1L/day. Home demeclocycline briefly
held in ICU, but then continued. Na 136 on discharge.
.
# Prophylaxis: Patient received heparin products during this
admission.
.
# Code: Full
Medications on Admission:
- albuterol inhaler
- aspirin 81mg PO daily
- cardizem CD 240mg PO daily
- colace
- combivent 2 puffs qid
- dabigatran 150mg PO BID
- demeclocycline 150mg PO BID
- digoxin 0.25mg MWF, 0.125 other days
- flonase
- lasix 60mg PO daily
- prilosec 20mg PO daily
- spiriva
- toprol 50mg PO daily
- zyrtec 10mg PO daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**11-29**] Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
2. Cardizem CD 240 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Please hold for loose stools.
4. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day as needed for shortness of breath or
wheezing.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. demeclocycline 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],TU,TH,SA).
8. digoxin 250 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
9. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray
each nostril Nasal once a day as needed for nasal congestion.
10. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
12. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Zyrtec 10 mg Capsule Sig: One (1) Capsule PO once a day.
14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
15. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
as needed for anxiety/insomnia.
17. Outpatient Lab Work
Check CBC and CHEM-7 in 1 week ([**2112-1-5**]) to monitor for
resolution of isolated thrombocytosis & check renal function and
potassium after starting lisinopril.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] at [**Hospital 4415**]
Discharge Diagnosis:
Primary: Hemoptysis, ventilator associated pneumonia, chest pain
Secondary: Bronchiectasis, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
.
You were admitted for coughing up blood. You required a
breathing tube to protect your lungs. The bleeding was
controlled and you did not have any more cough with blood after
the breathing tube was taken out. You were also found to have a
lung infection and received antibiotics. You had some chest
pressure while you were in the hospital; you did NOT have a
heart attack.
.
Please make the following changes to your medications:
- STOP lasix
- STOP dabigatran
.
- INCREASE Toprol XL to 150mg daily by mouth for your heart rate
and blood pressure
- INCREASE aspirin to 325mg daily by mouth for your heart and to
thin your blood
.
- START simvastatin 40mg by mouth daily for your heart
- START lisinopril 5mg by mouth daily for your heart and blood
pressure
- START quetiapine 12.5 mg at night as needed for
anxiety/insomnia
.
Please continue all other medications as prescribed.
.
In 1 week ([**2112-1-5**]) you should get outpatient lab work to check a
CBC and CHEM-7 in to monitor for resolution of your high
platelet count & check your kidney function and potassium after
starting lisinopril.
.
It was a pleasure to meet you and participate in your care.
Followup Instructions:
**Please call your primary care doctor to make an appointment
for 1-2 weeks after you leave rehab.**
.
Name: [**Last Name (LF) **],[**First Name3 (LF) 275**] P
Location: [**Location **] [**Hospital1 2025**]
Address: [**Street Address(2) **], [**Location **],[**Numeric Identifier 66357**]
Phone: [**Telephone/Fax (1) 27258**]
Fax: [**Telephone/Fax (1) 89733**]
Completed by:[**2111-12-29**]
|
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"E934.2",
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"518.81",
"494.0",
"530.81",
"786.39",
"253.6",
"401.9"
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icd9cm
|
[
[
[]
]
] |
[
"88.42",
"88.49",
"99.29",
"96.6",
"33.22",
"96.72",
"38.97",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
16377, 16443
|
9392, 14229
|
319, 393
|
16598, 16598
|
4026, 4026
|
17990, 18383
|
3041, 3045
|
14595, 16354
|
16464, 16577
|
14255, 14570
|
16773, 17208
|
4542, 4818
|
3060, 4007
|
17237, 17967
|
4854, 9369
|
268, 281
|
421, 2207
|
4042, 4526
|
16613, 16749
|
2229, 2888
|
2904, 3025
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,508
| 123,566
|
39763
|
Discharge summary
|
report
|
Admission Date: [**2125-10-10**] Discharge Date: [**2125-12-21**]
Date of Birth: [**2047-4-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Esophageal cancer
Major Surgical or Invasive Procedure:
[**2125-10-10**]
1. [**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy.
2. Buttressing of intrathoracic anastomosis with thymic fat pad.
3. Laparoscopic jejunostomy.
4. Therapeutic bronchoscopy.
5. Esophagogastroduodenoscopy.
History of Present Illness:
Mr. [**Known lastname **] is a 78 year-old male who's recent endoscopic mucosal
resection revealed intramucosal adenocarcinoma that was invading
into the lamina propria and was focally present at the
cauterized margin. He is being admitted for minimal invasive
esophagectomy with Laparoscopic jejunostomy.
Past Medical History:
GERD
Sleep apnea on CPAP
Arthritis
Diverticulosis
Prostate CA s/p surgery [**2116**]
Back pain/surgies x 3 over 25 years
Appendectomy
Cholecystectomy
Social History:
Widower lives alone, Tobacco: quit 40 years ago
Family History:
non-contributory
Physical Exam:
VS: Tc 99.1 , 111/74 ( off pressors since AM), 88, A/c
mode(intubated)
HEENT: PERRL, EOMI, sclerae anicteric, neck supple, MMM, no
ulcers/lesions/thrush . NG tube, small amount of brown
fluid(sunction mode)
CV: Distant S1/S2 , no murmurs,
PULM: Decreased BS BL, rhonchi diffuse
Chest tube right lower hemithorax and incision site. Appears
clean. No d/c
GI: Distended Abd, hypoactive sounds, not rigid. Endoscopy
incision clean. (4)Scrotal edema
EXT: warm and well perfused, 2+ DP pulses palpable bilaterally
LYMPH: no cervical, axillary, or inguinal lymphadenopathy
SKIN: no rashes, no jaundice .
Pertinent Results:
CT chest/abd/pelvis [**2125-11-2**]:
CONCLUSION:
1. Relatively large rim-enhancing collection in the right thorax
wall
adjacent to the thoracotomy site.
2. No clear sign of ongoing leak.
CT Chest [**2125-11-13**]:
IMPRESSION:
1. Stable appearance of periesophageal fluid following stent
placement.
Drains remain within the pleural space, with no interval
increase in
periesophageal fluid. No periesophageal abscess. Adjacent
compressive
atelectasis.
2. Interval near resolution of left pleural effusion.
3. Multifocal atelectasis.
4. Exam not optimized for assessment of tracheomalacia.
5. Colonic diverticulosis without diverticulitis.
CT Chest/Abd/Pelvis [**2125-12-6**]:
1. Slightly decreased intrathoracic fluid collection with
decreased passive
atelectasis.
2. Resolution of extrathoracic fluid collection.
3. No additional source found to explain the patient's spiking
fevers.
4. Endotracheal tube 3.5 cm above the carina. NG tube with the
distal tip in
a subdiaphragmatic position within the stomach. Jejunostomy tube
in the
appropriate place with contrast opacifying bowel distal to the
tip of this
tube.
Pathology [**2125-10-10**]:
1. Lymph node, level 7 (A-B):Fragments of lymph node, no
carcinoma seen.
2. Esophagus and stomach, esophagogastrectomy (C-X):Focal
intramucosal adenocarcinoma, See Synoptic Report.
3. Gastric donut (Y):No carcinoma seen.
4. Esophageal donut (Z):No carcinoma seen.
5. Stomach, gastric fundus (AA):No carcinoma seen.
Echo [**2125-12-7**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Grossly preserved biventricular systolic function.
Mild mitral regurgitation. Limited study.
Brief Hospital Course:
Mr. [**Known lastname **] is a 78 year-old male admitted following successful
[**First Name9 (NamePattern2) 12351**] [**Doctor Last Name **] esophagectomy, Buttressing of intrathoracic
anastomosis with thymic fat pad Laparoscopic jejunostomy,
Therapeutic bronchoscopy, Esophagogastroduodenoscopy. He was
transferred to the SICU intubated and sedated, NGT, right chest
tube, JP drain and Epidural for pain. He was extubated on POD1,
placed on 3L NC and humidified face tent with oxygen saturations
> 90%. His oxygen requirement increased requiring aggressive
pulmonary toilet, nebs, and chest PT. Initially he was
hypovolemic, fluid challenge was given with a good response.
Once his respiratory status improved he transferred to the floor
on [**2125-10-15**]. On POD 6 ([**10-16**]) barium swallow negative for leak
and diet advanced to clears which were well tolerated. On POD 8
([**10-18**]), pt experienced acute R sided CP and RUQ abd pain,
hypoxia, and diaphoresis. CXR demonstrated ptx. DART placed with
bilious drainage, EGD showed necrosis at anastomotic site. Pt
returned to OR for debridement gastric conduit and repair POD 9
([**10-19**]) and admitted to TSICU postoperatively with CTx3, JPx2. Pt
underwent EGD POD 14 ([**10-24**]) with healthy-appearing anastomosis.
On POD 19 ([**10-29**]) pt undersent percutaneous tracheostomy
placement. Pt noted to have persistent JP drainage. On POD 30
([**11-9**]), pt underwent esophageal stenting and NGT was
discontinued. JP output transiently decreased but subsequently
increased after stent placement. On POD 46 ([**11-25**]) pt underwent
EGD which demonstrated good stent position and endoscopically
placed NGT. He continued to have respiratory distress requiring
mechanical ventilation, with tachypnea and agitation with any
withdrawal of sedation. His hospital course remained stable
until [**2125-12-18**], requiring sedation and mechanical ventilation.
On [**2125-12-19**], the family requested no further interventions, and
that he be allowed to pass if he began to worsen. On [**2125-12-21**],
with the family at bedside, his ventilation was turned off, and
he expired at 11:30am.
Medications on Admission:
allopurinol 300 mg daily, amlodipine 10 mg daily, pravastatin,
terazosin 10 mg qhs, omeprazole 40 mg, ranitidine, tamsulosin
0.4 mg qhs, finasteride 5 mg daijly, percocet, aspirin 81 mg
daily, CPAP.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Esophageal cancer.
Discharge Condition:
Expired
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2125-12-21**]
|
[
"510.0",
"518.5",
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"150.1",
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"997.4",
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"519.2",
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"E939.2",
"333.1",
"112.0",
"519.19",
"E878.2",
"041.6",
"041.4",
"117.9",
"682.2",
"V49.86",
"998.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"97.23",
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"31.1",
"44.5",
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] |
icd9pcs
|
[
[
[]
]
] |
6440, 6449
|
4009, 6161
|
300, 554
|
6512, 6522
|
1797, 3986
|
6575, 6611
|
1146, 1164
|
6411, 6417
|
6470, 6491
|
6187, 6388
|
6546, 6552
|
1179, 1778
|
243, 262
|
582, 891
|
913, 1065
|
1081, 1130
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,673
| 192,130
|
51888
|
Discharge summary
|
report
|
Admission Date: [**2158-5-29**] Discharge Date: [**2158-6-6**]
Date of Birth: [**2095-6-3**] Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
hypercarbic resp failure
Major Surgical or Invasive Procedure:
Extubation [**2158-5-30**]
History of Present Illness:
Ms [**Known lastname 10132**] is a 62F h/o myasthenia [**Last Name (un) 2902**] (dx 3 weeks ago, tx at
[**Hospital1 112**]) on cyclosporine and pyridostigmine who presented to OSH w/
chest pain, 2 weeks of calf pain, hypoxia (oxygen sat 82%),
weakness, shortness of breath and ultimately diagnosed with
DVT/PEs. She was found to have a RLE DVT and bilateral PE's with
RLL infarct. She was started on lovenox in addition to coumadin.
The patient did well initially, then on [**5-27**] she became acutely
confused with expressive aphasia, was incontinent and stopped
obeying commands. This was in setting of BP ~92/28. Head CT
negative. MRI inconclusive due to artifact. Echo was negative
for PFO. On the evening of [**5-27**], she developed hypercarbic
respiratory failure (pH 7.1 / pCO2 95), leading to intubation.
She was seen by Neurology at OSH who felt did not feel this was
releated to MG exacerbation and recommended against IVIG. It was
unclear at the time of discharge whether repiratory failure was
related to PE.
The patient had an episode of brief desaturation this morning to
80s ( PaO2 was > 400 on FiO2 100) during which she became more
lethargic, with ?difficulties moving her right arm. This was
felt possibly related to ventilator plugging, atelectasis, PE's
or worsening MG. By report, she was due to have head CT,
however, was transported to [**Hospital1 18**] before this could be
performed. Following this, the family requested transfer to
[**Hospital1 18**] for tertiary care. At the time of transfer, she was on
pressure support ventilation 15/5, Fio2 of 40%, saturating in
high 90s. She was sedated with propofol. Most recent ABG prior
to transfer: 7.33/60/411 on 100%.
She was also briefly on Vanc/Zosyn out of concer for PNA,
however, RLL CXR findings felt secondary to pulm infarct and
sputum culture was non-revealing. She was also treated for a UTI
with most recent negative urine culture.
Past Medical History:
-Pulmonary embolism (see above)
-Myasthenia [**Last Name (un) 2902**] dx [**3-/2158**] on mestinon, cyclosporin
---Ptosis
---Diplopia
-Exophoria
-Meibomitis
-S/P Colonoscopy
-Morbid Obesity
-Hypertension
-Hypothyroidism
-Superficial Thrombophlebitis
-Migraine
-COPD
-Positive PPD: age 15, started on INH given immunosuppressants
for MG
-Asthma
-Poliomyelitis
-Chronic Fatiogue Syndrome
-Osteoarthritis
Social History:
Smoking: Former Smoker ([**2146-1-29**]) 1 ppd, 35 pack-years
Alcohol: Rare
Illicits: None
Family History:
Father: CAD/PVD
Maternal Grandmother: Cancer, Thyroid Disorder
Sister with PE thought [**3-2**] hypercoagulopathy
Per husband no family h/o MG
Physical Exam:
VS: 98.1 69 139/90
General: intubated, arousble to voice
HEENT: MMM, PERRL bilaterally
Neck: supple, JVP difficult to assess
CV: Regular rate and rhythm, 1/6 SEM LUSB/RUSB, soft
holosystolic murmur at apex, ?right carotid bruit vs radiation
of SEM
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation (limited given pt
intubated)
GU: foley
Ext: LLE cold compare to RLE but no cyanosis. 2+ PT bilaterally,
normal capillary refill
Neuro: follows commands, distal upper 4-5/5 strength upper/lower
extremities bilaterally,
Pertinent Results:
[**2158-6-6**] 09:11AM BLOOD WBC-5.2 RBC-4.18* Hgb-12.4 Hct-40.3
MCV-96 MCH-29.7 MCHC-30.9* RDW-12.7 Plt Ct-331
[**2158-6-6**] 09:11AM BLOOD PT-19.5* INR(PT)-1.8*
[**2158-6-6**] 09:11AM BLOOD Glucose-170* UreaN-11 Creat-0.6 Na-145
K-3.5 Cl-102 HCO3-40* AnGap-7*
[**2158-6-2**] 06:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.0
[**2158-6-1**] 03:35AM BLOOD ALT-41* AST-37 LD(LDH)-239 AlkPhos-74
Amylase-41 TotBili-0.4
[**2158-6-1**] 03:35AM BLOOD Cyclspr-77*
[**2158-6-1**] 03:35AM BLOOD TSH-1.1
NONCTRAST HEAD CT [**2158-5-29**] 8:28 PM
Two attempts were made at imaging, however, this examination is
severely
limited by patient motion. There is no evidence of acute
intracranial
hemorrhage, edema, mass, mass effect or large vascular
territorial infarction.
There is relative hypoattenuation of the periventricular white
matter,
denoting chronic microvascular ischemic disease. The [**Doctor Last Name 352**]-white
matter
differentiation appears preserved. The ventricles and sulci are
normal in
size and configuration. No acute fracture is detected. There is
mild mucosal
thickening within the ethmoid, sphenoid, and left maxillary
sinuses (2:9).
Included views of the right maxillary sinus, middle ear
cavities, and mastoid
air cells are clear.
.
CXR [**2158-5-29**] 5:31 PM
Contour of the right diaphragmatic pleural surface suggests
small effusion.
At the periphery of the right lower lung is a small region of
consolidation
which could be infection or infarction. Aside from linear
atelectasis at the
left base left lung is clear. Heart size is top normal. ET tube
is in
standard placement, nasogastric tube passes below the diaphragm
and out of
view and right PIC line ends in the upper SVC.
.
Head CT [**2158-6-1**]: 1. No acute intracranial process, specifically
no intracranial hemorrhage detected within the limitations of
this study.
2. Evidence of chronic microvascular ischemic disease.
.
CXR [**2158-6-1**]:
There is moderate cardiomegaly. Bilateral pleural effusions are
small, larger on the right side. Adjacent bibasilar opacities,
larger on the right side, are likely atelectasis. Right PICC tip
is in the mid SVC. There is no pneumothorax. Superimposed
infection in the right lower lobe cannot be excluded in the
appropriate clinical setting.
x
x
x
x
x
xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx
OSH INFORMATION
Micro:
BC [**5-28**]: NTD
SPUTUM [**2158-5-27**]: NML FLORA (MOD G+ COCCI, RARE G+RODS)
Urine culture [**5-25**]: few contaminents
Urine culture [**5-28**]: no growth
Images:
ECHO [**5-27**]
EF 65%, no WMA, LA size nml, no PFO, trace MR
[**5-27**] cxr
mild pulm vascular congestionn: chf, small bil pleural effusions
and associated bibasilar airspace dz
HEAD CT NON-CON [**5-27**] (eval right hemiparesis)
no acute intracranial process-->f/u mri recommended
HEAD CT [**5-26**]
No acute intracranial process
HEAD MRI [**5-26**]
prominence of supraclinoid right ica flow void: ?supraclinoid
right ica aneurysm-->advise MRA/CTA
[**2158-5-24**] OSH LENI
occlusive thrombus in 2 soleal deep calf muscular veins of right
calf. No thrombophlebitis of veins of peroneal, post tibial
poplitieal, common femoral bilateral LE
EKG: [**5-23**]: NSR, anterior TW flattening, low voltage
Brief Hospital Course:
discharge exam
97.8 144/64 69 91 % 2L
distant BS, no wheezes
trace peripheral edema
aox3, speech fluent
hematuria noted per nursing
Ms [**Known lastname 10132**] is a 62F with h/o myasthenia [**Last Name (un) 2902**], PE/DVT,
hypercarbic respiratory failure, transferred from OSH for
further evaluation and management of respiratory failure.
.
# HYPERCARBIC RESP FAILURE: (requiring mechanical ventilation on
admission)
The patient was intubated at OSH prior to arrival to the MICU
and was in stable condition. She was weaned off the ventilator
on HD2 without complications.
The details surrounding the acute decompensation event that lead
to intubation are unclear. The patient has a chronic respiratory
acidosis which is likely from obesity hypoventilation syndrome.
It is possible that myasthenia [**Last Name (un) 2902**] played a role but her
myasthenia does not otherwise appear to be that severe. The
combination of these factors, as well another acute insult
(pulmonary embolus) may have resulted in acute respiratory
failure. However unclear why PE would have resulted in her
worsening several days after initiating treatment. She was
extubated in the ICU here and her respiratory status improved.
Her baseline oxygen saturation levels are likely in the 88-93%
range. Ambulatory oxygen sat was >88% on 2L NC.
.
# PE/DVT, acute: At the OSH the patient was diagnosed with
occlusive thrombus in 2 soleal deep calf veins and bilateral PE
with RLL infarct. Anticoagulation was started with lovenox and
warfarin with plan for at least 6 months of anticoagulation.
Underlying etiology of hyper-coagulable state at this time is
unclear, but she likely has an inherited hypercoagulable
condition, given her family history. In addition, cyclosporin is
known to increase the risk of thrombosis. We recommend that she
have a screen for inheritable hypercoagulable mutations as an
outpatient because there is a family history of DVT/PE. She
should also have age-appropriate cancer screenings (mammogram,
colonoscopy). She is discharged on weight based dosing of
therapeutic lovenox to bridge her coumadin until it is >2. for 2
consecutive days with a goal INR of [**3-3**]. Her INR on [**6-5**] was
1.7.
- Continue warfarin with lovenox bridge until therapeutic
.
# Myasthenia [**Last Name (un) **]: Diagnosed clinically and serologically in
[**3-/2158**], although she has not had an EMG to confirm the
diagnosis. Her primary MG signs are diplpoia and ptosis which at
this moment she only demonstrates left eye ptosis and no fatigue
on sustained up gaze. Neurology was consulted here. Dose of
cyclosporine was increased. Pyridostigmine was continued. She
should follow-up with her outpatient neurologist: in particular,
whether there could be hypercoagulability related to cyclosporin
and whether EMG is necessary to confirm the diagnosis of MG.
According to the inpatient neurology team, the patient's
history, exam and positive antibody titers are sufficient to
confirm diagnosis. Vital capacity and negative inspiratory
force (NIF) were checked here and were -40mm hg and >900cc. She
should have formal PFTs arranged as an outpatient. Her last
trough cyclosporine level was 71, though below an ideal range of
100-400 the dose is already up from her baseline of 50 [**Hospital1 **] to 75
[**Hospital1 **] and her proximal strength and ptosis are all improved. If
further questions arise please contact her neurology Dr.
[**Last Name (STitle) 65301**].
.
# Nocturnal agitation and confusion suspected metabolic
encephalopathy: overnight on [**5-31**] and [**6-1**], she became agitated
and confused, claiming that her roommate was engaged in
inappropriate behavior and verbally abusing staff. She did not
exhibit this behavior during the daytime, and could not recall
details of the events at night. Per Neurology, this was
unlikely to be related to MG or to cyclosporine/pyridostigmine.
Head CT and infectious work-up were unrevealing. Hypercarbia
was a consideration, and goal oxygen sats were lowered.
Ultimately this may have been sundowning. Her mental status has
completely improved for the past 3 days and her wake/sleep
cycles are improved as seroquel was started as needed in the
evenings for sleep.
.
# Hypertension, benign:
Patient remained well controlled on: (dose reduced given stable
BPs)
- Lisinopril 10 mg PO/NG DAILY
- Atenolol 25 mg PO/NG DAILY
.
# Latent TB: Patient has a history of +PPD and therefore was
started on treatment in [**3-/2158**] prior to starting
immunosuppressive meds for MG.
- continued isoniazid 300 mg PO DAILY and pyridoxine 50 mg PO
DAILY
.
# Hypothyroidism: continued levothyroxine
#Hematuria: developedo n [**6-5**] PM, no gross clots being passed,
painless. UA with 182 RBC, 42 WBC and 10 epi, UTI unlikely.
--recommend outpatient urology eval for cystoscopy to ensure
bladder appears normal
TRANSITIONAL ISSUES:
=======================
- Continue Lovenox to warfarin bridge
- Follow-up with Neurology
- Follow-up with Pulmonary
- Should have outpatient sleep study
- Follow-up with PCP for [**Name9 (PRE) 54974**] cancer screening and
inherited hypercoagulable studies
--urology referral
Medications on Admission:
Home Medications (Per Atrius Records, needs confirmation):
Isoniazid 300 mg Oral Tablet Take 1 tablet daily
Pyridoxine 50 mg Oral Tablet T PO QD
Cyclosporine Modified (NEORAL) 25 mg Oral Capsule 2 [**Hospital1 **]
Pyridostigmine Bromide (MESTINON) 60 mg take one tablet TID
Atenolol 100 mg Oral Tablet 1 tablet daily
Hydrochlorothiazide 25 mg Oral Tablet TAKE ONE TABLET DAILY
Levothyroxine (LEVOXYL) 175 mcg Oral Tablet one po qd
Lisinopril 10 mg Oral Tablet Take 1 tablet daily
VITAMIN D 1,000 UNIT TAB (CHOLECALCIFEROL) 1 tablet daily
CALCIUM-CHOLECALCIFEROL (D3) 500 MG (1,250 MG)-200 UNIT TAB
(CALCIUM CARBONATE/VITAMIN D3) 1 tablet twice daily;
MULTIVITAMIN CAP (MULTIVITAMINS) One capsule daily; available
over the counter
.
MEDICATIONS ON TRANSFER:
Atenolol 25mg dily
calcium vitamin D 1250mg [**Hospital1 **]
cyclosporin neoral 50mg [**Hospital1 **]
Dexmedetomide 400cg
Lisinopril 10mg dialy
Exoxaparin 105mg Q12
INH 300mg daily
Levothyroxine 150mcg daily
MVI daily
nystatin powder topical TID
Pantoprazole 40 IV QD
Propofol 1000mg
Pyridostigmine 60mg TID
Pyridoxine 50mg daily
Warfarin
Zofran PRN
.
Discharge Medications:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. pyridostigmine bromide 60 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours).
6. cyclosporine modified 25 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. enoxaparin 100 mg/mL Syringe Sig: One (1) sc Subcutaneous
Q12H (every 12 hours).
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
11. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
12. multivitamin Tablet Sig: One (1) Tablet PO once a day.
13. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: Two (2)
Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
-Pulmonary embolism and DVT, acute
-Hypercarbic respiratory failure, acute (mechanically
ventillated)
-Myasthenia [**Last Name (un) 2902**]
-Encephalopathy, metabolic, NOS (resolved)
-Hypertension
Hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please continue to take Lovenox and warfarin as prescribed. You
should have your INR (warfarin level) followed. The lovenox can
be discontinued after your INR is >2 for 2 days. INR goal is
[**3-3**]
It is recommended that you follow-up with Neurology and
Pulmonology as an outpatient. Your PCP or pulmonologist can
arrange for a sleep study.
Please discuss cancer screening (including Pap smear, mammogram,
and colonoscopy) with your PCP and testing for inherited
hyercoagulable states
You should also have a referral to urology because of hematuria.
MED CHANGES
decreased dose of atenolol to 25 from 100
decreased hcts to 12.5 from 25
added coumadin and lovenox
increased cyclosporine 50 to 75 [**Hospital1 **]
Followup Instructions:
Please contact patient's PCP at time of discharge from rehab to
arrange close PCP follow up and anticoagulation management
Please refer the patient to a urologist for cystoscopy for
painless hematuria which developed on [**6-5**] which developed on
anticoagulation.
Please refer patient to pulmonologist for baseline PFTs, sleep
study
Please have patient return to her neurologist for management of
her myasthenia [**Last Name (un) 2902**]
Business Address [**Hospital 882**] Hospital
[**Street Address(2) **], [**Apartment Address(1) **]
[**Location (un) 86**], [**Numeric Identifier 7023**]
United States of America
Business Telephone ([**Telephone/Fax (1) 107431**]
if there are any questions re: cyclosporine dosing or myasthenia
please contact him.
|
[
"278.01",
"518.81",
"784.3",
"373.12",
"453.42",
"780.09",
"327.23",
"458.29",
"415.19",
"244.9",
"780.71",
"V15.82",
"599.71",
"715.90",
"374.32",
"795.51",
"401.9",
"401.1",
"348.31",
"346.90",
"493.20",
"293.9",
"788.30",
"368.2",
"358.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
14212, 14332
|
6893, 11752
|
293, 321
|
14582, 14582
|
3637, 6870
|
15476, 16236
|
2826, 2971
|
13210, 14189
|
14353, 14561
|
12076, 12808
|
14732, 15453
|
2986, 3618
|
11773, 12050
|
228, 255
|
349, 2275
|
14597, 14708
|
12833, 13187
|
2297, 2701
|
2717, 2810
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,775
| 111,008
|
46823
|
Discharge summary
|
report
|
Admission Date: [**2155-7-3**] Discharge Date: [**2155-7-8**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right sided weakness
Major Surgical or Invasive Procedure:
Received IV tPA
History of Present Illness:
88 year old right handed man hx of atrial fibrillation (on
coumadin) and hypercholesterolemia, who had acute onset of
expressive aphasia and right sided hemiparesis at 7pm on [**7-3**]. Patient was gardening at home and was last seen normal at
6:30pm. His family found him at 7pm on the ground with right
sided weakness. He was unable to get. Patient was unable to
produce any speech. He was taken to [**Hospital1 18**] and arrived at ED at
7:55pm. Stroke code was called at 7:55pm. Stroke fellow was at
bedside at 8:08pm. His
vitals were BP 136/81, pulse 120, RR 20, and O2 94%. His NIHSS
was 22 (-2 questions, -2 expressive aphasia, -2 dysarthria, -2
right homonymous hemianopsia, -2 gaze deviation to the left, -2
visual and sensory neglect, -2 right lower facial droop, -4
right
arm weakness, -2 right leg weakness, -2 right hemisensory loss,
unable to test coordination on the right side due to weakness.
Patient was agitated during the CT non-contrast. He required
Ativan 1mg for completion of the imaging. CT brain showed no
signs of acute infarct. No bleed or mass. Initial read of CTA
brain showed no
evidence of stenosis or occlusion of intracranial vessels. No
aneurysm seen. CTA neck showed no significant atherosclerosis of
carotids or vertebrals.
Patient was given iv TPA bolus of 6.1mg at 8:58pm. He got an
infusion of 55.3mg iv TPA over one hour. He was transferred to
the Trauma ICU.
Past Medical History:
Angina
NSTEMI
hypercholesterolemia
Atrial fibrillation
PSH:
Cardiac cath and PCI
left knee surgery
Social History:
Lives with his son. Does not smoke or use illegal
drugs
Family History:
non-contributory. No hx of strokes or MI for either parent
Physical Exam:
VS: BP 136/81 P 120 R 20 02 94% RA
Gen: thin
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: irregularly irregular, no murmurs,
Abd: soft, non-distended, non-tender, no mass, positive bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert, follows commands to lift left arm and leg,
sticks out tongue to command, unable to produce speech, patient
is able to moan,
CN: right homonymous hemianopsia, no papilledema in the right
fundus, unable to see the left fundus, pupils equal, round, and
reactive, eyes are deviated to the left and do not cross midline
to the right, right lower facial droop
Motor: flaccid right arm, decreased bulk of all 4 ext., no
tremor
right arm is 0/5 strength, right leg is anti-gravity for
four seconds and then drifts down to the bed
left arm and leg are anti-gravity
Sensory: does not withdraw right arm or leg to noxious
does withdraw left arm and leg to noxious
Reflex: T BR B K A toes
Left 2 2 2 1 1 down
Right 1 1 1 1 1 up
Coord: unable to assess
Gait: unable to assess
Pertinent Results:
[**2155-7-3**] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->=1.035
[**2155-7-3**] 09:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2155-7-3**] 09:30PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0
[**2155-7-3**] 08:10PM GLUCOSE-119* UREA N-36* CREAT-1.3* SODIUM-142
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14
[**2155-7-3**] 08:10PM WBC-5.5 RBC-5.11 HGB-15.0 HCT-46.0 MCV-90
MCH-29.4 MCHC-32.6 RDW-14.0
[**2155-7-3**] 08:10PM NEUTS-59.2 LYMPHS-31.3 MONOS-6.1 EOS-2.7
BASOS-0.7
[**2155-7-3**] 08:10PM PLT COUNT-235
[**2155-7-3**] 08:10PM PT-17.3* PTT-27.8 INR(PT)-1.6*
[**2155-7-4**] 03:06AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-7-6**] 05:30PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2155-7-6**] 11:00PM BLOOD CK-MB-3 cTropnT-<0.01
[**2155-7-8**] 05:40AM BLOOD PT-17.2* PTT-28.3 INR(PT)-1.6*
[**2155-7-8**] 05:40AM BLOOD Glucose-98 UreaN-11 Creat-0.7 Na-141
K-4.1 Cl-108 HCO3-26 AnGap-11
[**2155-7-4**] 03:06AM BLOOD %HbA1c-5.5
[**2155-7-4**] 03:06AM BLOOD Triglyc-70 HDL-35 CHOL/HD-4.6 LDLcalc-113
Blood and urine cultures from [**2155-7-6**]- nothing to date, pending
CT head/CTA head and neck/CT-perfusion [**2155-7-3**]:
IMPRESSION:
1. CT perfusion shows an acute infarction in the distribution of
the distal inferior division of the left MCA vascular territory.
No evidence of acute intracranial hemorrhage on non-contrast CT.
No definite stenosis or occlusion seen in the left MCA on CTA.
2. Atherosclerotic plaques which are partially calcified at the
bifurcation of the ICA causes minimal narrowing without evidence
of stenosis or occlusion.
3. Hypodensity along right lateral temporal lobe may represent
old infarct or old insult.
Repeat CT head [**2155-7-4**]:
IMPRESSION: Increased conspicuity to infarct involving the left
frontal lobe in the distribution of the left MCA. No evidence of
hemorrhagic
transformation and no new significant mass effect.
Transthoracic ECHO [**2155-7-4**]:
The left atrium is markedly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is markedly dilated. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%) The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-22**]+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: No PFO, ASD, or cardiac source of embolism seen.
Normal global and regional biventricular systolic function. Mild
aortic regurgitation. Mild-moderate mitral regurgitation.
Moderate tricuspid regurgitation. Marked biatrial enlargement.
CXR [**2155-7-3**]:
Mild cardiomegaly, peripheral and central pulmonary vascular
engorgement and mild edema all point toward cardiac
decompensation. Pleural effusion, if any, is minimal. There are
no focal findings to suggest pneumonia.
EKG [**2155-7-3**]:
Atrial fibrillation with rapid ventricular response.
Non-specific ST-T wave changes. RSR' pattern in lead V2.
Brief Hospital Course:
After receiving IV tPA, the patient was admitted to the ICU for
further monitoring per protocol post tPA. CT perfusion
eventually showed an acute infarction in the distribution of the
distal inferior division of the left MCA vascular territory.
The patient was monitored on telemetry his his atrial
fibrillation with rapid ventricular response carefully
controlled so as not to drop blood pressure in the acute period.
His evaluation included fasting lipids that revealed an LDL
113; his lipitor was increased to 40 mg daily. A1C was within
normal limits. Transthoracic ECHO showed atrial septal defect,
patent foramen ovale, or source of cardioembolism.
Nevertheless, given the presentation in atrial fibrillation with
rapid ventricular response, it was thought that the most likely
mechanism for the infarct was cardioembolic. Given the tPA
load, the decision was made to resume the patient on warfarin
with aspirin bridging to a therapeutic INR (range 2-3).
Therefore, the aspirin should be stopped once the INR is greater
than 2. The patient passed speech and swallow and was started on
a diet. He was stable for transfer to the floor on [**2155-7-6**].
Physical and occupational therapy saw the patient and
rehabilitation was recommended. On [**7-6**], the patient developed
a transient fever on the floor, but urinalysis and urine/blood
cultures were negative and a chest x-ray was unchanged. He
defervesced and remained clinically stable. His heart rate was
generally well-controlled on a low dose beta-blocker, but was
transiently tachycardic with periods of exertion; the resolved
spontaneously. Over the course of the hospitalization, the
patient remained aphasic with a dense right upper extremity
flaccid paralysis. There was trace weakness in the leg with hip
flexion that seemed to improve. The patient was DNR/DNI during
the hospitalization.
Medications on Admission:
Atenolol 25mg daily
Aspirin 81mg daily
Coumadin 2.5mg daily
Lipitor 10mg qod
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for fever or pain.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): Please
discontinue aspirin when the patient's INR on warfarin is
greater than 2. Tablet, Delayed Release (E.C.)(s)
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Cerebral embolism with infarct
Atrial fibrillation
Discharge Condition:
Stable, has aphasia and flaccid right arm paralysis/plegia and a
perhaps trace weakness on right hip flexion.
Discharge Instructions:
The patient should take medications as prescribed and follow up
with appointments as scheduled. Should the patient experience
any new, worsening or concerning symptoms, including vision
change, confusion, or new weakness, please contact the patient's
neurologist (Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] at [**Telephone/Fax (1) 40554**]) or immediately
take him to the nearest emergency department. The patient is
currently on both warfarin and aspirin. His INR was 1.6 this
morning, and should be checked daily. The aspirin should be
stopped when the INR is greater than 2. His warfarin should be
re-dosed to a target INR of [**2-23**].
Followup Instructions:
Neurologic follow-up:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2155-9-8**] 2:00
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2156-5-28**] 11:15
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
"434.11",
"780.6",
"414.01",
"427.31",
"584.9",
"342.90",
"401.9",
"784.3",
"V45.82",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
9682, 9752
|
6905, 8775
|
283, 300
|
9847, 9959
|
3284, 6882
|
10673, 11176
|
1950, 2010
|
8905, 9659
|
9773, 9826
|
8801, 8880
|
9983, 10650
|
2025, 3265
|
222, 245
|
328, 1738
|
1760, 1860
|
1876, 1934
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,893
| 151,621
|
51914
|
Discharge summary
|
report
|
Admission Date: [**2137-5-15**] Discharge Date: [**2137-5-17**]
Date of Birth: [**2091-6-30**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headaches
Major Surgical or Invasive Procedure:
Suboccipital craniotomy for chiari decompression
History of Present Illness:
45 year old woman who presents to the office today
with complaints of left arm pain. In addition, she has been
experiencing progressive memory loss and visual loss. The
patient
states that for the past 5 years she has been "seeing spots"
with
coughing episodes.
The patient states that for the past 2 months she has
experiences
left hand and arm weakness, numbness, and poor coordination. She
describes her left hand /left arm numbness as "electrical"
pulses.
She has left arm, wrist continuous ache. She states that she
notices difficulty with balance and coordination when
standing still. She begins to sway and her head will shake
slightly. In addition, she reports progressive memory issues
that are daily for the past three years. The patient frequently
forgets names, dates, and tasks that she should complete. She
experiences neck and low back pain periodically.
The patient denies any change in her general health over the
past
year, history of migraine headache. She states that in the past
she has experienced headache but not for the past 4 years since
the time that her antihypertensive medication was initiated.
Past Medical History:
hypertension, hepatitis C, sleep apnea in initial work up.
Social History:
Smokes 1ppd
Family History:
NC
Physical Exam:
Gen: comfortable, NAD.
HEENT: Pupils: 4-3mm bilaterally EOMs: intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-23**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-25**] except left biceps/triceps/grip
4+/5. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
NO Clonus
NO Hoffmans
On Discharge:
L arm subjective weakness and numbness in fingers
otherwise intact
Pertinent Results:
[**4-8**] MRI Head
1. Chiari malformation is visualized with cerebellar tonsils 15
mm below the level of foramen magnum with a syrinx in the upper
cervical spinal cord
extending from C2 inferiorly with the inferior extent not
visualized on the current study but was seen on the previous
outside cervical spine MRI of [**2137-2-1**].
2. CSF flow imaging demonstrates absence of flow posterior and
inferior to
the tonsils and upper cervical spinal cord, but bidirectional
flow is
maintained anteriorly indicating moderate craniocervical CSF
flow obstruction.
2. No evidence of enhancing brain lesions, mass effect, or
hydrocephalus.
[**5-16**] MRI Head
1. Status post suboccipital craniotomy and C1 laminectomy for
Chiari
malformation, with expected postsurgical changes including a
small amount of fluid in the surgical site.
2. No evidence of acute infarction.
3. Stable tonsillar fullness of the foramen magnum and syrinx in
the upper
cervical cord.
Brief Hospital Course:
Pt was admitted to the neurosurgery service and underwent
suboccipital craniotomy for chiari decompression. She tolerated
the procedure well with no complications. She was transferred to
the ICU for further care including SBP control and q1 neuro
checks. Her post op exam remained stable. She was transferred to
the floor in stable condition on POD#1. She was tolerating a PO
diet and was able to get OOB without difficulty. She complained
of headache and she was started on Fioricet with good relief. On
POD 2 she was continued to improve, was ambulatory in teh halls,
and was deemed fit for discharge. Her central line was
discontinued and she was given instructions for followup as well
as prescriptions for all required medications.
Medications on Admission:
HCTZ 25mg qd, clonazepam PRN, ambien 10mg qHS, motrin PRN
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID PRN () as
needed for anxiety.
3. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
4. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-21**]
Tablets PO Q4H (every 4 hours) as needed for headache.
Disp:*90 Tablet(s)* Refills:*0*
6. erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.5 inch
Ophthalmic [**Hospital1 **] (2 times a day) for 5 days: instill 0.5 inches of
ointment into each eye twice a day.
Disp:*1 tube* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Chiari malformation
Discharge Condition:
AOx3. Activity as tolerated. No lifting greater than 10 pounds.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? If you have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-30**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2137-5-17**]
|
[
"348.4",
"401.9",
"300.00",
"305.1",
"327.23",
"070.54",
"375.15"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
5442, 5448
|
3891, 4629
|
318, 369
|
5512, 5578
|
2914, 3868
|
7069, 7697
|
1659, 1663
|
4738, 5419
|
5469, 5491
|
4655, 4715
|
5602, 7046
|
1678, 1807
|
2827, 2895
|
269, 280
|
397, 1531
|
2100, 2813
|
1822, 2084
|
1553, 1614
|
1630, 1643
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,847
| 115,715
|
49116
|
Discharge summary
|
report
|
Admission Date: [**2120-8-12**] Discharge Date: [**2120-8-16**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Pulmonary embolus
Major Surgical or Invasive Procedure:
CT angiogram
History of Present Illness:
[**Age over 90 **]F history of dementia, oriented x1 CRI, multiple recent
admissions, was reportedly hypoxic to 69% on room air during
physical therapy earlier today, and appeared lethargic. she is
not able to provide any helpful history. She is DNR/DNI. recent
admission for anemia, altered mental status, and acute renal
failure. Work-up that admission found that renal insufficiency
improved with IVF and anemia was likely chronic in nature.
.
In ED intial VS: 97.1, 63, 106/80, 20, 95% on NRB.
EKG showed av paced @ 61. continues to be hypoxic here, on room
air it went to 88%, nasal cannula applied only went to 91%,
nonrebreather be applied, with O2 sat 97%. Guaiac-negative.
Discussed in detail with healthcare proxy [**Name (NI) **] [**Name (NI) 103058**] (nephew)
[**Telephone/Fax (1) 103059**] confirmed DNR, DNI, but otherwise would like
treatment including heparin drip.
.
Labs showed WBC 10.6, Hct 29.9 (baseline at discharge), 277.
Electrolyte with creatinine 1.6 (baseline 1.1-1.6 last
admission), trop .22 (baseline normal), D-dimer [**Numeric Identifier **], lactate
1.5. UA with few bact, 2 RBC, 1 WBC, neg leuk/nit.
.
CT showed 1. bilateral PE affecting RUL, RML, RLL, LLL, and to a
lesser extent LUL.
2. straightening to mild bulging of intraventricular septum into
the LV cavity, concerning for early R heart strain.
.
CXR showed low lung volumes but similar to prior with PPM in
place.
Urine and blood cultures sent.
She was started on a heparin drip with bolus of 6100, currently
at 1350 units/hr.
.
Prior to transfer she was placed on ventimask.
VS were 62 109/50 20 97% 12L venti mask
Two 20G IVs were in. OX 1 at baseline.
.
On the floor, the patient is orienged to person. She is sleepy
but arousable.
.
Review of systems:
Unable to obtain.
Past Medical History:
hypertension
hypercholesterolemia
osteoporosis
depression
chronic kidney disease, stage 3
macular degeneration
carpal tunnel syndrome
3rd degree AV block s/p pacemaker
lumbar spinal stenosis and leg pain
syncope
sensorineural hearing loss
skin cancer right leg s/p excision
Social History:
Lives alone in nursing home which was her choice for the past 2
months. Nephew notes that has had decline/dementia for the past
3 months.
Tobacco: Former smoker. Smoked 2 cigarettes/day for a few years,
never was a heavy smoker. EtOH: none. Drugs: none
Family History:
Has no children. Father had cancer (unknown type) in 70s. Mother
had heart disease in 70s. Has sister.
Physical Exam:
Admission physical exam
Vitals: 97.4 62, 108/59, 94%/
General: Sleepy, easily aroused
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge PE:
VS: 96.5 130/70 61 20 98 on 2L
Gen: elderly female sleeping comfortably in bed, NAD
CV: faint heart sounds; RRR, S1, S2
lungs: anterior lung fields clear to ausculation b/l
abdomen: soft, nontender, nondistended, +BS
extremities: pedal edema b/l L>R, warm, well perfused, no LE
edema b/l
hand swollen b/l, L>R, improved from yesterday
Pertinent Results:
Admission labs:
[**2120-8-12**] 02:30PM BLOOD WBC-10.6 RBC-3.47* Hgb-10.0* Hct-29.9*
MCV-86 MCH-28.7 MCHC-33.3 RDW-14.6 Plt Ct-277
[**2120-8-12**] 02:30PM BLOOD Neuts-79.8* Lymphs-14.6* Monos-3.6
Eos-1.7 Baso-0.4
[**2120-8-12**] 02:30PM BLOOD Glucose-95 UreaN-53* Creat-1.6* Na-145
K-4.5 Cl-110* HCO3-22 AnGap-18
[**2120-8-12**] 09:35PM BLOOD ALT-67* AST-42* CK(CPK)-164 AlkPhos-113*
TotBili-0.4
[**2120-8-12**] 02:30PM BLOOD cTropnT-0.22*
[**2120-8-12**] 08:21PM BLOOD cTropnT-0.21*
[**2120-8-12**] 09:35PM BLOOD CK-MB-11* MB Indx-6.7* cTropnT-0.19*
[**2120-8-13**] 04:33AM BLOOD CK-MB-9 cTropnT-0.18*
[**2120-8-14**] 04:35AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.3
[**2120-8-12**] 02:30PM BLOOD D-Dimer-[**Numeric Identifier **]*
[**2120-8-14**] 04:35AM BLOOD TSH-2.4
[**2120-8-14**] 04:35AM BLOOD T4-6.3
Discharge labs:
[**2120-8-16**] 05:15AM BLOOD WBC-7.2 RBC-3.16* Hgb-9.2* Hct-27.1*
MCV-86 MCH-29.0 MCHC-33.8 RDW-16.4* Plt Ct-267
[**2120-8-14**] 04:35AM BLOOD Neuts-76.4* Lymphs-18.1 Monos-3.5 Eos-1.5
Baso-0.5
[**2120-8-16**] 05:15AM BLOOD PT-34.1* PTT-94.9* INR(PT)-3.4*
[**2120-8-16**] 05:15AM BLOOD Glucose-83 UreaN-20 Creat-1.0 Na-143
K-4.0 Cl-110* HCO3-25 AnGap-12
[**2120-8-16**] 05:15AM BLOOD ALT-33 AST-23
[**2120-8-16**] 05:15AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.3
CTA:
FINDINGS: Again, a hypodense nodule in the left lobe of the
thyroid is seen measuring 15 x 13 mm, similar in appearance to
prior study.
The aorta shows no evidence of dissection or intramural
hematoma.
Extensive filling defects are seen within the pulmonary arterial
tree involving both right and left branches and nearly all
pulmonary lobes and segments. There is relative sparing of the
left upper lobe. There is enlargement of the right ventricle
with leftward bowing of the interventricular septum, concerning
for right heart strain.
The lungs are clear aside from mild bibasilar atelectasis. There
is no pleural or pericardial effusion. Calcified atherosclerotic
disease in the coronary arteries bilaterally.
The visualized portion of the upper abdomen appears
unremarkable.
The bones demonstrate degenerative changes in the thoracic spine
but no aggressive-appearing lytic or sclerotic lesions.
IMPRESSION:
1. Massive pulmonary emboli with CT signs of right heart strain.
These
findings were communicated to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 18:45 on
[**2120-8-12**] by [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 11623**] over the phone.
2. Left thyroid nodule - nonemergent ultrasound may be
considered if
clinically indicated.
Brief Hospital Course:
[**Age over 90 **]F with chronic kidney disease, dementia, HTN and recent
admission for rising BUN and reduction in hematocrit admitted
with hypoxia and found to have large bilateral pulmonary emboli
.
#Acute pulmonary embolism: CTA showed massive pulmonary embolus
with evidence of right heart strain. She also had a troponin
leak (peak 0.22), as well as an elevated BNP. In addition, she
was also hypoxic on presentation, and the patient was admitted
to the MICU. She was started on a heparin drip. Her Hct were
monitored and stable. Based on her impaired renal function, she
was not candidate for lovenox and she was transitioned to
coumadin via heparin drip. On transition to the floor, the
patient was satting mid-90s on 2L NC. She was therapeutic on
her coumadin with INR peaking at 3.8 and heparin drip was
discontinued after two days of therapeutic INR. Coumadin was
held when INR > 3 with instructions for her to restart coumadin
when INR <3. She was weaned down on her oxygen to 1-2 L by time
of discharge with instructions to increase nasal cannula if
oxygen levels fall below 92%.
.
# Acute on chronic renal failure: Cr on admission was 1.6. She
improved with IVF last admission. She was given gentle hydration
creatinine improved. On transition to the floor, her creat has
stablized, on discharge it is 1.0.
.
#Anemia: Stable on last admission at which point this was felt
to be anemia of chronic inflammation. During hospitalization,
patient had no signs or symptoms of occult bleed and was guiac
negative. Her HCT remained stable in the high 20s and upon
discharge her Hct was 31.0. Iron studies were consistent with
anemia of chronic inflammation.
.
#Dementia: Patient has dementia at baseline, oriented to person.
Rapidly deteriorating course per family and documentation. She
was continued on home haldol for agitation - QTc noted to be
prolonged at baseline (peaking in the 490s) and rechecked during
stay. Home trazodone was held initially for hypotension. Home
depakote was continued. On transition to the flor, the patient
was continued on her home Haldol regimen, with daily EKGs to
check her QTc.
.
#Hypertension: Home diltiazem was held on admission for SBP in
100s while in the MICU, but after transition to the floor, her
pressures increased that patient was restarted on her Diltiazem,
with pressures stable in the 130s systolic.
.
Transitional Issues:
# goals of care: The patient is DNR/DNI, but issues such as do
not hospitalize and goals of care should be addressed as an
outpatient.
.
#Thyroid nodule: CTA chest showed incidiental left thyroid
nodule. Thyroid function tests were within normal limits. She
should follow-up with an ultrasound as outpatient.
Medications on Admission:
*per nursing home paperwork*
500cc fluids daily
Tylenol 650 mg daily
Bisacodyl 10mg daily prn constipation
Senna 2 tabs daily
Trazodone 50mg QHS
Haldol 0.5mg Qam and Qpm
Haldol 0.5mg [**Hospital1 **] prn agitation
Milk of Magnesia prn
Mutlivitamin with minerals daily
House supplement twice a day
Vitamin D 1000 U daily
Miralax 17 gm daily
Depakote 125mg Qam, 1pm and QHS
Diltiazem 120mg daily
Docusate 100mg [**Hospital1 **]
Ground nectar prethickened liquid diet
Discharge Medications:
1. fluids Sig: 500 cc cc once a day: 500 cc fluids daily.
2. bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO qdayPRN as
needed for constipation.
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO once a day.
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID PRN as
needed for agitation.
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed for constipation.
8. house supplement Sig: One (1) twice a day.
9. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
10. Miralax 17 gram Powder in Packet Sig: One (1) PO once a
day.
11. Depakote 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day: please take qam,
1pm, and qhs.
12. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
13. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
14. ground nectar prethickened liquid diet Sig: as directed
once a day.
15. Coumadin 1 mg Tablet Sig: as directed Tablet PO once a day:
please check your blood levels and take coumadin accordingly.
16. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO once a day.
17. Outpatient Lab Work
Please check INR every other day starting [**2120-8-17**]; if level is
between 2 and 3, please start coumadin at 2mg daily and continue
checking levels every other day until stable with dose
adjustments as needed. [**Month (only) 116**] check INR twice weekly when levels
and dosing more stable
18. Multiple Vitamin-Minerals Tablet Sig: One (1) Tablet PO
once a day.
19. Outpatient Lab Work
Please check CBC on [**2120-8-19**] (patient with history of anemia)
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
primary diagnosis:
pulmonary embolism
secondary diagnosis:
dementia
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 Ms. [**Known lastname 103057**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were hospitalized because your oxygen levels were
low at the nursing home. When you got to the hospital we did
some imaging of your lungs and found a blood clot in your lungs
that was causing your decreased oxygen levels.
We started you on medications that will thin your blood, and
your breathing and oxygenation levels have been improving.
While you are on this medication, it is very important that you
check your blood levels of this medication. For the first week,
please get your blood checked every other day starting tomorrow,
and the doctor at your facility will change your coumadin dose
depending on your blood level. After the first two weeks, you
can start checking your blood levels 2 times per week when your
levels become stable. You will need to be on this medication
for at least six months; the duration of therapy should be
discussed with your doctor.
The CAT scan of your lungs showed an incidental nodule in the
thyroid. Your thyroid function tests were normal. You should
follow up as outpatient regarding further evaluation, including
a thyroid ultrasound.
We made some changes to your medications:
START Coumadin; your dosage and schedule for taking the
medication will depend on the blood level. Hold coumadin until
INR<3; start coumadin at 2mg daily when INR is between 2 and 3
Followup Instructions:
You will be seen by a doctor at your nursing facility
Completed by:[**2120-8-18**]
|
[
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,745
| 151,356
|
5950+55718
|
Discharge summary
|
report+addendum
|
Admission Date: [**2126-8-6**] Discharge Date: [**2126-8-13**]
Date of Birth: [**2081-5-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Polysubstance overdose/suicide attempt
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
45 yo F c hx depression, borderline PD, multiple suicide
attempts in past. [**Name (NI) **] mother recently died and patient has
had decompensation of psychiatric issues. Pt had been admitted
to [**Hospital1 **] 4 for expression of suicidal ideation and discharged
approx. 1 week ago. Pt. then found unresponsive on [**8-6**] with
multiple Rx medication bottles and suicide note nearby. Suspect
overdose on ativan, seroqual, verapamil, inderal, trazadone,
clonidine, levothyroxine combination. Brought to ED, had 1
episode of vomiting enroute with concern for aspiration; she was
intubated for airway protection in the ED. Treated with
activated charcoal and levofloxacin, metronidazole IV for
possible aspiration pneumonia.
.
In MICU, pt required Levaphed and briefly Neosynephrine to
maintain her BP given her ingestion. She was briefly
Dexamethasone awaiting [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim although her BPs recovered
off pressors prior to this being performed. She was extubated on
[**8-7**] and sent to the floor after her mental status had returned
to baseline. She was seen by psych who recommended restarting
her psych meds.
.
On [**8-8**], around 11am, pt began to experience worsening SOB that
initially did not respond to nebulizer treatments. She had an
ABG that showed 7.32/35/175 and she recieved 20mg of prednisone
at 12pm. After several hours of persistant tachypnea, we were
asked to evaluate patient. A repeat ABG was 7.49/26/121 on 50%
face mask with visible respiratory distress, accessory muscle
use with RR in the 30s. Her VS 99.1, BP 172/94, HR 76, o2sat
100% on face mask as above.
Pt was transferred back to the floor after 24hrs in the MICU
where a trial of BIPAP was used in combination with regular
nebulizer treatments of albuterol and ipratropium. The patient
had a 3liter oxygen requirement, mild wheezes and complained of
mild parasternal tenderness worse with deep inspiration.
Past Medical History:
- asthma, intubated 2-3x (? laryngeal component)
- hx of chronic constipation due to laxative abuse
- hx of hypokalemia due to laxative abuse
- hx of kidney stones
- hx of hypothyroid
- hx of psoriasis and fungal superinfection under breasts
- hx depression, PSA, incest survivorship
- history of restrictive eating habits
- multiple psych hospitalizations starting in mid-[**2110**]'s
- one suicide attempt - [**2118**] took OD
- psychiatrist: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 18741**] at MMHC
Social History:
Hx of etoh/cocaine abuse. Currently reports drinking a 40oz of
beer daily, and expressed desire to cut down in an effort to
"clear her head." Denies tobacco use. Moved out of DBT housing
in [**5-21**], currently lives in her own Section 8 apartment and
supports herself with disability payments (depression). Has been
living with mother and caring for her. Will be moving back in
with boyfriend soon. [**Name2 (NI) **] hx of homelessness; sexually abused by
a brother in childhood.
Section 8 apartment. Has been living with mother and caring for
her. Will be moving back in with boyfriend soon. hx homelessness
- 2nd oldest of 9 children, has a twin brother
- was sexually abused by a brother in childhood
- was in school training to become a mental health counselor
Family History:
mother: dementia
Physical Exam:
VS: T97.9 HR60 BP151/72 RR36 o2:99% on BiPAP
VENT: PS 12/5 @ 50%
GEN: Female in mild respiratory distress; diaphoretic, using
accessory muscles to inspire. Able to speak with
HEENT: Anicteric sclera. PERRL.
NECK: No elev JVP
CV: Regular, nml s1,s2. No murmurs
RESP: Wheezing present diffusely, poor air movement throughout.
No crackles or rales.
ABD: Soft, NTND. +BS.
EXT: No edema bilat
NEURO: AAOx3, responsive.
Pertinent Results:
[**2126-8-6**] 12:05AM ASA-NEG ETHANOL-161* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2126-8-6**] 12:20AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
.
ECHOCARDIOGRAM:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial
effusion.
.
CHEST, SINGLE AP FILM [**8-6**]
For CV line placement.
Endotracheal tube is 4 cm above carina. Right subclavian CV line
is in mid SVC. NG tube has tip located in body of stomach. No
pneumothorax. Since the previous film of the same date, there is
a new large area of right perihilar and right basilar opacity
most likely consolidation secondary to aspiration. Findings
discussed by telephone with Dr. [**Last Name (STitle) 23464**].
.
CHEST, AP [**8-8**]
A right subclavian vascular catheter remains in place,
terminating in the lower superior vena cava. Cardiac and
mediastinal contours are stable. Bilateral asymmetrical
perihilar areas of consolidation, right greater than left show
slight interval improvement. Mild interstitial edema and small
amount of intrafissural fluid in the minor fissure are
unchanged.
.
CHEST, AP [**8-9**]
The heart size is normal. The mediastinal contours and position
are unremarkable. The bilateral perihilar interstitial opacities
have been slightly increased representing worsening of
previously demonstrated congestive heart failure. There is some
local improvement of the right lower lobe consolidation
representing most probably aspiration. There is no sizeable
pleural effusion or pneumothorax.
The tip of the right subclavian line is at the level of the
cavoatrial junction.
IMPRESSION:
1. Slight worsening in pulmonary edema.
2. Improvement in the right lower lobe consolidation.
Brief Hospital Course:
SUMMARY IN BRIEF
Suspect overdose on ativan, seroqual, verapamil, inderal,
trazadone, clonidine, levothyroxine combination. Brought to ED,
had 1 episode of vomiting enroute with concern for aspiration;
she was intubated for airway protection in the ED. Tx c
activated charcoal and levafloxacin, metronidazole IV * 1 for
possible aspiration PNA.
.
In MICU, pt's mental status rapidly cleared. Required dopamine
to maintain BP briefly. Started on dexamethasone 4 mg q12
Quickly titrated off and BP recovered to systolic 150s off all
hypertensive meds. Extubated and transferred to floor, however
over the course of 12hrs pt had audible wheezing, elevated RR
depite, Q4nebs and 20mg Prednisone PO. pt was transferred back
to the MICU for an acute asthma exacerbation.
.
Pt was in MICU for 2d tx with BiPAP (1x 2-3 hrs) and frequent
nebs and continued prednisone 60mg daily. She did not require
intubation. Pt was transferred to the floor awaiting psych
transfer once medically stable. She c/o mild wheeze, but no SOB.
Some pleuritic chest pain at midline and at bases. Denies
fevers/chills. No N/V. Pt is currently not contemplating
suicide.
.
1)Respiratory:
Patient was treated for aspiration pneumonia with likely
post-intubation bronchospasm. She required a brief re-admission
to the MICU after being transferred to the floor for audible
wheezeing and signs of respiratory distress. With regular
nebulizer treatments every 2hours, Prednisone, and ipratropium
her respiratory symptoms stabilized. At time of discharge she
was off of prednisone, requiring regular albuterol treatments.
She does not have an O2 requirement at time of dishcarge. Of
note, patient had complete PFT's done and did not reveal pattern
consistent with asthma. At time report mild "heavy" sensation
along length of sternum, worse with deep inhalation. She has a
minimal dry cough. Repeat CXR was consistent with aspiration
PNA. Treatment of levofloxacin and Metronidazole should continue
for another 5 days. Last day of therapy should be [**8-18**].
.
2. Psychiatry -
The patient was followed closely by the psychiatry service
throughout her medical inpatient stay. With 1:1 sitter due to
her history of impulsivity. She currently denies SI but the
patient lacked insight into her psychiatric condition. She is
medically stable for transfer to inpatient psychiatry for
treatment.
.
3. Hypertension:
The patient was admitted on beta blocker and calcium channel
blocker. She was switched to hydrochlorothiazide in the setting
of her reactive airways. She will likely require titration of
her thiazide diuretic in order to achieve goal BP control.
.
4. Anemia:
Pt had labs consistent with iron deficiency, ferritin < 20. She
was started on oral iron replacement. stool guaiac was negative.
Medications on Admission:
Protonix 40mg daily
Lamictal 100mg twice daily
Singulair 10mg daily
Trazodone 150mg qhs
Clonidine 0.2mg qhs
Verapamil SR 120mg daily
Paxil 60mg daily
Synthroid 75mcg daily
Albuterol prn
Flovent 220mcg 4 puffs [**Hospital1 **]
Propanolol SR 80mg daily
Ativan 1mg twice daily
Questran
? Serevent
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. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
9. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
10. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
11. Verapamil 40 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
13. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day) as
needed for 2 puffs.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
15. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
16. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
18. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulizer
Inhalation Q2-3H (every 2-3 hours).
19. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary: multiple drug overdose/suicide attempt
Secondary:
Aspiration Pneumonia
Bronchospasm
Discharge Condition:
Good.
Discharge Instructions:
You had aspiration pneumonia and respiratory problems after a
drug overdose.
You should contact your doctor or call 911 if you experience any
feelings of hurting yourself or others, any difficulty
breathing, worsening of your wheezing that is not improved by
using your inhalers or nebulizers, chest pains, nausea,
vomiting, or any other concerning symptoms.
Followup Instructions:
You will require inpatient psychiatric care for your mental
health needs.
You should be seen by your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e follow up on your pneumonia and other routine medical
care.
Name: [**Known lastname 4020**],[**Known firstname 1873**] Unit No: [**Numeric Identifier 4021**]
Admission Date: [**2126-8-6**] Discharge Date: [**2126-8-13**]
Date of Birth: [**2081-5-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2544**]
Addendum:
Addendum:
Clarification regarding pt's complaint of parasternal
"heavyness." This sensation was sharp to heavy, reproducible to
palpation at the sterno-costal margin. Echocardiogram at time of
admission was unremarkable, no EKG changes. This pain was
thought to be non-cardiac in origin and likely costochondritis
vs. intercostal muscle irritation from increased work of
breathing in the setting of her reactive airways and aspiration
pneumonia.
Brief Hospital Course:
Addendum:
Clarification regarding pt's complaint of parasternal
"heavyness." This sensation was sharp to heavy, reproducible to
palpation at the sterno-costal margin. Echocardiogram at time of
admission was unremarkable, no EKG changes. This pain was
thought to be non-cardiac in origin and likely costochondritis
vs. intercostal muscle irritation from increased work of
breathing in the setting of her reactive airways and aspiration
pneumonia.
Discharge Disposition:
Extended Care
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2545**] MD [**MD Number(2) 2546**]
Completed by:[**2126-8-13**]
|
[
"969.3",
"E950.4",
"969.4",
"296.30",
"972.6",
"518.81",
"972.0",
"584.5",
"276.2",
"309.81",
"507.0",
"V13.01",
"280.9",
"401.9",
"301.83",
"969.0",
"564.00",
"244.9",
"962.7",
"493.92",
"E950.3",
"995.0",
"972.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"38.93",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
13284, 13456
|
12814, 13261
|
352, 377
|
11300, 11308
|
4192, 6369
|
11716, 12791
|
3723, 3742
|
9502, 11125
|
11184, 11279
|
9183, 9479
|
11332, 11693
|
3757, 4173
|
274, 314
|
405, 2357
|
2380, 2919
|
2935, 3707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,478
| 113,744
|
46736
|
Discharge summary
|
report
|
Admission Date: [**2118-2-24**] Discharge Date: [**2118-3-8**]
Date of Birth: [**2062-3-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Decompensated cirrhosis
Major Surgical or Invasive Procedure:
Multiple paracenteses
EGD
History of Present Illness:
Mr. [**Known lastname 99200**] is a pleasant 55 yo man with recently-diagnosed
presumed alcoholic cirrhosis who presents from clinic today with
gross volume overload.
He had not seen a doctor for 10-15 years until about 1 month
prior toadmission, at which time he found a primary care
physician for generalized malaise and fatigue. He was apparently
sent from her office to an OSH for evaluation. During that
admission, he was diagnosed with cirrhosis and what appears to
be acute alcoholic hepatitis, as he was discharged on
prednisone.
He returned to the OSH with abdominal pain and chills. He was
found to be in renal failure, which was thought to be secondary
to a combination of obstruction and contrast-induced
nephropathy, and he was discharged with a Foley catheter after
being started on tamsulosin and finasteride.
He has had loose stools for about 6 months, and he was
apparently started on an empiric course of vancomycin PO for C.
difficile, although D/C summaries from the second
hospitalization showed no evidence of C. diff in his stool. In
addition, he has been on a course of amoxicillin-clavulanic acid
for an unknown indication. He has also been taking levofloxacin
qweek for his chronic Foley catheter.
He presented to liver clinic today, and was admitted for
management of decompensated liver failure.
He reports increasing lower extremity swelling and abdominal
girth since being discharge [**2-11**]. Over the past few days, he also
reports lower back pain that is both positional and worse with
movement. He has been having trouble ambulating because of the
swelling in his legs and his increasing weight. He has not
weighed himself since his last discharge.
He denies fevers, chills, night sweats, cough, nausea, vomiting,
hematemesis, coffee-ground emesis, melena, abdominal pain. He
does report mild abdominal distension. He does report
blood-streaked light-brown stool but he does have a h/o
hemorrhoids.
ROS was otherwise essentially negative.
Past Medical History:
Cirrhosis
Alcoholism
BPH
Social History:
Drank 1.5L of wine per day for 10-15 years; has been abstinent
for about one month now; denies tobacoo or drug use; no h/o
transfusions; no tattoos; no h/o incarceration or homelessness;
no IVDU
Family History:
No h/o liver disease
Physical Exam:
Vitals: T: 96.5 BP: 109/80 P: 115 R: 18 SaO2: 98%
General: Awake, alert, NAD, pleasant, appropriate, cooperative
HEENT: NCAT, PERRL, EOMI, mild scleral icterus, MMM, no lesions
noted in OP
Neck: supple, no significant JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally, bibasilar rales, no wheezes or
ronchi
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: Distended, nontender, + shifting dullness, normoactive
bowel sounds, no masses or organomegaly noted
Extremities: Deep pitting edema to midcalf, with edema evident
to thighs bilaterally
Lymphatics: No cervical, supraclavicular lymphadenopathy noted
Skin: no spider angiomata, no gynecomastia
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact. Normal bulk, strength
and tone throughout. No abnormal movements noted. No deficits to
light touch throughout. No nystagmus, dysarthria, intention or
action tremor. 2+ biceps, triceps, brachioradialis, patellar
reflexes and 2+ ankle jerks bilaterally. Plantar response was
flexor bilaterally.
Pertinent Results:
[**2118-2-24**] 12:40PM URINE RBC-398* WBC-2 BACTERIA-NONE YEAST-MANY
EPI-0
[**2118-2-24**] 12:40PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0
LEUK-TR
[**2118-2-24**] 12:40PM URINE COLOR-LtAmb APPEAR-SlCloudy SP
[**Last Name (un) 155**]-1.018
[**2118-2-24**] 12:40PM PT-17.7* PTT-34.2 INR(PT)-1.7*
[**2118-2-24**] 12:40PM PLT COUNT-107*
[**2118-2-24**] 12:40PM NEUTS-88.8* LYMPHS-6.0* MONOS-5.1 EOS-0.1
BASOS-0.1
[**2118-2-24**] 12:40PM WBC-20.8* RBC-3.90* HGB-13.5* HCT-42.2
MCV-108* MCH-34.4* MCHC-31.9 RDW-14.6
[**2118-2-24**] 12:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG marijuana-NEG
[**2118-2-24**] 12:40PM URINE HOURS-RANDOM
[**2118-2-24**] 12:40PM HCV Ab-NEGATIVE
[**2118-2-24**] 12:40PM ETHANOL-NEG
[**2118-2-24**] 12:40PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE HAV Ab-NEGATIVE
[**2118-2-24**] 12:40PM TSH-2.1
[**2118-2-24**] 12:40PM TOT PROT-5.9* ALBUMIN-3.2* GLOBULIN-2.7
CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.4
[**2118-2-24**] 12:40PM LIPASE-76*
[**2118-2-24**] 12:40PM ALT(SGPT)-441* AST(SGOT)-293* ALK PHOS-267*
AMYLASE-66 TOT BILI-6.2* DIR BILI-3.6* INDIR BIL-2.6
[**2118-2-24**] 12:40PM LIPASE-76*
[**2118-2-24**] 12:40PM ALT(SGPT)-441* AST(SGOT)-293* ALK PHOS-267*
AMYLASE-66 TOT BILI-6.2* DIR BILI-3.6* INDIR BIL-2.6
[**2118-2-24**] 12:40PM estGFR-Using this
[**2118-2-24**] 12:40PM UREA N-45* CREAT-1.8* SODIUM-133
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-19* ANION GAP-17
[**2118-2-24**] 12:40PM GLUCOSE-146*
[**2118-2-24**] 05:51PM ASCITES WBC-51* RBC-51* POLYS-18* LYMPHS-16*
MONOS-46* MESOTHELI-2* MACROPHAG-18*
[**2118-2-24**] 05:51PM ASCITES TOT PROT-0.4 GLUCOSE-181 LD(LDH)-39
ALBUMIN-<1.0
[**2118-2-24**] 06:01PM URINE HOURS-RANDOM UREA N-806 CREAT-66
SODIUM-18
Brief Hospital Course:
55 yo man with newly-diagnosed cirrhosis and BPH who presented
with decompensated cirrhosis and renal failure and subsequent
shock.
.
On presentation, patient was found to be in shock with MRSA
bacteremia. He was started on Vancomycin and his blood pressure
was supported with pressors and steroids. He eventually became
hemodynamically stable and pressors were being weaned off.
However, his overall prognosis was poor with decompensated
cirrhosis and resultant renal failure and pulmonary edema/ARDS.
Patient was also very sedated and even off sedating medications,
had a depressed mental status, likely from hepatic
encephalopathy. Discussions with the family about goals of care
eventually caused the patient to become CMO. All unnecessary
medications were discontinued. The patient passed away on
[**2118-3-8**] with his family at the bedside.
Medications on Admission:
lactulose
Tamsulosin
Finasteride
Prednisone 20 [**Hospital1 **]
Pantoprazole
.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cirrhosis
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"518.81",
"038.11",
"250.00",
"572.8",
"112.84",
"789.5",
"571.2",
"286.6",
"038.9",
"276.51",
"276.4",
"600.01",
"572.4",
"112.0",
"572.2",
"285.9",
"785.52",
"112.2",
"698.9",
"995.92",
"303.91",
"584.9",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.04",
"38.93",
"45.13",
"96.72",
"86.59",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
6659, 6668
|
5651, 6501
|
337, 364
|
6721, 6730
|
3796, 5628
|
6782, 6788
|
2652, 2674
|
6631, 6636
|
6689, 6700
|
6527, 6608
|
6754, 6759
|
2689, 3777
|
274, 299
|
392, 2375
|
2397, 2423
|
2439, 2636
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,398
| 174,040
|
34557
|
Discharge summary
|
report
|
Admission Date: [**2131-10-30**] Discharge Date: [**2131-11-1**]
Date of Birth: [**2078-7-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53 yo male with h/o DMI, HTN, HL, and PAD who presents to the ED
with DKA.
.
On arrival to the ED, vitals were 98.3 170 161/86 16 100% 6L. He
triggered for tachycardia on arrival. He appeared tachypnic with
shallow breathing. He was noted to have a BS >500 when EMS
arrived and received 300cc on route to the hospital. Glc was 602
in the ED. His bicarb was 5 and his gap was 30. He received 10
units of insulin IV and was started on an insulin gtt at 6/hr
and given 6L of IVF. His repeat chem 7 was notable for a bicarb
of 6 and a gap of 23. His glc improved to 381. His white count
was elevated to 20.5 with 83.7% neutrophils. His creatinine was
elevated to 1.9 up from 0.9 in [**Month (only) 1096**] of last yr. His serum
tox screen was negative. His EKG was notable for inferior and
laterally t wave changes that were thought to be rate related.
There was concern for etoh withdrawal and he was given 4mg of IV
ativan for anxiety and a banana bag was hung. His last drink was
last night. He had reported cough and fever at home. His CXR
showed + spine sign. His vbg was pH 7.00 pCO2 21 pO2 96 HCO3 6.
he had 2 18 gauge IVs in place. Vitals prior to transfer were
139/74 HR 174 RR25 99% RA.
.
On arrival to the floor pt reports pain in his bottom. He
reports that his emesis started on Saturday evening. Of note he
had traveled to [**Location (un) 3844**] and had 7-9 beers. He denies any
history of etoh withdrawal and says that he generally drinks 2-3
beers a night. When he arrived home he began to have non bloody
emesis. He reports that he took his insulin as [**Location (un) 2875**]. BS on
Saturday were between 140s-170s and on Sunday were 120s-160s. He
reported having a cough only after starting to vomit and it was
generally unproductive. He has been unable to keep any food down
since Sunday night. He reports his last episode of DKA was overa
yr ago. His BS was 381 on arrival to the floor. It was rechecked
in 1 hr and was 398. Insulin gtt was turned up from 6 to
9units/hr.
Past Medical History:
Diabetes Mellitus, Type 1: diagnosed in [**2126-2-5**].
Hypertension
Hypercholesterolemia
PAD s/p fem-[**Doctor Last Name **] on [**2129-12-13**]
Social History:
Social History:
Firefighter. Lives with wife. Denies IVDU. Smokes [**2-8**] cig/day.
30 yr smoking hx per records. Drinks 2-3 beers most nights.
Admits to drinking up tp 5-6 beers at night at times.
.
Family History:
Family History:
Mom - cancer history on mom's side
+ HX of SCD: Dad - deceased from MI at age 42
Physical Exam:
VS: T97.3 BP122/68 HR161 RR22 98% RA
GEN: fatigued, A & O x3 (thought it was [**2131-11-1**])
HEENT: PERRL, [**Month/Day/Year 3899**], anicteric, very dry mm, no supraclavicular
or cervical lymphadenopathy
RESP: CTA b/l with good air movement throughout
CV: tachycardic, S1 and S2 wnl, no m/r/g
ABD: mild tenderness in the lower abdomen +b/s, soft, no rebound
or guarding
EXT: no c/c/e, radial and dp pulses +2
SKIN: no rashes
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated
Pertinent Results:
Admission labs:
[**2131-10-30**] 01:35AM NEUTS-83.7* LYMPHS-10.4* MONOS-5.1 EOS-0.4
BASOS-0.4
[**2131-10-30**] 01:35AM WBC-20.5*# RBC-4.71# HGB-15.3# HCT-48.7#
MCV-104*# MCH-32.5* MCHC-31.4 RDW-13.6
[**2131-10-30**] 01:35AM CALCIUM-9.3 PHOSPHATE-7.7*# MAGNESIUM-2.4
Brief Hospital Course:
53 yo male with h/o DMI, etoh abuse, PAD, HTN, HL, and smoking
who presents in DKA in the setting of recent alcohol use and ?
of an aspiration pneumonia.
.
#. DKA: s/p 6L of IVF in the ED with gap and bs both improved.
Likely infectious etiology given WBC of 20.5. CXR with + spine
sign. UA negative for infection. He was given Unasyn for
possible aspiration pneumonia. He was initially given NS and
insulin gtt. NS was transition ed to D5 1/2 NS when FSBG <250.
Potassium and phosphate were repleted. Electrolytes were
monitored q4h until anion gap closed. The patient was
transferred to the floor where he was stable with good glucose
control and his electrolytes remained normal. A repeat CXR was
negative for pneumonia and his ABX were discontinued. An attempt
was made to schedule follow up with his PCP and his [**Name9 (PRE) **]
endocrinologist however due to the holiday the appointments
could not be made. He was told to call them the Monday after the
holiday to schedule follow up.
#. Tachycardia: HR 160s on arrival. Pt tolerating it well with
SBP 130/79. EKG showed likely AVRT vs AVNRT. This may have been
secondary to a combination of DKA, severe dehydration,
withdrawal from etoh, and infection. After metoprolol IV, this
resolved. Home beta blocker was restarted. On the floor his HR
remained normal. His home BB was continued.
.
#. EKG changes: Pt with CAD equivalent given h/o DMI. Pt with t
wave inversions in the inferior and lateral leads and ST
depressions in lateral leads. Repeat EKG in ICU still with t
wave inversions but resolution in ST depression. He received 325
mg [**Name9 (PRE) **]. Enzymes were cycled and negative. He was without chest
pain and this was not felt to be ischemic in nature.
.
#. Acute on chronic renal failure: Ace inhibitor was initially
held but with resolution of his [**Last Name (un) **] was restarted..
#. PAD: Home [**Last Name (un) **] was continued
.
#. Etoh abuse: CIWA scale 5mg-10mg po q2hr prn CIWA >10 was
ordered. He did not require this. He was given a banana bag
followed by MVI, folate, thiamine. He was counciled to reduce
his alcohol intake.
Medications on Admission:
-INSULIN GLARGINE [LANTUS] 100 unit/mL Solution - 25 units daily
-INSULIN [NOVOLOG] 100 unit/mL Solution - sliding scale with
meals
-LISINOPRIL 10 mg by mouth daily
-ROSUVASTATIN [CRESTOR] 30 mg by mouth DAILY
-ASPIRIN 81 mg by mouth DAILY
-FERROUS GLUCONATE 325 mg by mouth daily
-MULTIVITAMIN by mouth daily
****Supposed to be on per OMR, but not taking per pharmacy
records-
-METOPROLOL TARTRATE - 25 mg Tablet - one Tablet(s) by mouth
twice
a day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. rosuvastatin 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous once a day: or as directed by Dr.[**Name (NI) 4849**].
6. Novolog 100 unit/mL Solution Sig: Sliding scale Subcutaneous
three times a day: with meals according to sliding scale.
7. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. ferrous gluconate 325 mg (36 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Diabetic ketoacidosis
- Type I diabetes mellitus
- Acute renal failure (resolved)
Secondary:
- Hypertension
- alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] with
complaints of nausea and vomiting. Blood tests showed that you
had very elevated blood sugar and an electrolyte imbalance
consistent with an episode of diabetic ketoacidosis (DKA). You
were admitted to the medical ICU where you received IV fluids
and insulin, and your electrolytes and blood sugar improved. You
were transferred to the medical wards where your electrolytes
returned to [**Location 213**]. You were treated with IV antibiotics for a
possible infection in your lungs, but a chest x-ray taken prior
to your discharge did not show a clear infection, so antibiotics
were stopped.
We have made the following changes to your medication regimen:
- BEGIN TAKING metoprolol tartrate 25 mg by mouth twice daily
- BEGIN TAKING folic acid 1 mg by mouth daily
- BEGIN TAKING thiamine 100 mg by mouth daily
Please take your medications as [**Location 2875**] and follow up with
your doctors as recommended below. Given your type I diabetes,
we recommend that you do not drink alcohol. If you choose to
drink alcohol, you should limit your intake to no more than one
drink per day.
Followup Instructions:
PRIMARY CARE - Dr. [**Last Name (STitle) **]
Phone: [**Telephone/Fax (1) 24796**]
- Please call on the next business day to schedule a follow up
appointment for 1-2 weeks
ENDOCRINOLOGY ([**Last Name (un) **]): Dr.[**Doctor Last Name 4849**]
[**Telephone/Fax (1) 2378**]
- Please call on the next business day to schedule a follow up
appointment for 1-2 weeks
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"276.51",
"443.9",
"305.1",
"585.9",
"272.0",
"403.90",
"584.9",
"272.4",
"V58.67",
"785.0",
"250.13"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7322, 7328
|
3702, 5833
|
308, 314
|
7508, 7508
|
3406, 3406
|
8813, 9297
|
2757, 2839
|
6336, 7299
|
7349, 7487
|
5859, 6313
|
7659, 8790
|
2854, 3387
|
265, 270
|
342, 2335
|
3422, 3679
|
7523, 7635
|
2357, 2505
|
2537, 2725
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,636
| 181,763
|
16009
|
Discharge summary
|
report
|
Admission Date: [**2158-4-17**] Discharge Date: [**2158-4-21**]
Date of Birth: [**2105-9-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Ultram
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath following NSTEMI
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x
3(LIMA-LAD,SVG-diag,SVG-PDA)[**2158-4-17**]
reoperation for bleeding [**2158-4-17**]
History of Present Illness:
Lipitor 80mg daily
Plavix 75mg daily
Lisinopril 2.5mg daily
Lopressor 25mg daily
Nitro SL prn(not taking)
Pantoprazole 40mg daily
Aspirin 325mg daily
Multivitamin daily
Lorazepam prn
Fluticasone 50mcg 2 sprays each nostril daily
Past Medical History:
recent inferolateral STEMI- s/p BMS to LCX in [**2158-2-23**]
Transient Atrial fibrillation(setting of MI) s/p DCCV
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Carpal tunnel syndrome
s/p Right Shoulder/Bicep surgery
s/p Polypectomy
Social History:
Married, works in customer service for Clean Habors.
- Tobacco history: Never
- ETOH: No, previous alcoholism in [**2127**].
- Illicit drugs: No
Family History:
Father had MI at 60. No family history of arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
admission:
Pulse: 68 Resp: 16 O2 sat: 100% RA
B/P Right: 111/75 Left: 107/73
Height: 65 inches Weight: 169 lbs
General: WDWN male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2158-4-21**] 05:05 7.4 2.89* 8.5* 25.3* 88 29.4 33.6 14.4 248
[**2158-4-19**] 04:45 108*1 10 0.8 139 4.1 100 32 11
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 45822**] (Complete)
Done [**2158-4-17**] at 8:08:58 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2105-9-2**]
Age (years): 52 M Hgt (in): 65
BP (mm Hg): 123/67 Wgt (lb): 157
HR (bpm): 67 BSA (m2): 1.79 m2
Indication: Intraoperative TEE for CABG procedure. Chest pain.
Coronary artery disease. Left ventricular function. Mitral valve
disease. Preoperative assessment. Right ventricular function.
ICD-9 Codes: 786.05, 786.51, 424.0
Test Information
Date/Time: [**2158-4-17**] at 08:08 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 45823**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: aw1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.1 cm <= 3.4 cm
Findings
LEFT ATRIUM: Normal LA size.
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: Normal LV wall thickness and cavity size. Normal
LV wall thickness. 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 aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened
aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Mild [1+] TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. 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 aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results on [**2158-4-17**] at 845 am.
Post bypass
Patient is in sinus rhythm and receiving an infusion of
phenylephrine. There is mild hypokinesia of the apical and mid
portions of the anterior septum LVEF=45-50%. RV function is
normal. Aorta is intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2158-4-17**] 11:23
[**Known lastname **],[**Known firstname **] [**Medical Record Number 45824**] M 52 [**2105-9-2**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2158-4-19**] 9:30
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2158-4-19**] 9:30 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 45825**]
Reason: ? ptx/effusions
Final Report
CHEST RADIOGRAPH
INDICATION: CABG, re-operation for bleeding. Chest tubes
removed.
COMPARISON: [**2158-4-17**].
FINDINGS: As compared to the previous radiograph, all monitoring
and support
devices have been removed. There is improved ventilation of the
left lung.
No evidence of pneumothorax. The pre-existing retrocardiac
atelectasis has
decreased. Minimal left pleural effusion that has not increased
since removal
of the chest tube.
No other relevant changes.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: [**Doctor First Name **] [**2158-4-20**] 12:22 PM
Brief Hospital Course:
He was admitted for same day surgery and underwent triple bypass
grafts and weaned from bypass on Neo Synephrine and Propofol.
He awoke neurologically intact and was extubated without
difficulty. He then developed significant chest tube bleeding
and hemodynamics were labile. Coagulaopathy was corrected, and
he received PRBCs. He was returned to the Operating Room where
exploration revealed a bleeder from the mammary bed. This was
controlled, he was stable and returned to the ICU.
He subsequently extubated, remained stable and transferred to
the floor on POD 1. Beta blockers and diuretics were begun, CTs
were able to be removed on POD 2. Physical Therapy worked with
him for mobility and strength evaluation. The remainder of his
postoperative course was essentially uneventful. We discussed
whether he still needed Plavix with Dr. [**Last Name (STitle) 171**] and he does not
need it because he had a bare metal stent six weeks ago. On
POD# 4 he was cleared for discharge to home with VNA. All follow
up appointments were advised and he will see Dr. [**Last Name (STitle) **] on [**5-18**]
@ 1PM.
Medications on Admission:
Lipitor 80mg daily
Lisinopril 2.5mg daily
Lopressor 25mg daily
Nitro SL prn(not taking)
Pantoprazole 40mg daily
Aspirin 325mg daily
Multivitamin daily
Lorazepam prn
Fluticasone 50mcg 2 sprays each nostril daily
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours)
for 5 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **]
Discharge Diagnosis:
coronary artery diseae
s/p coronary artery bypass grafts
hyperlipidemia
gastroesophageal reflux
hypertension
carpal tunnel syndrome
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
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming until cleared by surgeon. Look at your
incisions daily for redness or drainage.
No lotions, cream, powder, or ointments to incisions.
Each morning you should weigh yourself and then in the evening
take your temperature, These should be written down on the chart
.
No driving for approximately one month, until follow up with
surgeon.
No lifting more than 10 pounds for 10 weeks.
Please call with any questions or concerns ([**Telephone/Fax (1) 170**]).
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon:Dr. [**Last Name (STitle) **] on [**5-18**] at 1:30pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 250**]) in [**11-26**] weeks
Cardiologist: Dr. [**Last Name (STitle) **] [**11-26**] 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:[**2158-4-21**]
|
[
"272.4",
"414.01",
"401.9",
"530.81",
"285.1",
"410.22",
"998.11",
"427.31",
"V45.82",
"286.9",
"E878.2",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"99.07",
"39.63",
"36.15",
"34.03",
"99.04",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9332, 9379
|
7002, 8114
|
309, 428
|
9555, 9788
|
1983, 6979
|
10543, 11101
|
1138, 1264
|
8376, 9309
|
9400, 9534
|
8140, 8353
|
9812, 10520
|
1279, 1964
|
233, 271
|
456, 686
|
708, 959
|
975, 1122
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,332
| 144,413
|
30261
|
Discharge summary
|
report
|
Admission Date: [**2159-12-14**] Discharge Date: [**2159-12-21**]
Date of Birth: [**2109-9-16**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
severe headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Reason for Consult: Called by Emergency Department to evaluate
headache
HPI: The pt is a 50 year-old right-handed man who presents with
severe headache. He reports that 4-5 weeks ago he developed a
cold with cough and sinus pressure. Following this he had a
period where he felt like he had fluid in his ears, but was
overall doing somewhat better. On Sunday he was working in his
yard doing some landscaping when he had a sudden onset of pain
shooting from his neck to the top of his head. At the same time
he felt as though his ears suddenly drained and he could hear
much better. He then notes feeling extremely dizzy, with
significant vertigo and nausea. He was able to stagger over to
the steps where he sat down, and then threw up at least twice.
His partner notes that he then seemed very sleepy, and kept
drifting in and out of sleep, though was very easily rousible.
He went to [**Hospital 882**] hospital, where he reports he was given 2
liters of IV fluid, they looked in his ears, gave him an an
antihistamine, and sent him home. The vertigo had resolved by
this point, but the somnolance and headache persisted. He
described the headache at this point as feeling like a bowl of
pressure on top of his head that then build up behind his eyes.
This was made worse by standing and lifting or otherwise
exerting
himself. The pain varied from a [**7-13**] to a [**11-12**], and he notes
he
was taking up to 9 Excedrin/day, with no relief. He also notes
significant pain with eye movements. On Wednesday he notes he
was feeling just slightly better, and tried to take a bath, but
on getting in the tub he developed sudden onset of bilateral arm
and leg numbness, extending from the hips and the shoulders
distally. This lasted ~30 minutes, and self resolved. He went
back to [**Hospital1 882**], where he reports he was given 1L of fluid,
Flonase, and had an EKG. He was then referred to see his PCP
today, who sent him to our ED for further evaluation.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
None
Social History:
Lives in [**Location 2312**] with his partner. [**Name (NI) 1403**] for
[**Company 2475**] studying potential cures for MS. Smokes 1 pack/week.
No
EtOH or illicits.
Family History:
Mother died at 83 following an aspiration after a heart valve
replacement.
Father died at 49 of heart failure following malaria and yellow
fever.
Physical Exam:
Physical Exam:
Vitals: T: 97.7 P: 84 R: 18 BP: 168/94 SaO2: 99% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**4-5**] at 5 minutes. Can name 18
animals in one minute. The pt. had good knowledge of current
events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, slightly increased tone with contralateral
activation. No pronator drift bilaterally. No adventitious
movements, such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor on the right.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Unsteady with tandem. Romberg absent.
====================
.
Exam on discharge:
- unchanged
Pertinent Results:
Admission labs:
[**2159-12-14**] 12:25PM WBC-11.4* RBC-5.97 HGB-17.9 HCT-50.9 MCV-85
MCH-30.0 MCHC-35.1* RDW-12.2
[**2159-12-14**] 12:25PM NEUTS-83.1* LYMPHS-10.1* MONOS-5.8 EOS-0.7
BASOS-0.2
[**2159-12-14**] 12:25PM PLT COUNT-386
[**2159-12-14**] 02:03PM PT-13.3 PTT-22.4 INR(PT)-1.1
[**2159-12-14**] 12:25PM GLUCOSE-88 UREA N-13 CREAT-1.1 SODIUM-137
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-25 ANION GAP-19
[**2159-12-14**] 12:25PM CALCIUM-10.5* PHOSPHATE-4.7* MAGNESIUM-2.0
[**2159-12-14**] 12:25PM ALT(SGPT)-36 AST(SGOT)-26 CK(CPK)-113 ALK
PHOS-69 TOT BILI-0.6
Other pertinent labs:
[**2159-12-14**] 12:25PM cTropnT-<0.01
[**2159-12-14**] 12:25PM CK-MB-1
[**2159-12-14**] 12:25PM ASA-13.6 ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
Pertinent radiology reports:
[**2159-12-14**] CT HEAD W/O CONTRAST
FINDINGS: There is a 1.2 x 6 mm focus of parenchymal hemorrhage
in the head of the left caudate nucleus with intraventricular
extension affecting the bilateral frontal horns and the left
occipital [**Doctor Last Name 534**] of the lateral ventricles as well as the third
and fourth ventricles. There is minimal mass effect as
demonstrated by 2 mm rightward shift of the septum pellucidum.
There is mild dilatation of the temporal [**Doctor Last Name 534**] of the left
lateral ventricle. The remainder of the intraventricular system
and sulci is within normal size. There is no evidence of
territorial infarction. The cisterns are well visualized without
evidence of herniation. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The osseous structures are unremarkable.
IMPRESSION: Intraparenchymal hemorrhage in the left caudate
nucleus head with intraventricular extension into the lateral,
third and fourth ventricles. Minimal mass effect with 2-mm
rightward shift of the septum pellucidum.
[**2159-12-14**] CTA NECK W&W/OC & RECON
FINDINGS: There is a large amount of intraventricular blood in
the frontal
horns of the lateral ventricles and occipital [**Doctor Last Name 534**] of the left
lateral
ventricle. Evidence of intraparenchymal hemorrhage is noted in
the left
caudate nucleus. These findings are consistent with NECT of the
head on
[**2159-12-14**]. The carotid and vertebral arteries and their major
branches are
patent with no evidence of stenosis. The distal cervical
internal carotid
arteries measure 4 mm on the right and 5 mm on the left. There
is no evidence
of aneurysm formation or other vascular abnormality.
IMPRESSION:
1. Large intraventricular bleed involving the frontal horns of
the lateral
ventricles and the occipital [**Doctor Last Name 534**] of the left lateral ventricle.
Intraparenchymal hemorrhage of the left caudate nucleus.
Findings are
consistent with NECT of the head on [**2159-12-14**].
2. No evidence of aneurysm/AVM.
[**2159-12-15**] MR HEAD W & W/O CONTRAST
FINDINGS: Correlation was made with the CTA examination of
[**2159-12-14**].
There is intraventricular hemorrhage identified predominantly in
the left
lateral ventricle and extending to the third and fourth
ventricles. Subtle
blood products are also seen in the posterior interhemispheric
fissure.
On series 3, image 16, there is a small area of hemorrhage
identified in the periventricular region which appears to be
within the region of the caudate nucleus. On post-gadolinium
images, no distinct enhancement is seen in this region. However,
there appears to be a small developmental venous anomaly in the
adjacent area, best visualized on series 3, image 18. There is
no acute infarct seen. There is no hydrocephalus.
IMPRESSION:
1. Intraventricular hemorrhage without hydrocephalus.
2. Probable hemorrhage within the body of the left caudate
nucleus extending to the ventricle. Although no underlying
enhancement is identified, suspected developmental venous
anomaly in the adjacent brain raises the possibility of an
underlying cavernous malformation. Followup is recommended for
further assessment.
U/S Doppler renal
IMPRESSION:
1. Normal renal morphology.
2. Symmetric and normal renal resistive indices and arterial
waveforms.
3. Discrepant maximal systolic renal arterial velocities, 131
cm/sec on the right versus 58 cm/sec on the left. Cannot exclude
renal artery stenosis on the left. Consider MRA if clinically
appropriate.
MRA Kidney:
IMPRESSION:
1. No evidence of renal artery stenosis.
2. Fatty deposition of the liver.
Brief Hospital Course:
Mr. [**Known lastname 72048**] is a 50 year old man with no significant medical
history who presents with a severe headache of 1 week duration,
associated with elevated blood pressures, nausea and vertigo,
who was admitted for probable stroke. On admission his blood
pressure was 170/92. His initial exam was nonfocal, only notable
for slightly increased tone in his right arm with contralateral
activation, an extensor plantar response, and difficulty with
tandem gait. CT head showed a left caudate ICH with extension
into the frontal horns of the lateral ventricles and the
occipital [**Doctor Last Name 534**] of the left lateral ventricle. CTA was
unrevealing. His stroke risk factors were assessed: Total
cholesterol 184, LDL 99, HDL 66, TG 94, HbA1C 5.2.
Over the weekend ([**Date range (1) 45442**]) his blood pressures were
difficult to control, refractory to both lisinopril and
hydralizine. On the morning of [**12-15**] he was briefly transferred
to the SICU for nicardipine gtt. He also complained of a severe
headache, at times [**11-12**], which was responsive to dialudid but
not to oxycodone or acetaminophen. On [**12-16**] he also spiked a
low-grade fever of 100.8 with a leukocytosis of 13.0. CXR showed
no evidence of pneumonia, UA was negative, UCx and BCx pending.
On [**12-17**], his blood pressures continued to spike into the 180's
systolic despite adding amlodipine, metoprolol (IV and PO), and
therefore required labetalol. Given difficulty of blood pressure
control, secondary causes of hypertension were investigated. A
renal ultrasound showed slower flow in left renal artery, but
MRA kidney showed no evidence of renal artery stenosis. Other
causes of secondary hypertension (pheochromocytoma and primary
hyperaldosteronism) were also investigated. Metanephrines, serum
catecholamines, renin/aldosterone are pending. As his blood
pressures remained high, he was transferred to the SICU on [**12-18**]
for nicardine drip. He got a cerebral angiogram which did not
show any evidence of aneurysm, arteriovenous malformation, or
dural AV fistual. In the ICU, his blood pressure was well
controlled (<160 systolic); he was weaned off the nicardine drip
([**12-19**]) and transitioned to PO meds which were uptitrated
(lisinopril increased to 40mg, amlodipine increased to 10mg, and
labetalol increased to 400mg [**Hospital1 **]). As his pressures remained
<160 systolic on his PO meds he was transferred to the floor for
observation, awaiting discharge. As his blood pressures were
elevated on admission and difficult to control it was thought
that he had baseline hypertension which, previously, was not
well-controlled.
His exam remained stable. In order to investigate vascular
causes of hemorrhage, he had a MRI of his vessels which did not
show occlusion or dissection.
He was in good condition upon discharge. His headache were
well-controlled with fioricet; no associated nausea, vomiting,
visual changes. His BP remained in the 120-140 systolic range.
He will be discharged with 3 new BP medications that should be
continued until his BP normalized: Lisinopril 40mg daily,
Labetalol 400mg [**Hospital1 **] and amlodipine 10mg daily.
He was told to stop aspirin as there is a rebleeding risk and no
need for it at this time.
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
================================================================
.
Transitional issues:
.
1. Stroke: likely secondary to hypertension, he will continue 3
medications for BP, to be titrated on follow-up. He will stop
taking aspirin.
2. Headache: likely related to intracranial hemorrhage and will
likely improve after discharge. He was given fioricet to help
control the pain.
3. HTN: likely exacerbated by the intracranial hemorrhage but
unclear baseline BP, possibly quite high. Renal artery stenosis
was ruled out. He should undergo further med titration and
investigation of secondary causes of HTN including thyroid
disease, pheochromocytoma,
Medications on Admission:
- Aspirin 81mg
- Excedrin (up to 9/day)
- MVI
- Coenzyme Q
- Fish oil
- Probiotic
- Garlic
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
6. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left caudate intracranial hemorrhage.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your hospital stay.
You had a stroke on the left side of your brain. Your headache
is a related symptom and should resolve with time.
Your blood pressures were elevated during this admission. This
is likely related to your stroke. We have started blood pressure
medications, which we expect will be weaned as your blood
pressure normalizes. You should follow up with your primary care
physician. [**Name10 (NameIs) **] these medications decrease blood pressure, please
watch out for lightheadedness, especially upon rising from a
supine position.
Please take all your medications as instructed. If you have any
worrisome symptoms please seek medical attention.
Followup Instructions:
You have an appointment with neurologist, Dr. [**Last Name (STitle) **] on
Please call [**Telephone/Fax (1) 5723**] to make an appointment with your
primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 6164**], in [**2-4**] weeks to check
progress of your convalesence and blood pressure. His office is
located at the following address:
[**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
[**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
|
[
"431",
"401.9",
"288.60",
"780.60",
"305.1",
"784.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"88.48"
] |
icd9pcs
|
[
[
[]
]
] |
15275, 15281
|
10533, 13907
|
331, 338
|
15363, 15363
|
6067, 6067
|
16246, 16759
|
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|
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|
15514, 16223
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|
13928, 14489
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276, 293
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366, 3008
|
6035, 6048
|
6084, 6643
|
6665, 10510
|
15378, 15490
|
3030, 3036
|
3052, 3221
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,587
| 100,108
|
30732
|
Discharge summary
|
report
|
Admission Date: [**2143-4-29**] Discharge Date: [**2143-5-12**]
Date of Birth: [**2083-3-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
abd pain, nausea/vomiting
Major Surgical or Invasive Procedure:
Intubation
Placement of central venous catheter
CVVHD
Hemodialysis
History of Present Illness:
60 y/o M w/alcohol abuse, HTN, who presented to [**Hospital3 **]
on Saturday [**4-27**] c/o severe abd pain, n/v. Had started 2 days
prior in setting of binge drinking with whiskey. Pain was
epigastric radiating to his back. He was found to have a lipase
of >3000. and was admitted to their medical service for acute
pancreatitis. He was kept NPO and given IVF. He also was given
Levaquin for "lethargy" and an infiltrate on CXR. The next day,
[**4-28**], his bilirubin increased (0.8-2.6) and he continued to have
severe abd pain, so he was changed from levaquin to primaxin,
and he was trnasferred to their ICU. He was put on a lasix [**Hospital1 **]
due to rales and cardiomegaly, and kept on NS at 100 cc/hr. He
had a CT scan with po and IV contrast that showed acute
pancreatitis with intrahepatic ductal dilatation; multiple
hypodense irregular lesions in the right lobe of the liver,
thickened GB wall with pericholecystic fluid, and a 5x4 cm
hypodense collection in the RLQ adjacent to the psoas muscle.
.
On [**4-29**], he was supposed to go to MRCP but was claustrophobic
and required ativan. After this, he felt better but required
more ativan while in Radiology. [**Name8 (MD) **] RN notes, his heart rate was
"sporadic" from the 40s to the 160s. He was given more ativan
and then his HR dropped to the 20s (bp 145/63 at this time). He
then became diaphoretic, c/o chest pain, and the MRCP was
stopped. He was transferred to the stretcher and then turned
[**Doctor Last Name 352**], "started to seize" and was noted to be pulseless. [**Name8 (MD) **] RN
note, he was asystolic but per d/c summary and cardiology
consult note, it was VT/VF. He received "several" shocks and CPR
as well as one bolus dose of amiodarone. He was intubated during
the code. He regained a pulse after an unknown amt of time. He
became hypotensive requiring dopamine. He was then seen by Renal
due to worsening renal failure (creatinine 0.8 on admission to
3.5 on d/c) who felt this was likely pre-renal failure from
volume depletion plus contrast from the CT. His MRCP was read as
showing small ascites, peripancreatic stranding, pericholecystic
fluid, and a large gallstone. CBD did not appear dilated but the
images were quite limited; no obvious intrahepatic biliary
ductal dilatation or pancreatic ductal dilatation. Complex T2
hyperintesnsity along right psoas muscle as seen by CT measuring
5.2 x3.7 cm, representing a complex fluid collection. He was
transferred here for further management.
Past Medical History:
Alcohol abuse (reportedly binge drinks regularly)
HTN
Hypothyroidism
? pancreatitis
Social History:
Per OSH notes, he "binge drinks all the time" with recurrent
bouts of pancreatitis. Smokes tobacco, amt not documented.
Denied illicit drug use.
Family History:
unknown
Physical Exam:
On admission:
T: 99.4 BP: 87/49 P: 56
AC 500x14 FiO2 0.7 PEEP 5 O2 sat 94%
CVP 13
Gen: intubated, sedated, paralyzed
HEENT: icteric, ETT/OGT in place, pupils constricted
Lungs: CTA anteriorly, no w/r/c
CV: RRR, no m/r/g
Abd: distended, hypoactive but present bowel sounds, not tense
but difficult to assess peritoneal signs as paralyzed
Ext: no edema, feet cold, 1+ dp bilaterally
Pertinent Results:
Pre-admission labs of note:
[**4-29**] at 9 pm: Na 136, K 6.0, Cl 108, Bicarb 18, BUN 56, Creat
3.7
Calcium 6.5, T bili 10.0, AST 359, ALT 168, alk phos 161, CK
282, MB 6.2, MBI 2.1, Troponin T 0.02
WBC 22 with 25% bands, Hct 42, Plt 157, INR 1.3
ABG at 2:30 pm 6.88/83/68
ABG at 6:30 pm 7.14/55/260
Urine cx <1000 colonies/ml
Hepatitis serologies negative
Lipase on [**4-29**] 1541
Triglycerides 52
AFP 2.0
.
EKG: [**2143-4-30**]
Sinus rhythm. Left anterior fascicular block. Non-specific ST-T
wave
abnormalities.
.
Labs:
[**2143-4-30**] 12:27AM BLOOD WBC-16.1* RBC-4.07* Hgb-12.9* Hct-38.7*
MCV-95 MCH-31.6 MCHC-33.3 RDW-14.6 Plt Ct-153
[**2143-4-30**] 12:27AM BLOOD Plt Smr-NORMAL Plt Ct-153
[**2143-4-30**] 12:27AM BLOOD Neuts-69 Bands-16* Lymphs-6* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2143-4-30**] 12:27AM BLOOD PT-13.8* PTT-30.8 INR(PT)-1.2*
[**2143-4-30**] 12:27AM BLOOD Glucose-339* UreaN-58* Creat-4.4* Na-139
K-5.8* Cl-108 HCO3-21* AnGap-16
[**2143-4-30**] 12:27AM BLOOD ALT-134* AST-313* LD(LDH)-1755*
CK(CPK)-559* AlkPhos-142* Amylase-[**2143**]* TotBili-7.6*
[**2143-4-30**] 12:27AM BLOOD Lipase-1032*
[**2143-4-30**] 12:27AM BLOOD CK-MB-9 cTropnT-0.15*, 0.14, 0.13
.
Micro:
See OMR
.
Imaging:
[**2143-4-30**]: Abd u/s -
1. Minimal ascites in right upper and right lower quadrants.
2. Gallstone in the neck of the gallbladder with edema of the
gallbladder wall. This could reflect acute cholecystitis but
also could be a manifestation of changes due to the patient's
known acute pancreatitis.
3. No intrahepatic or extrahepatic biliary dilatation.
4. Patent portal vein.
.
[**2143-5-3**]: Head CT -
Diffuse hypodensity and loss of [**Doctor Last Name 352**]-white differentiation
suggesting global hypoxia and infarction. However, a similar
appearance could be caused by severe acute hepatic or renal
failure.
Subacute left parietal infarction without hemorrhage.
Possible small right parietal subacute infarction.
Brief Hospital Course:
In brief, the patient is a 60 year old man with history of
alcohol abuse, admitted to an OSH with severe acute
pancreatitis/pseudocyst, complicated by cardiac arrest, and ARDS
transferred for further management. The patient was treated in
the [**Hospital1 18**] ICU for approximately two weeks without recovery of
neurologic function. During that time, he was treated for ARDS,
severe pancreatitis, acute renal failure (with CVVHD and then
HD), anemia, and altered mental status. The patient remained
unresponsive after weaning sedation, and the patient's family
agreed that he should be made comfort measures only given that
his severely depressed mental status was due to anoxic brain
injury. This conclusion was established with the aid of
Neurology consultants. At that time, the patient was transferred
out of ICJ to the general medicine floor. He passed away on [**5-12**], [**2142**].
Medications on Admission:
1. Amlodipine 10 mg daily
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Lisinopril 40 mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Anoxic brain injury secondary to cardiac arrest
Necrotizing pancreatitis
Alcohol abuse
Renal failure
Adult respiratory distress syndrome
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2143-5-13**]
|
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icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.93",
"39.95",
"38.95",
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icd9pcs
|
[
[
[]
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] |
6625, 6634
|
5559, 6453
|
293, 361
|
6814, 6824
|
3591, 5536
|
6876, 6910
|
3165, 3174
|
6597, 6602
|
6655, 6793
|
6479, 6574
|
6848, 6853
|
3189, 3189
|
228, 255
|
389, 2879
|
3203, 3572
|
2901, 2987
|
3003, 3149
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,169
| 124,084
|
42373
|
Discharge summary
|
report
|
Admission Date: [**2132-2-3**] Discharge Date: [**2132-2-8**]
Date of Birth: [**2090-1-15**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
42-year-old male with history for esophageal cancer metastatic
to the brain, bilateral adrenals, bone, and peritoneum who was
recently discharged from [**Hospital1 18**] on [**2132-1-26**] following a
suboccipital craniotomy on [**2132-1-18**] (preceded by PEG placement
[**2132-1-11**]) with plans for Cyberkinfe therapy (start on [**2132-2-5**])
prior to induction of chemotherapy. He presents to the ED after
blood-tinged contents were aspirated from this PEG tube by VNA
this AM, in addition to some coffee-ground contents. The
patient reports that he had been doing well since discharge
until last night when he had some increased pain in his back.
As he attempted to reposition himself, he accidentally rolled
onto his G-tube resulting in it being pulled with a significant
amount of force. No bleeding from the site was noted at the
time, and his girlfriend was able to administer medications
through the tube afterwards without difficulty. However, this
morning when the VNA arrived for G-tube care, the contents
aspirated from the tube (during check for residuals) were noted
to be blood-tinged. He was advised to present to the ED for
further evaluation.
.
The patient denies any episodes of emesis or blood in his stools
although of note he reports that he has not had a bowel movement
in 5 days), some nausea but no vomitting. He has been passing
flatus and tolerating his tube feeds. Denies fever or chills.
.
In the ED, inital vitals were 97.4 136 105/55 16 99%. Labs were
notable for: hct 31.9 (34.2 at d/c), WBC 62.7 (40 at d/c), plt
90 (114 at d/c), significant bandemia to 12. Na of 126 (130
prior), K 6.2 repeat at 5.7 (prior 4.7), Cr. 1.7 prior was 1.0,
lactate of 6.4, HCO3 at 18, gap of 19. UA was negative. EKG
was performed without any changes from baseline - sinus tach.
An NG-lavage was performed which returned red coffee-ground
contents with bile. Rectal exam was noted to be guaiac
positive. Neurosurgery (aware), Thoracic Surgery (believe
chronic bleed), GI (no scope) and Oncology were consulted given
concern for upper GI bleed. He was given pantoprazole, zofran,
calcium, dextrose with insulin, Zosyn/Vanco, hydrocortisone
(given history of steroids). He was type and crossed for 2
Units. CXR showed RLL infiltrates. CT abd is without any acute
issues. foley was placed. Access: 3x20G, 4th Liter of fluid.
Vitals: 97.2 125 97/62 20 93% RA.
.
On arrival to the ICU, he is in good spirit with family by his
bedside. [**Hospital Unit Name 153**] was called regarding patient needs to be going to
[**Hospital Ward Name **] for OR related PEG placement.
.
MICU course: he underwent the open peg placement. Overnight,
he recieved 2 L of IVF and was drinking lots of fluid. PEG tube
is draining to gravity without blood. G-tube use needs to be
evaluated by Thoracic surgery, also need clarification on founda
vs. lep. Renal US order was placed but not done. Lytes, TLS,
Lysis labs are placed and pending. Per surgery request, patient
was placed on dexamethasone 2mg [**Hospital1 **], if need steroid, they like
to get [**Last Name (LF) 91764**], [**First Name3 (LF) **] throacics. Antibiotics were
restarted now on vanc/zosyn, need a lvl this AM. G6PD lvl was
added on out of concern if he needs rasburicase. vitals prior
to transfer: 97.7 125 87/56 15 96% 2L.
Past Medical History:
- metastatic esophageal cancer
- R knee arthroplasty ([**2122**])
Social History:
Born and raised in the area. Works as a bus driver for [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. Lives with his girlfriend [**Name (NI) **]. [**Name2 (NI) **] children. Notes that
his HCP is his brother and the alternate is his sister-in-law;
believes he gave documentation to the primary team. + Tobacco
30 pk yrs, quit 6 weeks ago, + ETOH [**1-8**]
times/wk, no IVDA
Family History:
Father - Deceased from an MI in his 80s.
Mother - Deceased of unknown causes in her 60s, unexpected
death.
Brother - testicular cancer
Not aware of any other history of malignancy in his family.
Physical Exam:
Vitals: T: 96.5 BP:104/62 P:120 R: 18 O2: 94% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple, JVP not elevated, + LAD, multiple growth on neck.
Lungs: CTAB, decreased BS on right side, no wheezes, rales,
rhonchi
CV: tachy, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds reduced,
no rebound tenderness or guarding, PEG noted on the left side of
the abd.
GU: foley
Ext: warm, well perfused, 2+ pulses, + edema, + clubbing, no
cyanosis
Pertinent Results:
[**2132-2-5**] 03:18AM BLOOD WBC-67.1* RBC-3.71* Hgb-11.9* Hct-34.9*
MCV-94 MCH-32.0 MCHC-34.0 RDW-15.3 Plt Ct-79*
[**2132-2-5**] 03:18AM BLOOD Neuts-71* Bands-12* Lymphs-0 Monos-3
Eos-6* Baso-0 Atyps-0 Metas-3* Myelos-5*
[**2132-2-5**] 03:18AM BLOOD PT-30.4* PTT-34.4 INR(PT)-2.9*
[**2132-2-5**] 03:18AM BLOOD Glucose-107* UreaN-71* Creat-2.0* Na-133
K-5.6* Cl-104 HCO3-15* AnGap-20
[**2132-2-4**] 11:23PM BLOOD Lactate-3.1*
[**2132-2-3**] CT ABD/PELVIS
1. Displacement of the gastrostomy tube, with the tube button
positioned
between the gastric wall and the rectus musculature. However,
there is no
evidence for gross leak, with all contrast injected through the
tube having reached the stomach, and no associated free air,
free fluid, or abscess formation within the abdomen.
2. Rapid progression of metastatic disease relative to [**1-7**], [**2132**].
There is a new right pulmonary nodule and interstitial
thickening compatible with lymphangitic spread at the right lung
base, along with an associated right pleural effusion. There are
bilateral adrenal lesions which are enlarged, innumerable
peritoneal deposits, and increased adenopathy involving
epicardial, mesenteric, retroperitoneal, iliac and inguinal
lymph nodes. Innumerable cutaneous metastases have also
progressed. Of note, known bone metastases seen on recent FDG
imaging are not apparent on this study.
3. Relative obstruction of the right ureter, as detailed above,
likely
secondary to a distal ureteral metastasis.
Brief Hospital Course:
42 year old male with metastatic esophageal cancer now presents
with concern for upper GI bleed after blood-tinged contents were
aspirated from G-tube, found to be in ARF, hypotensive,
bandemia, elevated lactate, hyponatremia, hyperkalemia, likely
secondary to sepsis with concern for potential adrenal crisis.
He was admitted to the [**Hospital Unit Name 153**] for concern of rapidly worsening
metastatic esophageal cancer leading to multiorgan failure. His
g-tube has been removed and this was replaced by surgery, who
also recommended decreasing PO intake to prevent leaking. He was
started on vanc/zosyn/levaquin for concern of infection of
unknown etiology. A consult with oncology was called and on the
evening of his arrival, discussed his poor prognosis given his
widely metastatic disease. The patient and his family decided
that they would prefer to pursue comfort measures given his
limited time left, and opted for discharge to his brother's home
with hospice.
His antibiotics and all other non-comfort treatments were
stopped. Stress dose steroids were continued until patient could
be discharged home to help maintain blood pressures. Mucositis
was controlled with caphasol and encouraging patient to drink as
needed. Pain was treated with fentanyl patch, dilaudid, and
ativan PRN. Most medications were given under the tongue as he
had an ileus from carcinomatosis and was not absorbing. Most PO
intake was lost through G-tube.
He was discharged to brother's home with hospice.
Medications on Admission:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 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. lithium carbonate 300 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. amiodarone 400 mg Tablet Sig: One (1) Tablet PO twice a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 weeks: Please begin on [**2132-1-24**].
Disp:*42 Tablet(s)* Refills:*0*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Begin on [**2132-2-14**] after completion of 3-week cours of [**Hospital1 **]
scheduling.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. dilaudid 20 mg/mL solution 5-10 mg SL every 2 hours prn pain.
Disp 500 mL, Refill 0
2. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours.
Disp:*10 patch* Refills:*0*
3. Ativan 2 mg/mL Solution Sig: 0.5 - 2 mg Injection q 2 hr as
needed for anxiety.
Disp:*30 mL* Refills:*0*
4. lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for pain.
Disp:*50 ML(s)* Refills:*0*
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
Disp:*60 ML(s)* Refills:*1*
6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q4H (every 4 hours) as needed for n/v.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
7. saliva substitution combo no.2 Solution Sig: Thirty (30)
ML Mucous membrane Q3H (every 3 hours) as needed for dry mouth.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of [**Location (un) 86**] and Greater [**Hospital1 1474**]
Discharge Diagnosis:
Metastatic esophageal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 31385**],
You were admitted to the ICU due to low blood thought to be
related to further spread of your esophageal cancer. You
expressed the wish to remain comfortable and go home with
hospice. Palliative care and hospice teams were called and you
were discharged home with their care.
Followup Instructions:
Please contact your primary care physician or hospice for any
follow-up care.
|
[
"289.84",
"198.7",
"112.0",
"V49.86",
"593.4",
"198.5",
"584.9",
"288.60",
"276.2",
"528.00",
"V66.7",
"338.3",
"276.1",
"V55.1",
"276.52",
"255.41",
"591",
"197.6",
"560.1",
"198.89",
"578.9",
"198.3",
"197.0",
"458.9",
"276.7",
"150.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"97.02"
] |
icd9pcs
|
[
[
[]
]
] |
9805, 9902
|
6451, 7949
|
281, 287
|
9974, 9974
|
4933, 6428
|
10484, 10564
|
4153, 4350
|
8894, 9782
|
9923, 9953
|
7975, 8871
|
10151, 10461
|
4365, 4914
|
233, 243
|
315, 3636
|
9989, 10127
|
3658, 3725
|
3741, 4137
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,523
| 160,029
|
10312
|
Discharge summary
|
report
|
Admission Date: [**2171-10-24**] Discharge Date: [**2171-10-29**]
Date of Birth: [**2110-4-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a patient with a long
history of COPD who was admitted to [**Hospital6 33**] on
[**2171-10-20**], to be treated for a flare. He was complaining of
chest pain at that time and therefore underwent an exercise
tolerance test on [**10-22**] where he was only able to complete two
minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol before he began having 2-[**Street Address(2) 2051**]
depressions and chest pain. On [**10-24**] he underwent a cardiac
catheterization that revealed a 60-70% stenosis of his left
main coronary artery, a 95-98% stenosis of his proximal RCA
and a left circumflex osteal lesion that was reported as
unable to define, but clinically significant. It was
therefore recommended that the patient undergo an elective
CABG and he was transferred to the [**Hospital1 190**] for stat evaluation.
PAST MEDICAL HISTORY: Significant for severe COPD with
multiple hospitalizations, pulmonary artery hypertension,
sleep apnea, hypertension, status post MRSA pneumonia, status
post appendectomy, status post umbilical herniorrhaphy, gout.
MEDICATIONS: On admission include Allopurinol 100 mg q d,
Paxil 20 mg po q d, Singulair 10 mg po q d, Albuterol and
Atrovent inhalers, Prednisone 10 mg q d which was tapered
starting one week before admission.
PHYSICAL EXAMINATION: On admission the patient had a
temperature of 96.8, pulse 61, respirations 18 and a blood
pressure of 143/74. His pupils were equal, round and
reactive to light. His neck was supple, there were no
masses, no bruits or lymphadenopathy. His chest was clear
with expiratory wheezes bilaterally. His heart had a regular
rate and rhythm with no murmurs or rubs. His abdomen was
protuberant, soft, nontender, non distended. There were no
masses or hernias. Genitourinary examination was significant
for a left testicular mass. Extremities were warm and well
perfused with no erythema, full range of motion. Neuro exam,
he is alert and oriented times three, had no motor weakness
or numbness and normal reflexes.
HOSPITAL COURSE: The patient was admitted on [**10-24**]. On [**10-25**]
he underwent an uncomplicated coronary artery bypass grafting
times three with a left internal mammary artery to the left
anterior descending coronary artery, reversed saphenous vein
graft from the aorta to the right posterior descending
coronary artery, reverse saphenous vein graft from the aorta
to the obtuse marginal coronary artery. The patient
tolerated the procedure well and was transferred to the
cardiothoracic Intensive Care Unit intubated and in stable
condition.
On postoperative day #1 a Neo-Synephrine drip was started and
the Nitroglycerin drip was discontinued. The patient spiked
a fever to 101.7. Sputum cultures were sent. He was A-paced
at a rate of 88. Over the course of the day he was weaned
off the ventilator and extubated. He was also weaned off of
all of his drips, his pacer was subsequently turned off and
his Swan Ganz catheter was pulled back to a position to
monitor his central venous pressure. On postoperative day #2
the patient's fever had spiked overnight again to 101.7 and
he was subsequently started on a course of Levofloxacin. The
patient was requiring nebulizer treatments and inhalers to
manage his COPD. As his condition was stable, the patient
was transferred to the floor on postoperative day #2.
On the floor he continued to spike fevers, although his white
count was trending downwards. On postoperative day #3 his
chest tube output had decreased to about 100 cc over the
course of the prior day and it was subsequently removed. He
was seen by the respiratory service which administered his
nebulizers and they felt that he was no longer in need of neb
treatment and he was switched to MDI inhalers on
postoperative day #3. At that time his incentive spirometer
was 1250 sustained. His Lasix was increased to 40 mg po tid,
his Foley and central lines were removed and the patient was
out of bed and ambulating. Chest x-ray the day before had
demonstrated a left lower lobe consolidation with the sputum
cultures growing out hemophilus so it was thought that the
patient was on adequate antibiotic treatment with the
Levaquin. On postoperative day #4 the patient's fever curve
continued to decline and his oxygen saturation continued to
improve. As the patient's pneumonia seemed to be improving
and he was stable from a cardiac standpoint, the patient was
discharged to a rehab facility in good and stable condition
with plans to continue the Levaquin for another 8 days.
DISCHARGE MEDICATIONS: Lopressor 12.5 mg po bid, Lasix 40 mg
po tid, Potassium chloride 20 mg po bid, Aspirin 81 mg po q
d, Levofloxacin 500 mg po q d times 8 days, Percocet 1-2
tablets po q 3-4 hours prn pain, Paxil 20 mg po q d,
Allopurinol 100 mg po q d, Singulair 10 mg po q d, Combivent
inhaler 1-2 puffs inhaled q 4 hours prn, Atrovent inhalers
1-2 puffs q 4 hours prn, Albuterol inhaler 1-2 puffs q 4
hours prn, Albuterol nebulizers one 3 mil unit dose qid prn,
Atrovent nebulizers one 500 mcg vial qid prn, Colace 100 mg
po bid.
Discharge Exam: The patient was afebrile, with heart rate of
78, blood pressure 135/79, respiratory rate 24, oxygen
saturations are 89% on room air, 91% on 2 liters. He was in
no acute distress. Neck was supple. He had slightly
diminished breath sounds bilaterally. His sternum was
stable, clean, dry and intact. Heart had a regular rate and
rhythm. Belly was soft, nontender, non distended.
Extremities were warm and well perfused and his incision was
clean, dry and intact.
The patient was subsequently discharged to rehab in stable
condition with instructions to follow-up with Dr. [**Last Name (STitle) 70**]
in one week and with his primary care physician [**Last Name (NamePattern4) **] [**2-12**] weeks.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post CABG times three.
2. Chronic obstructive pulmonary disease.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2171-10-29**] 12:07
T: [**2171-10-29**] 12:27
JOB#: [**Job Number 21522**]
|
[
"997.3",
"401.9",
"486",
"496",
"780.57",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4749, 5264
|
6005, 6414
|
2226, 4725
|
5281, 5984
|
1492, 2208
|
162, 1018
|
1041, 1469
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,182
| 115,587
|
15936
|
Discharge summary
|
report
|
Admission Date: [**2144-4-15**] Discharge Date: [**2144-4-21**]
Date of Birth: [**2078-8-28**] Sex: M
Service: SURGERY
Allergies:
Cymbalta / Robaxin
Attending:[**Known firstname 1481**]
Chief Complaint:
recurrent stomach cancer
Major Surgical or Invasive Procedure:
Revisional gastrectomy with near total gastrectomy and Roux-en-Y
reconstruction and feeding jejunostomy.
History of Present Illness:
Mr [**Known lastname 45688**] had gastric cancer (adenocarcinoma stage IIIA) resected
in [**2142-7-16**] with adjuvant radiation. Biopsies of the
anastomotic site in [**2143-11-15**] showed recurrent
adenocarcinoma, confirmed by our pathologist. CT and PET scan
were negative. However, there was concern this might be an
extension from the external growth of the tumor inwards given
the circumstance of excellent margins on the original [**2142**]
specimen. He was given several courses of chemotherapy and a PET
scan was again negative. He has been given his options and
wishes to have surgical treatment.
Past Medical History:
PMH: gastric adenocarcinoma, asthma, arthritis
PSH: subtotal gastrectomy [**2142**], two shoulder surgeries and
arthroscopy, open meniscus repair, tonsillectomy
Social History:
The patient does not drink. He smoked one pack of cigarettes per
day for 30 years and quit 2 years ago. He worked in realty but
is presently on disability.
Family History:
There is a history of diabetes and coronary artery disease in
his family.
Physical Exam:
Admission Exam
Gen: AOx3, NAD, pleasant.
HEENT: hair starting to return. Head, eyes, ears, nose, and
throat are normal. The neck is supple, without mass, nodes, or
thyromegaly.
RESP: CTAB, no increased work of breating
CV: RRR, no r/m/g; distal pulses palp
Abd: S/NT/ND; well healed midline incision
Ext: no cyanosis, no clubbing, no edema
Neuro: intact
Pertinent Results:
Admission/Post-operative Labs:
[**2144-4-15**] 06:43PM
WBC-18.9*# RBC-4.08* HGB-12.3* HCT-36.6*
SODIUM-137 POTASSIUM-5.9* CHLORIDE-103 TOTAL CO2-23 UREA N-17
CREAT-1.1 GLUCOSE-117* CALCIUM-8.9 PHOSPHATE-4.6* MAGNESIUM-2.0
PT-12.8 PTT-22.8 INR(PT)-1.1
Surgical Specimen Pathology (see [**2144-4-15**] report for further
details)
1. Extensive recurrent gastric adenocarcinoma present at
proximal gastric resection margin.
2. Distal small intestinal margin free of tumor.
3. Two lymph nodes free of tumor.
Brief Hospital Course:
Mr [**Known lastname 45688**] was admitted to the General Surgical Service for
evaluation and treatment. On [**4-15**] he underwent a revisional
gastrectomy with near total gastrectomy and Roux-en-Y
reconstruction and feeding jejunostomy. (Please see Dr [**Name (NI) 45689**] operative note of [**2144-4-15**] for further details) He was
monitored in the ICU after the operation. He was NPO/IVF with
NGT and dilaudid pca for pain. He was hemodynamically stable. He
has a history of severe delirium on narcotics and after
anesthesia, and he was closely monitored in the ICU until POD2.
He did not have any episodes of delirium and was transferred to
the floor in good condition on POD2
Neuro: He received dilaudid pca with good effect initially and
adequate pain control. He was transitioned to liquid oxycodone
via the Jtube with standing tylenol and intermittent IV
dilaudid. He complained of back pain, which was bothering him
more than his abdominal pain. By the day of discharge, his pain
was well controlled on liquid roxicet.
CV: He remained stable from a cardiovascular standpoint; vital
signs were routinely monitored.
Pulmonary: He remained stable from a pulmonary standpoint; vital
signs were routinely monitored. Good pulmonary toilet, early
ambulation and incentive spirrometry were encouraged throughout
hospitalization. CXR on POD5 was unremarkable.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. His NGT was kept in place until POD2 and then was dc'd.
He started Bariatric stage I diet on POD3, which he tolerated
well. He was slowly increased to Bariatric stage III when
passing flatus. He was then advanced to Bariatric V POD5. Tube
feeds were advanced as tolerated and we began cycling them on
POD5. Patient's intake and output were closely monitored, and IV
fluid was adjusted when necessary. He had a foley for 3 days
post-operatively to monitor urine output. Electrolytes were
routinely followed, and repleted when necessary. He will require
continued J-tube feeds to ensure adequate caloric intake.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. His wound remained
clean, dry, and intact during his hospital course. He had a
brief fever the evening of POD4; UA and CXR were negative and
the fever did not recur.
Endocrine: His blood sugar was monitored throughout his stay;
insulin dosing was adjusted accordingly.
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. He was tolerating a Bariatric V diet,
ambulating, voiding without assistance, and pain was well
controlled. He received some discharge teaching and follow-up
instructions but left prior to our nurse completing the task.
See documented progress note from [**4-21**] for further details.
Medications on Admission:
oxycodone, carisoprodol 350', celebrex 200', gabapentin 600",
buproprion 150", diazepam 2prn, reglan 5"", modafinil 200',
tantoprazole 20, tylenol, Advair, Spiriva
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day): Hold for loose stool.
Disp:*600 mL* Refills:*2*
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: [**2-16**] Inhalation Q6H (every 6 hours) as needed
for wheeze.
3. gabapentin 250 mg/5 mL Solution Sig: Ten (10) mL PO TID (3
times a day): 10mL in AM, 10mL with dinner, 15mL QHS.
Disp:*900 mL* Refills:*2*
4. oxycodone 5 mg/5 mL Solution Sig: [**6-23**] mL PO Q4H (every 4
hours) as needed for pain.
Disp:*150 mL* Refills:*0*
5. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) mL PO
Q6H (every 6 hours) as needed for pain.
Disp:*1000 mL* Refills:*2*
6. omeprazole magnesium 10 mg Susp,Delayed Release for Recon
Sig: Twenty (20) mg PO twice a day.
Disp:*1000 mg* Refills:*2*
7. diazepam 5 mg/5 mL Solution Sig: 2.5 mL PO at bedtime as
needed.
Disp:*100 mL* Refills:*0*
8. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: Two (2) puffs Inhalation once a day.
9. Reglan 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for nausea: CRUSH ALL PILLS.
10. bupropion HCl 75 mg Tablet Sig: Two (2) Tablet PO twice a
day: CRUSH ALL PILLS. DO NOT CRUSH EXTENDED RELEASE PILLS.
Disp:*120 Tablet(s)* Refills:*2*
11. Isosource 1.5 Cal Liquid Sig: Seven [**Age over 90 **]y (720)
cc PO at bedtime: Infuse at 60cc/hour for 12 hours each night.
Disp:*14 bags* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Recurrent gastric adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-23**] 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.
Followup Instructions:
Call Dr[**Name (NI) 1482**] office to schedule an appointment to be seen
in two weeks: [**Telephone/Fax (1) 2981**]
|
[
"715.95",
"721.3",
"V10.04",
"496",
"151.9",
"715.96",
"568.0",
"327.23",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.91",
"46.39",
"43.7",
"96.6",
"54.59"
] |
icd9pcs
|
[
[
[]
]
] |
7109, 7164
|
2414, 5470
|
302, 409
|
7241, 7241
|
1885, 2391
|
9512, 9631
|
1419, 1494
|
5684, 7086
|
7185, 7220
|
5496, 5661
|
7392, 8373
|
8999, 9489
|
1509, 1866
|
8405, 8984
|
238, 264
|
437, 1045
|
7256, 7368
|
1067, 1229
|
1245, 1403
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,168
| 111,806
|
33714
|
Discharge summary
|
report
|
Admission Date: [**2185-1-10**] Discharge Date: [**2185-2-17**]
Date of Birth: [**2118-9-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
L facial swelling/abscess
Major Surgical or Invasive Procedure:
Debridement of necrotizing fascitis
I&D of facial abscesses
Intubation
Tracheostomy
PEG tube placement
Chest tube placement
Pigtail insertion into chest
History of Present Illness:
Ms. [**Known lastname **] is a 66yo female with PMH significant for ETOH
abuse who presents with left facial swelling. History is
obtained from medical chart. She initially presented to [**Hospital1 3325**] this morning with swelling and redness of the left side
of her face and the tissue around both of her eyes. Per son, she
had been complaining of pain of one of her L wisdom tooth and
had seen a dentist 1 month ago. She was apparently scheduled to
have some further work-up. At OSH she underwent a CT head and
neck which were without evidence of orbital cellulitis. There
was also a report of a fall 1 day prior to admission but no
additional information was available. She received Vancomycin
1gm, Zosyn 3.375gm, and Clindamycin 900mg IV. She was then
transferred to [**Hospital1 18**] for further work-up.
.
Initial vitals in the ED were T 99.8 BP 72/46 AR 126 RR 18 O2
sat 86% on 2L NC. Given her hypoxia and trismus on exam, she
underwent an elective fiberoptic intubated by anesthesia. A R
femoral line was placed and she was started on a dopamine and
levophed gtt. She also received Solumedrol 125mg IV. She also
received 5.5L of NS. She underwent repeat imaging and CT neck
showed venous thromboses involving the superior sagittal sinus,
right transverse sinus and right sigmoid sinus. She was then
started on a heparin gtt prior to transfer to the MICU.
Past Medical History:
-ETOH abuse
-H/o PTX
-Borderline HTN (diet controlled-last outpt BP=120/70 per PCP)
-borderline DM (diet controlled, last HbA1C=5.9)
-Rosacea
-High Chol. (~300s)
-s/p hysterectomy
-liver bx
-foot [**Doctor First Name **]
Social History:
Patient lives alone. History of tobacco and alcohol use,
quantity unknown. Unclear about IVDA.
Family History:
NC
Physical Exam:
vitals T 97.8 BP 149/104 AR 101 RR 20
vent settings: AC/0.50/400/5
Gen: Patient sedated, not responsive to commands
HEENT: ETT in place, eyes closed and difficult to open on exam,
increased thick discharge, sclera erythematous
Heart: Sinus tachycardia, no m,r,g
Lungs: Course breath sounds anteriorly
Abdomen: soft, NT/ND, +BS
Extremities: No LE edema, 2+ DP/PT pulses bilaterally; R femoral
line in place; L face with significant edema and erythema,
bilateral periorbital edema
Pertinent Results:
[**2185-1-10**] 10:07PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.035
[**2185-1-10**] 10:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-15 BILIRUBIN-SM UROBILNGN-4* PH-6.5 LEUK-NEG
[**2185-1-10**] 08:30PM GLUCOSE-386* UREA N-16 CREAT-0.4 SODIUM-140
POTASSIUM-2.9* CHLORIDE-108 TOTAL CO2-23 ANION GAP-12
[**2185-1-10**] 08:30PM ALT(SGPT)-13 AST(SGOT)-19 LD(LDH)-221 ALK
PHOS-96 AMYLASE-21 TOT BILI-1.9*
[**2185-1-10**] 08:30PM ALBUMIN-1.8* CALCIUM-7.1* PHOSPHATE-2.8
MAGNESIUM-2.4
[**2185-1-10**] 08:30PM WBC-17.6*# RBC-3.71* HGB-11.3* HCT-34.2*
MCV-92 MCH-30.4 MCHC-33.0 RDW-13.2
[**2185-1-10**] 08:30PM PLT COUNT-132*
[**2185-1-10**] 08:30PM PT-15.8* PTT-150* INR(PT)-1.4*
[**2185-1-10**] 03:31PM LACTATE-2.0
[**2185-1-10**] 03:29PM GLUCOSE-158* UREA N-20 CREAT-0.3* SODIUM-137
POTASSIUM-2.4* CHLORIDE-96 TOTAL CO2-29 ANION GAP-14
[**2185-1-10**] 03:29PM estGFR-Using this
[**2185-1-10**] 03:29PM ALT(SGPT)-12 AST(SGOT)-20 CK(CPK)-23* ALK
PHOS-109 AMYLASE-37 TOT BILI-2.1*
[**2185-1-10**] 03:29PM LIPASE-28
[**2185-1-10**] 03:29PM cTropnT-<0.01
[**2185-1-10**] 03:29PM CK-MB-NotDone
[**2185-1-10**] 03:29PM ALBUMIN-1.9*
[**2185-1-10**] 03:29PM ALBUMIN-1.9*
[**2185-1-10**] 03:29PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2185-1-10**] 03:29PM URINE HOURS-RANDOM
[**2185-1-10**] 03:29PM URINE HOURS-RANDOM
[**2185-1-10**] 03:29PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2185-1-10**] 03:29PM WBC-11.4* RBC-4.17* HGB-12.5 HCT-36.7 MCV-88
MCH-30.1 MCHC-34.2 RDW-13.2
[**2185-1-10**] 03:29PM NEUTS-93.3* BANDS-0 LYMPHS-3.1* MONOS-3.2
EOS-0.1 BASOS-0.2
[**2185-1-10**] 03:29PM URINE RBC-0-2 WBC-0-2 BACTERIA-MANY YEAST-NONE
EPI-0 RENAL EPI-[**1-26**]
[**2185-1-10**] 03:29PM URINE COLOR-Amber APPEAR-SlHazy SP [**Last Name (un) 155**]->1.035
[**2185-1-10**] 03:29PM PT-13.5* PTT-29.8 INR(PT)-1.2*
[**2185-1-10**] 03:29PM PLT SMR-LOW PLT COUNT-113*
[**2185-1-10**] 03:29PM NEUTS-93.3* BANDS-0 LYMPHS-3.1* MONOS-3.2
EOS-0.1 BASOS-0.2
[**2185-1-10**] 03:29PM WBC-11.4* RBC-4.17* HGB-12.5 HCT-36.7 MCV-88
MCH-30.1 MCHC-34.2 RDW-13.2
[**2185-1-10**] 03:29PM URINE GR HOLD-HOLD
[**2185-1-10**] 03:29PM URINE HOURS-RANDOM
[**2185-1-10**] 03:29PM URINE HOURS-RANDOM
[**2185-1-10**] 03:29PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
Ms. [**Known lastname **] is a 66 year old female with PMH EtOH, borderline
diabetes who presents in septic shock in the setting of a facial
abcess/necrotizing faciitis.
.
# Odontogenic infection/facial abcess/necrotizing
faciitis/septic shock: Patient presented to OSH with increased
edema and erythema of her face and tissue surrounding her eye
suggestive of an underlying infection. She underwent a CT neck
here which confirmed the presence of a large, deep abcess
involving the muscles of mastication. Patient underwent
surgical abscess drainage on [**1-11**] by ENT and found to have
necrotizing faciitis with extensive debridement performed.
Cultures from the wound are demonstrating likely polymicrobial
infection. Blood cultures initially drawn at the OSH prior to
transfer were preliminarily growing actinomyces, with plans to
transfer those cultures to [**Hospital1 18**] lab for further evaluation.
Ultimately, the only positive culture data was for Bacteroides
sp and Peptostreptococcus in the blood from the OSH. Extensive
further culturing was unrevealing.
.
The source of infection was felt to be her wisdom teeth on her
left side, given the CT scan findings. Therefore oral surgery
was consulted and proceeded to bring patient to the OR for teeth
removal, and continued to follow along during her hospital
course. The patient developed a new left mandibular and
bilateral pre-septal abscesses several weeks after the initial
debridement. OMFS took the patient back to the OR for I/D of the
left mandibular abscess and further tooth extraction.
.
Given the extent of the infection and involvement of orbital
area, opthalmology was following along throughout hospital
course. Although the infection involved the pre-septal area, it
did not extend into the orbit/globe of eye, and intraocular
pressures remained normal. She developed bilateral pre-septal
abscesses and she had bedside I/D of these lesions with
improvement. She had a persistent fluid collection behind the
eye on the right side that was monitored by imaging, but not
aggressively intervened on given the extent of the procedure she
would require and the low likelihood that it was clinically
significant.
.
Infectious disease also followed along during hospital course
given extent of infection. The patient was maintained on
vancomycin, zosyn, and clindamycin initially, until an MRI scan
to evaluation for dural thromboses (see below) demonstrated
meningeal enhancement, therefore the zosyn was changed to
meropenem for better CNS coverage. She developed an extensive
drug rash, likely from meropenem, and she was changed to
levofloxacin, vancomycin and flagyl at ID recommendation.
Ultimately, clindamycin was re-added after the patient developed
recurrent abscesses (as above), without recurrence of her rash.
She was ultimately weaned down to PO levo and clinda for a 6
week course since last debridment, last day will be [**2-24**].
Plastics was consulted for wound closure and was going to take
the patient to OR for wound flap, however she developed a new R
hemiparesis (see below) and neurology did not want patient to be
taken off anticoagulation for the procedure given risk of new
infarcts. She will need to follow up with plastics one week
following discharge. Her wound was dressed with xeroform
dressing tid to prevent scalp dessication. She will also need to
follow up with ENT 2 weeks following discharge.
.
As stated above, the patient presented in septic shock, with
hypotension initially requiring dual pressor therapy. She was
given numerous IVF boluses to maintain her urine output and CVP
of [**7-3**], and had pressors slowly weaned off. During this
period, the patient responded well to blood transfusions,
therefore, her hematocrit goal was 25. Once her hemodynamics
stabilized, her transfusion threshold was lowered to 21.
.
# Dural venous thromboses/septic thrombophlebitis: Patient was
found to have venous thromboses involving the superior sagittal
sinus, right transverse sinus, and right sigmoid sinus on head
CT. Neurology was consulted and recommended initiating the
patient on heparin drip, and obtaining an MRV for further
evaluation, which confirmed thrombosis of posterior superior
sagital sinus, torcula, right transverse sinus, sigmoid/upper
internal jugular veins bilaterally. It also demonstrated
meningeal enhancement concerning for meningitis (see above). The
patient remained on heparin drip with monitoring from neurology.
Following the MRV, an ultrasound of her internal jugular veins
and subclavian veins showed that these were patent. She
underwent angiography, and was found to have nonocclusive
thrombi, thus was kept on heparin. She was briefly transitioned
to Lovenox, but when her abscesses recurred and her need for
procedures restarted, she was kept on heparin only. Prior to
scalp wound closure by plastics, as above, the patient was
evaluated by neurology and she was found to have a new right
sided hemiparesis. An MRI/V/A of the patient's head was
performed. The stroke service reviewed the imaging and saw
persistent venous thrombosis and concern venous infarct on the
left. Prior to discharge her heparin gtt was stopped and she was
transitioned to coumadin/lovenox bridge with goal INR of [**12-26**].
.
# Respiratory failure: Patient was noted to be hypoxic on
initial presentation to [**Hospital1 18**] ED. Also found to have significant
trismus on exam. Underlying facial edema likely contributing to
hypoxia. She underwent a fiberoptic intubation in the ED via her
nose. She initially was maintained on steady minimal ventilator
support without attempt to wean given frequent OR visits for
debridement/ENT procedures as above. On [**1-15**] she was noted to
have LUL airway collapse, at which time sputum culture
demonstrated pan-sensitive Klebsiella. This was felt to be a
colonizer versus an infection, as she was on antibiotics that
covered this organism and her respiratory status stayed stable
with just clearing of secretions allowing for opening of the
atalectasis of her LUL. On [**1-17**] she had placement of
tracheostomy and PEG tube. She was intermittently on the
ventilator in relation to procedures and dressing changes. On
[**2-3**] the patient underwent CT scan to evaluate for a loculated
effusion for persistent low grade fevers. This study
demonstrated a hydropneumothorax and a fluid-filled left lung
bleb. She underwent chest tube placement with resolution of the
hydropneumothorax which drained serosanguinous fluid with a HCT
of <2, but exudate. She also underwent pig-tail catheter
placement into the bleb space which drained thick serosanguinous
fluid with a HCT of 3, also exudate. The patient's chest tube
was pulled on the day prior to discharge as it no longer had
drainage. At the time of discharge the patient was no longer
requiring ventilatory support, though continued to require
frequent suctioning.
.
# Thrombocytopenia: Patient was noted to have decreasing
platelets on 1st week after admission, initially concerning for
DIC or HIT. DIC labs were sent and were negative. HIT Antibody
was sent, and returned negative. Her thrombocytopenia resolved
spontaneously.
.
# History of borderline Diabetes: Per the patient's PCP, [**Name10 (NameIs) **]
last HgA1c was 5.9%. Her blood sugars were initially quite
elevated in the setting of acute infection, requiring placement
on insulin drip. Once blood sugars stabilized, she was
transitioned to insulin sliding scale.
.
# History of EtOH: Per patient's son, she has a history of
active drinking, but unknown quantities. She was maintained on
thiamine and folate, did not require CIWA scale as was intubated
and sedated (with versed initially) during what would have been
her withdrawl period.
.
# FEN: Patient was initially on tube feeds via NGT, then
converted to tube feed via PEG tube after this was placed on
[**1-17**].
.
# Prophylaxis: Patient anti-coagulated with heparin gtt, PPI,
bowel regimen.
.
# Code: Full
Medications on Admission:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Necrotizing fascitis of face
Septic thrombophlebitis
L hydropneumothorax
Discharge Condition:
The patient's respiratory status is stable with her tracheotomy.
She is able to get out of bed with assistance.
Discharge Instructions:
The patient should take all medications as prescribed.
The patient should make all appointments as indicated below.
The patient's PCP should be [**Name (NI) 653**] or the patient should
return to the Emergency room if she develops:
--fever or chills
--shortness of breath
--chest pain
--red, painful, or warm skin at her surgery sites
--weakness or loss of sensation
--confusion
--any other symptom that concerns the patient or her health care
providers
Followup Instructions:
Please follow up with ENT surgeon Dr. [**First Name (STitle) **] on [**3-7**] at
10am. His office is located in [**Location (un) 55**], [**Location (un) **].
Please call [**Telephone/Fax (1) 2349**].
.
Please follow up with Infectious Disease, Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2185-3-21**] 10:30am.
.
Please follow up with Neurologist Dr. [**Last Name (STitle) **] on [**3-22**] at
4pm. His office is located on the [**Location (un) **] of the [**Hospital Ward Name 23**]
building. Please call [**Telephone/Fax (1) 657**] prior to your appointment to
update your registration information.
The patient should follow up with the out-patient plastic
surgery department within 1 week from discharge. The phone
number is [**Telephone/Fax (1) 4652**].
The patient should follow-up with the out-patient ophthalmology
department at [**Telephone/Fax (1) 78009**] within 1 week from discharge.
The patient should follow-up with the out-patient interventional
pulmonology department at [**Telephone/Fax (1) 3020**] within 1 week from
discharge.
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,742
| 169,464
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51069
|
Discharge summary
|
report
|
Admission Date: [**2101-11-25**] Discharge Date: [**2101-12-7**]
Date of Birth: [**2039-5-25**] Sex: F
Service: MEDICINE
Allergies:
Iron Dextran Complex / Heparin (Porcine) / Ibuprofen /
Gadolinium-Containing Agents / Morphine / Vancomycin
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Encephalopathy
Major Surgical or Invasive Procedure:
Intubation [**2101-11-25**]
Lumbar Puncture x2
History of Present Illness:
Ms. [**Known lastname **] is a 62F with multiple medical problems, most
significantly IgA nephropathy status post renal transplant with
subsequent graft failure and graft removal [**7-7**], now back on
hemodialysis
(Tu, [**Last Name (un) **], Sat), Hypertension, primary hyperparathyroidism s/p
resection who
presented to the [**Hospital1 18**] ED with confusion in the context of
hypertension. Of note, she has had two similar episodes earlier
this year. On presentation, the patient was confused an unable
to give a cohesive story, so the history was taken from the
patient's husband and the online medical record.
According to her husband the patient had dialysis the day prior
to admission without any problems. The morning of presentation
the patient awoke in her usual state of health. The husband was
unclear but it seemed as though she may have missed her morning
doses of medications. Around 2pm the patient began to become
increasingly agitated and confused, stating "I want to go home"
even though she was at home. The husband gave her some labetalol
and tylenol without improvement. Multiple efforts were made at
redirecting her but without success and she was brought to the
ED for further evaluation.
In the ED initial vitals were as follows: T 98.2 HR 83 BP
222/144 RR 22 O2sat 98%RA. She was found to be combative. She
was placed on a nitroprusside drip and given haldol and ativan
for agitation. They were unable to obtain a head CT due to
agitation so the patient was intubated and sedated with propofol
and a head CT was performed; the preliminary [**Location (un) 1131**] was
negative for bleed. Chest XR with mild pulmonary edema, EKG
with LVH, NSR at 73, no evidence of ACS.
Pertinent recent medical history course as per [**Location (un) **]:
From [**Date range (1) 77609**], she was admitted to the surgical service for pain
over transplant site. Initially given antibiotics (Vanc/Cipro)
for line infection and UTI, renal US showed signs of graft
rejection, was hypertensive (up to SBP 220s) treated with
labetalol and valsartan. She was asymptomatic from the elevated
BPs and underwent transplant nephrectomy on [**7-13**] without
complications.
From [**Date range (1) 106065**], she was admitted for Hypertensive urgency (BP
222/107) with no chest pain, EKG unchanged, cardiac enzymes
negative, and clear CXR. BP was 178/82 status post 10 mg IV
hydralazine x 3.
She had a mild headache, confusion, agitation, and decreased
muscle strength in upper left extremity (CT of head, MRI head,
MRA of head and neck were negative). After getting home dose
meds (which consisted of valsartan, amlodipine, and labetolol)
her BP came down to 167/78. Labetalol was titrated up from
600mg [**Hospital1 **] to 800mg [**Hospital1 **]. Additional incidental finding of
lymphocytosis was noted at the time.
From [**Date range (1) 106066**], she was initially admitted for febrile to 103
with associated diarrhea and cough. Initially covered with
pip/tazo and linezolid for a possible HAP, later held as not
evidence of infection. She had presistent Diarrhea with C. Diff
negative,
had 500 cc BRBPR with continued passing of clots. (NOTE: [**5-7**]
EGD and colonscopy showed internal hemorrhoids and
diverticulosis of the entire colon.) She had active LGIB w/
diverticular disease of entire colon. GI was unable to scope due
to bleed. IR was unsuccessful at selective catheterization of
the right colic artery. She recieved a total of 6 units of
PRBC. she had right colectomy ([**8-23**]) for lower GI bleed, had
side-to-side functional end-to-end ileal colostomy. She had a
relative uneventful postoperative course except for some
confusion probably related to elevated serum calcium (addressed
by nephrology) and incisional cellulitis (discharged on Keflex).
[**9-1**] - [**9-7**], for altered MS s/p HD, relatively lethargic and
confused. She was otherwise hemodynamically stable and also
found to have a blood glucose(BG) of 27. She was given 3 units
of insulin for sugar of 160. Patient is not a diabetic.
[**Date range (1) 106072**] the patient was admitted with a similar picture of
confusion in the setting of hypertension. She had normal
serum/urine tox, B12, RPR, ca. LP findings were within normal
range and HSV negative. Patient refused MRI and EEG which were
recommended by primary team and neurology. It was determined
that her confusion was likely due to a combination of poor
nutrition (improved with Thiamine), hypertension, hypoglycemia,
and possibly hypothryoidism.
Past Medical History:
# IgA nephropathy
-S/p failed renal transplant of living unrelated kidney [**10-30**]
with recent transplant nephrectomy
-Now on HD Tu/Th/Sat
# Asthma
# Hypertension
-With prior hospitalizations for confusion/agitation in the past
in the setting of severe HTN. MRI and CT done at the time
negative, resolved with home BP meds.
# Gastroesophageal reflux disease
# Hypercholesterolemia
# Coronary artery disease
-catheterization [**2087**] with 70% D1, 60% D2, echocardiogram [**2097**]
WNL
# Mild pulmonary hypertension
# Primary hyperparathyroidism s/p parathyroidectomy, has had
hypercalcemia in the past
# History of abnormal [**Last Name (un) 104**] stim test and previously on
hydrocortisone but no longer felt to be adrenally insufficient
per endocrine (see [**Last Name (un) **] note, [**Doctor Last Name **],[**Doctor Last Name **], [**2101-9-21**])
# Diverticulosis- s/p severe LGIB with colectomy [**6-/2101**]
# History of a highly resistant abdominal wound infection with
carbepenamase producing klebsiella.
# Hypothyroidism
# pre-eclampsia in her last pregnancy
# h/o ectopic pregnancy
# hypoglycemia of unclear etiology
.
PAST SURGICAL HISTORY:
# Status post appendectomy
# Status post Cesarean section
# Status post right colectomy [**2101-7-12**] secondary to severe GIB
# Status post renal transplant graft nephrectomy [**2101-7-12**]
Social History:
Patient lives with her husband, children and grandchildren. She
is a former smoker, but has not used tobacco since she was a
teenager. She denies alcohol and illegal substance use. Per [**Month/Day/Year **]
notes, the patient has a history of rape by a family member who
is now deceased ([**2101-10-4**] [**Month/Day/Year **] note).
Family History:
Mother died in her 70s of stroke. Sister with hypertension. No
history of cancer or DM in the family.
Physical Exam:
On Admission to MICU:
GEN: Intubated
HEENT: NCAT. PERRLA, no scleral jaundice. Moist mucous
membranes. Neck is supple with no meningismus
CARDIAC: Regular rhythm, normal rate, [**2-4**] sm. 2+ radial, and DP
pulses.
LUNG: Clear, no rales/wheezes
ABDOMEN: Soft, non-distended. NABS. 4 cm well-healed midline
scar below umbilicus.
EXTREMITIES: No edema, no erythema at HD line. + kernig's sign.
NEURO: Sedated, intubated, face symmetric, pupils equal and
reactive.
On transfer to floor:
Vitals: T: 97.3 BP: 146/61 P: 72 R: 20 O2: 99% on RA
GEN: AAOx3, looks in pain
HEENT: EOMI, anicteral sclera, MMM
CARDIAC: RRR, 2/6 systolic murmur
LUNG: CTAB, no rales, rhonchi or wheezes
ABDOMEN: Soft, non-distended. NABS. 4 cm well-healed midline
scar below umbilicus.
BACK: TTP in lumbar area
EXTREMITIES: no edema, no erythema at HD line
NEURO: pt not cooperative
Pertinent Results:
ADMISSION LABS:
[**2101-11-24**]
WBC 5.3 / Hct 36.6 / Plt 301
Na 138 / K 4.5 / Cl 100 / CO2 24 / BUN 20 / Cr 5.3 / BG 56
ALT 6 / AST 17 / CK(CPK) 22 / AlkPhos 153 / TotBili-0.5
Lipase 11
Serum Tox negative
[**2101-11-29**] TSH 9
[**2101-12-2**] PTH 162
DISCHARGE LABS:
WBC 5.3 / Hct 40.1 / Plt 287
Na 138 / K 4.2 / CL 105 / CO2 23 / BUN 13 / Cr 4.4 / BG 83
Alb 2.5 / Ca [**01**].3 / Mg 1.8 / Phos 3.7
MICROBIOLOGY:
[**11-24**], 27, 28 /09 Blood Cx negative
[**2101-11-26**] Sputum Culture - Moraxella Catarrhalis, Coag positive
staph
[**2101-11-26**] Stool Cx - C.diff positive
[**2101-11-26**] CSF Cx - negative
[**2101-11-30**] Crypto Ag negative
[**2101-11-30**] CSF Cx - negative
STUDIES:
CT HEAD W/O CONTRAST [**2101-11-24**]
No acute intracranial hemorrhage.
CHEST (PORTABLE AP) [**2101-11-24**]
Pulmonary edema. Recommend repeat radiograph to ensure
resolution after
treatment.
EEG [**2101-11-29**]
IMPRESSION: This is a severely abnormal extended routine EEG
which
shows a resolving electrographic status epilepticus before and
after the
administration of I.V. Ativan. The excessive beta activity
described in
the second portion of the study is likely secondary to the
benzodiazepine.
MR HEAD W/O CONTRAST [**2101-11-30**] 4:51 PM
1. Tiny foci of decreased diffusion in the left hemisphere,
involving the
left insular cortex, left temporal lobe and left
temporal/parietal lobe,
concerning for tiny foci of acute infarct with the distrubtion
concerning forembolic disease.
2. Otherwise, stable appearance of the brain, with FLAIR
hyperintensities in a nonspecific distribution, but likely
representing the sequela of chronic microangiopathy given the
patient's age.
Brief Hospital Course:
62 year old woman with End-Stage Renal Disease, hypertension,
seizure disorder, who presented with altered mental status and
was admitted to the ICU with encephalopathy in the context of
HTN. A brief description of her course according to problem is
listed below:
1. Delirium
Patient presented with altered mental status in the context of
HTN, which was similar to multiple prior presentations. Patient
was intubated for altered mental status in the ED to help
protect airway. Head CT was negative for acute intracranial
event. She was agitated while intubated and was given multiple
doses of haldol and ativan in the emergency room. Exam was
normal with exception of + Kernig's sign. She was transferred
to the MICU while intubated overnight, and an LP was done which
showed 14 WBCs in the fourth tube with no other signs of
infection. The patient was extubated without difficulty and
transferred to the floor.
After the floor, she was again noted to have worsening altered
mental status with decreased responsiveness. Within less than
48 hours, she no longer opened her eyes to sternal rub, and she
was noted to have drooling from her mouth, but an ABG showed
good oxygenation and ventilation. A twenty-minute EEG was done
which showed that she was in nonconvulsive status epilepticus.
Neurology was consulted, and she was immediately given 4mg of
intravenous ativan, after which EEG showed significantly
decreased epileptiform activity. She was immediately given two
more doses of 2mg ativan intravenously and was kept on a video
EEG event monitor overnight. She was also loaded with Dilantin
and started on Dilantin treatment for a couple of days. The
patient's mental status significantly improved overnight; she
slowly became more responsive and more alert and was oriented
x3. Though she was oriented, she was slow in speech and slow to
respond verbally to questions and had an almost child-like
affect with responses; her mental status continued to improve
further over the next couple of days.
There was concern that a meningitis may have triggered the
nonconvulsive status epilepticus, particularly because the
patient had been complaining of a headache at home prior to
presentation to the ED. Per Neurology recommendations, she was
started empirically on acyclovir for possible HSV meningitis in
addition to ceftriaxone and ampicillin for possible bacterial
meningitis; of note, the patient has a listed allergy to
vancomycin. A second LP was done which showed a WBC of 8 in the
fourth tube. The gram stain and culture for the CSF for both
LPs were negative, and HSV PCR was negative, so the acyclovir
was stopped. Ampicillin and Ceftriaxone were discontinued after
another day. It is possible, but unlikely, that the patient's
epileptiform activity was triggered by aseptic meningitis.
MRI showed tiny foci of decreased diffusion in the left
hemisphere, which could signify acute infarct, but the Neurology
team believed the effect on imaging was secondary to the patient
having spent over 24 hours in status epilepticus and not
necessarily representing an infarct.
The patient did have multiple episodes of agitation during
hospitalization. Haldol and other antipsychotics were avoided
for agitation because they have the potential to decrease the
seizure threshold. The patient responded well to small doses of
lorazepam.
2. Pneumonia/Respiratory distress:
Patient was intubated on presentation due to altered mental
status and concern for inability to protect airway. CXR was
suggestive of PNA, and she had spiked a fever to 101.1F, so she
was started on Vanc/Cefepime/Acyclovir/Ampicillin to cover HAP
and meningitis. Her acyclovir was stopped when first LP did not
reveal infection. After her sputum culture grew Moraxella
Catarrhalis and pan-sensitive Staph Aureus, the patient was
switched to Levofloxacin. On the floor, after patient was noted
to be in nonconvulsive status epilepticus, the levofloxacin was
discontinued because it can lower the seizure threshold. The
patient was afebrile for the remainder of her hospitalization
with no shortness of breath or cough.
3. Seizure Disorder:
After transfer to the floor, the patient was found by EEG to be
nonconvulsive status epilepticus for over 24 hours. She was
loaded on Dilantin, then transitioned to Keppra. A Keppra level
was drawn on the day of discharge, three days after starting it,
and will be followed up in [**Hospital 878**] clinic. She should follow
up closely with Neurology as an outpatient to ensure she is on
the proper antiepileptic regimen.
4. End-Stage Renal Disease:
Patient was followed by the Nephrology team and continued on
Hemodialysis on her Tuesday/Thursday/Saturday schedule. She was
continued on her home doses of sevelamer, cinacalcet,
nephrocaps. After improvement of her mental status, her diet was
not restricted for the remainder of this hospitalization in
order to ensure that she received enough nutrition; this diet
was approved by her primary nephologist in the setting of stable
electrolytes. Upon discharge, the patient should return to a
renal diet.
5. Malignant Hypertension:
Patient was on nitroprusside drip in the ED. She was started on
a labetalol drip given toxic metabolites of nitropruside in the
MICU. The labetalol drip was weaned, and the patient was
restarted on her home blood pressure medications, including
labetolol 600mg TID, diovan 160mg [**Hospital1 **] (normally 320mg QD),
amlodipine 10mg, doxazosin 2mg. Blood pressures were well
controlled on this regimen.
6. Hypothyroidism:
TSH was elevated at 9.0 but was trending down from much higher
level of 31 at previous check, so levothyroxine dose was left
unchanged at 50mcg daily. Patient will likely need TSH followup
in a few weeks as outpatient to ensure that it continues to
trend down.
7. Clostridium difficile:
Patient was noted to have a positive Clostridium difficile toxin
test on [**2101-11-26**], so she was started on treatment with
metronidazole. She was switched to per oral metronidazole after
mental status improvement. Her total course of metronidazole
will be 14 days, which will last for seven full days after her
last dose of antibiotics. The patient was noted to have
sloughing skin around her anus, which could be worsened if
diarrhea becomes worse or incontinent.
8. Hyperparathyroidism/Hypercalcemia:
Patient has history of primary hyperparathyroidism s/p surgical
resection of parathyroid glands. She additionally has secondary
hyperparathyroidism, secondary to her renal failure. PTH during
this hospitalization was 162, which is within the goal range for
an end-stage renal patient, per Nephrology team. On the day of
discharge, she appeared to have an increased calcium, which was
likely secondary to hemoconcentration. Her calcium level should
be monitored on dialysis days; the calcium in the bath may need
to be decreased further.
9. Physical Therapy: Patient was able to walk with minimal
assist on discharge. She insisted on returning directly home
rather than to nursing facility.
DVT Prophylaxis: Patient was placed on pneumoboots. She has a
listed allergy to Heparin.
Code: Full
Communication: Patient, husband [**Name (NI) **]
.
Medications on Admission:
Nephrocaps 1 QD
Cinacalcet 60 QD
Omeprazole 20
Sevelamer 800 TID
Amlodipine 10
Albuterol PRN
Labetolol 600 TID
Simvstatin 40
Valsartan 320
Synthroid 50
Trileptal 150 [**Hospital1 **]
Doxasoin 2mg QD
Discharge Medications:
1. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
[**12-31**] Adhesive Patch, Medicateds Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
5. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
6. Valsartan 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Levetiracetam 500 mg Tablet Sig: AS DIRECTED Tablet PO AS
DIRECTED: Please take 1000mg (2 tablets) each night before bed.
On Dialysis days, please take 250mg (0.5 tablet) extra after
dialysis.
Disp:*66 Tablet(s)* Refills:*2*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as
needed for wheezing.
11. Nephrocaps Oral
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 doses.
Disp:*7 Tablet(s)* Refills:*0*
13. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
14. Cinacalcet 60 mg Tablet Sig: One (1) Tablet PO once a day.
15. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
16. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Seizure Disorder
End-stage Renal Disease
Hypertension
Secondary Diagnoses:
Hypothyroidism
Hypercalcemia
Anemia
Discharge Condition:
Stable.
Alert, Oriented x3.
Needs minimum assistance to ambulate.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted to the hospital because you had very high
blood pressure and had become confused at home. You were
intubated in the intensive care unit for one night because there
was concern that you could aspirate into your lungs otherwise.
After you were transferred to the general medical floor, you
were found to have a nonconvulsive seizure and were started on
new seizure medications. A spinal tap was done twice, and the
results showed that you did not have a bacterial infection in
your spinal fluid, but you may have had a viral infection in
your spinal fluid. You were continued on dialysis three days
per week, and your blood pressure was kept under control with
your home blood pressure medications. You were also having
diarrhea which became worse from a Clostridium Difficile
infection in your colon, which improved before you were
discharged.
Please be sure to take all of your medications as directed,
particularly your blood pressure medications. When your blood
pressure becomes too high, you sometimes get confused, and you
are at high risk for getting a stroke.
The following changes have been made to your medications:
- Please STOP the Trileptal for your seizure disorder
- Please START Levetiracetam (Keppra) for your seizure disorder:
- You should take 1000mg (2 tablets of 500mg each) each night
before bed
- You should take an additional 250mg (0.5 tablet) after
dialysis on Dialysis days (Tues, Thurs, Saturday)
- You may START using Lidoderm patches to your back for pain
- Please START taking Metronidazole (Flagyl) 500mg every 12
hours for 3.5 more days (7 more doses) for the C. difficile
infection that was making your diarrhea worse
Please be sure to keep all of your followup appointments and
continue your Tuesday/Thursday/Saturday dialysis schedule.
Please seek medical attention if you experience any symptoms
concerning to you.
Followup Instructions:
Please be sure to keep all of your followup appointments,
including Dialysis Tues/Thurs/Saturday.
PRIMARY CARE:
Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2101-12-13**] 11:50
NEUROLOGY
-Please call Dr.[**Name (NI) 11858**] clinic at ([**Telephone/Fax (1) 63315**] or
([**Telephone/Fax (1) 81976**] to see if a sooner appointment can be scheduled in
addition.
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2102-1-26**] 4:00
PRIMARY CARE:
Provider: [**Name10 (NameIs) 7158**] [**Last Name (NamePattern4) 7159**], M.D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2102-2-15**] 10:50
|
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icd9cm
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[
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[
"03.31",
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icd9pcs
|
[
[
[]
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18428, 18486
|
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|
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|
18661, 18729
|
7737, 7737
|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,612
| 108,272
|
8103
|
Discharge summary
|
report
|
Admission Date: [**2101-7-27**] Discharge Date: [**2101-8-9**]
Date of Birth: [**2040-1-14**] Sex: M
Service: Surgery
HISTORY OF PRESENT ILLNESS: This is a 61-year-old male with
mucinous adenocarcinoma arising from appendix with extensive
carcinomatosis and tumor involving the small bowel near the
SMA diagnosed by exploratory laparotomy in [**2100-5-6**]. He
underwent a palliative bypass procedure at that time. He was
readmitted on [**7-27**] with a 2-week history of increasing
abdominal pain, fever, vomiting, and a temperature of 104.8
degrees with peritoneal signs on abdominal examination. CT
scan revealed worsening of small bowel distention, small
bowel wall thickening, increased ascites, and extra luminous
air, and a small collection in the right lower quadrant.
This collection did not appear amenable to drainage.
HOSPITAL COURSE: Thus, on [**2101-7-28**], in the early a.m.
the patient underwent an exploratory laparotomy and a small
bowel resection. Preoperative diagnosis was perforated
viscous. Postoperative diagnosis was small bowel
perforation. The surgeon of record was Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1305**].
Findings intraoperatively included a closed-loop obstruction,
bypass small bowel with perforation in the right upper
quadrant. The patient was admitted to the Surgical Intensive
Care Unit for postoperative care. He was intubated as of
postoperative day one. Due to the perforated viscous, the
patient was kept on Kefzol and Flagyl antibiotics
postoperatively. The patient was extubated on [**7-29**]. He
did remain n.p.o. with nasogastric tube suction at this time
and remained on Kefzol and Flagyl. He required transfusion
of 1 unit of packed red blood cells on [**7-30**] for a
hematocrit of 27.8.
The patient was transferred to the floor on [**7-31**]. His
nasogastric tube was discontinued. The patient was to be
transferred to the floor, but he still had some hypotension
issues and was actually kept until [**8-1**]. Enalapril and
Lopressor were able to keep his blood pressure under control,
and he was transferred to the floor on [**8-1**].
On [**8-2**], the patient continued to do well, and his
Kefzol and Flagyl were discontinued. The Foley catheter was
discontinued on [**8-3**]. The patient was tolerating clears
as of [**8-3**]. On [**8-4**], on the patient's abdominal
examination, there was noted to be an increase in
serosanguineous drainage from the site of the incision, and
the patient had a temperature of 101.2 degrees. A CT scan on
[**8-4**] revealed a right-sided intra-abdominal fluid
collection. This collection was drained by Interventional
Radiology on [**8-5**] with a #12 French pigtail placed in
the right lower quadrant; 70 cc of purulent material were
drained at this time. At the time of discharge, the culture
from this fluid had grown out no anaerobes, no enterococcus,
two colonies of gram-negative rods in moderate quantity. A
third gram-negative rod species, sparse, gram-positive
bacteria, also streptococcus and gram-positive rods in broth
only.
The patient did very well after this drain was put in. The
patient was also put on levofloxacin and Flagyl as of
[**8-5**]. The patient was advanced to a regular diet as of
[**2101-8-7**].
DISCHARGE DISPOSITION: As of [**2101-8-9**], the patient
was stable for discharge to home with [**Hospital6 1587**] care.
MEDICATIONS ON DISCHARGE: He was to be discharged on
Avandia 4 mg p.o. q.d., levofloxacin 500 mg p.o. q.d.,
Flagyl 500 mg p.o. t.i.d.
DISCHARGE FOLLOWUP: He was to follow up with Dr. [**Last Name (STitle) 1305**]. The
patient will also receive [**Hospital6 407**] for
drain care at home, and also b.i.d. dry sterile dressing
changes to his wound.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**]
Dictated By:[**Last Name (NamePattern1) 4039**]
MEDQUIST36
D: [**2101-8-9**] 13:21
T: [**2101-8-11**] 09:05
JOB#: [**Job Number 28903**]
|
[
"250.00",
"153.4",
"197.6",
"569.83",
"401.9",
"569.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
3317, 3417
|
3444, 3553
|
870, 3293
|
3574, 4045
|
164, 852
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,516
| 115,322
|
26462
|
Discharge summary
|
report
|
Admission Date: [**2194-12-11**] Discharge Date: [**2194-12-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Elevated Cr, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo male with h/o Parkinsons, HTN, and worsening renal failure
who presents with w/ K>6, Cr 4 from NH. a few days ago at [**Hospital 100**]
Rehab, he spiked a fever to 102. No night sweats or recent
weight loss or gain. Denies headache, rhinorrhea or congestion.
Positive cough productive of white phlegm. Patient also reports
that he has had DOE and shortness of breath for the last 6
weeks. He does not know whether this has changed recently.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting but developed diarrhea today. Patient states that he
has had constipation on and off and he was given something at
his rehab today to get his bowels moving. Then this afternoon he
devloped loose stools. The patient also c/o abdominal distention
which is not new. The patient also complains of chronic low back
pain radiating to the groin which is similar to the pain he had
on last admission when a compression fx was discovered. The
patient also states that he has had decreased PO intake over the
last week. He states that he has not felt hungry and "everything
tastes wrong"
.
The patient was recently admitted with worsening low back pain.
CT and plain films revealed a compression fracture. MRI spine
showed no evidence of epidural abscess, cord compression, osteo.
But may have acute compression of vertebrae causing pain. Pain
control was with tylenol standing, morphine prn, calcitonin
nasal spray. Patient with significant SOB and new oxygen
requirement that was thought [**2-20**] CHF exacerbation. CXR showed
atelectasis vs. PNA and evidence of CHF. The team held
Amiodarone in this patient as Amiodarone toxicity was thought to
possibly be contributing to his shortness of breath and hypoxia.
He was also treated for pneumonia given possible infiltrate in
gentleman with no clear source for fever, he was afebrile after
day one of admission. Echo during hospital stayed showed
decreased EF to 30% - 35% from 40% in [**Month (only) 404**]. He was
significantly volume overloaded on initial exam, with edema,
crackles and evidence of pulm edema and diuresed throughout the
admission.
.
In the ED today, EKG showed old AV delay, old LBBB, no TW
peaking.
CBC/chem revealed an AG of 16, elevated WBC. CEs showed an
elevated troponin but this is in the setting of ARF. MB was
flat. Guaiac test of stool was positive in setting of loose
stools. CXR/KUB -> bowel loops herniating to thorax but no
obstruction.
Past Medical History:
1. Parkinson's
2. Hypertension
3. Atrial fibrillation
4. CAD s/p MI [**2192**], recent cath in [**1-24**] showed right dominancy
circulation with 3VD, s/p stenting of mid LAD at that time
5. Ulcers
6. Asthma
7. Chronic renal insufficiency, baseline Cr 2.5-2.8
8. Diverticulosis
9. L groin hernia
10. h/o GIB (10y ago)
Social History:
Retired salesman. Widower. Lives independently in senior
housing. Nonsmoker. Only socially drinks ETOH. No IVDU. No
children.
Family History:
Mother- died at 86 of MI.
Father- heavy [**Name2 (NI) 1818**] and drinker. Died at 75y (? cause)
Brother- died of complications from [**Name (NI) 5895**]
Physical Exam:
Vitals: T 96.9 P 76 BP 110/70 97% 2L
General: Elderly man resting in bed, appears in mild respiratory
distress, NAD
HEENT: NC/AT, PERRL, EOMI, sclera anicteric. MM dry, OP without
lesions
Neck: supple, no JVD or carotid bruits appreciated
Pulm: Decreased air movement, diffuse wheezes
Cardiac: RRR, nl S1/S2, II/VI SEM at RUSB
Abdomen: distended, soft, typanic, hyperactive bowel sounds, in
ED good rectal tone, guiac negative.
Ext: 1+ bilateral pitting edema to knees, 1+ DP pulses
Lymphatics: No cervical, supraclavicular, axillary, or inguinal
LAD.
Skin: no rashes or lesions noted.
Neurologic: AAO x3, CN II-XII intact, muscle strength 5/5 in all
4 extremities.
Pertinent Results:
Labs on admission:
[**2194-12-11**] 12:55PM BLOOD WBC-12.6*# RBC-3.71* Hgb-11.7* Hct-34.1*
MCV-92 MCH-31.5 MCHC-34.3 RDW-14.6 Plt Ct-368
[**2194-12-11**] 12:55PM BLOOD Neuts-90.5* Bands-0 Lymphs-4.1* Monos-4.7
Eos-0.5 Baso-0.1
[**2194-12-11**] 12:55PM BLOOD PT-12.5 PTT-22.6 INR(PT)-1.1
[**2194-12-11**] 12:55PM BLOOD Glucose-123* UreaN-104* Creat-5.1*#
Na-128* K-6.4* Cl-90* HCO3-22 AnGap-22*
[**2194-12-11**] 12:55PM BLOOD CK(CPK)-675*
[**2194-12-11**] 09:30PM BLOOD CK(CPK)-536*
[**2194-12-12**] 06:10AM BLOOD CK(CPK)-389*
[**2194-12-11**] 12:55PM BLOOD cTropnT-0.37*
[**2194-12-11**] 09:30PM BLOOD CK-MB-8 cTropnT-0.34*
[**2194-12-12**] 06:10AM BLOOD CK-MB-6 cTropnT-0.35*
[**2194-12-11**] 12:55PM BLOOD Calcium-8.5 Phos-6.4*# Mg-4.3*
.
CXR [**12-11**]: Portable upright chest radiograph reviewed. Again
seen is a complex hiatal hernia containing stomach and bowel
loops. Evaluation of the heart size is thus limited. The lungs
are grossly clear though limited secondary to large hernia. The
right costophrenic angle is sharp. The left costophrenic angle
is obscured by mediastinal contour secondary to hernia. The
pulmonary vessels are within normal limits.
.
EKG: NSR rate 83, 1st degree AV block, LAD, LBBB
.
Renal U/S [**12-11**]: The right kidney measures 8.6 cm. The left
kidney measures 8.4 cm. Again seen are two right renal cysts.
There is no evidence of hydronephrosis, stones, or mass. The
distended bladder is unremarkable.
.
CT head [**12-11**]: There is no evidence of intracranial hemorrhage,
mass effect, hydrocephalus, shift of normally midline
structures, or major vascular territorial infarction.
Hypodensities in the periventricular and deep cerebral white
matter consistent with chronic microvascular infarction.
[**Doctor Last Name **]-white differentiation is preserved. Prominence of the
ventricles and sulci is consistent with brain atrophy. There are
bilateral basal ganglia calcifications. Extensive carotid
calcifications are also identified. Surrounding osseous and soft
tissue structures are unremarkable.
.
Urine Cytology- [**2194-12-22**] **atypical urothelial cells.
.
VIDEO OROPHARYNGEAL SWALLOW [**2194-12-22**] 11:15 AM
The study was performed in conjunction with the speech
pathologist. Various consistencies of barium were administered
to the patient under video fluoroscopy. Aspiration was
demonstrated with consecutive straw sips of thin liquids. The
patient had a spontaneous, ineffective cough. After the first
sip of thin liquids, a small amount of penetration was also
noted which was stripped out by the patient. Please see the
speech pathologist's report in CareWeb for more details and
treatment recommendations.
Brief Hospital Course:
Mr. [**Known lastname 1395**] is a pleasant and witty [**Age over 90 **] year old gentleman with h/o
Parkinsons, HTN, and worsening renal failure who presented with
a potassium of >6, Cr 4 from his nursing home. On admission he
developing worsening dyspnea requiring MICU transfer and around
the clock nebulizer treatments. He was never intubated and only
required 2L oxygen for mild hypoxia, and was transferred to the
general medical floor for management. It was thought severe
reflux and his very large paraesophageal hernia were primarily
related to his episode of dyspnea. The patient sustained an
NSTEMI and revealed worsening LV systolic function to 25% EF.
Coronary revascularization was not recommended given the
patient's episode of GI bleeding with heparinization and
baseline poor functional status. His medical therapies were
maximized from cardiac, renal and pulmonary perspectives.
#. Shortness of breath: No evidence of CHF or PNA on CXR.
Patient's lung exam + for wheezes. Does no appear overloaded on
pulmonary exam, however his significant lower extremity edema
was likely secondary to decreased oncotic pressures due to
nutritional depletion/low albumin. Given IV steroids and
nebulizers initially q30min but nebs were spaced to q2hours then
q4hours prn. Unfortunately patient had to relapsing episodes of
dyspnea requiring increased frequency in nebulizers. On his 2nd
relapse, LENI's were performed to rule out DVT's. A CTA was not
performed due to the patient's poor creatinine clearance. He
was started empirically on a heparin drip to PEs but it had to
be stopped because of rectal bleeding. Serial CXR did not reveal
a CHF picture. Pulmonary consultation was obtained and it was
thought his wheezing was secondary to his large paraesophageal
hernia in combination with severe reflux symptoms. He was placed
on [**Hospital1 **] pantoprazole, and slowly tapered down on prednisone to
30mg daily. He should continue his slow prednisone taper at the
MACU.
.
#. Acute on Chronic renal failure:
Pt with worsening renal function over the last year. Baseline
Creat is 2.3-2.6 and recent discharge Cr was 2.7. On admission
Creat was 5.1 in setting of probable dehydration. He likely has
prerenal ARF from poor forward flow from CHF, and also decreased
PO intake. No evidence of obstruction or hydronephrosis u/s done
in ED. Urine lytes c/w prerenal etiology with FeNa <1%.
Patient received gentle fluids overnight and Cr decreased to
4.4. UOP was steady following normalization of cardiac
function. We held ACE-I in the setting of his renal failure. We
did not diurese the patient in this setting either, but
maximized his heart function medically and allowed him to
autodiurese likely post-ATN. His BUN/Cr function was steadily
improving at time of discharge. Renal was consulted and
recommended the above measures. Urine cytology was ordered and
revealed atypical urothelial cells. This finding is of
indeterminant significance given his multiple medical problems
and high variability among urine cytology specimens. This should
be followed up on as an outpatient by Dr. [**Last Name (STitle) 1266**] to repeat
the study or decide with pt and family to pursue further
work-up.
.
#. Guaiac positive stool and loose stools:
Pt recently completed a course of Levaquin for PNA on admission.
Possible C. Diff in setting of Abx. Pt started on heparin for
presumed PE but had to be stopped because of bright red blood
per rectum. Pt's hematocrit remained stable. He was having
intermittent guaiac positive stools throughout the admission,
but did not significantly drop his hematocrit.
.
#. Back/Groin Pain:
Pt with recent CT and plain films which revealed compression
fracture. Recent MRI spine showed no evidence of epidural
abscess, cord compression, osteo. But may have acute compression
of vertebrae causing pain. His pain was well-controlled with
tylenol standing, morphine prn, calcitonin nasal spray. We had
PT see the patient daily to work on mobility.
.
.
#. Congestive heart failure:
Echo [**12-2**] showed decreased EF to 30% - 35% from 40% in [**Month (only) 404**].
Repeat echo on admission revealed an EF of 25-30%. This
worsening is likely related to an NSTEMI. Cardiology was
consulted and recommended maximizing medical therapy.
Revascularization is not a good approach given the pt's
intolerance of heparin, and would not do well with the plavix,
argatroban loading required for repeat PCI. We salt restricted
his diet. And allowed him to autodiurese. Aggressive diuresis
was not pursued given pulmonary function that was not supportive
of CHF. His lower extremity edema can be treated with
compression stockings/ACE bandages.
.
# CAD:
Pt has known 3VD, cath [**1-24**] with stent of LAD. No ECG changes
but pt has a LBBB. Tn elevated to 0.37 on admission and peaked
at 2.54 in the setting of his renal failure. His CK-MB fraction
trended down and normalized several days prior to admission. He
did not have any anginal symptoms. Pt was seen by cardiology who
recommended maximizing medical management given poor
risk/benefit of further PCI. We maximized statin to 80mg per
day, titrated his metoprolol to 37.5mg [**Hospital1 **], and continued
aspirin and plavix. We held ACE-I due to renal insufficiency.
.
#. Abdominal distension:
Noted on prior admission, pt with significant abdominal
distension, minimal discomfort with palpation. no evidence of
fluid. KUB showed many loops of gas filled bowel but no evidence
of bowel obstruction. Suspicion for C. diff infection was
considered given leucocytosis, but c. diff studies while in
hospital were negative.
.
#. Parkinson's disease: We continued ropinarole.
.
#. FEN: Cardiac diet. We obtained a video swallow evaluation
that cleared the patient for regular diet with only restriction
of avoiding straws for beverages given that they repeatedly
caused him to aspirate.
.
#. Prophylaxis: PPI, SC heparin, holding bowel regimen
.
#. Code: DNR/DNI as discussed with HCP.
.
#. Dispo: Pending clinical improvement
Medications on Admission:
1. Morphine 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed for pain.
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Ropinirole 1 mg Tablet Sig: Eight (8) Tablet PO TID (3 times
a day).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain control.
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 4 days.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Psyllium Packet Sig: One (1) Packet PO BID (2 times a
day) as needed for constipation.
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for bloating.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for wheezing/sob.
17. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q12H ON, Q12H OFF ().
18. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
19. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
20. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TIDAC (3 times a day (before meals)).
21. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
22. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
23. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
24. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Ropinirole 1 mg Tablet Sig: Eight (8) Tablet PO tid ().
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Albuterol Sulfate 0.083 % Solution Sig: [**1-20**] Inhalation every
4-6 hours as needed for shortness of breath.
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
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.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
14. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
18. Risperidone 0.5 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO BID, MR X1 [**Hospital1 **] ().
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
20. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
21. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
23. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
24. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Heart Failure
Secondary:
Paraesophageal hernia
gastroesophageal reflux
renal insufficiency
Parkinson's disease
Discharge Condition:
fair
Discharge Instructions:
You were admitted for kidney failure and shortness of breath.
You were treated with steroids and breathing treatments to
improve your breathing. Your kidney faily was likely related to
worsening function of your heart because of another heart
attack. You were seen by doctors [**Name5 (PTitle) 65386**] in your heart,
lungs, and kidneys who recommended changes to medications to
help with each of these organ systems. Ultimately your heart
function is the underlying problem for many of your symptoms and
we are currently giving you the best therapy possible given your
complex medical condition.
.
Please call Dr. [**Last Name (STitle) 65387**] or 911 if you experience any chest
pain, shortness of breath not responsive to nebulizer
treatments, high fevers or diarrhea,
Followup Instructions:
You will be seen regularly by Dr. [**Last Name (STitle) 1266**] at [**Hospital 100**] Rehab.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
|
[
"276.7",
"415.19",
"410.71",
"428.22",
"428.0",
"E934.2",
"493.22",
"530.81",
"578.9",
"332.0",
"276.51",
"427.31",
"585.9",
"553.3",
"584.9",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
17265, 17331
|
6816, 12819
|
281, 287
|
17495, 17502
|
4126, 4131
|
18322, 18540
|
3265, 3421
|
15071, 17242
|
17352, 17474
|
12845, 15048
|
17526, 18299
|
3436, 4107
|
225, 243
|
315, 2764
|
4145, 6793
|
2786, 3105
|
3121, 3249
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,894
| 197,656
|
32792
|
Discharge summary
|
report
|
Admission Date: [**2186-11-24**] Discharge Date: [**2186-12-19**]
Date of Birth: [**2136-9-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Suboccipital Crani for Mass
Major Surgical or Invasive Procedure:
[**11-24**]: Suboccipital crani for Mass
[**12-5**]: Bedside tracheostomy placement
History of Present Illness:
50-year-old right-handed gentleman who initially presented with
a 7 mm brain stem exophytic lesion that was stereotactically
biopsied. While the path was
nondiagnostic it was highly suggestive of astrocytoma, with such
the patient was closely observed without therapy. On subsequent
surveillance scan, however, the lesion was enlarged from
approximately 7 mm to now 3 cm in the largest diameter. In the
context of this the patient had developed increased difficulty
walking as well as swallowing. As such the patient elected to
undergo surgical debulking of this tumor.
Past Medical History:
HTN
Social History:
recent CVA in mother
lives with wife and 4 children
Family History:
Mother with CVA; no CA in family
Physical Exam:
Examination on Admission:
General NAD
Mental/Psychological alert and oriented x 3, speech clear
limited Englis to yes, no mouthing words. Voice inaudible due to
tracheostomy. No visible
tremors, PERRL 3.5mm to 3.0mm. Airway patent. Heart ns1, s2,
-s3, -s4 no murmurs, no carotid bruits bil.
Lungs Clear to Auscultation
Abdomen soft, non-tender, no masses
Extremities no pedal edema bil, + dp bil
Other CN 2-12 intact, full peripheral, full EOM's,
muscle st. upper ext. +5/+5 bil, lower ext.
+5/+5,
Pertinent Results:
Labs on Admission:
[**2186-11-25**] 04:22AM BLOOD WBC-15.3* RBC-3.99* Hgb-12.0*# Hct-34.6*
MCV-87 MCH-30.1 MCHC-34.7 RDW-14.7 Plt Ct-246
[**2186-11-25**] 04:22AM BLOOD Glucose-157* UreaN-23* Creat-1.2 Na-137
K-3.9 Cl-102 HCO3-21* AnGap-18
[**2186-11-25**] 04:22AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.6
Labs on Discharge:
[**2186-12-18**] TSH:1.3 WBC 5.1,HCT-24.5,HGB-8.2 U/A+C/S neg for
bacteria
Imaging:
Head CT [**11-24**]:
IMPRESSION:
1. Expected post-surgical changes in the left posterior fossa
consistent with resection of fourth ventricular mass. Continued
close followup is recommended.
LENIS [**11-25**]: No evidence of DVT.
CTA Chest [**11-25**]:
IMPRESSION:
1. No pulmonary embolism.
2. Patchy bilateral peribronchial airspace opacities,
predominantly in a
bibasilar distribution, but also seen in the right middle, right
upper lobes,and in the lingula. Although a portion of this
opacity could relate to atelectasis, the possibility of
aspiration or infection should also be
considered.
3. Marked diffuse fatty infiltration of the liver, with probable
areas of
focal fatty sparing.
4. A 1.4 cm right adrenal nodule.
Head CT [**11-26**]:
PFI: Acute hemorrhage in the region of fourth ventricle mass
resection with
resultant significant hydrocephalus. There is concern for
developing
tonsillar herniation which is not well evaluated on this
particular study.
MRI Head [**11-25**]:
IMPRESSION:
1. 2.1 x 1.1 cm area of enhancement in the region of the fourth
ventricle,
which may represent post-surgical changes vs. tumor. Followup
can be
considered to reassess this finding.
2. Scattered areas of microcalcifications/microhemorrhages or
cavernomas as described, most of which are unchanged compared to
the [**2186-1-15**]. A few new foci may again represent
microcalcifications or microhemorrhages or related to the
presence of air.
3. No new lesions noted. The previously described right frontal
lobe lesion, on [**2186-1-15**] does not have restricted diffusion
or enhancement on the present study. This may represent a
non-neoplastic etiology. Attention can be paid to this on
followup scans.
CT head [**2186-12-5**]:
FINDINGS: The study is compared with most recent post-operative
examination of [**2186-11-29**]. The patient is status post extensive
suboccipital craniectomy, with post-surgical changes at the
craniectomy bed, as before. However, there has been interval
virtual-complete resolution of the predominantly triangular
acute hemorrhage at the tumor resection bed, with significantly
less effacement of the dorsal aspect of the fourth ventricle and
some improvement in the ventricular dilatation, indicative of
improvement in degree of obstructive hydrocephalus. Persistent
small amount of hemorrhage layers dependently in the occipital
horns and atria of both lateral ventricles, with no new
hemorrhage seen. The cerebellar tonsils remain slightly
low-lying, also not significantly changed.
The remainder of the examination including chronic microvascular
infarction in bihemispheric subcortical and periventricular
white matter, with bilateral basal ganglia chronic lacunes, as
well as predominantly left parietovertex scalp subgaleal
hematoma, is unchanged. Paired paramedian frontal burr holes,
with overlying skin staples are again demonstrated.
IMPRESSION:
1.Status post recent suboccipital craniectomy with resolving
post-surgical changes, including hematoma at the tumor resection
bed and slight improvement in the findings of obstructive
hydrocephalus. However, as suggested previously, there may be
residual tumor at the caudal aspect of the fourth ventricle.
2.Persistent small amount of blood layering in bilateral lateral
ventricular occipital horns.
3. Chronic microvascular and lacunar infarction (as on FLAIR
sequence from
recent [**2186-11-25**] MR study), but no evidence of significant
cerebellar or
cerebral edema.
4. Left parietovertex scalp subgaleal hematoma, as before.
Brief Hospital Course:
Patient was electively admitted on [**11-24**] for planned
suboccipital crani for mass resection. Post-operativley he was
monitored for 24hrs with ICU level care with aggressive SBP
managment and monitoring. On POD#1 he was found to be
tachycardic, and evaluated for lower extremity venous thrombosis
and pulmonary embolus; both of which were negative for an acute
process. On [**11-25**], he was found to be in acute respiratory
distress, likely secondary to his tachycardia. Therefore pt was
intubated. Though the patient had a prior history of third
ventriculostomy, he had an EVD placed to exclude elevated
intracranial pressure as the cause of his deterioration. Clear
CSF was obtained on first pass, and the ICP was <10.
The patient remained extremely tachycardic and required a
tremendous amount of Diltiazam to control his heart rate. He
was extubated on [**11-27**] but respiratorily decompensated,
necessitating reintubation. This episode occurred in the
contact of Afib and was associated chest pain. Cardiac enzymes,
however, were negative.
Because the ICP remained consistently low, his EVD was removed
on post-placement day three without complications. He remained
respiratorily stable until [**11-30**] when he suffered an episode of
desaturation to the 80s. He had a bronch and sputum was sent.
It grew out >25PMNs, 3+gram +cocci, 2+gram +rods, 2+
gram(-)rods. he was treated empirically for aspiration PNA.
On the following day, TF was aspirated from his ET tube,
confirmation aspiration PNA, likely from over-feeding of TF.
Because of the prolonged intubation and the findings of PNA, the
patient underwent trach and PEG placement. He was the placed on
a trach mask in the following days. He was transferred to the
stepdown unit on [**12-8**].
Physical therapy and occupational therapy worked with him
throughout his ICU stay and again when he was in the stepdown
unit. Both recommended rehab placement. He remained stable
throughout the remainder of his hospital stay. All home
medications have been restarted and he is tolerating all tube
feeds well. No nausea or vomiting to report.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Cerebellar Mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair at 10 days post op.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**11-7**] days for a wound check.
Please call ([**Telephone/Fax (1) 88**] to schedule an appointment. If you
reside far away, you may have this checked by your PCP
??????You will need to follow up with Dr. [**First Name (STitle) **] in one month. You will
not need any additional imaging done for this appointment.
Please call [**Telephone/Fax (1) 1669**] for an appointment.
Completed by:[**2186-12-19**]
|
[
"427.31",
"331.4",
"041.11",
"560.1",
"518.81",
"997.31",
"507.0",
"401.1",
"191.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"33.22",
"02.2",
"31.1",
"01.59",
"43.11",
"96.6",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7773, 7820
|
5633, 7750
|
306, 392
|
7880, 7904
|
1681, 1686
|
9247, 9731
|
1110, 1145
|
7841, 7859
|
7928, 9224
|
1160, 1172
|
239, 268
|
2000, 5610
|
420, 996
|
1700, 1981
|
1018, 1024
|
1040, 1094
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,101
| 197,096
|
17683
|
Discharge summary
|
report
|
Admission Date: [**2132-8-21**] Discharge Date: [**2132-8-24**]
Date of Birth: [**2074-12-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Mental status change/slurred speech
Bradycardia
Major Surgical or Invasive Procedure:
1.) Central line placement (Left subclavian)
History of Present Illness:
57 yo Male with PMH of hep C/EtOH cirrhosis, history of
recurrent hepatic encephalopathy (controlled by lactulose at
home), history of seizures in [**2132-2-29**] (thought [**1-2**] narcotic
and cocaine withdrawl - further w/u not done) who presents to ED
after being sent by his PCP after noted to have some slurred
speech/change in mental status, then noted to have bradycardia
in ED.
.
Pt was called by his PCP at home last night to be given some lab
results and noted to have some slurred speech on the phone. As
patient has a history of recurrent hepatic encephalitis, was
sent to ED by PCP for further [**Name Initial (PRE) **]/u. Pt reports feeling confused
and some dizziness earlier in the day. Also c/o severe thirst.
Otherwise denied syncope/LOC, chest pain/pressure, SOB, N/V,
fever/chills, focal weakness, loss of sensation, neck stiffness,
HA, photophobia. Reports taking his lactulose as directed with
3 BM/day.
.
On presentation to ED, intitially (14:45) T 97.1, HR 35, BP
84/35, RR 18, O2 96% on RA. He was confused, agitated, noted to
have slurred speech, + asterixis on exam. Initial EKG
demonstrated HR 44, no change from previous EKG from PCP office
in [**2132-3-31**], read by Dr. [**Last Name (STitle) **], demonstrated ectopic atrial
rhythm at slow rate of 46 bpm (same p'-wave morphologies). When
HR 30, BP 94/56, pt c/o lightheadedness and was given atropine
0.5mg x 1 and Glucagon 5mg IV x 1 (at 16:32), HR increased to
61, BP 112/61. Repeat EKGs essentially unchanged, HR ranging
36-54. Patient also received 3L NS and lactulose 30mL x 1.
Stool was guiac negative in ED. Pt w/ improved mental status to
A+Ox3, still slightly agitated by time reached the floor.
Past Medical History:
--Cirrhosis (h/o ascites, h/o encephalopathy, esophageal
varicies, spenomegaly) - Appointment with hepatology on [**2132-8-27**]
--Seizures: from EtOH withdrawl AND in [**3-4**] presented to [**Hospital1 2177**]
with sz, thought to be [**1-2**] NARCOTIC (oxycontin/codone) withdrawl
- represented next day s/p syncope and tox screen positive for
cocaine - therefore thought sz [**1-2**] narcotic AND cocaine
withdrawl. PCP set up MRI for further w/u but patient did not
show up at appointment. PCP also set up appointment with
neurology but patient did not show.
--Guiac + stool in [**2129**] - s/p colonoscopy that showed incomplete
exam due to poor prep. Colonoscopy in [**2131-12-1**] that showed
sessile polyp that was removed - path showed fragments of
adenoma. Plans for f/u in 1 year.
--EGD in [**2129**] - grade II esophageal varices, hiatal hernia,
portal hypertensive gastropathy - started on Nadolol. Endoscopy
scheduled for [**2132-1-1**].
--Pancreatitis ([**1-2**] EtOH)
--Left foot injury - pins placed - on oxycodone and oxycontin
for pain control (Of note, when he stops taking, experiences
withdrawl symptoms such as N/V, piloerection, diaphoresis)
--HTN
--Thrombocytopenia - thought likely [**1-2**] EtOH use, also noted to
have hypersplenism.
--Pain control - currently on oxycodone and oxycontin. Has been
on methadone in past. Followed at pain clinic at [**Hospital1 18**].
Appointment scheduled for [**2132-8-27**]
Social History:
ETOH abuse [**12-2**] gallon of vodka/day, stopped one year ago.
Cocaine and heroine abuse currently. 1 [**12-2**] ppd cigarette smoker
x 40 yrs, down to 2-3 cigarettes/day over last year.
Family History:
NC
Physical Exam:
Vitals - T 97.8, BP 114/60, HR 47, RR 14, O2 97% RA, Wt 98kg
General - Awake, alert, NAD, still with slurred/slow speech
HEENT - PERRL (3mm->2mm), EOMI, no nystagmus, OP clear without
lesions, dry MM
CVS - RRR (HR 60 during exam), no M/R, +S1,S2, +S3
Lungs - CTA b/l
Abd - Soft, Obese, NT/ND, +BS, no fluid wave appreciated
Ext - No C/C/E
Skin - Prior site of cellulitis on L hand without
erythema/fluctuance, + b/l palmar erythema, no noted spider
angiomata, no noted track marks, no caput madusa
Neuro - A+O x 3, CNII-XII intact, Strength 5/5 UE and LE b/l, no
asterixis, finger-to-nose slow but no frank dysmetria,
thumb-to-finger coordination slow, +romberg, Patellar reflexes
brisk, symmetric b/l, gait slightly unsteady.
Pertinent Results:
Labs on admission:
[**2132-8-21**] 03:16PM BLOOD WBC-4.2 RBC-3.51* Hgb-11.0* Hct-34.2*
MCV-97 MCH-31.3 MCHC-32.2 RDW-17.2* Plt Ct-63*
[**2132-8-21**] 03:16PM BLOOD PT-14.5* PTT-30.5 INR(PT)-1.4
[**2132-8-21**] 03:16PM BLOOD Glucose-90 UreaN-24* Creat-1.1 Na-140
K-4.2 Cl-111* HCO3-22 AnGap-11
[**2132-8-21**] 03:16PM BLOOD ALT-30 AST-41* AlkPhos-111 Amylase-42
TotBili-1.4
[**2132-8-21**] 03:16PM BLOOD Lipase-30
[**2132-8-21**] 03:16PM BLOOD CK-MB-4 cTropnT-<0.01
[**2132-8-21**] 03:16PM BLOOD Albumin-3.0*
[**2132-8-21**] 03:00PM BLOOD Ammonia-91*
[**2132-8-21**] 03:16PM BLOOD TSH-4.1
[**2132-8-21**] 03:16PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2132-8-22**] 10:50AM BLOOD VitB12-1077*
Labs on discharge:
[**2132-8-24**] 05:30AM BLOOD WBC-7.0# RBC-3.25* Hgb-10.4* Hct-31.2*
MCV-96 MCH-31.9 MCHC-33.2 RDW-17.3* Plt Ct-58*
[**2132-8-24**] 05:30AM BLOOD Glucose-110* UreaN-14 Creat-0.8 Na-138
K-4.0 Cl-108 HCO3-24 AnGap-10
[**2132-8-24**] 05:30AM BLOOD Calcium-9.2 Phos-2.4* Mg-1.8
Microbiology:
[**2132-8-21**] Urine cx - negative
[**2132-8-22**] RPR - pending
[**2132-8-23**] Blood culture - NGTD
Imaging:
[**2132-8-21**] Head CT: No evidence of acute intracranial pathology,
including no evidence of acute intracranial hemorrhage.
[**2132-8-21**] CXR: Stable appearance of the chest, with no evidence of
acute cardiopulmonary abnormality.
[**2132-8-21**] EKG: Rate PR QRS QT/QTc P QRS T
44 190 86 484/432.15 -26 23 43
[**2132-8-22**] EKG: Rate PR QRS QT/QTc P QRS T
58 162 92 446/441.15 -46 29 41
Brief Hospital Course:
Assessment/Plan: 57 yo man with hx EtOH cirrhosis, Hep C, Hx
hepatic encephalopathy, hx sz of unclear etiology in recent past
who presents to ED with slurred speech, mental status changes,
also noted to be bradycardic in ED.
.
1.) Change in mental status: Tox screen negative, TSH normal
here (4.1). Etiology likely hepatic encephalopathy as had
asterixis on initial assessment, history of recurrent hepatic
encephalopathy in past. Also ?contributed to by
oxycodone/oxycontin overuse, as patient very intent on getting
his pain medication and both are hepatically metabolized. B12
deficiency was ruled out with normal B12 levels, RPR sent, but
pending at time of discharge. Seizure disorder was also
initially entertained, as patient had a history of seizures in
[**4-3**], attributed to his oxycodone/oxycontin withdrawl and
cocaine and heroin use, but had incomplete follow up (patient
failed to show up at scheduled MRI and neurology appointment).
Patient was treated with lactulose 60mL QID, titrated to 4 Bowel
movements/day, and decreased dose of oxycontin to 30mg [**Hospital1 **] (from
60mg [**Hospital1 **] as outpatient) with improvement of
mentation/somnolence. Also was kept on his outpatient dose of
B12, and given thiamine and folate, even though no evidence of
alcohol use x 1.5 years. Patient's hepatic encephalopathy
resolved, and patient was discharged on home dose of lactulose
(30mL TID, titrate to 3 bowel movements/day) with instructions
to follow up with his PCP, [**Name10 (NameIs) 151**] hepatology, and with pain clinic
appointment for further management of his ongoing pain issues
(SEE below).
.
2.) Bradycardia: Pt noted to be bradycardic to 30's in ED.
However, when compared to EKG in [**2132-3-30**], shows similar rate
and rhythm with ectopic atrial focus. Patient on nadolol as an
outpatient. Initial assessment = ?intrinsic disorder (i.e. sick
sinus syndrome) vs secondary to his nadolol. Nadolol was held
and Atropine and glucogon given in the ED with minimal
improvement. Patient was initially admitted to medicine floor
on telemetry, but demonstrated HR in 30's-40's with long pauses
on telemetry to 5-8 seconds. Therefore was transferred to CCU
on hospital day #1 for closer monitoring in case needed
temporary pacing. EP was consulted and initially recommended
placement of pacemaker, which patient refused at current time
and also non-candidate as evidence of recent IVDU. CCU course
notable for improvement of HR from 40's --> 60's, decrease in
pauses, without interventions (attributed to Nadolol effect
wearing off). Therefore thought likely bradycardia was
secondary to patient's nadolol initiating likely sick sinus
syndrome. Therefore, patient's nadolol continued to be held
throughout hospital course, and was discharged off of nadolol
with plans to follow up with PCP and hepatology. [**Month (only) 116**] follow up
with cardiology in future as well - will defer to PCP.
.
3.) Pain control: Pt with history of significant pain with
difficulty controlling. Currently on oxycodone and oxycontin
(60mg [**Hospital1 **]). Has been on methadone in past. During hospital
course, oxycontin dose was decreased to 30mg [**Hospital1 **] (as above, as
?mental status changes contributed to by oxycontin/codone use),
and oxycodone was held (although given x 2 due to patient's
pain). Has appointment scheduled with pain clinic for [**2132-8-27**].
Therefore discharged with instructions to take the decreased
dose of oxycodone and oxycontin only as needed and follow up
with pain clinic for further managment.
.
4.) Hx GI Bleed and known varices and Colon polyp: Patient was
guiac negative on presentation without complaints of melena,
maroon stools, or any BRBPR. Nadolol was held during
hospitalization in setting of bradycardia as described above.
Held on discharge with plans to follow up with PCP and
hepatology for ?alternative management of varices. No events
during hospital course. Patient also with follow up EGD
scheduled for [**2132-12-31**].
.
5.) Hx of sz: Unclear etiology. Per OSH records, secondary to
narcotic (oxycontin/codone) withdrawl and cocaine and heroin
use. Further work up was scheduled by PCP including MRI and
neurology follow up were not attended by patient. No active
seizure issues occurred during hospitalization. Defer to
outpatient managment.
.
6.) Thrombocytopenia: Patient with known thrombocytopenia as
outpatient. Platelets stable during hospital course. No
events.
.
7.) FEN: Patient maintained on low protien diet during hospital
course, in setting of hepatic encephalopathy.
.
8.) PPX: Patient maintained on SC heparin, protonix, bowel
regimen throughout hospital course.
Medications on Admission:
Lactulose 30ml TID
Nadalol 20mg QD
Oxycontin 60mg [**Hospital1 **]
Neurontin 600mg [**Hospital1 **]
Oxycodone
Protonix 40mg QD
Folate 1mg QD
Vitamin B
Trazadone 50mg qhs
Spironolactone
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for pain.
7. Lactulose (for Encephalopathy) 10 g/15 mL Solution Sig:
Thirty (30) mL PO three times a day: Please titrate up dose of
lactulose to have 3 bowel movements/day.
Disp:*qs qs for 4 week supply* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
1.) Hepatic encephalopathy
2.) Bradycardia - likely sick sinus syndrome
Discharge Condition:
Stable. Patient with improved mentation/somnolence (resolved
hepatic encephalopathy) and heart rate improved to 60's, no
pauses, asymptomatic.
Discharge Instructions:
1.) Please contact physician if develop [**Name9 (PRE) 49205**]/agitation,
fever > 100.4, vomit or stool with blood,
lightheadedness/dizziness, fainting, weakness, any other
questions/concerns
2.) Please take medications as directed
3.) Please follow up with appointments as directed
4.) Please STOP taking Nadolol
Followup Instructions:
1.) Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2132-8-27**] 11:40
2.) Provider: [**Name10 (NameIs) 8380**],[**Name11 (NameIs) 7436**](A) PAIN MANAGEMENT
CENTER Where: FD [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX)
PAIN MANAGEMENT CENTER Phone:[**Telephone/Fax (1) 1091**] Date/Time:[**2132-8-27**]
2:30
3.) PLEASE CALL this number provided on Monday morning ([**8-26**]) to
schedule earlier appointment for this week or next week for
follow up after hospitalization --> Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Where: [**Hospital6 29**] [**Hospital3 249**]
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-9-19**] 2:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
|
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"E947.8",
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"305.1",
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"291.81",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
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|
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|
363, 410
|
12053, 12199
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|
3624, 3815
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,251
| 194,500
|
34272
|
Discharge summary
|
report
|
Admission Date: [**2135-6-11**] Discharge Date: [**2135-8-2**]
Date of Birth: [**2104-8-11**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
nausea, vomiting, hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
30 year old man with history of biliary atresia s/p liver
transplant at age 4 who presents from home with nausea and
vomiting for the last several days. He called the transplant
center on the day of admission and they checked outpatient labs
which were remarkable for K of 6.0. He was advised to come to
the ED.
.
In the ED, initial vitals were T 97.7, HR 79, BP 119/77, RR 22,
98%RA. K was 6.3. CBC and LFTs were consistent with priors.
Creatinine was 2.8 (c/w recent basline). EKG showed no
hyperkalemic changes. Abdomen was soft and no imaging was felt
to be necessary. Patient got 10U insulin, 1 amp D50, 15g
kayexalate, and repeat K was 4.9. He was admitted for treatment
of nausea, vomiting, and hyperkalemia. Liver fellow was
contact[**Name (NI) **] in [**Name (NI) **] and requested Prograf level be checked 12 hours
post last dose. Liver fellow agreed with admission to liver
service. Vitals at time of transfer were afebrile, HR 86, BP
133/86, RR 18, sat99%RA.
.
Of note, patient was seen in kidney clinic on [**5-31**] (Dr [**Last Name (STitle) **]
for follow-up of postinfectious glomerulonephritis. He had been
hospitalized several days before for symptoms of flank pain in
the setting of recent URI in [**Month (only) **]. Renal biopsy during that
admission was c/w post-infectious GN. He was discharged on
lisinopril 5 qday, Phoslo, sodium bicarb and tacrolimus.
Creatinine since that time has ranged from 2.1-2.9. Per notes
from the office visit, plan was to continue above meds and add
Lasix, uptitrating prn, for anasarca.
.
Currently, patient denies nausea. He says that he has been
having vomiting on and off for the last three days, and he has
been unable to hold any food down. He denies abdominal pain and
there is no history of diarrhea. For his symptoms, he says he
has been taking ibuprofen, 1 pill at a time, but he cannot
specify how frequently. It appears from his allergy list that
this has been a documented allergy for him in the past, and it
is unclear why he continues to take this medicine.
Past Medical History:
-biliary Atresia s/p liver transplant at age 4 (25 years ago)
-asthma, well-controlled
-right hip avascular necrosis, per ortho may need THR
-postinfectious glomerulonephritis s/p renal biopsy [**2135-5-24**]
showed IgG dominent exudative proliferative GN, c/w
postinfectious GN
-nephrotic syndrome (4.1g proteinuria), hypoalbuminemia
Social History:
denies any tobacco, EtOH or illict drug use. Lives at home with
parents, engaged. Has one child with a prior girlfriend. Does
not work.
Family History:
NC
Physical Exam:
VITALS: T 96.9, BP 112/68, HR 71, RR 18, sat96%RA
GENERAL: young man in no distress, speaking comfortably
HEENT: normocephalic, atraumatic, non-icteric sclera, PERRLA
NECK: supple
CARDIAC: RRR, normal s1/s2
LUNGS: decreased breath sounds at bases bilaterally
ABDOMEN: distended (?[**12-27**] anasarca?), non-tender, normal bowel
sounds
EXTREMITIES: [**12-28**]+ pitting edema to above the knees bilaterally
Pertinent Results:
Labs on Admission ([**2135-6-11**]):
GLUCOSE-117* UREA N-83* CREAT-2.8* SODIUM-139 POTASSIUM-6.3*
CHLORIDE-111* TOTAL CO2-23 ANION GAP-11
ALT(SGPT)-42* AST(SGOT)-66* ALK PHOS-243* TOT BILI-0.8
LIPASE-68*
ALBUMIN-1.2* PHOSPHATE-4.8*
WBC-9.1 RBC-4.12* HGB-12.9* HCT-38.1* MCV-93 MCH-31.2 MCHC-33.7
RDW-13.7
NEUTS-79.3* LYMPHS-14.0* MONOS-3.4 EOS-3.1 BASOS-0.3
PLT COUNT-157
PT-13.6* PTT-25.6 INR(PT)-1.2*
tacroFK-6.7
[**2135-6-11**]
URINE RBC->50 WBC-21-50* BACTERIA-MOD [**Month/Day/Year **]-NONE EPI-0
URINE BLOOD-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD
IMAGING:
[**2135-6-11**] CXR FINDINGS: No previous images. Bibasilar
opacifications, more prominent on the left, consistent with
pleural effusions and compensatory basilar atelectasis. The
upper lung zones are clear and there is no evidence of vascular
congestion.
[**2135-6-12**] CXR FINDINGS: In comparison with the study of [**6-11**],
allowing for differences in technique, there is probably little
change in the bilateral pleural effusions, slightly more
prominent on the left. Basilar atelectatic change is also seen
on the left.
[**2135-6-12**] PORTABLE ABDOMEN: No previous images. There is a
relative paucity of bowel gas presenting in a nonspecific
pattern. Although no dilatation of gas-filled loops is seen, the
possibility of a dilated fluid-filled bowel loops can certainly
not be excluded. If there is any serious clinical concern for
obstruction, CT would be necessary.
Findings of avascular necrosis are seen in the right femoral
head.
[**2135-8-2**] 06:58AM BLOOD WBC-8.1 RBC-2.86* Hgb-8.6* Hct-27.0*
MCV-94 MCH-30.0 MCHC-31.9 RDW-18.0* Plt Ct-181
[**2135-6-27**] 03:42PM URINE Eos-POSITIVE
[**2135-7-26**] 05:37AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.034
[**2135-8-2**] 06:58AM BLOOD Neuts-67.3 Lymphs-15.1* Monos-5.4
Eos-11.9* Baso-0.3
[**2135-7-29**] 05:40AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2135-8-2**] 06:58AM BLOOD PT-14.6* PTT-34.6 INR(PT)-1.3*
[**2135-8-2**] 06:58AM BLOOD Glucose-126* UreaN-42* Creat-3.3* Na-140
K-4.0 Cl-104 HCO3-26 AnGap-14
[**2135-8-2**] 06:58AM BLOOD ALT-36 AST-90* AlkPhos-468* TotBili-0.6
[**2135-8-1**] 06:20AM BLOOD GGT-79*
[**2135-8-2**] 06:58AM BLOOD Albumin-2.2* Calcium-9.3 Phos-5.2* Mg-2.3
[**2135-6-30**] 10:38AM BLOOD calTIBC-43* Ferritn-402* TRF-33*
[**2135-6-30**] 10:38AM BLOOD Triglyc-586* HDL-5 CHOL/HD-10.8
LDLmeas-<50
[**2135-7-27**] 05:26AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE
[**2135-7-20**] 02:12AM BLOOD HAV Ab-NEGATIVE
[**2135-8-2**] 09:04AM BLOOD tacroFK-5.5
[**2135-7-26**] 05:10AM BLOOD HCV Ab-NEGATIVE
[**2135-6-30**] 10:38AM BLOOD CA [**44**]-9 -Test
[**2135-6-30**] 10:38AM BLOOD VITAMIN D 25 HYDROXY-Test
[**2135-7-8**] 12:36PM BLOOD HERPES SIMPLEX (HSV) 1, IGG-Test
[**2135-7-8**] 12:36PM BLOOD HERPES SIMPLEX (HSV) 2, IGG-Test Name
[**2135-7-31**] 07:05AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
[**2135-8-2**] 12:50PM BLOOD HISTOPLASMA ANTIBODY (BY CF AND ID)-PND
[**2135-8-2**] 12:50PM BLOOD SCHISTOSOMA ANTIBODIES-PND
Brief Hospital Course:
# Small bowel resection: Patient was admitted because of
hyperkalemia. On the night of admission he developed acute
abdomen and underwent emergent laparotomy. A 5cm area of
deserosalized tissues was found and a small bowel resection
performed. The post-op course was complicated by persistent
abdominal pain and intractable nausea and vomiting for ~2 weeks.
This subsequently resolved prior to the patient being transfered
to the hepatology service.
#SBP: At about 2 weeks post-op the patient developed increased
abdominal pain. A diagnositic paracentesis was done that
revealed a WBC of [**Numeric Identifier 26452**] with 90% neutrophils. He was
subsequently transfered to the hepatology service. He was
started on ceftriaxone and albumin. He continued to have
abdominal pain and a repeat diagnostic paracentesis was done 2
days after initiation of treatment. This revealed a WBC of 5300
with 50% neutrophils indicating persistent infection despite
treatment. On [**7-12**] a diagnostic paracentesis was done that
showed a WBC of 3. Treatment with ceftriaxone was continued for
a total course of 2 weeks and he was then started on
ciprofloxacin for prophylaxis.
# Hypoxemic respiratory failure: Patient was persistently
tachypneic to the mid 20s throughout his hospitalization. On the
morning of [**7-15**] he was found to be tachypneic to 30s, using
accesory muscles and had cough blood tinged sputum. His
respiratory status improved with diuresis and CXR showed
persistent left pleural effusion that was unchanged. An ABG was
done once the patient was off O2 and it revealed A-a gradient of
48 (nl 10) which was consistent with significant shunting. That
afternoon the patient again developed respiratory distress and
was transferred to the MICU with increased work of breathing and
after failing a trial of NPPV, he was intubated on [**7-15**]. He has
numerous reasons for baseline multifactorial hypoxia with A-A
gradient. He has known shunting from hepatopulmonary syndrome,
and also has V/Q mismatch from a large, stable left pleural
effusion and ascites. The patient's baseline PaO2 low 70s. Given
the patient's increased work of breathing and minute
ventilation, there was concern for increased Vd/Vt suggestive of
either worsening V/Q mismatch from increased pulmonary edema or
increased shunting from a pulmonary emboli. His hepatopulmonary
syndrome, ascites, and left pleural effusion appeared stable,
contributing to decreased pulmonary reserve but likely not
contributing to acute decompensation. CXR on [**7-15**] revealed new R
sided effusion, new R sided parenchymal opacities, old L sided
effusion. In context of worsening clinical status and
leukocytosis, he was started on cefepime, vanco, cipro for
health care associated pneumonia. However, sputum subsequently
grew out rare oropharingeal flora and [**Last Name (LF) 23087**], [**First Name3 (LF) **] these
antibiotics were discontinued. Thus, it was concluded that CT
and CXR changes were likely due to increased pulmonary edema
likely secondary to acute on sub-acute renal failure and
oliguria in the setting of receiving volume. He was started on
CVVH on [**7-15**], with net negative fluid balance of approximately
negative 13L by [**7-21**]. His respiratory status improved,
ventilation settings were weaned, and he was successfully
extubated on [**7-21**]. He subsequently developed a low grade fever
and leukocytosis by [**7-22**] and was pancultured, with cultures
pending; an IR paracentesis was also scheduled. CXR from [**7-22**]
showed stable LLL atelectasis with layering of a moderate L
pleural effusion and improved right multifocal airspace
opacities and pulmonary edema (now mild). After transfer to the
floor, he was continued on dialysis.
# Renal failure: Prior to admission the patient was diagnosed
with post-infectious GN, Cr. of . His renal function continued
to improve slowly throughout admission. Once his Cr stabilized
at low 2s he was started on diuretics to treat his fluid
overload. His renal function subsequently worsened. It was
thought that this acute decompensation might have also had a
component of HRS and ATN. He was treated for HRS with minimal
improvement. He was started on CVVH on [**7-15**] to treat his fluid
overload as above. During his hospitalization he was evaluated
by the transplant nephrology team who concluded that his renal
failure was likely due to his post-infectious GN with a
component of ATN and so he initially did not qualify at the
moment for liver-kidney transplant. However, Mr. [**Known lastname 40167**]
continued to require Hemodialysis at the end of his
hospitalization and ultimately was HLA typed and screened for
renal transplant. At time of discharge, patient was listed for
both liver and renal transplant.
#Anemia: Patient was persistently anemic despite multiple blood
transfusions. Hemolytic workup was negative. His anemia was
thought to be due to renal failure.
#L pleural effusion: The patient was found to have a persistent
left pleural effusion and that was causing mild left lower
collapse and contributing to his chronic respiratory distress.
He underwent U/S guided thoracentesis by IR and a total 1.7 L
was taken out. Fluid analysis showed that the fluid had a
similar composition to his ascites. The effusion re-accumulated
after 2 days. Pulmonary was consulted and they concluded that
this was due part to his ESLD with a component of nephrotic
syndrome.
#Abdominal Pain: Patient had persistent abdominal pain
throughout admission. Initially it was thought to be due to
SBP(see above) but it persisted even after SBP was treated. He
received multiple abdominal CT that never revealed an acute
process.
# Pulmonary HTN: Patient had a TTE done as part of the
evaluation for liver re-transplantation. It revealed an EF 70%,
a hyperdynamic LV and pulmonary HTN. A right heart cath was
subsequently done to further characterize his pulmonary HTN.
This revealed PCWP of 22 mmHg, elevated right sided filling
pressure at 15 mmHg and moderate pulmonary HTN of PASP of 44
mmHg. He was diagnosed with type 1 pulmonary hypertension caused
by his ESLD and nephrotic syndrome.
#Sinus Tachycardia: Patient was persistently in sinus
tachycardia to low 100s. His EKG revealed no abnormalities.
Right Heart Cath showed Pulmonary HTN.
# S/p Liver Transplant: Patient is s/p liver transplant at age 4
because of biliary atresia. His ESLD remained at baseline with a
MELD ranging in the mid 20s. He was re-evaluated and thought to
be a candidate for re-transplantation. He underwent complete
transplant workup while in the hospital and is currently listed
on the transplant list.
# Fever: Patient had a fever while on Vanc and Zosyn as well as
eosinophilia. There was concern for drug fever and antibiotics
were discontinued. Patient defervesced. He continued to have
occasionaly low-grade fevers with no source identified. He was
given Vancomycin HD protocol for possible HD line infection. He
was discharged afebrile.
.
# Eosinophilia - Noted during the end of his admission. Thought
likely secondary to antibiotics or other medication. however,
other causes were not excluded. Pending results for HISTOPLASMA
ANTIBODY (BY CF AND ID), SCHISTOSOMA ANTIBODIES, and
STRONGYLOIDES ANTIBODY,IGG were pending at discharge to be
followed up.
Medications on Admission:
alendronate 70mg qweek
-clcium acetate 667mg 2 capsule tid
-hydrocodone-acetaminophen 5-500 q6h prn
-lisinopril 5mg qday
-pantoprazole 40mg qday
-sucralfate 1g qid
-tacrolimus 0.5mg [**Hospital1 **]
-calcium carbonate-vitamin d3 600-400 [**Hospital1 **]
-sodium bicarbonate 650mg [**Hospital1 **]
-furosemide 80mg qday
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QD ().
Disp:*30 Capsule(s)* Refills:*2*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 30 days.
Disp:*30 Tablet(s)* Refills:*0*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezes.
Disp:*1 inh* Refills:*2*
5. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO QID (4 times
a day) as needed for constipation: titrate to 3 bowel movements
per day.
Disp:*qs * Refills:*3*
6. Ivermectin 3 mg Tablet Sig: Four (4) Tablet PO daily () for 4
days: start [**2135-8-3**].
Disp:*16 Tablet(s)* Refills:*0*
7. Outpatient Lab Work
Please draw a Quanteferon gold as ordered in Mr [**Known lastname 78898**]
electronic [**Medical Record Number 78899**]. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary Diagnosis:
1. End Stage Liver Disease
2. End Stage Renal Failure, Hemodialysis dependent
3. Respiratory Failure
4. Peritonitis
5. s/p Small bowel resection
6. Avascular necrosis Left hip
7. Malnutrition
Discharge Condition:
Afebrile, vital signs stable. Tolerating PO and continuous tube
feeds, electrolytes within normal limits on HD.
Discharge Instructions:
You were admitted to [**Hospital1 **] on [**2135-6-11**] for
nausea, vomiting, and high potassium. We gave you fluids and
medications for nausea. Due to your abdominal pain, you
required an operation to determine what was causing the pain.
During the operation a small portion of your bowel was removed
due to concern that there was a hole in the bowel wall causing
stool to leak into your abdomen. Because of this, you were
started on ciprofloxacin which you should continue. This is an
antibiotic which helps to prevent future infections in your
abdomen.
Additionally, during your admission, you had problems with your
breathing and were sent to the intensive care unit and required
a machine to breathe for you. Additionally, you had problems
with your kidneys that required hemodialysis, which will
continue ([**Date Range 766**], Wednesday, and Fridays) once you leave the
hospital. Your liver was determined to not be working properly
and you were listed for another liver transplant. You also may
need a kidney transplant--and were evaluated in the hospital for
this as well.
You were also given a medication called ivermectin in case you
have a parasitic infection. You should continue this medication
for the next 4 days ([**8-3**], [**8-4**], [**8-5**] and [**8-6**]). In addition, you
should have a blood test drawn in the [**Hospital Unit Name **] early on
[**8-10**] PRIOR to your appointment with Dr [**Last Name (STitle) 497**] at 8:20
am.
In the meantime, you were started on tube feeds to support your
nutrition which you should continue until you are told
otherwise.
Please return to the ER or call your doctor if you experience
chest pain, shortness of breath, severe nausea/vomiting, bloody
stools, abdominal pain, fevers, chills, or any other symptoms
that are concerning to you.
You should NEVER take ibuprofen or any other nonsteroidal
anti-inflammatory medications for pain.
Followup Instructions:
Please follow up in Liver Clinic with Dr [**Last Name (STitle) 497**] on Wednesday,
[**8-10**] at 8:20am. Please have labs drawn early the same
morning prior to your appointment. Please call ([**Telephone/Fax (1) 1582**]
should you need to reschedule.
.
Please follow up in kidney clinic ([**Hospital Ward Name 23**] 7) with Dr. [**Last Name (STitle) **]
on Tuesday [**9-20**] at 3:00pm. Please call ([**Telephone/Fax (1) 10135**] should
you need to reschedule.
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26,371
| 117,141
|
47975
|
Discharge summary
|
report
|
Admission Date: [**2129-10-16**] Discharge Date: [**2129-11-17**]
Date of Birth: [**2069-5-18**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Cipro / Penicillins / Gluten / Ativan
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Diarrhea, failure to thrive
Major Surgical or Invasive Procedure:
Pleuroscopy/Pleurodesis
Bronchoscopy on [**11-15**]
History of Present Illness:
HPI:
60 F with h/o celiac disease, partial colectomy, presents for
continued weight loss, albumin 1.1, anorexia, further eval of
celiac disease by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1356**], GI [**Hospital1 18**]. Patient has had
diarrhea and GI discomfort for the past 25 yrs per pt, and was
diagnosed with celiac disease in [**2124**] during a colectomy at [**Hospital1 2025**].
.
Over the past 2-3 months, the patient feels that she has
progressively deteriorated. Over this time, the patient has had
progressively more diarrhea, runny, brown, no blood, no mucus,
but she has progressively not been able to control the diarrhea
and has had increasing bouts of stool incontinence, for which
she now requires a diaper at all times. She has never seen
blood in her stool and has only seen black stool when taking
iron. She has diffuse abdominal pain intermittently with eating
too much, or with 3rd spacing in abdominal area. Her PO intake
of food and fluid has not been decreasing dramatically, but she
has been losing weight. Her legs, arms, buttock areas, backs of
her legs, and abdomen have become more swollen with fluid.
.
Patient was on TPN at OSH through RIJ. RIJ line was inserted on
[**10-4**] (dressing was changed on [**10-16**]). Patient briefly received
prednisone, but this was for a rash from presumptive OsCal
allergy.
.
Patient was admitted to [**Hospital3 1443**] Hospital on [**10-2**] with
N/V/SOB/CP, was diagnosed with pna and UTI, placed on
ceftriaxone, improved. Ruled out for MI by enzymes, EKG had TWI
inferiorly.
.
Patient has been admitted for further assessment of her celiac
disease by Dr. [**First Name (STitle) 1356**]. Concern at OSH has been for celiac
disease vs. malignancy vs. anorexia (psych) vs amyloid. Had
screening mammogram and abd CT as outpatient that were normal.
Patient was seen by Dr. [**Last Name (STitle) 8671**] (GI consult at LMH) but has
yet to have had endoscopy (upper or lower). LMH does not have
push enteroscopy capabilities so as to obtain a SB sample as
they were hoping for to r/o lymphoma. They were planning on
colonoscopy (r/o malignancy) and rectal bx (r/o amyloid), when
patient requested coming to a tertiary center to have extensive
work-up.
.
ROS: +cough, +sore throat, +CP, +SOB, +weight loss, +pna,
+urinary burning, +urinary incontinence, +abdominal pain, +LE
swelling and pain.
Past Medical History:
PMH:
HTN
Cystocele
Celiac disease - dxed [**2124**]
Mitral regurgitation
Left upper lobe lung nodule
Hematuria
Failure to thrive
20 lb weight loss since [**3-1**] after OSH admission, is s/p
admission from [**Date range (1) 101225**] for uterine prolapse.
Osteoporosis
.
PSH:
Partial colectomy in [**2124**] at [**Hospital1 2025**] - dxed with celiac disease at
this time
Cholecystectomy in [**7-1**] at [**Hospital3 1443**] Hospital
Social History:
Patient was living alone, but daughter is now moving in with her
in her single family house. She is disabled from day care work
since her admission [**Date range (1) 101225**] with significant deconditioning
and weight loss. No EtOH, smoked for 2 yrs in her 20s, no IVDU.
She has a daughter and son, and a grandson she takes care of.
Family History:
No family history of celiac disease. Other than daughter and
grandson, no history of autoimmune disease.
Daughter - Crohn's disease
Grandson - Type I diabetes mellitus
Father - died 61 of renal failure, had stroke at 57
Maternal aunt - breast cancer
Maternal aunt - ovarian cancer
Physical Exam:
Vs: 98.3 / 128/82 / 100 / 28 / 96% 2L nc
Gen: Breathing fast, lying in bed, irritable, cachectic, looks
tired
HEENT: No JVD, RIJ line appears clean and nonerythematous, no
LAD, oropharynx clear, moist mm, PERRL, anicteric sclerae, clear
nasal turbinates
Lungs: Dull to region 2 bilaterally, crackles and rhonchi that
clear with coughing; pain on palpation of costochondral
junctions
Heart: Regular but tachy, no m/r/g, PMI non-displaced
Abdomen: Shiny skin, 3rd spacing all over abdomen esp in
dependent areas, tenderness diffusely to palpation
Back: No CVA tenderness, no spinal tenderness
Extr: No cyanosis or clubbing, but 3+ pitting edema in LE,
proximal UE
Skin: No rashes, but shiny stretched skin over abdomen, legs,
arms, buttocks, backs of legs
Neuro: [**3-31**] motor UE, [**1-29**] motor LE due to pain upon movement,
sensation decreased in LE (per pt due to edema)
Pertinent Results:
[**2129-10-9**] from OSH:
Na 140, K 4.3, Cl 115 (high), CO2 21 (high)
Ca 6.6 (low), Phos 2.8, Mg 1.6 (low)
.
[**Last Name (un) **] stim: 18 at 60 min
.
TG 112, Tot Prot 4.1, Phos 2.0, ALBUMIN 1.1
TB 0.1, AP 160, ALT 34, AST 39,
.
CXR [**2129-10-9**] from OSH:
Continuing bilateral pleural effusions and/or infiltrates.
WBC 9.2
.
[**2129-10-16**] 05:50PM BLOOD WBC-6.7 RBC-2.84* Hgb-8.1* Hct-24.0*
MCV-84 MCH-28.7 MCHC-34.0 RDW-17.6* Plt Ct-272
[**2129-10-19**] 06:36PM BLOOD WBC-11.1* RBC-3.86* Hgb-12.0 Hct-33.5*
MCV-87 MCH-31.0 MCHC-35.8* RDW-17.3* Plt Ct-379
[**2129-10-20**] 04:31AM BLOOD WBC-9.1 RBC-3.44* Hgb-10.2* Hct-29.6*
MCV-86 MCH-29.6 MCHC-34.5 RDW-16.5* Plt Ct-368
[**2129-10-24**] 04:30AM BLOOD WBC-11.2* RBC-3.23* Hgb-9.6* Hct-27.8*
MCV-86 MCH-29.6 MCHC-34.4 RDW-15.9* Plt Ct-516*
[**2129-10-26**] 03:35AM BLOOD WBC-10.5 RBC-3.13* Hgb-9.2* Hct-27.3*
MCV-87 MCH-29.4 MCHC-33.9 RDW-15.7* Plt Ct-537*
[**2129-10-27**] 04:46AM BLOOD WBC-14.6* RBC-3.24* Hgb-9.6* Hct-27.9*
MCV-86 MCH-29.7 MCHC-34.5 RDW-15.5 Plt Ct-510*
[**2129-11-1**] 06:06AM BLOOD WBC-12.0* RBC-3.41* Hgb-10.1* Hct-30.4*
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.4 Plt Ct-558*
[**2129-11-2**] 06:15AM BLOOD WBC-10.2 RBC-3.22* Hgb-9.8* Hct-28.3*
MCV-88 MCH-30.4 MCHC-34.6 RDW-16.4* Plt Ct-564*
[**2129-11-3**] 04:09AM BLOOD WBC-33.7*# RBC-3.33* Hgb-9.9* Hct-29.5*
MCV-89 MCH-29.7 MCHC-33.5 RDW-15.1 Plt Ct-618*
[**2129-11-4**] 03:55AM BLOOD WBC-25.0* RBC-3.22* Hgb-9.6* Hct-28.9*
MCV-90 MCH-29.9 MCHC-33.3 RDW-16.6* Plt Ct-684*
[**2129-11-5**] 04:54AM BLOOD WBC-13.5* RBC-3.21* Hgb-9.2* Hct-28.8*
MCV-90 MCH-28.5 MCHC-31.7 RDW-15.2 Plt Ct-632*
[**2129-11-7**] 04:13AM BLOOD WBC-12.2* RBC-3.94*# Hgb-11.2*# Hct-36.1#
MCV-92 MCH-28.5 MCHC-31.1 RDW-15.2 Plt Ct-818*
[**2129-11-8**] 05:20AM BLOOD WBC-15.4* RBC-3.11* Hgb-8.7* Hct-27.5*
MCV-88 MCH-27.9 MCHC-31.6 RDW-15.5 Plt Ct-633*
[**2129-11-15**] 05:00AM BLOOD WBC-14.9* RBC-3.59* Hgb-10.2* Hct-31.6*
MCV-88 MCH-28.4 MCHC-32.3 RDW-15.7* Plt Ct-531*
[**2129-11-16**] 11:27AM BLOOD WBC-14.2* RBC-3.52* Hgb-10.1* Hct-31.1*
MCV-88 MCH-28.6 MCHC-32.4 RDW-15.9* Plt Ct-504*
[**2129-11-17**] 04:45AM BLOOD WBC-10.6 RBC-3.31* Hgb-9.5* Hct-29.2*
MCV-88 MCH-28.7 MCHC-32.5 RDW-16.0* Plt Ct-454*
[**2129-11-16**] 11:27AM BLOOD Neuts-71.0* Lymphs-19.3 Monos-9.1 Eos-0.3
Baso-0.4
[**2129-11-10**] 04:58AM BLOOD PT-13.1 PTT-31.5 INR(PT)-1.2
[**2129-11-4**] 03:55AM BLOOD D-Dimer-2614*
[**2129-11-17**] 04:45AM BLOOD Glucose-114* UreaN-17 Creat-0.3* Na-136
K-4.0 Cl-108 HCO3-23 AnGap-9
[**2129-11-16**] 05:22AM BLOOD Glucose-112* UreaN-18 Creat-0.3* Na-140
K-4.3 Cl-110* HCO3-21* AnGap-13
[**2129-10-16**] 05:50PM BLOOD Glucose-141* UreaN-6 Creat-0.5 Na-139
K-3.7 Cl-102 HCO3-31 AnGap-10
[**2129-11-17**] 04:45AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.7
[**2129-11-9**] 11:27AM BLOOD Hapto-411*
[**2129-10-18**] 06:34AM BLOOD VitB12-770
[**2129-10-16**] 05:50PM BLOOD calTIBC-105* Ferritn-550* TRF-81*
[**2129-11-15**] 05:00AM BLOOD Triglyc-156*
[**2129-10-19**] 05:04AM BLOOD Triglyc-76
[**2129-10-16**] 05:50PM BLOOD TSH-2.1
[**2129-11-1**] 06:06AM BLOOD IgG-1478 IgA-420*
[**2129-10-18**] 06:34AM BLOOD PEP-ABNORMAL B IgG-991 IgA-371 IgM-77
IFE-BAND OF MO
[**2129-10-19**] 06:36PM BLOOD HIV Ab-NEGATIVE
[**2129-11-9**] 04:56PM BLOOD Type-ART pO2-74* pCO2-41 pH-7.47*
calHCO3-31* Base XS-5 Comment-NASAL [**Last Name (un) 154**]
[**2129-11-7**] 10:33PM BLOOD Type-ART O2 Flow-5 pO2-101 pCO2-45
pH-7.37 calHCO3-27 Base XS-0 Comment-NASAL [**Last Name (un) 154**]
[**2129-11-2**] 07:17PM BLOOD Type-ART Rates-/30 FiO2-94 pO2-76*
pCO2-38 pH-7.45 calHCO3-27 Base XS-2 AADO2-566 REQ O2-92
Intubat-NOT INTUBA
[**2129-11-3**] 12:42AM BLOOD Type-ART pO2-103 pCO2-37 pH-7.44
calHCO3-26 Base XS-0
[**2129-11-4**] 01:18AM BLOOD Lactate-1.1 K-4.4
[**2129-11-3**] 12:42AM BLOOD Glucose-217* Lactate-1.8 Na-134* K-3.0*
Cl-102 calHCO3-25.
.
CXR [**10-16**]:
CHEST: A single portable semi-upright view at 4:00 p.m. shows
bilateral pleural effusions with bibasilar atelectasis. There is
vascular engorgement, indicating mild CHF.
The evaluation of both lower lungs is limited due to pleural
effusions and compressive atelectasis and concomitant pneumonia
cannot be excluded. A right IJ central venous catheter is noted
with the tip in SVC.
.
CT abd [**10-17**]:
IMPRESSION: Bilateral pleural effusions, anasarca, and small
amount of ascites. This patient will return for an IV contrast
enhanced CT scan.
.
PICC placed [**10-17**]
.
Pleural fluid11/23:
NEGATIVE FOR MALIGNANT CELLS.
Histiocytes, mesothelial cells and small lymphocytes.
CD 20 and CD 3 stains were performed on cytospins. Scattered T
cells are noted. B-cell (CD 20) stain is negative.
.
EGD biopsy [**10-26**]: chronic active inflammation, no tumor
.
Colonoscopy [**2129-10-26**]:
Strictures of the duodenum and jejunum
Small hiatal hernia
Abnormal mucosa in the duodenum and jejunum
There was dilated jejunum with pooled bilious fluid suggestive
of stasis.
Erythema and congestion in the gastroesophageal junction
Ulcers in the distal duodenum and visualized jejunum
.
Chest CT [**2129-10-25**]:
1. Mediastinal adenopathy, a nonspecific finding.
2. Left upper lobe nodule. Per given history, this was present
and stable for fifteen years. Recommend direct comparison to
prior studies to confirm stability.
3. Bilateral lower lobe atelectasis and mucoid impaction,
occlusive on the right.
4. Bilateral pleural effusion, moderate left and small right,
decreased in size from the prior study, consistent with interval
thoracentesis.
.
CXR [**11-13**]:CHEST: PA and lateral views are compared to previous
examination of [**2129-11-9**]. There are bilateral pleural
effusions. The right pleural effusion has slightly decreased
since the previous exam. The left hydropneumothorax is smaller
on the current exam. Again seen is bibasilar atelectasis with
probable pneumonia in the right lower lung. The left suprahilar
pulmonary nodule remains stable.
A right PICC line is seen with the tip in distal SVC.
.
Pleural biopsy [**11-2**]:Fragments of reactive mesothelium with acute
and chronic inflammation, granulation tissue, and blood; no
malignancy identified.
.
ucx [**11-23**]: no growth
.
bcx [**11-7**], [**11-3**], [**10-26**]:NGTD
.
stool cx [**11-2**]: c.diff +
.
CMV viral load negative
.
sputum cx [**10-20**]: sparse growth MRSA, pseudomonas
Brief Hospital Course:
Hospital Course:
60 F with h/o celiac disease, partial colectomy, presented for
continued weight loss, albumin 1.1, anorexia, further eval of
celiac disease.
.
*Anorexia: Patient is a 60 F with an extremely complicated PMHx
notable for celiac disease, partial colectomy, who initially
presented on [**2129-10-16**] for continued weight loss, albumin
1.1,anorexia and diarrhea further eval of celiac disease by Dr.
[**First Name (STitle) 1356**]. Given her [**Known lastname **] standing history of celiac disease and
non-compliance with gluten free diet, exacerbation of celiac
disease was thought to be likely cause, though an underlying
malignant process has not been completely ruled out. EGD on
[**10-26**] showed strictures in duodenum and jejunum c/w celiac dx.
No evidence of malignancy seen on biopsy. Patient was kept on a
strict gluten free diet and diarrhea resolved. Appetite improved
on megace and remeron and TPN was started because of weight loss
and failure to thrive and was continued throught her admission.
SPEP was done and found to have MGUS likely c/w autoantibodies
from celiac disease. A severe Vitamin D deficiency was noted.
At d/c will start Vit D [**Numeric Identifier 1871**] units qd x one one week, then
qweek after that. Levels will need to be checked in one month.
Will continue TPN as an outpatient.
.
*SOB/PNA/Pleural effusions: Pt was found to have PNA at OSH
prior to transfer with improvement on ceftriaxone. She was
initially continued on Ceftriaxone for PNA and UTI found at OSH.
At admission CXR showed bilateral pleural effusions and
bibasilar atelectasis with mild CHF. She was diuresed with
lasix during the beginning of her admission until she was
euvolemic for volume overload and edema. Sputum cultures were
obtained here that showed sparse growth of MRSA and pseudomonas.
Chest CT was done on [**10-25**] for w/u of possible malignancy and
showed right occlusive mucoid impaction. She was not immediately
started on abx b/c she was thought to be colonized with the
bacteria. However, she had some increasing SOB, chest pain and
fevers so she was started on Vanc and Ceftaz on [**10-26**] with
improvement in fevers. She completed a 14 day course of these
medications. At that time her SOB was thought to be
multifactorial secondary to pleural effusions, possible PNA,
anxiety, CHF and possible pericardial effusion. Echo was done
and showed only trivial pericardial effusion with EF >75%.
In terms of her bilateral pleural effusions, her L sided
effusion was tapped on [**10-19**], c/w transudate with 1500cc
removed. Re-tapped on [**10-31**] and was c/w exudate with significant
amount of bloody drainage. Because of the exudative effusion and
some atypical cells (T cells) noted in prior pleural fluid she
was sent for pleuroscopy and pleurodesis for her L sided
effusion on [**11-1**]. Pleural space had inflammatory changes but
pleural fluid was negative for malignancy. She had a chest tube
placed at that time and this caused her a significant amount of
pain. Patient was tachypneic to 40s-50s although satted well on
5L NC O2(could have tolerated less O2 but did not want to be
weaned down). Pain controlled with morphine. Was briefly sent to
the intensive care unit because of her tachypnea, but serial
ABGs were stable and she was observed with no intervention.Chest
tubes were removed and patient started to improve. During the
entire course she was on MRSA precautions, scheduled atrovent
nebs, PRN albuterol and chest PT. On [**2129-11-15**] she had a
bronchoscopy to further evaluate for malignancy and retrieve
tissue from an enlarged subcarinal LN seen on chest CT. One
biopsy specimen was obtained but the procedure was terminated
secondary to the patient desatting during the procedure. Had two
episodes of desaturation during this admission, once on 5L NC
thought to be secondary to mucous plugging, and once after
walking with PT. Currently she is stable on 1.5 L NC O2 and O2
may likley be weaned down, but patient is anxious when attempt
to wean O2 down. Will need to f/u on biopsy results from
bronchoscopy.
.
*LE edema: Patient had significant amount of lower extremity
edema at admission with mild CHF on exam and bilateral pleural
effusions. Much of this was thought to be d/t
hypoalbuminemia since albumin was 1.1. She was aggressively
diuresed early in her admission and nutritional status was
increased with TPN and appetite stimulation and edema resolved.
.
* C.diff colitis: Had diarrhea at admission which was thought
to be secondary to noncompliance with gluten free diet. Her
c.diff toxin assay was negative at that time and diarrhea
improved on gluten free diet. On [**11-3**] WBC jumped to 33 and
patient's stool was found to be positive for c. diff. She was
treated with 2 weeks of flagyl and diarrhea improved and WBC
trended down.
.
*Lung nodule: Patient has had stable lung nodule in left upper
lobe for past 15 years. This nodule was again seen on chest CT
here, but no intervention was done and likely not malignancy
since it has been stable for many years.
.
*h/o Recurrent UTI: Patient had UTI at admission and was on
ceftriaxone. She was continued on it initially at admission. She
had a foley placed during her admission b/c of need for
aggressive diuresis and urinary incontinence. Subsequent urine
cultures were free of bacteria but were positive for yeast. She
was treated with 5 days of diflucan. Foley was dc'd prior to
discharge.
.
*Chest pain: Patient had reproducible left sided chest pain
during her admission with no new EKG changes. Was thought to be
secondary to PNA, chostochondritis or possible pericardial
effusion. Echo showed trivial pericardial effusion and pain
improved after
.
* Anemia: Patient has history of guiac positive stools and
required several blood
transfusions over the course of her admission. Likely was
secondary to GI source as she was noted to have some ulceration
in her duodenum during colonoscopy. Hct stable at d/c.
.
*Anxiety: Patient very anxious throughout admission. Got
confused on ativan. Did not want to try clonazepam. Tried
zyprexa and stated it made her sleepy and did not want to take.
.
*Outpatient follow-up: Will need to f/u with Dr. [**First Name (STitle) **] in [**Hospital 191**]
clinic in one month. Phone number is [**Telephone/Fax (1) 250**]. Prior to
doing this, she will need to change her PCP at [**Name9 (PRE) **] Health to
Dr. [**First Name (STitle) **].
Medications on Admission:
Meds:
Remeron 15 mg PO QHS (has not started yet)
FeSO4
Welchol for diarrhea
MVI
Albuterol nebs prn
Oxycodone prn for LE edema pain
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) tablet PO Q6H
(every 6 hours).
2. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
3. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical PRN (as
needed).
4. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): until patient
ambulating.
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
neb Inhalation Q6H (every 6 hours).
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for throat pain.
12. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
day for 7 days: 1st week.
15. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week for 3 weeks: for 3 weeks after loading for 1 week.
16. Vitamin D 400 unit Capsule Sig: Two (2) Capsule PO once a
day: after 1 month of loading.
17. TPN
at night, see attached for current formulation
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Recurrent pleural effusions.
Pneumonia.
Mediastinal lymphadenopathy.
C. Difficile infection.
Malnutrition.
MGUS
Celiac Sprue
Anemia
Discharge Condition:
Fair
Discharge Instructions:
Continue all discharge meds at [**Hospital1 **] as well as TPN.
Follow up as below.
If, after going home from [**Hospital1 **], you experience fevers,
chills, SOB, other concerning symptoms, you should call your PCP
or go to the ER.
Followup Instructions:
F/u with
1. Dr. [**First Name8 (NamePattern2) 6665**] [**Name (STitle) 1356**], in gastroenterology at [**Telephone/Fax (1) 7091**].
2. You have to call Masshealth to change your primary care site
to [**Hospital1 **] before we can make you an appointment.
After doing that, you should make an appointment with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **]. YOu can do that by calling ([**Telephone/Fax (1) 1300**].
|
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"579.0",
"300.00",
"285.29",
"933.1",
"261",
"273.1",
"482.1",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.29",
"34.24",
"34.91",
"33.23",
"34.92",
"99.15",
"45.16",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
19358, 19437
|
11173, 11173
|
349, 402
|
19613, 19620
|
4853, 11150
|
19901, 20333
|
3648, 3932
|
17787, 19335
|
19458, 19592
|
17632, 17764
|
11190, 17606
|
19644, 19878
|
3947, 4834
|
282, 311
|
430, 2820
|
2842, 3277
|
3293, 3632
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,474
| 134,454
|
14713+14723+14724+56567
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2174-6-3**] Discharge Date: [**2174-6-25**]
Date of Birth: [**2124-10-23**] Sex: M
Service:
NOTE: This is a dictation of the [**Hospital 228**] Medical Intensive
Care Unit course from [**6-3**] until [**6-24**]. Please see
following dictation for the remainder of the patient's
hospitalization.
CHIEF COMPLAINT: Transfer for gastrointestinal bleed
HISTORY OF PRESENT ILLNESS: This is a 49-year-old gentleman
with a history of alcohol abuse, cirrhosis and recent history
of upper gastrointestinal bleed who presented to the
Emergency Room at the outside hospital with maroon stools and
nasogastric lavage was subsequently positive for bright red
blood. Blood pressure 147/89, heart rate 120. First
hematocrit was 31. The patient was admitted to the Intensive
Care Unit at outside hospital where he was transfused a total
of 7 units of packed red blood cells over 24 hours. He also
received 4 units of fresh frozen plasma for an INR of 2.3.
Hematocrit trend was 31.6 to 27.1 to 30.1 to 20.7 to 30.1.
The patient had an esophagogastroduodenoscopy done at the
outside demonstrating stomach with blood immediately after
the patient was intubated for area protection. He was
transferred to [**Hospital6 256**] on an
octreotide drip.
At [**Hospital6 256**],
esophagogastroduodenoscopy was repeated demonstrating grade 3
varices in the lower third of the esophagus and the middle
third of the esophagus. The varices were bleeding and
hemostasis was attempted with injection of sodium morrhuate
with partial success over four different quadrants. The
patient was noted to have blood in the whole stomach and in
the duodenum.
The patient was transferred to the Medical Intensive Care
Unit of further care.
PAST MEDICAL HISTORY:
1. Alcohol abuse
2. History of upper gastrointestinal bleed in [**2174-6-4**] with duodenal ulcer. Endoscopy [**2174-3-13**]
demonstrating duodenal bulb ulcer and portal gastropathy.
3. History of cirrhosis diagnosed 15 years prior to
admission. According to patient's daughter, the patient in
the past one year had been bloated and jaundiced.
ALLERGIES: No known drug allergies.
TRANSFER MEDICATIONS:
1. Combivent
2. Ciprofloxacin
3. Folic acid
4. Pepcid
5. Lopressor
6. Lasix
SOCIAL HISTORY: The patient is divorced with two daughters
and one son. One daughter lives in [**State 350**]. Other
siblings live in [**State 108**]. The patient is estranged from his
daughter for one year prior to this admission. The patient
smokes two cigarettes per day and two six packs a day.
FAMILY HISTORY: Unable to be obtained, as the patient is
intubated.
PHYSICAL EXAMINATION UPON ADMISSION:
VITAL SIGNS: Blood pressure 115 to 119/64 to 60 and
saturating 100% of SIMV, 700/16/5 and 50% FIO2.
GENERAL: The patient is sedated and intubated.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils are equal, round
and reactive to light and accommodation. Nasogastric tube in
place.
HEART: Tachycardic, no murmurs, rubs or gallops noted.
LUNGS: Coarse rhonchi bilaterally.
ABDOMEN: Distended with good bowel sounds, nontender, but
patient is sedated and difficult to assess.
EXTREMITIES: Without edema, dorsalis pedis pulses 2+
bilaterally.
IMAGING: Electrocardiogram demonstrates normal sinus rhythm
at 120 with normal axis and intervals, no ST or T wave
changes noted. No old electrocardiogram for comparison.
LABS ON ADMISSION: White count 4.8, hematocrit 31.6,
platelets 93. Sodium 142, potassium 4.4, chloride 108,
bicarbonate 24, BUN 26, creatinine 0.9 and glucose 112. INR
is 2.3.
HOSPITAL COURSE: In summary, this is a 49-year-old gentleman
with a history of alcohol abuse, recent upper
gastrointestinal bleed and cirrhosis who presents with
variceal bleed. Briefly, the patient was in the Medical
Intensive Care Unit for three weeks. For the first 24 hours,
supportive therapy was undertaken with transfusion of four
more units of packed red blood cells, intravenous octreotide,
intravenous Protonix and frequent hematocrit checks. The
patient was extubated the day after admission to the
Intensive Care Unit, but subsequently became agitated and
developed seizures consistent with DTs requiring
reintubation. The patient subsequently developed aspiration
pneumonia and eventually developed ARDS requiring vent
support for the next two weeks. Eventually, the patient was
weaned from the vent and transferred to the floor for further
medical management. More detailed explanation of the
[**Hospital 228**] hospital course in the Medical Intensive Care Unit
is following.
1. GASTROINTESTINAL: A. Gastrointestinal bleed: The
patient continued to melenic stools during this
hospitalization, but required no further blood transfusions,
as his hematocrit remained stable, greater than 25. The
patient had re-endoscopy demonstrating esophageal varices
which were banded. Third endoscopy was performed on
Thursday, [**6-9**] which demonstrated grade 3 varices in the
lower third of the esophagus, status post banding x2 and
final endoscopy was performed on [**Last Name (LF) 2974**], [**6-24**]
demonstrating grade 1 varices in the lower third of the
esophagus which were non bleeding and a superficial ulcer was
overlying the varices. The varices were not banded at this
time. Also noted was diffuse continuous congestion and
abnormal vascularity of the mucosa of the stomach without any
active bleeding which is compatible with portal gastropathy.
The patient was on octreotide GGT for the first two days of
his hospitalization which was subsequently discontinued. He
continued on sucralfate and Protonix for the remainder of his
hospitalization and also was started on propanolol for
varices which was titrated up as tolerated.
B. Cirrhosis: Patient with a long history of alcohol abuse
according to the patient's daughter who was able to give us
some history while the patient was intubated. The patient
also came back with hepatitis C antibody positive and
genotyping is pending. According to the patient's daughter,
the patient had discussed liver transplant with his primary
care physician several years ago, but had not followed up on
this. The patient's daughter was unable to tell us who the
patient's primary care physician [**Name Initial (PRE) **]. Lactulose was started
to prevent hepatic encephalopathy.
C. Ascites: The patient underwent paracentesis on
approximately [**6-8**] which was negative for SBP by
traditional criteria, however did have several polys. In
discussion with infectious disease and considering patient
had been on course of ciprofloxacin for variceal bleeding and
SBP prophylaxis. It was felt that the patient may be
suffering from an under treated SBP. Ceftazidine was started
for treatment of SBP and patient continued on a 10 day course
of this antibiotic. Second repeat paracentesis demonstrated
cure of SBP.
2. PULMONARY: As above, the patient was reintubated on [**6-4**], status post DTs. The patient subsequently developed
aspiration pneumonia and ARDS. He was treated with
approximately a two week course of clindamycin for aspiration
pneumonia. Chest x-rays demonstrated significant interval
improvement over this time of his bilateral multilobar
alveolar infiltrates. In the meantime, the patient also
became less ventilator dependent and was able to be
transferred to pressure support ventilation and then
eventually trach mask ventilation. The patient had
tracheostomy placed on [**6-14**]. Trach was downsized on
[**6-24**] and patient will undergo trach weaning in the next
week or two.
On [**6-22**], the patient was noted to have fevers to 102.5??????.
Blood cultures, urine cultures, sputum cultures were all
negative, however the patient was noted to have a new right
middle lobe infiltrate on chest x-ray. For concern of
redeveloping pneumonia, Ceftaz was started and as per
gastrointestinal recommendations, vancomycin was also
started. The patient subsequently became afebrile. The
patient remained hemodynamically stable throughout this time.
3. INFECTIOUS DISEASE: The patient underwent a 15 day
course of clindamycin for aspiration pneumonia and ARDS. The
patient underwent 10 day course of ceftazidine for SBP. The
patient also underwent six day course of linezolid for VRE.
The VRE was from a femoral line tip and never grew out in
blood cultures, but at the time that it was started on [**6-14**], the patient was noted to be hypotensive and all other
cultures were negative. It was felt that potentially the VRE
from the femoral line tip may have seeded a bacteremia or
even potentially a new bug in the patient's peritoneal fluid.
The patient responded to treatment with linezolid with
increased blood pressures and generalized increased stability
of his status.
4. NEUROLOGIC: Patient with DTs upon admission and
subsequently requiring very slow Versed wean during his
hospitalization. The patient was successfully weaned and
rehabilitated. Neurology had been consulted on [**6-4**] and
CT head was obtained which was negative. No further issues
with mental status were noted.
5. CARDIOVASCULAR: Patient initially hypotensive in the
beginning of his Intensive Care Unit course and required
Levophed pressure support. However, the patient was
gradually weaned off of the Levophed and on further episodes
of hypotension, became responsive to normal saline boluses.
By [**6-18**], the patient had a stable blood pressure and was
able to tolerate propanolol with no episodes of hypotension.
6. FLUIDS, ELECTROLYTES AND NUTRITION: Patient initially on
TPN, but during the latter part of his hospitalization course
the patient was able to tolerate tube feeds. Speech and
swallow was consulted and the patient was initially unable to
swallow or speak with a valve on his tracheostomy closed.
Further evaluation from speech and swallow and further trach
changes are pending.
7. RENAL: Patient without any issues during this admission
and had good urine output and stable creatinine.
8. LINES AND ACCESS: The patient had right IJ during this
admission which was changed once. Pending PICC placement for
long-term antibiotics.
9. SOCIAL: The patient's daughter who had been estranged
from him for one year prior to his admission became the
[**Hospital 228**] health care proxy. The patient has another
daughter and son who live in [**Name (NI) 108**] who declined to be
health care proxy and this daughter since she was closest in
geographical location and closest to the patient has become
involved in his care. Her name is [**Name (NI) **] [**Name (NI) 43300**] and her home
phone number is ([**Telephone/Fax (1) 43301**].
The patient remained full code throughout this admission.
Please see following discharge summary for discharge
medications and follow up instructions.
As per gastrointestinal, the patient should follow up in one
month for a repeat esophagogastroduodenoscopy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3090**], M.D. [**MD Number(1) 3091**]
Dictated By:[**Last Name (NamePattern1) 43302**]
MEDQUIST36
D: [**2174-6-25**] 13:22
T: [**2174-6-25**] 13:35
JOB#: [**Job Number 43303**]
Admission Date: [**2174-6-3**] Discharge Date: [**2174-7-6**]
Date of Birth: [**2124-10-23**] Sex: M
Service: [**Hospital1 **] MEDICINE
NOTE: This is addendum #3. Addenum #2 should also be stat
discharge summary, as well.
STAT ADDENDUM:
DISCHARGE MEDICATIONS:
1. Sucralfate 1 gm po qid
2. Nystatin oral suspension 5 ml po qid prn
3. Lacrilube ointment 1 application prn
4. Miconazole powder 2% 1 application prn
5. Albuterol 4 to 8 puffs inhaled q6 prn
6. Simethicone 40 mg po qid prn
7. Lactulose 15 mg po tid
8. Propanolol 80 mg po qid
9. Spironolactone 50 mg qd
10. Pantoprazole 40 mg po qd
DISCHARGE CONDITION: Good
DISCHARGE STATUS: The patient will be discharged to his
daughter's home. There, he will receive outpatient PT and
OT. This should help him get back to ambulating without a
cane.
DISCHARGE DIAGNOSES:
1. Alcoholic cirrhosis of the liver
2. Pneumonia
3. Variceal bleed
4. ARDS
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Last Name (NamePattern1) 43319**]
MEDQUIST36
D: [**2174-7-6**] 07:47
T: [**2174-7-6**] 07:55
JOB#: [**Job Number 43320**]
Admission Date: Discharge Date: [**2174-7-7**]
Date of Birth: Sex: M
Service:
ADDENDUM
Mr. [**Name13 (STitle) **] will be discharged on [**2174-7-7**], to the Greenery
in [**Location 9583**], [**State 350**]. He will not be discharged
to his daughter's home at this time.
DR.[**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] 12-899
Dictated By:[**Last Name (NamePattern1) 9352**]
MEDQUIST36
D: [**2174-7-6**] 22:31
T: [**2174-7-7**] 00:00
JOB#: [**Job Number 43321**]
Name: [**Known lastname 447**], [**Known firstname **] Unit No: [**Numeric Identifier 7894**]
Admission Date: [**2174-6-3**] Discharge Date: [**2174-7-7**]
Date of Birth: [**2124-10-23**] Sex: M
ADDENDUM: This addendum will cover the patient's course
after he was transferred from the Intensive Care Unit to the
floor.
alcohol abuse and hepatitis C with liver cirrhosis. He was
admitted to the hospital with a variceal bleed, and
subsequently developed aspiration pneumonia and ARDS. The
patient had a long course in the MICU and was eventually
weaned from his intubation onto a trach mask. He was put on
Vancomycin, Ceftazidime for his pneumonia.
164/90, pulse 64, respirations 20, satting 100% on 40% trach,
600 in/3,050 out in the Foley and one OB negative bowel
movement. Generally, this was a somewhat cachectic man lying
in bed in no acute distress, alert and oriented. HEENT:
Extraocular movements intact, pupils are equal, round, and
reactive to light and accommodation, no scleral icterus, no
oropharyngeal thrush. Neck, no JVD or lymphadenopathy.
Chest, diffuse bilateral rhonchi without rales. Cardiac,
regular rate and rhythm, S1 and S2, no rubs, gallops or
murmurs. Abdomen, moderately distended, normoactive bowel
sounds, nontender, no appreciable hepatosplenomegaly.
Extremities, no edema, clubbing, cyanosis. Neuro, no focal
neuro deficits. Skin, no rashes present.
LABORATORY DATA: On transfer showed white count 5.9,
hematocrit 28.5, platelet count 134,000, PT 14.9, PTT 33.3,
INR 1.5, sodium 135, potassium 3.6, chloride 104, CO2 24, BUN
10, creatinine 0.6, glucose 105, ALT 37, AST 62, alkaline
phosphatase 96, total bilirubin 1.0, calcium 8.5, phosphorus
2.9, magnesium 1.6.
HOSPITAL COURSE: While on the medicine unit.
[**Unit Number **]. Pulmonary: The patient's pulmonary status continued to
improve while he was on the floor. He initially had
complained of airway obstruction when his tracheostomy tube
was capped for speaking and this was exchanged with a smaller
diameter tracheostomy tube, which the patient tolerated very
well. The patient's pulmonary status continued to improve
such that he gradually was weaned off the tracheostomy mask
and could tolerate room air and still hold saturations in the
high 90%. He was weaned off his trach and decannulated from
the trach tube on floor day #6 and tolerated this very well.
2. ID: The patient was on Vancomycin as treatment for
pneumonia which was later complicated by ARDS. The patient
showed no signs of pneumonia while on the floor with high
saturations, chest exam without rales. He did cough up a
large amount of sputum on floor days #1 and 2 while his
pneumonia and ARDS were resolving but this declined towards
the end of his floor stay. The patient did not show any
signs of other infection during his floor stay and was
continued on Vancomycin the entire time. He will require 14
total days of Vancomycin and therefore needs to continue up
to the 14th day upon discharge.
3. GI: The patient has a history of alcoholic liver
cirrhosis and hepatitis C, as well as variceal bleeding,
portal gastropathy. His liver function was stable while on
the floor with little change in his coagulation studies or
liver function tests. The patient will require a repeat EGD
exam about 4 weeks status post discharge.
4. Fluids & Electrolytes: The patient experienced a large
diuresis from his ARDS third spacing while on the floor. He
was 15 liters positive while in the unit and proceeded to
diurese to be 15 liters negative while on the floor. Upon
discharge he was normovolemic, maintained good blood
pressures and normal pulse. His electrolytes were stable
with occasional dips in potassium which was readily replaced
with po 40 mg of potassium. Patient's nutritional status
upon admission to the floor, the patient had an NG tube which
was pulled out on one occasion and fell out on another. The
patient had a post pyloric tube placed which also fell out.
During the time the NG tubes were in, he was fed tube feeds.
After the post pyloric tube fell out, the patient was given a
swallow study and deemed ready for swallowing and was given a
ground diet which was then advanced to a regular diet after
his trach was decannulated. The patient at first took small
po but gradually was increasing to good po.
5. Line Access: The patient had a PICC line placed on day
#2 of his [**Hospital1 **] course for IV access for discharge antibiotics
of Vancomycin. The patient had his central line pulled.
6. Renal: The patient had good renal function during his
[**Hospital1 **] stay. No issues. He had his Foley catheter
discontinued on day #6 of his medicine [**Hospital1 **] stay.
CONDITION ON DISCHARGE: Good. He will be discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Alcoholic liver disease with variceal bleed, pneumonia,
ARDS.
2. Hepatitis C.
DISCHARGE MEDICATIONS: Vancomycin 1 mg IV q 12 hours for a
total of 14 days, Lactulose 15 ml po tid, Propranolol 80 mg
po qid, Pantoprazole 40 mg IV q 24 hours. This could
actually be changed to Pantoprazole po 40 mg q 24 hours.
Spironolactone 50 mg po q d, Sucralfate 1 gm po qid,
Albuterol MDI 4-8 puffs q 6 hours prn.
The patient remained full code during this admission.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 7895**]
Dictated By:[**Last Name (NamePattern1) 7896**]
MEDQUIST36
D: [**2174-7-1**] 16:23
T: [**2174-7-13**] 10:13
JOB#: [**Job Number **]
|
[
"571.2",
"780.39",
"456.20",
"303.90",
"291.0",
"518.5",
"789.5",
"507.0",
"567.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"45.13",
"96.71",
"99.15",
"42.33",
"96.04",
"31.1",
"33.22",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
11833, 12021
|
2588, 2664
|
12042, 14744
|
17947, 18587
|
17839, 17923
|
14762, 17733
|
355, 392
|
2183, 2266
|
421, 1751
|
3413, 3572
|
1773, 2161
|
2283, 2571
|
17758, 17818
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,581
| 170,631
|
51152
|
Discharge summary
|
report
|
Admission Date: [**2165-11-9**] Discharge Date: [**2165-11-13**]
Date of Birth: [**2122-7-11**] Sex: M
Service: General Medicine
HISTORY OF PRESENT ILLNESS: Patient is a 43-year-old male
with a history of chronic pancreatitis, alcohol abuse, and
ankylosing spondylitis. Is transferred from an outside
hospital after he presented there with epigastric pain since
[**9-1**], which had worsened and was unresponsive to pain
medicine. At the outside hospital, he was found to have
gallstones and a dilated common bile duct on ultrasound.
Laboratories at that time were significant for an ALT of 470,
AST of 173, T bilirubin of 3.5, amylase of 287, and lipase of
2070, all consistent with gallstone pancreatitis.
Initial attempt at [**Hospital3 **] for ERCP was unsuccessful with
inability to sedate the patient and he was rescheduled for
ERCP under general anesthesia. He underwent ERCP again on
[**2165-11-10**], was very difficult to intubate due to his
ankylosing spondylitis, and he was stabilized in the MICU
postoperatively due to result in bleeding and edema secondary
to intubation attempts.
ERCP on [**2165-11-10**] revealed a shelf-like stricture that was
15 mm of the common bile duct, near the junction of the
cystic duct. He had a sphincterotomy, balloon dilation of
the common bile duct stricture, and a common bile duct stent
placed at this time.
After ERCP, he was feeling better, and denied any fevers,
chills, nausea, vomiting, diarrhea, and was reporting minimal
epigastric pain.
PAST MEDICAL HISTORY:
1. Alcohol abuse.
2. Ankylosing spondylitis.
3. Status post umbilical hernia repair.
SOCIAL HISTORY: He has a history of alcohol abuse, and he
says that he quit two years ago. He is married and lives
with his wife. [**Name (NI) **] works as a private investigator. He
denies any drug or tobacco use.
FAMILY HISTORY: Noncontributory.
ALLERGIES:
1. Demerol.
2. Codeine.
3. Percocet.
MEDICATIONS ON TRANSFER FROM THE MICU:
1. Methylprednisolone 60 mg IV q.8h.
2. Sliding scale of regular insulin.
3. SubQ Heparin.
4. Pepcid 20 mg IV b.i.d.
5. Morphine 2-4 mg IV q.4h. prn.
6. Levofloxacin 500 mg IV q.d.
7. Flagyl 500 mg IV q.8h.
8. Zofran 2 mg IV q.6h. prn.
PHYSICAL EXAM: Vitals revealed a temperature of 97.0, heart
rate of 75, blood pressure of 121/84, respirations are 21,
and oxygen saturation of 98% on room air. In general, he was
a well-nourished male, appearing stated age in no acute
distress, and alert and oriented times three. HEENT revealed
pupils are equal, round, and reactive to light. Extraocular
muscles were intact. His oropharynx was with moist mucous
membranes, and he had no JVD or lymphadenopathy. He had no
appreciable scleral icterus. His heart was regular, there
were no murmurs, rubs, or gallops. Lungs revealed bilateral
basilar crackles, but otherwise clear to auscultation.
Abdominal examination revealed mild epigastric tenderness to
palpation, and decreased bowel sounds. He had no rebound or
guarding. His extremities were without edema, and he had
dorsalis pedis pulses bilaterally. On neurologic
examination, he was alert and oriented times three, and her
cranial nerves II through XII are intact bilaterally.
Sensation was intact bilaterally to light touch. Strength is
[**6-3**] on upper and lower extremities, and his deep tendon
reflexes were [**3-3**] bilaterally.
LABORATORIES ON TRANSFER: CBC revealed white count of 6.0,
hematocrit 37.1, platelets of 301. He had normal
chemistries. He had a lipase of 33, down from 229, total
bilirubin of 0.8 down from 2.6, amylase of 47, down from 147,
LDH of 112, AST of 65 down from 96, ALT of 246, down from
289, and an alkaline phosphatase of 360 down from 384. He
also had a normal calcium, magnesium, and phosphate.
HOSPITAL COURSE:
1. Gastrointestinal: As mentioned above, patient was
transferred from an outside hospital with epigastric pain,
laboratory findings and ultrasound findings consistent with
gallstone pancreatitis. He was transferred to [**Hospital1 346**] for ERCP, with a first attempt
failed due to inability to successfully sedate the patient,
therefore, he underwent second ERCP on [**2165-11-10**] with
general anesthesia. At that time, findings included a 15 mm
common bile duct stricture, and he underwent sphincterotomy
and common bile duct stent placement. It was also noted at
this time that he had drainage of sludge and pus from his
common bile duct.
Differential of his common bile duct stricture included PSC,
cholangiocarcinoma, and chronic pancreatitis, or some sort of
other external mass including a pancreatic tumor compressing
the common bile duct. After ERCP, he had improving LFTs,
total bilirubin was decreasing, it was felt that the stent
was working fine.
At the time of ERCP, he had common bile duct brushings sent
for cytology, which revealed no malignant cells. He also had
a CEA and AFP drawn, both of which are normal. He had a
serum ANCA which was negative. He also had a CA19-9 drawn
which is sent out and is currently pending. He also had
hepatitis serologies drawn, which were all normal.
It was recommended by ERCP to be followed up with a CT
angiogram of the abdomen to rule out any pancreatic or other
mass in the area around the common bile duct possible
compressing common bile duct.
He underwent a CT angiogram, which revealed edema in the head
of the pancreas, but no obvious mass. This was read out with
the attending radiologist, who recommended followup abdominal
CT in one month.
It was also recommended that he follow up with Dr. [**Last Name (STitle) 468**] in
the Department of Surgery for discussion of cholecystectomy
at a future date. This appointment was scheduled for him.
He was also seen by the Hepatology service while admitted,
who recommended all of the above tests as already done, and
he will be followed up with Dr. [**First Name (STitle) **] as an outpatient, and this
appointment was made for him prior to him leaving. He will
also need followup with ERCP in eight weeks for removal of
the common bile duct stent, and this appointment was made for
him as well. He is also scheduled for a followup abdominal
CT in one month after discharge.
At the time of discharge, it was unclear the etiology of his
common bile duct stricture, however, it was felt that
cholangiocarcinoma and tumor at the head of the pancreas was
ruled out based on common bile duct cytology and his
abdominal CTA. The idea of primary sclerosing cholangitis
was still being entertained, however, he had a normal ANCA,
and not have characteristic appearance of the common bile
duct for primary sclerosing cholangitis on his cholangiogram.
On the day of discharge, he is without abdominal pain,
fevers, or chills, and was tolerating p.o.
2. Infectious disease: Patient reported one episode of
subjective fever prior to admission, however, he was afebrile
throughout his admission. He was transferred to [**Hospital1 346**] on Unasyn, which was changed to
levofloxacin and Flagyl. At the time of ERCP, pus drainage
from the common bile duct was noted, and he was continued on
levofloxacin and metronidazole to complete a 10 day course.
3. Musculoskeletal: Patient has a history of ankylosing
spondylitis, which was not apparently active or worsening
upon admission. He does not have a PCP currently and due to
recent move and change of his jobs, however, he will be
scheduling an appointment with his PCP at the time of
discharge for further maintenance of his ankylosing
spondylitis and other issues.
DISCHARGE DIAGNOSES:
1. Gallstone pancreatitis.
2. Choledocholithiasis.
3. Ankylosing spondylitis.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg q.d. x9 days.
2. Flagyl 500 mg t.i.d. x9 days.
3. Protonix 40 mg q.d.
4. Morphine 15 mg q.4-6h. prn for pain x5 days.
DISCHARGE CONDITION: At the time of discharge, patient was
stable and without abdominal pain or fevers. He was
tolerating p.o. and ambulating without difficulty.
FOLLOWUP:
1. He is to followup with Dr. [**Last Name (STitle) 468**] in the Department of
Surgery on [**2165-11-22**] at 9 a.m. to discuss further plans for
cholecystectomy.
2. He has an appointment with Dr. [**Last Name (STitle) 497**] in the Department of
Gastroenterology on [**2165-12-20**] at 12:20 p.m.
3. He has followup with Dr. [**Last Name (STitle) 10108**] with Gastroenterology on
[**1-2**] at 8 a.m. for ERCP and removal of common bile
duct stent.
4. He has followup in [**Company 191**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
[**2165-11-25**] at 10:30 a.m. He will have this initial
appointment and his PCP will be changed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
5. He has an appointment as well for abdominal CAT scan on
[**2165-12-20**] at 11:30 a.m.
DISCHARGE STATUS: Patient was discharged to home with the
above followup.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 14268**]
MEDQUIST36
D: [**2165-11-13**] 16:53
T: [**2165-11-14**] 11:59
JOB#: [**Job Number 106186**]
|
[
"574.51",
"303.90",
"720.0",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87",
"51.14",
"96.04",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
7817, 9147
|
1866, 2209
|
7551, 7630
|
7653, 7795
|
3788, 7530
|
2225, 3771
|
175, 1521
|
1543, 1629
|
1646, 1849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,515
| 152,958
|
46149
|
Discharge summary
|
report
|
Admission Date: [**2102-6-29**] Discharge Date: [**2102-7-3**]
Date of Birth: [**2022-2-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Keflex
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
DDD Pacemaker Placement Left upper chest
History of Present Illness:
This is an 80 year old female with no PMHx who presents with a 3
day history of palpitations, increasing dyspnea on exertion and
shortness of breath. Three days ago she started getting these
symptoms and went to see her primary care doctor. She was found
to be bradycardic. She was sent to [**Location (un) 47**] ED and was found
to be in a high degree heart block. She was given Atropine x 2.
Her pressure dropped to the 60s systolic. She was started on
dopamine drip and transfered to [**Hospital1 18**].
Past Medical History:
None.
Social History:
Patient lives in [**Location 47**] with her husband. She also has a
daughter who lives in [**Location 1514**]. Patient was a stay-at-home mom
until her children were older, at which point she worked as a
teacher and volunteered in the community. Patient does not
smoke cigarettes, and she rarely drinks alcohol.
Family History:
Patient's grandfather and great-uncle had [**Name2 (NI) **] in the late 60s.
Her grandfather also had [**Name (NI) 11398**]. Patient has an extensive history
of skin cancer on both sides of her family.
Physical Exam:
Vitals: BP: 141/64, HR: 31, RR: 12, O2 sat: 94% on RA
Gen: Well appearing elderly woman in NAD
HEENT: MMM
Neck: Right IJ, No JVP
Heart: S1+, S2+, Bradycardic, No murmurs.
Lungs: CTA b/l
Abd: Soft, NT, ND, +BS
Ex: No edema, DP pulses present b/l
Neuro: AAO x 3
Pertinent Results:
ADMISSION LABS:
[**2102-6-29**] 11:59PM BLOOD WBC-9.7# RBC-3.96* Hgb-12.6 Hct-36.3
MCV-92 MCH-31.9 MCHC-34.8 RDW-12.9 Plt Ct-187
[**2102-6-29**] 11:59PM BLOOD Neuts-90.0* Lymphs-7.3* Monos-2.2 Eos-0.3
Baso-0.2
[**2102-6-29**] 11:59PM BLOOD PT-12.7 PTT-24.2 INR(PT)-1.1
[**2102-6-29**] 11:59PM BLOOD Glucose-136* UreaN-27* Creat-1.0 Na-145
K-4.1 Cl-111* HCO3-22 AnGap-16
[**2102-6-29**] 11:59PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2102-6-29**] 11:59PM BLOOD Calcium-8.8 Phos-3.8 Mg-2.4
[**2102-6-29**] 11:59PM BLOOD TSH-1.1
PERTINENT LABS/STUDIES:
Hct: ([**6-29**]) 36.3 -> 35.5 -> 31.3 -> 30.4 -> ([**7-3**]) 34.3
BUN: ([**6-29**]) 27 -> 31 -> 35 -> 47 -> 32 -> ([**7-3**]) 28
Troponin: 0.04 ([**6-29**])
Micro:
[**2102-6-29**] 11:53 pm URINE Source: Catheter.
URINE CULTURE (Final [**2102-7-1**]): NO GROWTH.
[**2102-6-30**]: Time Taken Not Noted Log-In Date/Time: [**2102-6-30**]
9:16 am
SEROLOGY/BLOOD CHEM # 63263W [**6-30**] 8:16AM.
**FINAL REPORT [**2102-7-3**]**
LYME SEROLOGY (Final [**2102-7-3**]):
NO ANTIBODY TO B. BURGDORFERI DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
[**12-25**] weeks.
EKG: rate of 30 Atrial tachycardia with ventricular Bradycardia,
4:1 conduction, Left axis deviation, Prolonged QTc 630, Right
Bundle block with Left anterior fasicular block.
.
TELEMETRY: Bradycardia.
ECHO ([**2102-6-30**]): Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. There is a small pericardial effusion. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade.
ECHO ([**2102-6-30**]): Overall left ventricular systolic function is
normal (LVEF>55%). with normal free wall contractility. There is
a small pericardial effusion. No right ventricular diastolic
collapse is seen (slight RV compression is seen on some views
suggestive of levated intrapericardial pressure without overt
tamponade). Compared with the prior study (images reviewed) of
[**2102-6-30**], no definite change.
ECHO ([**2102-6-30**]): The estimated right atrial pressure is
10-20mmHg. Overall left ventricular systolic function is normal
(LVEF>55%). with normal free wall contractility. There is a
small pericardial effusion. There are no echocardiographic signs
of tamponade. Compared with the prior study (images reviewed) of
[**2102-6-30**], no change.
ECHO ([**2102-7-1**]): Left ventricular wall thickness, cavity size,
and global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is a very small (<0.5cm)/trivial circumferential
pericardial effusion without echocardiographic signs of
tamponade physiology. Compared with the prior study (images
reviewed) of [**2102-6-30**], the findings are similar.
ECHO ([**2102-7-3**]): Mild symmetric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. No pericardial effusion. Mild pulmonary artery
systolic hypertension. Mild aortic regurgitation.
CXR ([**2102-7-1**]): Small right pleural effusion with bibasilar
opacities, likely atelectasis. No evidence of pneumothorax.
CXR ([**2102-7-2**]): In comparison with the study of [**7-1**], there is
still bibasilar atelectatic change and pleural effusions,
although slightly less prominent than on the previous study.
Right IJ sheath has been removed. Pacemaker device remains in
place.
DISCHARGE LABS:
[**2102-7-3**] 07:00AM BLOOD WBC-5.9 RBC-3.70* Hgb-11.8* Hct-34.3*
MCV-93 MCH-31.9 MCHC-34.4 RDW-12.6 Plt Ct-154
[**2102-7-2**] 06:25AM BLOOD Neuts-83.0* Bands-0 Lymphs-8.8* Monos-5.7
Eos-2.2 Baso-0.2
[**2102-7-3**] 07:00AM BLOOD Plt Ct-154
[**2102-7-3**] 07:00AM BLOOD Glucose-88 UreaN-28* Creat-1.1 Na-141
K-4.1 Cl-109* HCO3-26 AnGap-10
[**2102-7-3**] 07:00AM BLOOD Calcium-7.9* Phos-2.6* Mg-2.3
Brief Hospital Course:
Assessment: Patient is an 80 year old female with no PMH who
presented to an OSH with new onset bradycardia and was found to
have 4:1 conduction. She was started on Dopamine drip for low BP
at OSH.
.
# Bradycardia: Patient was admitted with bradycardia and was
found to have a 4:1 conduction block. She had a DDD pacemaker
placed on [**6-29**]. Patient had a perforation after this
procedure, which resulted in a small effusion. The patient had
serial ECHOs after this procedure, which demonstrated a
resolution of the effusion. It is unclear as to the etiology of
this new heart block. TSH demonstrated that the patient is not
hypothyroid, a Lyme titre did not demonstrate Lyme disease, and
patient's Troponins did not demonstrate an acute ischemic event.
Patient continued to improve after her pacemaker placement and
is no longer bradycardic.
.
#. Supraventricular Tachycardia: After the patient's pacemaker
placement, she had an episode of supraventricular tachycardia.
She was started on Metoprolol 25 mg [**Hospital1 **]. She did not have any
further episodes of SVT after beginning the Metoprolol, and she
was discharged on this medication regimen.
.
# Rash: Patient developed a rash on her chest, upper
extremities, and back after receiving Keflex. This drug was
discontinued, and she was started on a three-day course of
Levofloxacin. The patient was given hydrocortisone cream and
oral Benadryl as needed. Her rash improved, and she was
instructed to continue this regimen for her symptoms as an
outpatient.
.
# Hypertension: Pt does not have a history of hypertension. She
had an episode of hypotension at the OSH, with her systolic BP
in the 60s. Patient was started on Dopamine at the OSH. Her
blood pressure has been stable since her pacemaker placement.
.
# Code: Full
.
Medications on Admission:
Multivitamin daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for rash.
4. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Topical three
times a day: for rash.
5. Cortisone 1 % Cream Sig: One (1) Topical three times a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Bradycardia
Discharge Condition:
Stable. Afebrile.
Discharge Instructions:
You were admitted to the hospital because you had a slow heart
rate and required a pacemaker. You had a small collection of
blood around your heart because of a perforation during the
pacemaker insertion, but it is now resolved.
.
Do not take a shower until after your check up at the device
clinic on [**7-7**]. Please keep the dressing clean and dry.
You may take a bath, but please keep the dressing dry.
.
Please avoid extreme movements with you left arm such as tucking
your shirt in or reaching to lift something. Do not lift more
than 5 pounds for one week.
.
You have finished a dose of antibiotics. You developed a drug
rash to Keflex, therefore you should not take this antibiotic or
any other cephalosporin or penicillin as you probably are
allergic to them.
.
Please keep all of your follow-up appts. Please call Dr. [**Last Name (STitle) 98155**]
or Dr. [**Last Name (STitle) **] you have any weakness, fevers, trouble breathing,
fainting, blood in your stools, increased coughing, vomiting or
pain in your chest. Please call the device clinic if your chest
area around the pacemaker becomes more sore or red. Make sure
you drink plenty of water or juice when you get home.
.
New Medications:
Metoprolol 25mg twice daily: this is to prevent abnormal fast
heart beats.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2102-7-7**]
11:00
.
Primary Care:
[**Name6 (MD) 98156**] [**Name8 (MD) 27267**], MD Phone: ([**Telephone/Fax (1) 98157**] Date/time: Wednesday
[**7-19**] at 11:00 am.
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5051**], MD Phone: ([**Telephone/Fax (1) 20259**] Address: Heart Ctr of
[**Hospital1 **] [**Last Name (NamePattern1) 26916**] [**Location (un) 551**], [**Location (un) 47**].
Date/time: Office will call you at home with appt.
Completed by:[**2102-7-4**]
|
[
"511.9",
"998.2",
"E878.1",
"426.0",
"518.0",
"427.5",
"E870.8",
"E849.7",
"E930.5",
"693.0",
"997.1",
"423.9",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.72",
"38.93",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8523, 8582
|
6162, 7964
|
301, 344
|
8638, 8658
|
1764, 1764
|
9988, 10577
|
1264, 1468
|
8033, 8500
|
8603, 8617
|
7990, 8010
|
8682, 9965
|
5740, 6139
|
1483, 1745
|
249, 263
|
372, 887
|
1781, 5723
|
909, 916
|
932, 1248
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,868
| 157,650
|
44127
|
Discharge summary
|
report
|
Admission Date: [**2125-7-13**] Discharge Date: [**2125-9-28**]
Date of Birth: [**2060-7-29**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Linezolid
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
- Neurological deficits described as "spinning" while at acute
rehab.
- Originally had right innominate artery aneurysm which was
repaired with left carotid to aortic innominate artery bypass
[**2125-5-22**], c/b respiratory failure and PEA arrest.
Major Surgical or Invasive Procedure:
On this hospital stay:
1. Right VATS and thoracic duct ligation [**2125-7-20**]
2. Thoracic duct embolization and talc pleurodesis [**2125-7-27**]
3. Tracheostomy and percutaneous endoscopic gastrostomy [**2125-8-8**]
4. Exploratory laparotomy, pancreatic necrosectomy, gastrostomy
tube [**2125-8-22**]
5. Exploratory laparotomy, abdominal wash out [**2125-8-23**]
6. Exploratory lap, takedown gastrostomy, debride necrotic
pancreas and multiple retroperitoneal abscesses [**2125-8-25**]
7. Abdominal closure and vac dressing application [**2125-8-26**]
8. Left thoracotomy and decortication, flexible bronchoscopy
[**2125-9-19**]
On previous hospital stays:
9. Aorto innominate and left carotid bypass [**2125-5-22**]
10. Left carotid to left subclavian bypass using 8 mm PTFE and
thoracic aortic stent graft placement [**2125-5-23**]
History of Present Illness:
65F c complex medical history, s/p repair of aortic innominate
aneurysm (please see list of operative procedures), who returned
to [**Hospital1 18**] from acute rehab with neurological symptoms and found
to have numerous problems both related and unrelated to previous
operative procedures.
Past Medical History:
-- DM2
-- chronic foot ulcers/PVD
-- HTN
-- OA
-- obesity
-- asthma
-- leg pain/neuropathy
-- depression
-- anemia
-- h/o MRSA bacteremia [**11-18**], also septic arthritis treated at
[**Hospital3 **]
.
Right thalamic hemorrhage resulting in a gait disorder and
incontinence of urine, followed by Dr. [**Last Name (STitle) **].
Old CVAs.
Neuropathy, peripheral.
Anxiety and panic disorder.
Status post total abdominal hysterectomy.
Hypercholesterolemia.
Social History:
The patient lives with her daughter [**Name (NI) 2048**] and her three kids
since being d/c'ed from a nursing home last [**Month (only) 205**]. Has seven
children, many grandchildren. Smokes [**1-16**] to 1 pack per day.
Family History:
Brother died of an MI in his 30's, she denies diabetes mellitus
in the family. Cancer in parents (mother died in 40s, father in
80s), at least two siblings, but unsure what kind.
Physical Exam:
On admission:
NAD, alert
RRR, no murmurs
Decreased BS left hemithorax
Abd: obese, soft, ? NT, ? ND, unable to auscultate bowel sounds
Rect: guiac negative, no masses
Ext: warm and well perfused, + peripheral edema
Pulse: DP/PT dopplerable bilaterally
Pertinent Results:
[**2125-9-24**] 03:14PM BLOOD WBC-10.6 RBC-2.52* Hgb-7.8* Hct-23.0*
MCV-91 MCH-31.1 MCHC-34.1 RDW-16.0* Plt Ct-68*
[**2125-9-24**] 03:14PM BLOOD Plt Ct-68*
[**2125-9-24**] 03:14PM BLOOD Glucose-117* UreaN-37* Creat-1.1 Na-137
K-3.3 Cl-106 HCO3-24 AnGap-10
[**2125-9-24**] 03:14PM BLOOD ALT-13 AST-27 LD(LDH)-588* AlkPhos-119*
Amylase-52 TotBili-0.2
[**2125-9-24**] 03:14PM BLOOD Lipase-34
[**2125-9-24**] 03:14PM BLOOD Albumin-1.4* Calcium-6.6* Phos-3.8 Mg-1.7
UricAcd-7.1* Iron-57
[**2125-9-24**] 03:14PM BLOOD calTIBC-68* Ferritn-GREATER TH TRF-52*
[**2125-9-24**] 03:14PM BLOOD TSH-16*
[**2125-9-18**] 12:15PM PLEURAL Triglyc-242
Microbiology:
Time Taken Not Noted Log-In Date/Time: [**2125-9-20**] 1:02 am
PLEURAL FLUID
**FINAL REPORT [**2125-9-25**]**
GRAM STAIN (Final [**2125-9-20**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2125-9-24**]):
ENTEROBACTER CLOACAE. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity testing available on
request.
PROTEUS SPECIES. RARE GROWTH.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 236-6444J [**2125-9-19**].
ENTEROCOCCUS SP..
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S
PENICILLIN------------ =>64 R
PIPERACILLIN---------- 32 I
TOBRAMYCIN------------ <=1 S
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2125-9-24**]): NO ANAEROBES ISOLATED.
[**2125-9-19**] 5:14 pm URINE Source: Catheter.
**FINAL REPORT [**2125-9-22**]**
URINE CULTURE (Final [**2125-9-22**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| ENTEROBACTER CLOACAE
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S =>64 R
CEFTRIAXONE----------- <=1 S =>64 R
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- 2 I =>4 R
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN---------- <=4 S 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
[**2125-9-19**] 11:52 am BLOOD CULTURE
Source: Line-tunneled cath - no peripheral access.
**FINAL REPORT [**2125-9-22**]**
AEROBIC BOTTLE (Final [**2125-9-22**]):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
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.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2125-9-22**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] AT 0755 ON [**2125-9-20**].
STAPH AUREUS COAG +. SENSITIVITIES PERFORMED FROM
AEROBIC BOTTLE.
[**2125-9-19**] 10:47 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2125-9-23**]**
GRAM STAIN (Final [**2125-9-19**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2125-9-23**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
UNABLE TO DEFINITIVELY DETERMINE THE PRESENCE OR ABSENCE
OF
OROPHARYNGEAL FLORA.
UNABLE TO R/O PATHOGENS DUE TO OVERGROWTH OF SWARMING
PROTEUS SPP..
PROTEUS SPECIES. MODERATE GROWTH.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Trimethoprim/Sulfa sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- S
VANCOMYCIN------------ <=1 S
[**2125-9-13**] 5:08 pm VARICELLA-ZOSTER CULTURE Site: BACK
2 M4 REC'D, ALSO R/O HSV.
**FINAL REPORT [**2125-9-27**]**
VARICELLA-ZOSTER CULTURE (Final [**2125-9-27**]):
HERPES SIMPLEX VIRUS TYPE 2.
CONFIRMED BY MONOCLONAL FLUORESCENT ANTIBODY..
[**2125-8-25**] 2:00 pm TISSUE PANCREAS.
**FINAL REPORT [**2125-9-5**]**
GRAM STAIN (Final [**2125-8-25**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
TISSUE (Final [**2125-9-5**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) 640**] [**Last Name (NamePattern1) 94708**] [**2125-8-27**] CC7C.
THIS IS A CORRECTED REPORT ([**2125-8-31**]).
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] ([**Numeric Identifier 94709**]) [**2125-8-31**].
ENTEROCOCCUS SP.. MODERATE GROWTH.
ADDITIONAL SENSITIVTY TESTING PER DR [**First Name (STitle) **].
Tigecycline 1.0 MCG/ML (NON-SUCEPTIBLE).
Tigecycline IS NOT APPROVED FOR TESTING WITH [**Doctor Last Name **]
RESISTANT
ENTEROCOCCI. SYNERCID SENSITIVE BY [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
REPORTED BY PHONE TO DR [**Last Name (STitle) **] [**2125-8-30**] AT 10:45AM.
. PREVIOUSLY REPORTED AS.
SENSITIVE TO Tigecycline ([**2125-8-30**]).
Daptomycin. 16 MCG/ML (PERFORMED AT [**Hospital1 4534**]
LABORATORIES).
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2125-8-29**]): NO ANAEROBES ISOLATED.
[**2125-8-30**] 7:39 pm STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2125-8-31**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2125-8-31**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
Brief Hospital Course:
Neuro: Ms. [**Known lastname 1661**] is a woman with a history of right thalamic
hemorrhage and left genu/internal capsular lacunar infarcts who
is admitted for vascular surgeries
and treatment of sepsis on whom we were re-consulted for
disconjugate gaze in the setting of sedating medications for
intubation. Her neuro exam is notable for decreased mental
status (following commands only intermittently) although she is
arousable by voice and a disconjugate gaze that returns to
conjugate midline when she is aroused. Certainly, it is
reassuring that her gaze corrects itself when she is aroused.
She also has all her other brainstem reflexes intact and when
aroused
she is able to occasionally follow commands. Most likely, the
intermittent disconjugate gaze (occurring only when she is
unconscious) is the result of an encephalopathy. Certainly, she
has many metabolic reasons to be encephalopathic, as she has
bacteremia and pneumonia. However, given her history of
intracranial hemorrhage and her maintenance on a Heparin gtt
(for a history of clotting), we would recommend a low threshold
for re-imaging her head. Although our suspicion for recurrent
intracranial hemorrhage is low, it cannot be fully excluded and
she does have risks and a history. CT head [**2125-8-29**]: 1. Stable
appearance of the brain. 2. New air-fluid levels in the
sphenoid sinus. The appearance may reflect
recent intubation but could be seen in sinusitis, in the
appropriate clinical
setting.
CV: Ms. [**Known lastname 1661**] was intermittently on vasopressors throughout
her long hospital course, most often for BP support in the
setting of sepsis. No evidence of myocardial infarction. Most
recent echo [**2125-7-26**] showed: The left atrium is elongated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is mildly depressed with inferior/inferolateral
akinesis (LVEF= 50%). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. There are three aortic valve leaflets. The aortic
valve is not well seen. There is no aortic valve stenosis. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
She has been otherwise stable from a cardiovascular standpoint.
No apparent difficulty with her vascular repair. Pt also has
very difficult vascular access with significant thrombosis of
upper neck veins, currently with a left IJ CVL which has been
placed and repositioned multiple times in interventional
radiology. The CVL presently infuses but does not aspirate.
Pulmonary: Ms. [**Known lastname 1661**] experienced chylothorax treated with
multiple operative procedures (please see operative report
list). At present, drainage from the left hemithorax greatly
reduced. Two chest tubes were removed on date of discharge with
one remaining draining to gravity.
GI: Ms. [**Known lastname 1661**] experience near total pancreatic necrosis of
unknown etiology treated with pancreatic debridement and
necrosectomy and abdominal drainage (please see operative report
list). At present, most recent CT abd/pelvis [**2125-9-20**] showed:
There is evidence of peripancreatic fat stranding and a small
peripancreatic fluid collection measuring 2.9 x 1.2 cm. General
surgery consultation deemed that this fluid collection was
remarkable but not necessitating intervention. Pt was
maintained on tube feeds at a stable rate and frequency.
Heme: Ms. [**Known lastname 1661**] has experienced anemia and thrombocytopenia
which has necessitated intermittent transfusion of packed RBC
and platelets.
ID: Ms. [**Known lastname 1661**] has numerous positive cultures from various
sites (please see pertinent lab results for more detail) that
have been treated with antibiotics intermittenly per the ID
consultation service. These infections have manifested with
hypothermia and hypotension, sometimes requiring vasopressor
support. Pt is currently on Synercid, Meropenem, and
Caspofungin. Antibiotics x 7 days post-discharge with the
knowledge that the pt is likley heavily colonized with multiple
resistant organisms and may deteriorate without antibiotic
support.
Medications on Admission:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours).
4. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
INH Inhalation Q6H (every 6 hours).
5. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) INH Inhalation [**Hospital1 **] (2 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): Hold for SBP < 100 or HR < 60.
10. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours) for 4 weeks: from [**6-15**] /
may DC [**7-29**] Follow labs as on Pg 1.
11. Insulin
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale
Regular
Glucose Insulin Dose
0-60 mg/dL 1 amp D50
61-120 mg/dL 0 Units
121-140 mg/dL 2 Units
141-160 mg/dL 4 Units
161-180 mg/dL 6 Units
181-200 mg/dL 8 Units
201-220 mg/dL 10 Units
221-240 mg/dL 12 Units
241-260 mg/dL 14 Units
261-280 mg/dL 16 Units
281-300 mg/dL 18 Units
> 300 mg/dL Notify M.D.
12. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 7 days: DC when INR is greater then 2/
Keep INR [**2-17**].
13. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime: INR
goal is [**2-17**].
Discharge Medications:
1. MED Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN [**9-19**] @ 2257
2. MED Aquaphor Ointment 1 Appl TP TID:PRN [**9-19**] @ 2257
3. MED Sarna Lotion 1 Appl TP TID:PRN [**9-19**] @ 2257
4. MED Miconazole Powder 2% 1 Appl TP TID:PRN [**9-19**] @ 2257
5. MED Dextrose 50% 25 gm IV PRN Glu<55 [**9-19**] @ 2257
6. MED Levothyroxine Sodium 25 mcg PO/NG DAILY [**9-19**] @ 2257
7. MED Heparin 5000 UNIT SC TID [**9-19**] @ 2257
8. MED Quinupristin-Dalfopristin 650 mg IV Q8H [**9-19**] @ 2257
9. MED Insulin SC (per Insulin Flowsheet)
Sliding Scale 09/05 @ 2257
10. MED Meropenem 1000 mg IV Q8H [**9-19**] @ 2257
11. MED HYDROmorphone (Dilaudid) 1 mg IV Q4H:PRN pain [**9-19**] @
2257
12. MED Metoclopramide 5 mg PO/IV QID:PRN [**9-20**] @ 0846
13. MED Ranitidine (Liquid) 150 mg PO DAILY [**9-20**] @ 0900
14. MED Albuterol [**4-20**] PUFF IH Q4H [**9-20**] @ 2148
15. MED Ipratropium Bromide MDI [**4-20**] PUFF IH Q4H [**9-20**] @ 2148
16. MED Caspofungin 50 mg IV Q24H [**9-22**] @ 0937
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. Peripheral vascular disease
2. Chylothorax
3. Pancreatic necrosis
4. Sepsis
5. Upper vein thrombosis
6. Diabetes mellitus
7. Hypertension
8. COPD
9. Right thalamic hemorrhage
10. Innominate artery aneurysm
Discharge Condition:
Stable
Discharge Instructions:
1. D/C antibiotics 7 days post discharge.
2. Vac dressing change Q4days.
3. Trach mask as tolerated.
Followup Instructions:
1. Follow up with Dr. [**Last Name (STitle) **] regarding removal of chest
tube.
|
[
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"434.91",
"457.8",
"401.9",
"577.0",
"510.9",
"599.0",
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"496",
"511.9",
"287.5",
"584.9",
"285.9",
"995.92",
"518.81",
"998.59",
"453.8",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.21",
"33.23",
"51.22",
"40.64",
"96.04",
"45.13",
"31.1",
"96.71",
"44.62",
"34.04",
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"39.79",
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"99.15",
"34.51",
"96.6",
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] |
icd9pcs
|
[
[
[]
]
] |
19973, 20052
|
12854, 17247
|
532, 1370
|
20304, 20312
|
2889, 12831
|
20461, 20544
|
2422, 2603
|
18941, 19950
|
20073, 20283
|
17273, 18918
|
20336, 20438
|
2618, 2618
|
244, 494
|
1398, 1690
|
2632, 2870
|
1712, 2168
|
2184, 2406
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,490
| 166,168
|
51628
|
Discharge summary
|
report
|
Admission Date: [**2195-12-22**] Discharge Date: [**2195-12-30**]
Date of Birth: [**2116-5-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
obtunded at rehab
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79yoM with h/o dementia, CHF (EF 55% with regurg), s/p pacer,
s/p MVR/AVR, admitted to [**Hospital1 18**] [**Date range (1) 63728**]/06 with right hip pain
and diagnosed with MRSA UTI, LLL pneumonia, and C.difficile
infection, discharge to [**Hospital **] Rehab where today he was found
obtunded with agonal respirations and sent to [**Hospital1 18**] ED. Prior
hospital course was complicated by acute renal failure due to
prerenal azotemia, delirium, coagulopathy due to
supratherapeutic warfarin, and hypothyroidism. He was discharged
to [**Hospital1 **] on a continued course of azithromycin, vancomycin,
ceftriaxone, and metronidazole. He completed all courses other
than the metronidazole which was scheduled to continue for
14days after completion of other antibiotics. This had been
changed to po vancomycin. He was also on PCN V ?infection.
According to records from [**Hospital1 **] the patient was short of
breath on the night prior to presentation, agitated, and refused
all food and po medications. Today his oxygen saturation dropped
to low 80%s, and he was placed on a non-rebreather mask. Lasix
was administered, and saturation improved to 96%. Per EMS report
patient was obtunded, moving extremities but not responding to
voice or pain, with agonal respirations RR 10. However, transfer
report from [**Hospital1 **] reports VS on transfer BP 107/63 HR 62 RR
22 100%on NRB. He was intubated in the field for airway
protection and transferred to [**Hospital1 18**] ED.
On arrival to the ED VS T 96.0R HR 63 BP 83/31 RR 16 100%vent.
He received 1L NS bolus, vancomycin, levofloxacin, and
metronidazole. BP improved to 105/55 prior to transfer to the
ICU. ABG in ED reported to be 7.16/63/46 on 100%FiO2, although
was likely venous. Repeat ABG unchanged. On presentation to the
ICU he is intubated and sedated but responding to pain and
manipulation by swinging arms bilaterally. no response to
commands. withdraws to pain in all four extremities.
Past Medical History:
Dementia
HTN
CAD s/p CABG
CRI
mechanical MVR and AVR ([**2184**])
s/p dual chamber PCM (for bradycardia, syncope in [**2183**])
Cardiomyopathy with EF 30% ([**2187**])
pulm HTN
s/p left MCA stroke ([**2185**])
s/p hip fracture
hypothyroidism
gout
.
PSHx: left inguinal herniorrhaphy in [**2193**]
Social History:
Heavy smoker for 50 years, quit 10 years ago, no current alcohol
use. He lives at home and gets VNA services.
Family History:
Noncontributory
Physical Exam:
PE: T 94.2R HR 65 BP 122/67 RR 25 100% Wt 62kg
AC Tv 400 RR 20 FiO2 40% PEEP 5
Gen: initially agitated and hitting with hands, then sedated,
kyphotic
HEENT: PER, sluggishly reactive, anicteric, conjunctiva pink,
ETT
Neck: supple, palpable but nonenlarged cervical LAD, JVP
nondistended
CV: RRR, PMI lateral, II/VI SEM at LUSB with mechanical click
Resp: CTA posteriorly with decreased BS left base, coarse
anteriorly
Abd: +BS but decreased, soft, ND, no masses
Ext: diffuse 3+ BLE, BUE edema
Skin: diffuse skin tears on BUE/BLE, bullous lesions on BLE,
erthema/scaling over sacrum
Neuro: [**Last Name (LF) 2994**], [**First Name3 (LF) 2995**], withdraws to pain in all four extremities
Pertinent Results:
[**2195-12-22**] 05:30PM BLOOD WBC-14.5* RBC-3.09* Hgb-9.2* Hct-30.9*
MCV-100*# MCH-29.6 MCHC-29.6* RDW-24.1* Plt Ct-175
[**2195-12-30**] 04:18AM BLOOD WBC-11.1* RBC-3.05* Hgb-9.0* Hct-28.8*
MCV-94 MCH-29.4 MCHC-31.2 RDW-22.7* Plt Ct-170
[**2195-12-22**] 05:30PM BLOOD Glucose-142* UreaN-28* Creat-1.7* Na-148*
K-4.9 Cl-119* HCO3-20* AnGap-14
[**2195-12-30**] 04:18AM BLOOD Glucose-76 UreaN-25* Creat-1.7* Na-145
K-3.8 Cl-114* HCO3-20* AnGap-15
[**2195-12-25**] 05:29AM BLOOD ALT-25 AST-44* AlkPhos-128* TotBili-1.0
[**2195-12-22**] 05:30PM BLOOD calTIBC-204* VitB12-[**2118**]* Folate-10.2
Hapto-<20* Ferritn-170 TRF-157*
[**2195-12-22**] 05:30PM BLOOD TSH-14*
[**2195-12-28**] 05:24AM BLOOD Free T4-1.2
Brief Hospital Course:
79yoM with h/o vascular dementia, CHF, CAD s/p CABG, s/p
MVR/AVR, chronic kidney disease p/w hypothermia, acidemia,
delirium.
# Respiratory failure: intubated for airway protection in field,
hypercapneic and hypoxemic on admission. CXR concerning for
untreated PNA, community-acquired vs rehab-acquired vs
aspiration. Pt tolerated extubation well. Satting fine on O2 by
NC. Nothing growing in cultures. Initial presentation likely [**1-29**]
oversedation followed by aspiration pneumonitis/pneumonia. Pt
made DNR/DNI during later part of admission, then soon made CMO
and palliative care consulted. Pt discharged to palliative care.
# CKD: h/o CKD but creatinine 1.0 prior to last hospitalization
during which he suffered acute prerenal azotemia. Creatinine now
1.6. Likely new baseline is 1.2-1.4.
# Acidemia: Resolved after intubation. Patient had combined
non-gap metabolic and respiratory acidosis on admission that
resolved on the ventilator. Had elevated lactate and hypothermia
on admission that was concerning for sepsis. Respiratory
component likely [**1-29**] oversedation at rehab facility. Head CT
unchanged from prior.
# CHF: EF >55% on echo [**2195-12-7**]. No acute decompensation.
Initially held metoprolol given concern for sepsis. Not on ACE
likely [**1-29**] recent acute renal failure. Volume status managaed
with prn furosemide.
# CAD: s/p CABG. Elevated troponin on admission with nml CK
likely due to strain in setting of renal dysfuction.
# s/p MVR/AVR: INR supratherapeutic on admission; held warfarin
given acute decompensation. Discharged to palliative care.
Medications on Admission:
Warfarin per INR level
Aspirin 81mg daily
Colace 100mg [**Hospital1 **]
Levothyroxine 50mcg daily
Metoprolol 25mg [**Hospital1 **]
MVI
Olanzapine 5mg QAM, 2.5mg QPM, 2.5mg prn
Protonix 40mg daily
PCN V 500mg po Q6hr
KCl 20mEq daily
Vancomycin 250mg po Q8hr
Atrovent neb prn SOB
Oxycodone 2.5mg Q8hr prn pain
Tylenol Q4hr prn pain, fever
Albterol neb Q4hr prn SOB
Dulcolax 10mg PR prn constipation
Discharge Medications:
1. Lorazepam
Lorazepam liquid 2 mg/mL
0.25-2 mg PO q4-6hrs prn agitation/anxiety/shortness of breath
Dispense 10 mL
2. Hospital bed
Please provide semi-electric bed with air mattress
3. Oxygen
PLease provide oxygen with liter flow via nasal canula
4. Suction system
Please provide portable suction system and tubing
5. Ativan/Benadryl/Haldol
ABH 1 mg/12 mg/2 mg TD gel
Apply 1 mL transdermally q4-6hrs prn severe agitation
dispense 6 mL
6. Compazine
Compazine 50 mg/mL TD gel
5-20 mg PO/SL q2hrs prn pain/shortness of breath
dispense 40 mL
7. haloperidol
Haloperidol 2 mg/mL oral solution
0.5-2 mg PO/SL q4-6hrs prn agitation
dispense 5 mL
8. Hycosamine
Hycosamine 0.25 mg/mL oral solution
0.125-0.25 mg PO/SL q4-6hrs prn secretions
Dispense 5 mL
9. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal every 4-6 hours as needed for fever or pain.
Disp:*2 Suppository* Refills:*0*
10. Scopolamine Base 1.5 mg Patch 72HR Sig: [**12-31**] Patches
Transdermal every seventy-two (72) hours as needed for
congestion.
Disp:*12 * Refills:*0*
11. Oxyfast 20 mg/mL Concentrate Sig: 5-20 mg PO q2hrs as needed
for pain or shortness of breath.
Disp:*40 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice Care, Inc.
Discharge Diagnosis:
Primary:
Respiratory failure secondary to aspiration
Secondary:
Vascular Dementia
Hypertension
CAD s/p 1v CABG (SVG-OM [**7-/2176**])
s/p DDD pacer for recurrent syncope [**7-/2184**]; s/p dual chamber
pacer for bradycardia, syncope [**2183**]
Chronic kidney disease
s/p mechanical MVR and AVR ([**2184**])
h/o CHF, Cardiomyopathy (EF >55%)
Moderate Pulmonary hypertension
s/p left MCA stroke ([**2185**])
s/p pubic rami fracture
Hypothyroidism
Gout
h/o C. difficile infection
Discharge Condition:
Hemodynamically stable
Discharge Instructions:
Please take all of your medications as prescribed.
Followup Instructions:
None
|
[
"584.9",
"437.0",
"414.00",
"578.1",
"585.6",
"V45.81",
"281.9",
"780.99",
"290.40",
"428.0",
"244.9",
"V02.59",
"V45.01",
"V09.0",
"507.0",
"425.4",
"518.81",
"V43.3",
"441.4",
"403.91",
"276.2",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
7502, 7551
|
4265, 5858
|
333, 340
|
8073, 8098
|
3536, 4242
|
8197, 8205
|
2796, 2814
|
6306, 7479
|
7572, 8052
|
5884, 6283
|
8122, 8174
|
2829, 3517
|
276, 295
|
368, 2332
|
2354, 2652
|
2668, 2780
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,441
| 180,325
|
6822
|
Discharge summary
|
report
|
Admission Date: [**2109-12-23**] Discharge Date: [**2110-1-2**]
Date of Birth: [**2036-3-16**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: This a 73-year-old gentleman
who was referred to the Urology Service after a workup for
hematuria prompted a pelvic MRI on [**12-20**]. Findings on
that study were significant for a large mass on the left side
of the bladder consistent with a primary neoplasm extending
into the muscle without definite evidence of extension into
the pelvic-floor fat. There were also multiple bony
metastases noted in the pelvis along with a small lymph node
in the right external iliac chain. The patient was
subsequently scheduled for a transurethral resection of
bladder tumor with Dr. [**Last Name (STitle) 9125**] on [**2109-12-25**].
On the evening of [**2109-12-22**], the patient's family
contact[**Name (NI) **] the GU resident on call with concerns of
Mr. [**Known lastname 25823**] profound weakness and pallor. The patient's
family was advised to bring the patient into the emergency
department for prompt evaluation. In the emergency
department the patient was found to be in severe diabetic
ketoacidosis with INR of 7; potassium of 7.5, blood glucose
of 800 and hematocrit of 25. He was passing large clots from
his penis. The EKG done at that time was notable for peak T
waves and a prolonged PR interval. The patient was promptly
admitted to the Medical Intensive Care Unit for management of
his diabetic ketoacidosis.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Atrial fibrillation.
3. Carotid artery stenosis.
4. Diabetes mellitus type 2.
5. Hypothyroidism.
6. Chronic obstructive pulmonary disease.
7. Benign prostatic hypertrophy.
8. Colonic polyps.
9. Peripheral vascular disease.
10. Chronic renal insufficiency (baseline CR 1.3 to 1.7).
11. ATN secondary to IV contrast.
12. Glaucoma.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft with a St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**] in [**2099**].
2. Aortobifemoral bypass.
3. Right fifth toe amputation.
4. Right femoral posterior tibial bypass graft with a left
toe amputation.
5. A left jump bypass with femoral to posterior tibial to
dorsalis pedis bypass graft.
6. Right femoral above-knee popliteal graft and a right
below knee popliteal to dorsalis pedis graft.
7. Amputation of the right second toe.
8. Exploration of right arm for vein conduit.
9. Right above knee amputation.
MEDICATIONS:
1. Insulin NPH 40 AM and 6 PM, as well as Humalog sliding
scale.
2. Coumadin 8 mg a day.
3. Xalatan eye drops.
4. Lopressor 25 mg t.i.d.
5. Hydralazine 10 mg q.i.d.
6. Levothyroxine 112 mcg PO q.d.
7. Atorvastatin 20 mg PO q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is a nondrinker and a former
smoker, who recently began smoking again.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: Vital signs: Temperature 99.5, heart rate 95
sinus, blood pressure 99/31, respiratory rate 28, oxygen
saturation 99% on two liters. LUNGS: Lungs were clear to
auscultation bilaterally. HEART: Heart had a regular rate
and rhythm with a mechanical S1 and S2. ABDOMEN: His belly
was soft, nontender, and nondistended with normoactive bowel
sounds. He had positive stool in his rectum.
LABORATORY DATA: The patient had a white count of 28,000,
hematocrit of 25.1, PT 32, PTT 91.4, and INR or 7.1, sodium
125, potassium 7.0, chloride 94, bicarbonate 16, BUN 112,
creatinine of 4.1, and blood glucose of 795. Urinalysis was
notable for large amounts of blood, positive nitrites,
greater than 100,000 glucose, 15 white blood cells, few
bacteria. The LFTs were normal. He had a chest x-ray, which
was notable for mild cardiomegaly, but without evidence of
pneumonia or congestive heart failure. The EKG was notable
for prolonged PR interval and peaked T waves.
The patient was admitted to the medical ICU. He was
transfused with two units of packed red blood cells, given
vitamin K, and transfused with fresh frozen plasma to correct
his coagulopathy. He was started on Ceftriaxone for presumed
urinary tract infection. He was placed on an insulin drip
and he was aggressively hydrated for the metabolic acidosis
and acute renal failure. Cardiac enzymes were subsequently
sent, which ultimately ruled him out for a myocardial
infarction. Foley was changed out to a three-way catheter
and constant bladder irrigation was initiated.
The patient responded well to the initiation of the
above-mentioned therapies. His coagulopathy resolved as did
his diabetic ketoacidosis.
Over the course of the next two days, the patient remained in
the ICU. An endocrine consultation from the [**Last Name (un) **] Service
was obtained for management of the patient's labile blood
glucose. The Renal Service was consulted to make
recommendations regarding the patient's acute renal failure.
On [**2109-12-25**], the patient underwent a renal ultrasound, which
was notable only for small cysts in the left kidney with no
evidence of hydronephrosis or hydroureter.
The remainder of his ICU course was relatively uneventful.
He continued to improve on all indices.
On [**12-25**], the patient was transferred out of the ICU
into the medical floor. Both his blood and urine cultures
had no growth. His white count had dropped from 28,000 to
14,000 and his antibiotics were switched to Levaquin. The
patient was taken off his insulin drip and transferred to the
floor in stable condition.
Continued workup included echocardiogram performed on [**12-26**], which demonstrated mild left ventricular hypertrophy,
2+ MR, 2+ TR and ejection fraction of greater than 55%.
On the 25th, he had a bone scan, which was notable for
multiple bony metastases, as well as numerous small foci of
increased uptake consistent with metastatic disease. The
oncology service was consulted and among their
recommendations was a request for plain films of the hip to
rule out impending fracture. This study was ultimately done
on [**2109-12-29**] and it was without any significant
findings.
On [**12-27**], the patient underwent an uncomplicated
transurethral resection of bladder tumor. Findings during
that procedure were significant for a large apparently
invasive bladder tumor mostly on the left lateral wall of the
bladder. The left ureteral outlet was identified and it was
believed that there was tumor growing into the left UO. The
patient tolerated the procedure well. The patient was
transferred to the GU Service postoperatively.
The remainder of the [**Hospital 228**] hospital course was relatively
uneventful. The patient remained afebrile throughout the
entire course. His blood glucoses, however, remained to be
somewhat challenging; these were primarily managed by
recommendations from the [**Last Name (un) **] Staff. He was able to start
a regular diet immediately after reaching the floor.
On postoperative day #2, the CBI was discontinued. The Foley
remained. He was placed on oral pain medication. He was
restarted on his Coumadin at a dose of 10 q.h.s. He was
begun on a Heparin drip for the purposes of anticoagulation
for his St. [**Last Name (un) 923**] valve.
The patient was rapidly therapeutic on the heparin. The
patient was screened for rehabilitation and offered at bed at
[**Location (un) 1036**]. Unfortunately, because they were unable to
manage the heparin drip while the Coumadin was becoming
therapeutic, the patient needed to stay in the hospital so
that this could be maintained.
By postoperative day #5, the patient had continued his
perioperative Ciprofloxacin antibiotic coverage and he was
afebrile. The rest of his vitals were stable and his oxygen
saturations ranged from 94% to 98% on room air. Blood
glucose levels were under better control. He continued to
tolerate a regular diet with excellent urine output. The
patient's urine, which had cleared up postoperatively, once
again became grossly hematuric, after the initiation of his
heparin. After ensuring that there were no clots, and that
the patient was not in retention, the heparin was continued.
After three days of anticoagulation with 10 mg of Coumadin,
the patient's INR still remained subtherapeutic at around
1.8. He was subsequently started on low-molecular weight
heparin after consultation with his cardiologist,
Dr. [**Last Name (STitle) **] and the heparin was discontinued. He was
then transferred to [**Location (un) 1036**] on Lovenox and Coumadin with
plans to have them manage his anticoagulation.
MEDICATIONS ON DISCHARGE:
1. Ciprofloxacin 250 mg q.o.d.
2. NPH insulin 36 units q.AM; 8 units q.PM.
3. Lopressor 75 mg PO t.i.d.
4. Pantoprazole 40 mg PO q.d.
5. Levoxyl 112 mcg PO q.d.
6. Atorvastatin 20 mg PO q.d.
7. Lisinopril 40 mg p.o.q.d.
8. Levsin .25 mg q.6h.p.r.n. bladder spasm.
9. Percocet 1 to 2 tablets PO q.3 to 4 hours p.r.n.
10. Colace 100 mg PO b.i.d. while taking Percocet.
11. Coumadin 10 mg PO q.h.s.
LABORATORY DATA: Labs at the time of discharge revealed PT
of a 15.7, PTT 88.8 and INR of 1.7. White blood cell count
of 12,600, hematocrit of 25.4, and platelet count 293,000.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(1) 13269**]
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2110-1-2**] 14:18
T: [**2110-1-2**] 14:34
JOB#: [**Job Number 25824**]
|
[
"188.8",
"599.0",
"496",
"250.10",
"276.7",
"584.9",
"244.9",
"427.31",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.49"
] |
icd9pcs
|
[
[
[]
]
] |
8623, 9518
|
1909, 2791
|
2915, 8597
|
1516, 1886
|
2808, 2892
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,441
| 190,281
|
40734
|
Discharge summary
|
report
|
Admission Date: [**2143-4-3**] Discharge Date: [**2143-4-3**]
Date of Birth: [**2076-12-17**] Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Rollover MVC
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
66M s/p rollover MVC. Per report, patient was the restrained
passenger. Unclear LOC or whether airbags were deployed. There
was prolonged extrication time at the scene. Initial GCS was 14
on scene and persisted upon arrival to [**Hospital1 18**]. The patient then
had an abrupt decline in mental status with son[**Name (NI) 7884**]
respirations and eventually became unresponsive. The patient was
intubated for airway protection without difficulty.
.
In the ED, FAST exam was negative. Patient underwent CT head,
neck and torso which were remarkable for likely old compression
fracture of C7. Tox was notable for an ETOH level of 171 and
Benzo's.
Past Medical History:
PMH: DM2
PSH: hip replacement
Social History:
Social ETOH per patient. Lives in [**Location **] with wife and dog. No
ilicit drug use.
Family History:
NC
Physical Exam:
On Discharge:
Vitals: AVSS
Gen: A and O x 3, NAD
Heart: RRR
Lungs: CTA
Abd: Soft, NT/ND, +BS
Ext: no edema. Moving all 4 extremities.
Pertinent Results:
CT Cspine: No acute cervical spine fracture or malalignment.
Mild anterior wedge compression of C7 vertebra, without
significant
surrounding soft tissue swelling, likely representing chronic
changes.
CT Torso:
1. No acute traumatic injury identified in the chest, abdomen,
and pelvis.
2. Subcentimeter hypodense lesions, are not characterized in
this study. A
non-emergent ultrasound can be performed for further evaluation.
3. Ectasia of the infrarenal aorta measuring 2.8 cm.
4. Chronic granulomatous disease in the right lung.
5. Nasogastric tube ends in the lower thoracic esophagus,
recommended
advancement to at least 8 cm, for optimal positioning.
CTH: 1. No acute intracranial hemorrhage or fracture.
2. Global cortical atrophy.
Brief Hospital Course:
Mr. [**Known lastname 89063**] was admitted to the TSICU while intubated. He was
agitated over night biting the ETT and pulling at the foley
requiring a propofol gtt. While agitated he was pulling at the
foley catheter. He remained hemodynamically stable. All of the
imaging was negative for an acute process. He was extubated
without difficulty in the morning. His cspine was cleared. He
did have hematuria after removal of the foley likely secondary
to uretheral trauma with the foley. He was also complaining of a
slightly an abnormal bite but was not having any difficulty
opening/closing his mouth and no obvious deficits. After two
hours he was reporting that his bite feels fine. No further
workup was required.
Medications on Admission:
metformin and folic acid
Discharge Medications:
1. metformin Oral
2. folic acid Oral
continue all home meds
Discharge Disposition:
Home
Discharge Diagnosis:
Motor Vehicle Collision.
Discharge Condition:
Ambulating without assistance.
Mental status is intact.
Discharge Instructions:
You were involved in a car accident and did not suffer any
injuries. You did have a breathing tube inserted so you may have
sore throat and hoarseness today and tomorrow. This should go
away with time. You also had a foley catheter and some trauma to
the urethera after it was placed. You may have some bloody urine
for the next few days. This too should get better over the next
few days. If you suddenly are unable to urinate and develop
abdominal pain you should seek medical attention immediately. It
is normal to have body aches and pains secondary to the car
accident.
Continue all of your home medications as needed.
You can take tylenol or motrin as needed for aches/pains.
Followup Instructions:
Follow up with your PCP as needed.
|
[
"305.00",
"307.9",
"599.70",
"V43.64",
"867.0",
"250.00",
"E812.0",
"E928.9",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2983, 2989
|
2101, 2821
|
296, 309
|
3058, 3116
|
1335, 2078
|
3848, 3886
|
1162, 1166
|
2896, 2960
|
3010, 3037
|
2847, 2873
|
3140, 3825
|
1181, 1181
|
1195, 1316
|
244, 258
|
337, 986
|
1008, 1040
|
1056, 1146
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,148
| 192,910
|
2610
|
Discharge summary
|
report
|
Admission Date: [**2163-9-21**] Discharge Date: [**2163-9-27**]
Date of Birth: [**2104-7-1**] Sex: M
Service: MEDICINE
Allergies:
Ceftriaxone
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
multiple paracentesis
History of Present Illness:
Pt is a 59 yo man w/ h/o Hep C cirrhosis s/p Liver xplant in
[**11-8**], w/ chronic rejection (demonstrated on biopsy in [**9-9**]),
recurrent Hep C on INF and ribavirin, B cell lymphoma, who p/w
fevers, abdominal pain, SBP. Pt was in USOH until 1 week PTA
when began feeling fatigued, had N/V approximately 1-2 episodes
per day, non-bloody, non-bilious. 3 days PTA, pt began to have
severe abdominal pain. He also noted increased abd girth,
increased LE edema, R > L, denied any calf pain. Over past 3
days, pt also c/o cough with some sputum production, although
difficult to bring up 2/2 abd pain. He also c/o laryngitis
starting 3 days ago. ROS otherwise negative for BRBPR, melena,
SOB, CP/pressure."
.
On [**9-21**], the patient saw Dr. [**Last Name (STitle) 497**] in clinic, the complained of
severe abdomninal pain, was noted to have a fever to 101, and
therefore was sent to the ED for further evaluation.
.
In [**Name (NI) **], pt was noted to be febrile to 102.8, HR 119, BP 104/74,
O2 sat 95% on RA, decreased to low 90's on [**Last Name (LF) **], [**First Name3 (LF) **] placed on 2L
NC and O2 sat increased to mid-90's. Labs notable for WBC 10.7
with 17% bands, T [**First Name3 (LF) **] elevated to 20.5 (last T [**First Name3 (LF) **] 15 on
[**9-19**]), lactate 2.4, INR 1.2 (elevated from 1.0). Paracentesis
was done that demonstrated 8520 WBC w/ 62% polys, c/w SBP. CT
scan report demonstrated no free air, no bowel obstruction,
increased ascites, and ?LLL pna vs clot in lung vs hepatic vein
clot. Pt was given levofloxacin 500mg IV x 1, flagyl 500mg IV x
1, morphine.
.
Due to pt's ill-appearance, and severe SBP, he was admitted to
MICU [**9-21**] for further care and monitering.
Past Medical History:
1. hepatitis C (s/p transfusion for bursitis surgery in '[**31**] vs.
EtOH cirrhosis), s/p orthotopic liver transplant on [**2162-11-12**],
followed by Dr. [**Last Name (STitle) 497**]. Post-op complications have been
recurrent hepatitis C viremia and development of cholestatic
jaundice of uncertain etiology, both occurring four months after
liver transplant.
2. B cell lymphoma: nodal marginal zone CD5 positive B-cell
lymphoma noted at the time of transplant; bone marrow biopsy
performed during hospitalization for pancytopenia and PNA in
[**2-7**] revealed approx. 25% involvement. Decision was for no chemo
at that time.
3. h/o PNA in [**2-7**]: Pseudomonas and Staph. cx positive treated
with aztreonam and levofloxacin.
4. Headaches: rxn to Prograf; was taken off for some time then
restarted; HA are throbbing, constant and encompass whole head.
Responds well to cold compress; refractory to pain medications.
5. IDDM 2: diagnosed in [**2160**], HbA1C 5.4 ([**1-10**]).
6. Arthritis s/p long hospitalization in the 70's.
7. Chronic neck pain s/p cervical procedure [**4-4**].
8. R inguinal hernia; unable to operate given recent liver
transplant.
9. Alpha-1 antitrypsin deficiency - this diagnosis appeared in a
prior discharge summary but was denied by the patient.
Social History:
Married >30 years. Lives with wife and her 10 year old
grandson, whom he takes care of. Never previously married and
never had children of his own. [**Country 3992**] veteran and describes
PTSD following 13 months of combat, which he received some
counseling for but no formal treatment. He used to work as a
custodian in the [**Hospital1 3494**] public schools but is now on
disability following a work injury.
.
Pt drank heavily in the past. Last drink was >1yr ago, prior to
liver transplant. Admits to marjuana use and occasional cocaine
use in the past. Tobacco history, smokes 10 cigarettes daily,
reports only taking 2 puffs and then throwing it away; up to one
pack daily over the last 45 years. Would like to quit, has
tried in the past with the patch and been successful for up to 2
weeks.
Family History:
Mother died at 76 from lung cancer. Father is 85, healthy.
Brother committed suicide ~10 years ago. Two brothers and two
sisters alive and healthy.
Physical Exam:
Vitals - T 100.9/100.9, 102 on [**9-22**] at 2PM , HR107 , BP102/58 ,
RR 14, O2 97% room air
General - cachectic, non-toxic, alert, oriented x3
HEENT - scleral icterus
CVS - tachycardic, regular, no noted M/R/G
Lungs - Decreased BS at bases b/l, ?crackles at left base
Abd - distended, incisional and umbilical hernia noted,
reducible, diffuse tenderness, no reboudn or guarding, tap site
without focal tenderness, erythema
Ext - [**12-6**]+ LE edema b/l, R>L--this was noted on admit as well
Skin - jaundiced
Neuro - No noted asterixis, oriented x 3
.
On discharge, Afebrile BP 114/77, HR 85, 97% RA.
similar exam. Abdomen distended, but soft w/o TTP, rebound, or
guarding.
Pertinent Results:
On Admission:
[**2163-9-21**] 04:00PM BLOOD WBC-10.7# RBC-3.62* Hgb-10.8* Hct-30.8*
MCV-85 MCH-29.9 MCHC-35.2* RDW-19.1* Plt Ct-111*
[**2163-9-21**] 04:00PM BLOOD PT-13.8* PTT-31.7 INR(PT)-1.2*
[**2163-9-21**] 04:00PM BLOOD Glucose-211* UreaN-22* Creat-0.6 Na-137
K-3.3 Cl-102 HCO3-21* AnGap-17
[**2163-9-23**] 03:52AM BLOOD calTIBC-144* VitB12-GREATER TH
Folate-18.4 Ferritn-247 TRF-111*
.[**2163-9-21**] 04:00PM ALT(SGPT)-94* AST(SGOT)-109* ALK PHOS-1529*
AMYLASE-33 TOT [**Month/Day/Year **]-20.5*
[**2163-9-21**] 04:00PM LIPASE-27
[**2163-9-21**] 04:00PM ALBUMIN-2.9*
.
On Dishcarge
WBC 2.3, Hct 22.8, Plt 101
Na 134, K 3.4, Cl 101, Bicarb 21, BUN 12, Cr 0.6
Tbili 17.4
AP 960, ALT 51, AST 157
rapamycin 8.3
.
Microbiology:
[**2163-9-21**], [**9-22**], [**9-23**] Blood cx: Pending
[**2163-9-21**] Peritoneal fluid cx: GBS, sensitive to levofloxacin
[**9-22**] sputum: beta strep
.
Imaging:
[**9-22**] CXR: There is consolidation in the left lower lobe with
marked leftward displacement of the mediastinum and elevation of
the left hemidiaphragm suggesting complete or almost complete
atelectasis of the left lower lobe. There are no other
consolidations or masses. There is no sizeable pleural effusion.
The heart size is normal. The mediastinal contours are
unremarkable.
Revision of the recent PET/CT and CT abdomen demonstrates
intermittent obstruction of the left lower lobe segmental
bronchi with subsequent atelectasis. Given this intermittent
nature of the radiological findings and absence of any
endobronchial obstructing lesion on the PET/CT from [**8-31**], [**2162**], recurrent aspirations are the most likely diagnosis.
.
[**2163-9-21**] CT Abdomen and Pelvis:
IMPRESSION:
1. Increase in abundant ascites.
2. Left lower lobe consolidation is likely pneumonia, but
pulmonary infarct
is a consideration given presence of possible left lower lobe
pulmonary embolus.
3. Left lower lobe thrombus that is either within the pulmonary
arteries or veins.
Brief Hospital Course:
This is 59 year-old man with hep C cirrhosis s/p liver
transplant 10 months ago complicated by recurrent Hep C and
chronic rejection who presented with abdmonial pain and was
found to have severe spontaneous bacterial peritonitis.
.
Due to pt's ill-appearance, and severe SBP, he was admitted to
MICU [**9-21**] for further care and monitering.
.
While in the MICU the patient was started on aztreonam,
linezolid, flagyl and levoquin to cover sbp and a possible
pneumonia. His antibiotic regimen was changed to vancomycin,
levofloxacin, and flagyl when he was found to have group B
Streptococci growing from peritoneal culture. Mr [**Known lastname 13149**]
abdominal pain improved rapidly with antibiotic therapy as well
as a therapeutic paracentesis. The GBS was found to be
sensitive to levoquin and he was eventually transitioned to
levoquin monotherapy and was discharged to finish a 14 day
course with subsuquent ciprofloxacin SBP prophylaxis.
.
Additionally Mr. [**Known lastname 2379**] was briefly hypoxic in the MICU (wich
resolved). CT scan revealed a question of LLL pneumonia versus
pulmonary embolus versus atelectasis. The radiologists
subsuquent discussions with the primary team indicated that the
CT appearance was more consistent with atelectasis and Mr.
[**Name14 (STitle) 13150**] hypoxia resolved without heparin therapy.
.
Mr. [**Known lastname 2379**] is 10 months s/p liver transplant and has both chronic
rejection as well as reactivation of his hepatitis C. He was on
treatment with interferon and ribavirin for his hepatitis C on
admission in addition to his immunosuppressive regimen. He was
admitted with an acute rise in his LFTs over baseline most
likely secondary to his rejection and HCV. His hepatitis C
treatment had to be discontinued due to his acute illness, and
it was difficult to increase his immunosuppressants to treat
rejection due to his reactivation of hepatitis C. He was
continued on his home regimen of rapamune, prednisone, and
ursidiol. He was not encephalopathic in house and did not
require lactulose.
.
Mr [**Known lastname 2379**] also suffered from portal hypertension with resultant
chronic ascites and lower extremity edema that were quite
symptomatic. His diuretics were originally held in house due to
his illness and concern for potentially initiating renal failure
in his infected state. He was maintainted on a low sodium diet
with one therapeutic paracentesis, which he tolerated. When he
clinically improved from an infectious standpoint; lasix 40 and
spironolactone 100 were reintroduced without significant renal
dysfunction.
.
Mr [**Known lastname 2379**] also received the standard care of a PPI; insulin to
treat his diabetes, electrolyte repletion, heparin prophylaxis,
nutritional input and physical therapy.
.
Ultimately with regards to his chronic liver failure and
difficult to manage ascites the patient initiated conversations
with Dr. [**Last Name (STitle) 497**] and the hepatology team about his overall
prognosis and therapeutic options. Because of his ill health
and particularly because he was found to have lymphoma in his
explanted liver he is not a candidate for a second liver
transplant. Mr. [**Known lastname 2379**] decided he would prefer to therefore
direct the remainder of his medical care to comfort measures.
[**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] with the Palliative care service along with the
social workers were very involved in setting up hospice care for
the patient at home and he was discharged with that goal in
mind.
.
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: Six (6) Tablet PO Q4H (every 4
hours) as needed.
2. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Oxycodone 40 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
8. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed: please do not take if oversedated.
Disp:*40 Tablet(s)* Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days: Last dose to be on [**10-5**].
Disp:*8 Tablet(s)* Refills:*0*
10. Norfloxacin 400 mg Tablet Sig: One (1) Tablet PO once a day:
to start on [**10-6**], after you complete the levofloxacin.
Disp:*30 Tablet(s)* Refills:*2*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of [**Location (un) 270**]-East & Visiting Nurse Hospice
Discharge Diagnosis:
1. Spontaneous bacterial peritonitis
2. hepatitis C s/p liver transplant
3. Chronic liver rejection
4. lymphoma
Discharge Condition:
fair. Afebrile, VSS
Discharge Instructions:
You were admitted to the hospital with an infection in your
abdomen, you will need to complete a 14-day course of
levofloxacin for this, and afterwards you will need to be on a
medicine called norfloxacin daily to prevent further infections.
You should seek medical attention if you develop fevers,
chills, or worsening abdominal pain because this may be a sign
that your infection has returned.
.
To treat your ascites and leg swelling we have started you on
lasix 40mg daily and spironolactone 100mg daily.
.
We are also asking that hospice be involved in your care and
they will help you manage things like your pain, encephalopathy,
and other comfort measures.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]. Thursday [**10-6**];
Dr[**Name (NI) 948**] office should contact you with an appoinment time.
|
[
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"996.82",
"305.1",
"273.4",
"041.02",
"572.3",
"250.00",
"567.23",
"202.80"
] |
icd9cm
|
[
[
[]
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[
"54.91",
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icd9pcs
|
[
[
[]
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11888, 11979
|
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|
276, 300
|
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|
5040, 5040
|
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|
4177, 4328
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10637, 11865
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12000, 12118
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12186, 12853
|
4343, 5021
|
231, 238
|
328, 2033
|
5054, 7014
|
2055, 3335
|
3351, 4161
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,026
| 131,164
|
36673
|
Discharge summary
|
report
|
Admission Date: [**2195-2-17**] Discharge Date: [**2195-2-21**]
Date of Birth: [**2142-6-27**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Adhesive Tape
Attending:[**First Name3 (LF) 7303**]
Chief Complaint:
Right Hip Pain
Major Surgical or Invasive Procedure:
1. Right hip revision and reimplantation of total hip
arthroplasty; acetabular component and femoral component.
2. Hardware removal, right femur.
3. Strut allograft and cancellous bone grafting, right femur.
4. Open reduction internal fixation right periprosthetic femur
fracture.
History of Present Illness:
Patient is a 52 yo F with a complex history of right hip
problems. She had a total hip replacement performed by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at [**Hospital 1474**] hospital in [**2194-6-2**] through an anterior
approach. Two weeks later she sustained a periprosthetic femur
fracture which was treated with ORIF on [**2194-7-2**] at [**Hospital 1474**]
Hospital. She then developed a deep MRSA infection and was
transferred to [**Hospital1 18**]. She underwent a washout [**2194-7-13**] and a
washout with hardware removal and antibiotic spacer placement
on [**2194-7-15**]. She was discharged to [**Hospital 8971**] Rehab but returned
to [**Hospital1 18**] on [**2194-7-23**] with increased drainage from the incision
and underwent 9 further I&Ds with vac changes. She has had a
spacer in situ and has been off antibiotics. A hip aspiration
was negative. She reports her pain has been unchanged. She
does not mobilize. She denies paresthesias or weakness.
Past Medical History:
PMH: HTN, HL, Hx of EtOH abuse, Spinal stenosis, Mild COPD,
Obesity
PSH: s/p THR [**6-3**], s/p periprosthetic ORIF [**7-3**], s/p washout
[**2194-7-13**], s/p washout with hardware removal and antibiotic spacer
placement on [**2194-7-15**], s/p further washouts with vac s x9, s/p
TAH/BSO, s/p appy
Social History:
Current tobacco smoker, approximately one pack per day x 30
years. Reports occasional EtOH, denies illicits. Married.
Family History:
Noncontributory.
Physical Exam:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
Respiratory: CTAB
Cardiovascular: RRR
Gastrointestinal: NT/ND
Genitourinary: Voiding independently
Neurologic: Intact with no focal deficits
Psychiatric: Pleasant, A&O x3
Musculoskeletal Right Lower Extremity:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* 5/5 strength TA/GS/[**Last Name (un) 938**]/FHL
* SILT DP/SP/T/S/S
* Dopplerable DP pulse
* Toes warm
Pertinent Results:
[**2195-2-17**] 06:04PM BLOOD WBC-18.4*# RBC-3.16*# Hgb-10.7*#
Hct-30.2*# MCV-96 MCH-33.9* MCHC-35.5* RDW-13.2 Plt Ct-250
[**2195-2-17**] 06:04PM BLOOD PT-13.4 PTT-24.9 INR(PT)-1.1
[**2195-2-17**] 06:04PM BLOOD Glucose-146* UreaN-9 Creat-0.6 Na-141
K-4.6 Cl-113* HCO3-23 AnGap-10
[**2195-2-18**] 04:24AM BLOOD WBC-9.8 RBC-2.61* Hgb-8.7* Hct-25.2*
MCV-97 MCH-33.4* MCHC-34.6 RDW-13.5 Plt Ct-173
[**2195-2-18**] 04:24AM BLOOD Glucose-127* UreaN-8 Creat-0.6 Na-140
K-4.2 Cl-111* HCO3-21* AnGap-12 Calcium-7.4* Phos-3.3 Mg-1.6
[**2195-2-19**] 07:10AM BLOOD WBC-7.6 RBC-3.37*# Hgb-10.7* Hct-30.0*
MCV-89# MCH-31.8 MCHC-35.8* RDW-15.5 Plt Ct-149*
[**2195-2-20**] 07:25AM BLOOD WBC-6.3 RBC-3.35* Hgb-10.7* Hct-29.9*
MCV-89 MCH-32.1* MCHC-36.0* RDW-15.3 Plt Ct-184
Brief Hospital Course:
The patient was taken to the operating room on [**2195-2-17**] by Dr.
[**Last Name (STitle) 5322**] for a revision right total hip arthroplasty. Please see
operative report for details. The surgery was uncomplicated and
the patient tolerated the procedure well. She received two units
of PRBC intraoperatively. Postoperatively she had some
hypotension and was transferred to the ICU for close monitoring.
She was transferred out of the ICU the following morning in
stable condition. Peri-operative vancomycin and Lovenox for DVT
prophylaxis were given as per routine. Pain was controlled
initially with a PCA and then transitioned to oral pain meds on
POD#1. The patient was transfused several units of PRBC
postoperatively for postoperative blood loss anemia; her HCT on
[**2-21**] was 31.9. The Foley was removed on POD#2 and the patient
was voiding independently thereafter. The surgical dressing was
changed on POD#2 and the surgical incision was found to be clean
and intact without erythema or abnormal drainage.
The patient was seen by the Infectious Disease service who felt
the perioperative Vanco was adequate coverage. She was started
on Bactrim DS for 6 weeks as prophylaxis against infection given
her history of MRSA and the presence of a relatively large
cadaveric allograft in the operative site per Dr. [**Last Name (STitle) 5322**]. In
addition, she was also seen by Ophthalmology for transient
blurry vision. Her eye exam was normal and her blurry vision
resolved spontaneously.
While in the hospital, the patient was seen daily by Physical
therapy. She was fitted for an abduction brace and assisted with
mobilization. Labs were checked throughout the hospital course
and repleted accordingly. At the time of discharge she was
tolerating a regular diet and feeling well. She was afebrile
with stable vital signs. Her hematocrit was acceptable and her
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the wound was benign.
She progressed well with Physical Therapy. Post-operative Xrays
demonstrated hardware in good position. She was discharged in
stable condition. Her weight-bearing status is touchdown weight
bearing on the right lower extremity with posterior hip
precautions and trochanter off precautions.
She was discharged to home with services and instructions for
follow up were provided.
Medications on Admission:
MEDS: Combivent inhaler, advair inhaler, dilaudid, tricor,
atenolol, ambien, lorazepam, MVI, calcium, vitamin D
Discharge Medications:
1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) 40mg Syringe
Subcutaneous once a day for 4 weeks: Please take lovenox daily
for four weeks. After finishing the lovenox, take aspirin 325mg
daily for an additional two weeks.
Disp:*28 40mg Syringe* Refills:*0*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day for 2 weeks: Please
take lovenox daily for four weeks. After finishing the lovenox,
take aspirin 325mg daily for an additional two weeks.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: Do not exceed 4000mg tylenol in
24hrs.
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for Pain: Do not drive, operate machinery, or
drink alcohol while taking this medication. As your pain
decreases, take fewer tablets and increase the time between
doses. Take a stool softener to prevent constipation.
Disp:*90 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
6. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation Inhalation [**Hospital1 **] (2 times a day).
11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-27**]
Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheeze.
12. Fenofibrate 150 mg Capsule Sig: One [**Age over 90 8821**]y Five (145)
mg PO QAM (once a day (in the morning)).
13. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)): Hold for SBP<100, HR<60.
14. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO QHS (once a day (at
bedtime)) as needed for Insomnia.
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Anxiety.
16. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 6 weeks: Please take this
medication for six weeks to prevent infection.
Disp:*84 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. Deep infection of right total hip arthroplasty.
2. Periprosthetic femur fracture s/p open reduction internal
fixation.
3. Periprosthetic femur fracture nonunion.
3. Heterotopic ossification stage [**Last Name (un) 82938**] type 3.
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool
softener (such as colace) as needed to prevent this side effect.
5. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
6. Please keep your wounds clean. You may shower starting five
days after surgery, but no tub baths or swimming for at least
four weeks. No dressing is needed if wound continues to be
non-draining. Any stitches or staples that need to be removed
will be taken out by the visiting nurse or rehab facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue the lovenox for four weeks
to help prevent deep vein thrombosis (blood clots). After
completing the lovenox, please take Aspirin 325mg daily for an
additional two weeks.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four week
checkup. Please place a dry sterile dressing on the wound each
day if there is drainage, otherwise leave it open to air. Check
wound regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be removed by the visiting nurse or rehab facility
in two weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Touchdown weight bearing right lower extremity.
Posterior hip precautions (no excessive hip flexion or internal
rotation). Trochanter off precautions (no active hip abduction).
Abduction pillow while sleeping. Abduction brace while out of
bed and walking: OK to have abduction brace off while in
bed/shower/chair and while transferring to chair. No strenuous
activity until follow up appointment.
13. ANTIBIOTICS: Please take Bactrim DS twice a day for 6 weeks
to prevent infection. This is necessary since you have a
relatively large cadaveric bone graft in place.
Physical Therapy:
ACTIVITY: Touchdown weight bearing right lower extremity.
Posterior hip precautions (no excessive hip flexion or internal
rotation). Trochanter off precautions (no active hip abduction).
Abduction pillow while sleeping. Abduction brace while out of
bed and walking: OK to have abduction brace off while in
bed/shower/chair and while transferring to chair. No strenuous
activity until follow up appointment.
Treatments Frequency:
WOUND CARE: Please keep your incision clean and dry. It is okay
to shower five days after surgery but no tub baths, swimming, or
submerging your incision until after your four week checkup.
Please place a dry sterile dressing on the wound each day if
there is drainage, otherwise leave it open to air. Check wound
regularly for
signs of infection such as redness or thick yellow drainage.
Staples will be removed by the visiting nurse or rehab facility
in two weeks.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2195-3-11**] 11:00
[**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**]
Completed by:[**2195-2-21**]
|
[
"996.44",
"733.82",
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"368.8",
"724.00",
"736.81",
"728.89",
"305.1",
"496",
"782.0",
"401.9",
"278.00",
"458.29",
"276.52",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"84.57",
"00.70"
] |
icd9pcs
|
[
[
[]
]
] |
8513, 8568
|
3465, 5846
|
293, 576
|
8846, 8846
|
2681, 3442
|
12941, 13248
|
2084, 2102
|
6008, 8490
|
8589, 8825
|
5872, 5985
|
9019, 10827
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2117, 2662
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12021, 12428
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12450, 12450
|
239, 255
|
12462, 12918
|
604, 1608
|
8861, 8995
|
1630, 1932
|
1948, 2068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,351
| 174,564
|
798
|
Discharge summary
|
report
|
Admission Date: [**2179-4-28**] Discharge Date: [**2179-5-3**]
Date of Birth: [**2119-3-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
post infarction angina
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x
4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
History of Present Illness:
This 60 year old white male developed chest pain on [**4-17**]
while driving. He was found to be bradycardic in the 40s and
was admitted to [**Hospital3 417**] Hospital and ruled in for
infarction with a Troponin of 11. Angioplasty and DES were
performed to the mid right coronary. A stress test was
performed prior to discharge and was positive with ECG changes
and pain. He was transferred here after recatheterization
revealed triple vessel disease.
Past Medical History:
Coronary artery disease
s/p stents x 2 to left anterior descending
hypertension
HIV positive
s/p right carotid endarterectomy
peripheral vascular disease
h/o deep vein thrombophlebitis
Social History:
He denies any use of alcohol or IV drugs. He has smoked [**1-30**]
packs of cigarettes per day for the last 30 years.
Family History:
non contributary
Physical Exam:
Admsiision:
Pulse: 72 Resp:17 O2 sat: 98% on RA
B/P Right: Left:
Height:5'[**80**]" Weight:152 LBS
General:
Skin: Dry [xx] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] R CEA incision
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema 0 Varicosities
+1
Neuro: Grossly intact
Pulses:
Femoral Right: Dressing in place Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2179-4-30**] 05:00AM BLOOD WBC-10.1 RBC-2.87* Hgb-10.3* Hct-29.5*
MCV-103* MCH-35.8* MCHC-34.7 RDW-12.3 Plt Ct-124*
[**2179-4-30**] 05:00AM BLOOD Glucose-122* UreaN-27* Creat-1.2 Na-136
K-4.3 Cl-103 HCO3-28 AnGap-9
Brief Hospital Course:
Cardiac catheterization after stenting demonstrated triple
vessel disease with an EF by echocardiogram of 45%. He was
prepared for surgery.
On [**4-28**] he was taken to the Operating Room where
revascularization was performed. See operative note for
details. He weaned from bypass on Propofol infusions. He
awoke, was weaned from the ventilator and extubated. He
remained stable. CTs were removed according to protocol. He was
transferred to the floor being atrially paced with a slow sinus
underlying. He developed rapid atrial fibrillation which was
treated with Amiodaone and lopressor with conversion to sinus
bradycardia in the 50s. Amiodarone was stopped and the
Lopressor dose dropped.
He remained in sinus for 48 hours and felt well. He was
preparing to go home on POD 4 when he developed atrial
fibrillation again with a ventricular rate of 120s. He
tolerated this well and Amiodarone was begun. He quickly
converted to sinus rhythm and Coumadin was begun. Arrangements
were made for his primary carer physician to regulate this with
as target INR of [**3-2**].5. Amiodarone was prescribed for 4 weeks
and it will be discontinued, along with the Coumadin, at that
time if sinus rhythm persists.
Physical Therapy worked with him for strength and mobility
prior to discharge. The lasix was stopped when his BUN elevated
to 38 but fell to 28 the next day. Even though his weight was
slightly above preop he had minimal edema and was doing well.
Follow up, medications and precautions were discussed with the
patient before discharge.
Medications on Admission:
Medications at home:
ASA 325mg po daily
Pravastatin 80mg po daily
Lisinopril
Truvada
Nevirapine
Metoprolol (dose unknown)
Meds on Transfer:
Prasugrel 10mg po daily
Percocet PRN
Nitrostat PRN
Lipitor 80mg po daily
ASA 325mg po daily
Zestril 2.5mg po daily
Discharge Medications:
1. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily). Tablet(s)
2. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
11. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day) for 4 weeks: two tablets twice daily for 2 weeks,
then one tablet twice daily for two weeks, then discontinue.
Disp:*92 Tablet(s)* Refills:*0*
12. Outpatient [**Date Range **] Work
Please draw a PT/INR on [**5-5**] and then prn. Report results to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 798**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
s/p coronary artery stents
peripheral vascular disease
HIV positive
s/p right carotid endarterectomy
h/o deep vein thrombophlebitis left
s/p femoral embolectomy
h/o pulmonary tuberculosis
Discharge Condition:
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**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] on Tuesday, [**6-8**] at 1PM ([**Telephone/Fax (1) 170**])
Please [**Telephone/Fax (1) **] appointments with:
Primary Care: Dr.[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in [**1-30**] weeks ([**Telephone/Fax (1) 798**])
Cardiology: Dr. [**First Name4 (NamePattern1) 5699**] [**Last Name (NamePattern1) **] in 2 weeks
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks. Your nurse [**First Name (Titles) **] [**Last Name (Titles) **] an
appointment.
Completed by:[**2179-5-3**]
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16,088
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18176
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Discharge summary
|
report
|
Admission Date: [**2202-4-25**] Discharge Date: [**2202-5-18**]
Date of Birth: [**2122-2-13**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
referred for right renal artery stenting and coronary
angiography
Major Surgical or Invasive Procedure:
Renal artery stenting
Cardiac catheterization with BMS placed in LAD, two overlapping
BMS's placed in proximal LCX
History of Present Illness:
Ms. [**Known lastname 22627**] is an 80 year old woman with a history of aortic
stenosis s/p mechanical AVR [**8-4**], atrial fibrillation s/p
cardioversion, HTN, GERD, and PVD who presented [**2202-4-25**] for
elective coronary and renal angiogram complicated by pna and [**Last Name (un) **]
and is transferred to the CCU s/p cath for hemodynamic
monitoring.
.
The patient was referred for renal angiogram after a recent
hospitalization for claudication work up that revealed bilateral
superior femoral artery disease and right renal artery stenosis
>95%. She was referred for coronary angiogram after having an
"abnormal EKG" at Dr.[**Name (NI) 9654**] office. Of note, she has been
having episodes of chest burning for the last 2 months described
as "heartburn" that occurs primarily at rest and often when
laying in bed after a late night snack. This pain lasts 30 min
and is intermittently and inconsistently associated with
bilateral arm and jaw pain, and always self-resolves without
intervention.
.
The patient was admitted for pre-cath hydration given her Cr of
1.8. She initially complained of epigastric tightness radiating
to her chest and EKG showed no acute ST changes.
Past Medical History:
Aortic stenosis (valve area 0.5 in [**2198**]) s/p mechanical aortic
valve replacement [**8-4**]
Afib s/p cardioversion
HTN
GERD
thyroid nodules/thyroid goiter
peripheral neuropathy
degenerative joint disease
sciatica
chronic bilateral pleural effusions
s/p cholesterol emboli to left eye in [**2188**] (per patient)-
Started on Coumadin at that time
s/p tonsillectomy
s/p laparoscopic salpingo-oophorectomy for benign ovarian mass
[**1-3**]
s/p cholecystectomy [**7-7**]
s/p right hammer toe surgery [**8-6**]
Social History:
Tobacco: Denies currently; 45 year history of smoking ~2
cigarettes/day.
ETOH: Rare.
Drugs: Denies.
Married and lives at home with her husband. Retired.
Functionally limited by pain from sciatica and DJD, but denies
exertional chest pain or exertional dyspnea.
Family History:
Brother passed from sudden death age 54, cause unknown. Mom with
HTN and possibly AF.
Physical Exam:
On admission:
Gen: WDWN female in NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. EOMI. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP difficult to assess [**3-2**] prominent carotid
pulse and EJ, but ~10 cm.
CV: RR, prominent S1, S2. GIII holosystolic murmer at apex, GII
holosystolic murmer at LSB, GII systolic murmer at RUSB. RV
heave. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Rales at bases b/l, no
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c. 2+ pitting edema at ankles.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Bandaged left second toe.
Pulses:
Right: Carotid 2+ DP thready
Left: Carotid 2+ DP thready
On discharge:
VS: 98.8, 147/71, 69, 20, 95% 2L
Gen: Pale elderly female in NAD, fatigued, AAOx3, Mood, affect
appropriate.
HEENT: PERRLA, EOMI, slightly dry MMM, neck supple, JVP flat
CV: RR, prominent S1, S2. GIII holosystolic murmur at apex, GII
holosystolic murmer at LSB, GII systolic murmer at RUSB. RV
heave. +S3, no S4
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Rales at bases b/l and
decreased breath sounds, no wheezes or rhonchi.
Abd: Soft, NT, ND, +BS, no abdominal bruits, no HSM
Ext: No c/c. 1+ pitting edema to ankles b/l
Skin: No stasis dermatitis, ulcers, scars, or xanthomas
.
Pulses:
Right: Carotid 2+ DP thready
Left: Carotid 2+ DP thready
Pertinent Results:
REPORTS:
ECHO CARDIAC CATH [**2202-4-26**]:
1. Coronary angiography in this right dominant system
demonstrated two
vessel CAD. The LMCA was patent. The LAD had a proximal 50%
stenosis.
The LCx had a 90% stenosis in the mid vessel. The RCA was known
to be
totally occluded and was not engaged.
2. Limited resting hemodynamics revealed moderate systemic
arterial
systolic hypertension with an SBP of 162 mmHg.
3. Renal artery angiography demonstrated a recanalized total
occlusion
of the right renal artery.
4- Successful revasculrrization of a chronically occluded
(recanalized)
right renal artery, stented with a 5.0x18 mm Genesis Aviator
stent with
excellent result.
5- Return for LCX intervention on Thursday after hydration
FINAL DIAGNOSIS:
1. Two vessel CAD.
2. Moderate systemic hypertension
3. Successful stenting of right renal artery with Aviator stent.
4. Return to cath lab for LCX intervention on Thursday [**2202-4-29**]
after
hydration
CXR AP [**2202-4-27**]:
IMPRESSION: New left mid lung opacity, concerning for pneumonia.
Right lower lobe atelectasis and bilateral effusions. Recommend
followup radiograph in 4 weeks following treatment to assess for
resolution.
CARDIAC CATH [**2202-5-3**]:
COMMENTS:
1- [**Name (NI) 50257**] PTCA and stenting of the proximal LCX with two
overlapping (3.0x8 and 3.0x12 mm) Vision BMSs with excellent
results
(see PTCA Comments)
2- Unsuccessful attempt to revascularize the OM2 CTO.
3- Staged PCI of the mid LAD (+/- re-attempt to open the OM2)
4- Limited resting hemodynamic assessment showed mildly elevated
systemic arterial hypertension (154/68 mmHg).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA and stenting of the proximal LCX with two
overlapping
Vision BMSs
3. Unsuccessful attempt to revascularize the OM2 CTO
4. Staged PCI of mid LAD
5. Monitor renal function, continue with Mucomyst and hydration
(add
lasix to maintain urine output of 100 cc/hour)
6. Continue medical therapy
CARDIAC CATH [**2202-5-4**]:
1. Successful PCI of the mid LAD with a 2.5x18mm bare metal
stent.
2. Unsuccessful attempt to open the occluded OM branch.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PCI of the LAD with BMS.
3. Unsuccessful PCI of the occluded OM branch.
RENAL ARTERY U/S [**2202-5-5**]:
1. Normal-sized kidneys with no evidence of hydronephrosis.
2. A likely dilated or calyceal diverticulum in the right kidney
which
contains milk of calcium.
3. Patient was unable to breathhold due to dyspnea, and
therefore an accurate evaluation of the renal arteries could not
be performed.
CXR [**2202-5-12**]:
FINDINGS: New left PICC terminates in the lower superior vena
cava. Heart
remains enlarged, and there is bilateral asymmetrical perihilar
alveolar
pattern, which has improved on the left, but is newly developed
on the right. This is likely related to the patient's known
multifocal pneumonia, but coexisting edema is also possible.
Moderate right pleural effusion with adjacent right retrocardiac
opacity is not substantially changed. Moderate left pleural
effusion has slightly changed in distribution but is probably
similar in overall size.
Brief Hospital Course:
80 F with HTN, mechanical AVR, A fib s/p cardioversion, PVD
admitted for coronary and renal angiogram. Hospitalization
complicated by NSTEMI, acute renal failure, pneumonia, GI bleed,
and hyponatremia
.
#. Coronaries/NSTEMI: Patient with non-exertional epigastric
tightness radiating to the chest, found to have 90% occluded
left circ on cardiac angio on [**2202-4-26**], but was not intervened
upon because of poor renal function. Patient had chest pain
following renal stenting, found to have new ST depressions on
EKG and rising cardiac enzymes consistent with NSTEMI. Pt needed
cardiac cath but renal functions following renal artery stenting
was elevated. Patient maintained on nitrodrip while renal
functions improved. Patient was brought for cath on [**2202-5-3**],
where she underwent a staged PCI of the mid LAD, following which
was directly transferred to CCU for closer monitoring. Overnight
in the CCU the patient had more chest pain and concerning EKG
changes which prompted a second cardiac catheterization on
[**2202-5-4**] where she underwent a [**Hospital1 2177**] also placed in the LAD. She
then remained on Aspirin 325mg PO daily after which was switched
to 81mg PO daily upon starting heparin and coumadin (pt also on
plavix 75). The patient was also started on atorvastatin 40 (not
80 due to ARF). The patient had no further episodes of chest
pain.
.
# Anuric acute on chronic renal failure: In the CCU, the patient
developed anuric ARF after her 3rd catheterization on [**2202-5-4**]
with a peak creatinine of 6.5. The etiology was thought to be
contrast-induced ATN as well as likely embolization from recent
renal artery revascularization. The patient developed anuria.
Renal was consulted, who recommended against HD. Instead they
recommended Lasix gtt, which resulted in pt slowly starting to
make urine. Unfortunately, the patient developed hyponatremia
thought to be secondary to diuresis from lasix and this was
discontinued. Fortunately, the pt made urine on her own.
Electrolytes remained grossly normal except for hyperphos and
hypermag which remained stable. The patient's creatinine
continued to improve, on discharge her creatinine was 2.4.
Patient will follow up with nephrology as an outpatient
# Hyponatremia: Nadir down to 118, thought to be secondary to
free water excess in the setting of ATN. Pt was aggressively
fluid restricted down to 1L/day and heparin drip D5W solution
was changed to NS and sodium improved on its own. Pt remained
largely asymptomatic except for a headache and nausea which
self-resolved briskly. On discharge her serum sodium was 129.
# Hypoxia: Thought to be secondary to multifocal pneumonia and
moderate and loculated (on 1 side) pleural effusions. Pulmonary
edema was also thought to be a contributing factor. Pt remained
hypoxic at a 5L O2 requirement throughout most of her CCU stay.
The effusions were thought to be most likely secondary to CHF
given the lack of fevers or white count even after antibiotics.
IP was consulted to tap the effusions to r/o parapneumonic
effusion, however given the aspirin, plavix, heparin, thought it
would be too high risk and risk of parapneumonic effusion was
low. Diuresis was also thought to wait given the patient's
resolving ARF. The hypoxia remained stable, saturating well on
2L, and is expected to self-resolve over time at rehab and
beyond.
# GI Bleed: On [**2202-5-11**] pt passed a small red clot of blood in
stool. Pt without any history of GI bleed. No endoscopy or
colonoscopy in our system. Given the red blood seen, this would
suggest a lower GI source. And given the lack of pain, this
would suggest diverticular disease. Bleeding is in the setting
of being on a heparin drip. Patient was transfused 2 units of
pRBCs over the course of this admission for a very slowly
downtrending hematocrit. She continued to have guiaic positive
stool, but no longer had any overt blood. On discharge, her
hematocrit is 23.8. A repeat hematocrit will be checked at
rehab. She would benefit from an outpatient colonoscopy,
patient will discuss this with her primary care physician.
# History of AS s/p mechanical AVR: patient was maintained on
heparin drip for most of her admission because warfarin was held
for procedures. She was restarted on warfarin. Goal INR of
25.3.5 for the mechanical valve. On discharge her INR was
therpeutic at 2.6.
#. Pump: history of AS s/p mechanical AVR in [**2199**]. TTE on this
admission shows regional LV systolic dysfunction consistent with
CAD, probable severe mitral regurgitation, moderate to severe
tricuspid regurgitation and pulmonary hypertension. Following
chest pain, patient found to have new S3, crackles on lung exam,
concerning for heart failure. Patient does not have baseline
BNP for comparison. Patient was maintained on heparin drip for
mechanical AVR while warfarin was held because of need for
procedures. In the CCU the patient remained euvolemic to
slightly hypervolemic. No prolonged diuresis was attempted.
.
#. Rhythm: Patient with h/o Afib s/p cardioversion. Currently
in NSR. Patient was continued on amiodarone
.
#. Pneumonia/?sepsis - found to have left midlobe pneumonia.
Had one episode of hypotension and was febrile for one night.
Patient was treated with 7 day course of vancomycin and cefepime
with no further fevers.
.
#. Confusion - was confused/delirious for a day, likely due to
morphine which was given for CP. Patient was kept off of
sedating medications. Infectious workup was concerning for a
pneumonia, which was treated with IV antibiotics.
.
#. Renal Artery Stenosis: Patient with severe 95% R renal
artery stenosis now s/p stenting on [**2202-4-26**]. Creatinine
worsened in setting of cardiac and renal angiogram, may have
been due to IV contrast, embolized plaque from stenting, newly
started antibiotics, hypoperfusion of kidneys from hypotension.
No eosinophils in urine, less suggestive of cholesterol emboli
to kidneys. Renal functions have been gradually improving. On
discharge her creatinine was trending down at 2.4. She will
follow up with nephrology as an outpatient.
.
#. Hypertension: patient was controlled on carvedilol
.
#. GERD: Stable. Changed to ranitine given need for plavix
.
#. Thyroid nodules/thyroid goiter: Continued on home
Levothyroxine.
.
#. Peripheral neuropathy/Restless legs: started on ropinirol
.
#. Urinary Dysfunction: Continue home Terazosin, Oxybutynin per
home regimen.
.
#. Degenerative joint disease: Pain control with Tylenol as per
home regimen.
.
#. s/p cholesterol emboli to left eye: continued on warfarin
Medications on Admission:
ASPIRIN 81 mg Tablet po daily
AMIODARONE 200 mg Tablet po qod
AMLODIPINE [NORVASC] 10 mg po daily
ISOSORBIDE MONONITRATE [IMDUR] SR 120 mg po daily
LISINOPRIL 40 mg Tablet po daily
METOPROLOL SUCCINATE SR 100 mg po daily
OLMESARTAN-HYDROCHLOROTHIAZIDE 40 mg-25 mg Tablet po daily
WARFARIN [COUMADIN] 3 mg Tablet po daily - last dose pre
procedure [**Date Range **] [**4-20**]
ROPINIROLE 0.25 mg Tablet po daily
LEVOTHYROXINE 50 mcg Tablet po daily
OXYBUTYNIN CHLORIDE SR 10 mg Tab po daily
TERAZOSIN 2 mg Capsule po daily
ALPRAZOLAM 0.25 mg Tablet po PRN
PANTOPRAZOLE EC 40 mg Tablet po daily
VITAMIN B COMPLEX
ERGOCALCIFEROL (VITAMIN D2)
Tylenol prn
Duculax prn
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO QOD ().
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for GERD.
15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
16. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)): Give 1-2 hours before bedtime .
17. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
18. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
20. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
21. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
22. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Primary Diagnosis:
- Acute renal failure
- NSTEMI
- Hyponatremia
- Pneumonia
Secondary Diagnosis:
- Aortic stenosis (valve area 0.5 in [**2198**]) s/p mechanical aortic
valve replacement [**8-4**]
- Afib s/p cardioversion
- HTN
- GERD
- thyroid nodules/thyroid goiter
- peripheral neuropathy
- degenerative joint disease
- sciatica
- chronic bilateral pleural effusions
- s/p cholesterol emboli to left eye in [**2188**] (per patient)-
Started on Coumadin at that time
- s/p tonsillectomy
- s/p laparoscopic salpingo-oophorectomy for benign ovarian mass
[**1-3**]
- s/p cholecystectomy [**7-7**]
- s/p right hammer toe surgery [**8-6**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
renal artery stenting. Your hospital course was complicated
with pneumonia, acute renal failure, and heartattack. You were
transferred to the cardiac ICU where you were closely monitored
and went for two cardiac catheterizations during which they
placed 3 bare metal stents to the arteries that feed your heart.
It will be important that you continue to take plavix every day
for at least a year. Your kidney functions have been steadily
improving. You will need to follow up with a cardiologist and a
nephrologist after discharge from the hospital.
You will need to follow up with your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] after discharge from rehab. You will need a
colonoscopy. Please discuss this with your primary care
physician
Your medications have changed. Please only take the medications
as listed below:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO QOD ().
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for GERD.
15. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
16. Ropinirole 0.25 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)): Give 1-2 hours before bedtime .
17. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
18. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
20. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
21. Warfarin 3 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
22. Hydralazine 25 mg Sig: One (1) Tablet PO twice a day
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], once you have been discharged from the
rehabilitation facility. Her office number is [**Telephone/Fax (1) 6699**]
Please follow up with your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7047**], on
[**Last Name (LF) **], [**2202-5-25**] at 1:20PM. His office number is
[**Telephone/Fax (1) 8725**]
Please follow up with Dr. [**Last Name (STitle) **] (neprhology) on [**6-22**] at
2:30PM. The address is [**Location (un) **], [**Hospital Ward Name 23**] Center, [**Location (un) **]. The office number is [**Telephone/Fax (1) 721**]
|
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icd9cm
|
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"39.50",
"36.06",
"99.20",
"00.40",
"39.90",
"00.46",
"37.22",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
16792, 16859
|
7402, 13992
|
340, 457
|
17540, 17540
|
4209, 4937
|
20801, 21496
|
2502, 2589
|
14706, 16769
|
16880, 16880
|
14018, 14683
|
6357, 7379
|
17723, 20778
|
2604, 2604
|
3483, 4190
|
235, 302
|
485, 1672
|
16978, 17519
|
16899, 16957
|
2618, 3469
|
17555, 17699
|
1694, 2207
|
2223, 2486
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,621
| 104,589
|
51033
|
Discharge summary
|
report
|
Admission Date: [**2131-5-24**] Discharge Date: [**2131-6-2**]
Date of Birth: [**2073-8-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
rectal bleeding
Major Surgical or Invasive Procedure:
[**5-28**] Exam under anesthesia, control of internal hemorrhoidectomy
bleeding
History of Present Illness:
57F with rectal bleeding pod 13 from hemorrhoidectomy for
bleeding internal hemorrhoids by Dr. [**Last Name (STitle) 1120**]. She said the week
after her surgery she was fine. However this last week she has
had increasing spotting and bleeding with bms. Earlier this
week
her inr was 4.5. Her goal is 2.5 - 3.5. This last day it has
been fairly constant and she has to keep changing pads. She
feels occasionally lightheaded.
Past Medical History:
Significant for alcohol abuse
Status post AVR and MVR in [**2123**] (due to rheumatic HD)
Migraines
Depression
Hepatitis C
Status post hysterectomy
Hypertension
Anemia with a baseline hematocrit in the low 30s to mid 30s
Social History:
Works in a multidisciplinary clinic on [**Hospital Ward Name **] for patients
with melanoma. Married, no children.
- Tobacco: 1 pack per week
- EtOH: Couple of drinks every night but hasn't drank in a week,
has been in detox in the past
- Illicits: Denies
Family History:
Mom had breast cancer in her 50s. No h/o abdominal/GI diseases.
Family h/o DM.
Physical Exam:
On Admission:
98.2 94 117/68 16 100
NAD
RRR
CTAB
Abd soft
Rectal - no external hemorrhoids, small amount of bleeding from
anus, unable to pass an anoscope due to patient discomfort.
Ext - no edema
Pertinent Results:
[**2131-5-25**] 02:09AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.3*
[**2131-5-29**] 10:33PM BLOOD Calcium-7.8* Phos-3.9 Mg-1.2*
[**2131-5-24**] 04:00AM BLOOD Glucose-210* UreaN-15 Creat-1.5* Na-141
K-3.6 Cl-108 HCO3-23 AnGap-14
[**2131-5-29**] 10:33PM BLOOD Glucose-107* UreaN-6 Creat-0.8 Na-139
K-3.3 Cl-107 HCO3-26 AnGap-9
[**2131-5-24**] 04:00AM BLOOD PT-92.5* PTT-50.0* INR(PT)-11.4*
[**2131-5-24**] 04:00AM BLOOD Plt Ct-336
[**2131-5-24**] 11:08AM BLOOD PT-34.9* PTT-46.4* INR(PT)-3.6*
[**2131-5-24**] 11:08AM BLOOD Plt Ct-186
[**2131-5-24**] 01:52PM BLOOD PT-21.1* INR(PT)-2.0*
[**2131-5-24**] 05:15PM BLOOD PT-19.6* INR(PT)-1.8*
[**2131-5-25**] 02:09AM BLOOD PT-15.5* PTT-67.5* INR(PT)-1.4*
[**2131-5-25**] 02:09AM BLOOD PT-15.5* PTT-67.5* INR(PT)-1.4*
[**2131-5-25**] 02:09AM BLOOD Plt Ct-125*
[**2131-5-25**] 08:36AM BLOOD PT-13.4 PTT-52.2* INR(PT)-1.1
[**2131-5-25**] 03:08PM BLOOD Plt Ct-178
[**2131-5-25**] 03:20PM BLOOD PT-13.0 PTT-59.2* INR(PT)-1.1
[**2131-5-25**] 10:00PM BLOOD PTT-73.1*
[**2131-5-26**] 04:00AM BLOOD PT-13.9* PTT-62.2* INR(PT)-1.2*
[**2131-5-26**] 05:20PM BLOOD PT-13.6* PTT-56.8* INR(PT)-1.2*
[**2131-5-27**] 02:06AM BLOOD PT-14.5* PTT-82.2* INR(PT)-1.3*
[**2131-5-27**] 08:40AM BLOOD PT-14.3* PTT-41.2* INR(PT)-1.2*
[**2131-5-27**] 09:15PM BLOOD PTT-82.2*
[**2131-5-28**] 04:30AM BLOOD PT-15.7* PTT-67.0* INR(PT)-1.4*
[**2131-5-28**] 04:30AM BLOOD Plt Ct-161
[**2131-5-28**] 10:20AM BLOOD PTT-37.8*
[**2131-5-29**] 09:22AM BLOOD PT-14.7* PTT-33.5 INR(PT)-1.3*
[**2131-5-29**] 10:33PM BLOOD PTT-97.3*
[**2131-5-30**] 07:00AM BLOOD PT-14.2* PTT-46.2* INR(PT)-1.2*
[**2131-5-30**] 03:30PM BLOOD PTT-150*
[**2131-5-30**] 09:47PM BLOOD PTT-40.8*
[**2131-5-30**] 09:47PM BLOOD PTT-40.8*
[**2131-5-31**] 05:53AM BLOOD PT-17.6* PTT-108.9* INR(PT)-1.6*
[**2131-5-31**] 06:57AM BLOOD PT-17.4* PTT-86.4* INR(PT)-1.6*
[**2131-5-31**] 01:24PM BLOOD PTT-119.6*
[**2131-5-31**] 09:40PM BLOOD PTT-75.0*
[**2131-6-1**] 06:16AM BLOOD PT-20.2* PTT-61.1* INR(PT)-1.9*
[**2131-5-24**] 04:00AM BLOOD WBC-8.0# RBC-2.62* Hgb-7.5* Hct-23.9*
MCV-91 MCH-28.5 MCHC-31.3 RDW-17.2* Plt Ct-336
[**2131-5-24**] 11:08AM BLOOD WBC-8.0 RBC-2.00* Hgb-6.1* Hct-18.0*
MCV-90 MCH-30.7 MCHC-34.1 RDW-16.9* Plt Ct-186
[**2131-5-24**] 01:52PM BLOOD Hct-28.4*#
[**2131-5-24**] 05:15PM BLOOD Hct-28.1*
[**2131-5-25**] 02:09AM BLOOD WBC-5.6 RBC-3.18*# Hgb-9.5*# Hct-26.9*
MCV-85 MCH-29.8 MCHC-35.2* RDW-16.5* Plt Ct-125*
[**2131-5-25**] 08:36AM BLOOD Hct-26.7*
[**2131-5-25**] 03:08PM BLOOD WBC-6.7 RBC-3.71* Hgb-10.8* Hct-32.3*
MCV-87 MCH-29.0 MCHC-33.3 RDW-16.6* Plt Ct-178
[**2131-5-25**] 10:00PM BLOOD Hct-29.3*
[**2131-5-26**] 04:00AM BLOOD WBC-5.7 RBC-3.10* Hgb-9.3* Hct-27.2*
MCV-88 MCH-29.9 MCHC-34.1 RDW-15.6* Plt Ct-155
[**2131-5-26**] 03:10PM BLOOD Hct-28.0*
[**2131-5-27**] 02:06AM BLOOD Hct-26.5*
[**2131-5-27**] 08:40AM BLOOD Hct-27.2*
[**2131-5-27**] 05:00PM BLOOD WBC-4.8 RBC-2.89* Hgb-8.5* Hct-25.5*
MCV-88 MCH-29.5 MCHC-33.4 RDW-15.8* Plt Ct-174
[**2131-5-28**] 04:30AM BLOOD WBC-4.4 RBC-2.48* Hgb-7.4* Hct-21.9*
MCV-89 MCH-29.7 MCHC-33.5 RDW-15.6* Plt Ct-161
[**2131-5-28**] 04:30AM BLOOD WBC-4.4 RBC-2.48* Hgb-7.4* Hct-21.9*
MCV-89 MCH-29.7 MCHC-33.5 RDW-15.6* Plt Ct-161
[**2131-5-28**] 03:30PM BLOOD Hct-28.9*#
[**2131-5-28**] 09:35PM BLOOD Hct-28.6*
[**2131-5-29**] 03:30AM BLOOD Hct-26.6*
[**2131-5-29**] 09:55AM BLOOD Hct-28.5*
[**2131-5-29**] 10:33PM BLOOD Hct-25.6*
[**2131-5-30**] 06:54AM BLOOD Hct-28.7*
Brief Hospital Course:
[**2131-5-24**] - Admitted to SICU for rectal bleeding, decreased
hematocrit and elevated INR.; Foley catheter, A-line placed,
transfused 3 units of PRBC's and 1U FFP, surgi-cel rectal tampon
placed, ICU consent obtained. Hct stable, INR decreased to <2,
heparin gtt initiated.
[**2131-5-25**] - Low electrolytes, repleated per sliding scale,
Serial hematocrits were checked and coumadin was held.
Patient was transferred to the floor after Hct, BP, UOP and
coagulopathy were stabilized.
[**5-28**] patient underwent exam under anesthesia control of internal
hemorrhoidectomy bleeding
[**5-29**] coumadin restarted and hematocrits continued to be checked
and stable in mid to upper 20's. heparin drip continued to
bridge patient to warfarin given the AVR and MVR.
[**6-2**] INR was therapeutic at 2.7
By time of discharge the INR was therapeutic and the patient's
Hct was stable.
Medications on Admission:
amlodipine 2.5', fioricet q6 prn, premarin cream, anusol supp'',
lisinopril 80', metoprolol 100'', mirtazapine 45', percocet prn,
trazodone 200 qhs, coumadin as dir.
Discharge Medications:
1. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
3. Trazodone 50 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime) as needed for insomnia.
4. Lisinopril 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
5. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain for 1 weeks.
Disp:*30 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: AFTER your dose tonight, and your dose Sunday, you are to
GO TO [**Hospital Ward Name **] ONE ON MONDAY MORNING [**2131-6-4**] FOR an INR Draw.
Tablet(s)
Discharge Disposition:
Home
Discharge Diagnosis:
rectal bleeding from internal hemorrhoidectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call if you notice further rectal bleeding. Call if
fevers >101. Call if light headed, dizzy, bleeding, chest pain,
change in mental status, sudden weakness or slurring of speech.
Call with any concerns or questions.
You were admitted to the hospital due to rectal bleeding and
elevated INR. On [**5-28**] you had an exam under anesthesia with
control of internal hemorrhoidectomy bleeding. After bleeding
was adequately controlled you were restarted on coumadin and
heparin drip as a bridge to coumadin. Your therapeutic goal INR
is 2.5 to 3.5. It is very important that you follow up in
coumadin clinic for frequent INR checks and appropriate
adjustmenjt of your coumadin.
Followup Instructions:
On Monday MORNING you are to go to [**Hospital Ward Name **] 1 for a blood draw
and INR check, at which your comadin dose will be adjusted by
the doctor on-call. Then later that week, we ask that you
please follow-up with Dr. [**First Name (STitle) **] for INR checks and coumadin
dose adjustment. Phone: [**Telephone/Fax (1) 250**]
Please call Dr. [**Last Name (STitle) 1120**] to schedule follow up in [**2-3**] weeks
|
[
"E878.8",
"V43.3",
"V58.61",
"455.0",
"790.92",
"346.90",
"998.11",
"E934.2",
"401.9",
"285.9",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"48.32",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7324, 7330
|
5160, 6048
|
330, 412
|
7421, 7421
|
1720, 5137
|
8286, 8713
|
1407, 1487
|
6265, 7301
|
7351, 7400
|
6074, 6242
|
7572, 8263
|
1502, 1502
|
274, 292
|
440, 873
|
1516, 1701
|
7436, 7548
|
895, 1117
|
1133, 1391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,529
| 133,942
|
37490
|
Discharge summary
|
report
|
Admission Date: [**2185-10-10**] Discharge Date: [**2185-10-24**]
Date of Birth: [**2114-4-10**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Transfer from [**Hospital6 204**] in DKA with groin
infection
Major Surgical or Invasive Procedure:
[**2185-10-14**] 1. Excision of right femoral to anterior tibial bypass
graft with complete removal of foreign material.
2. Extensive debridement of the right groin including the
native common femoral artery in its entirety.
3. Right external iliac to distal common femoral bypass
graft using cadaveric deep femoral vein (CryoVein).
4. Right groin sartorius muscle flap.
[**2185-10-18**]
Right below-knee amputation
History of Present Illness:
71 yo F wtih h/o of PVD and recent right fem-[**Doctor Last Name **] bypass in [**Month (only) **]
with Dr. [**Last Name (STitle) **] who presented to [**Hospital3 **] today with
pus from bypass site and found to be in DKA. She initially
presented because she thought she was having dark stools and was
concerned for a GIB which she's had in the past. She was found
to have dark pus coming from her fem-[**Doctor Last Name **] bypass site. At OSH,
her right leg was noted to be red from the surgical site down to
her knee.
.
VS at OSH: 113/34 60-70 98.3 96% 2L. Fingerstick was 548.
Sodium 129. WBC 19 with 11% bandemia. K 6.8. Serum acetone
1:8. Urine and blood cx drawn. No CXR done. UA was negative
except for ketones and glucose. She was given 2L IVF, 5u iv
insulin and placed on insulin gtt at 10u hr. Repeat sugar was
348. EKG had non-specific ST changes, but none was available for
comparison. No cardiac enzymes were drawn. Her right leg was
noted to be red with drainage from surgical site. She was
treated with Unasyn 3g and vancomygin 1g iv.
.
On arrival to the ICU patient reports that she noticed drainage
from the bypass incision site 1-2 days ago. She denies fever or
chills. She endorses nausea though no vomiting. She denies
diarrhea.
.
ROS: pos per HPI, otherwise negative.
Past Medical History:
DM I
CAD s/p MI and 4 vessel CABG in [**2176**]
RLE endarterectomy/patch angioplasty of distal popliteal artery
[**2184**]
L SFA angioplasty
Social History:
She is a retired clerical worker. Lives alone. Has a daughter
that helps her. No tobacco, EtOH or recreational drugs.
Family History:
No h/o DM.
Physical Exam:
Admission:
General Appearance: No acute distress, Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: dry MM, cracked lips
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Absent), (Left DP pulse:
Diminished)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : , No(t) Crackles : , No(t) Wheezes : , No(t)
Rhonchorous: )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: Trace
Skin: Cool, No(t) Rash: , No(t) Jaundice
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Tone: Normal
Discharge:
VS: 99.1 HR: 80 BP: 114/52 RR:20 Spo2: 99%
Gen: Alert and oriented x3, Pain under aqeduate managment
Neuro: CN II-XII intact
CV:RRR
Lungs with bilateral crackles, diminshed bases
Abd: soft, NT, ND
Right BKA wound improved decrease in erythema, 3 + edema
Pulses: Fem [**Doctor Last Name **] DP PT
Left palp palp dop dop
Right palp - BKA
Pertinent Results:
Admission Labs:
[**2185-10-10**] 08:25PM WBC-14.8*# RBC-3.92* HGB-10.3* HCT-32.3*
MCV-82 MCH-26.3* MCHC-32.0 RDW-15.1
[**2185-10-10**] 08:25PM NEUTS-89.3* LYMPHS-8.4* MONOS-1.8* EOS-0.1
BASOS-0.4
[**2185-10-10**] 08:25PM PLT COUNT-463*
[**2185-10-10**] 08:25PM PT-11.5 PTT-23.0 INR(PT)-1.0
[**2185-10-10**] 08:25PM CALCIUM-8.7 PHOSPHATE-1.7*# MAGNESIUM-1.6
[**2185-10-10**] 08:25PM ALT(SGPT)-11 AST(SGOT)-10 CK(CPK)-30 ALK
PHOS-93 TOT BILI-0.2
[**2185-10-10**] 08:25PM CK-MB-4 cTropnT-<0.01
[**2185-10-10**] 08:25PM GLUCOSE-70 UREA N-23* CREAT-0.8 SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-16
[**2185-10-10**] 10:04PM LACTATE-1.9
Studies:
[**2185-10-10**]: Sinus rhythm with atrial premature beats. ST-T wave
abnormalities. Since the previous tracing of [**2185-7-14**] the atrial
premature beats are new. ST-T wave abnormalities may be more
marked.
[**2185-10-10**]: CXR: As compared to the previous radiograph, today's
image shows
multiple respiratory motion artifacts and is limited in
interpretability. The lung volumes are normal. There is no
evidence of pleural effusions. The sternal wires have been
removed in the interval, however, several clips projecting over
the mediastinum are still visible. No evidence of pathological
parenchymal opacities, no pulmonary edema. No focal parenchymal
opacity suggesting pneumonia. The size of the cardiac silhouette
is at the upper range of normal.
[**2185-10-14**]:
Final Report
PORTABLE CHEST, [**2185-10-14**]
CLINICAL INFORMATION: PICC pulled back.
FINDINGS:
Frontal view of the chest is compared to multiple prior
examinations. The
right PICC has been pulled back and now resides within the
superior vena cava. The lungs demonstrate mild bibasilar
atelectasis. There is a small left-sided pleural effusion.
There is a small right-sided pleural effusion. Upper lung zones
are clear. No pneumothorax. Cardiomediastinal silhouette is
unremarkable. Status post CABG. Clips in the left paratracheal
region.
IMPRESSION:
Right PICC pulled back, terminates in superior vena cava.
Small bilateral pleural effusions, bibasilar atelectasis.
[**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with has had multiple surgeries (vascular).
Please redo upper
extremities
REASON FOR THIS EXAMINATION:
please asses conduit for conduit for BPG
Final Report
INDICATION: 71-year-old woman being evaluated prior to CABG.
Patient has history of multiple intravenous catheters in the
right upper
extremity.
TECHNIQUE AND FINDINGS: Vein mapping of the upper extremity was
performed
with B-mode ultrasound. Also the left small saphenous vein was
evaluated with
B-mode ultrasound.
On the right upper extremity, the right cephalic vein is patent
and
compressible with diameters ranging between 0.37 and 0.13 cm.
The right
basilic vein is patent and compressible with diameters ranging
between 0.46
and 0.2 cm.
On the left side, the left cephalic vein is patent and
compressible with
diameters ranging between 0.32 and 0.21 cm. The wall of the
distal segment of
the left cephalic vein in the left arm presents with increased
thickness.
The left basilic vein is patent and compressible with diameters
ranging
between 0.35 and 0.21 cm. There is some thickening of the wall
of the left
basilic vein.
The left small saphenous vein is patent and compressible
demonstrating thick
walls.
IMPRESSION: Patent cephalic and basilic veins bilaterally with
diameters
described above. The left basilic and the distal segment of the
left cephalic
veins demonstrated thick walls.
The left small saphenous vein demonstrated thick walls.
INDICATION: 71-year-old woman being evaluated prior to CABG.
Patient has history of multiple intravenous catheters in the
right upper
extremity.
TECHNIQUE AND FINDINGS: Vein mapping of the upper extremity was
performed
with B-mode ultrasound. Also the left small saphenous vein was
evaluated with
B-mode ultrasound.
On the right upper extremity, the right cephalic vein is patent
and
compressible with diameters ranging between 0.37 and 0.13 cm.
The right
basilic vein is patent and compressible with diameters ranging
between 0.46
and 0.2 cm.
On the left side, the left cephalic vein is patent and
compressible with
diameters ranging between 0.32 and 0.21 cm. The wall of the
distal segment of
the left cephalic vein in the left arm presents with increased
thickness.
The left basilic vein is patent and compressible with diameters
ranging
between 0.35 and 0.21 cm. There is some thickening of the wall
of the left
basilic vein.
The left small saphenous vein is patent and compressible
demonstrating thick
walls.
IMPRESSION: Patent cephalic and basilic veins bilaterally with
diameters
described above. The left basilic and the distal segment of the
left cephalic
veins demonstrated thick walls.
The left small saphenous vein demonstrated thick walls.
Labs on DC:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2185-10-21**] 05:04 10.4 3.42* 10.1* 29.0* 85 29.5 34.7 15.9*
444*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps
Metas
[**2185-10-12**] 07:15 89.5* 8.1* 2.0 0.3 0.2
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2185-10-21**] 05:04 444*
LAB USE ONLY
[**2185-10-21**] 05:04
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2185-10-24**] 05:58 155*1 17 0.8 138 4.3 100 30 12
Source: Line-PICC
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2185-10-18**] 04:13 Using this1
Source: Line-arterial
Using this patient's age, gender, and serum creatinine value of
0.9,
Estimated GFR = 62 if non African-American (mL/min/1.73 m2)
Estimated GFR = 75 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 70+ is 75 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2185-10-11**] 10:27 351
LPD ADDED [**10-11**] @ 10:58
[**2185-10-11**] 01:58 321
NEW REFERENCE INTERVAL AS OF [**2185-1-24**];UPPER LIMIT (97.5TH %ILE)
VARIES WITH ANCESTRY AND GENDER (MALE/FEMALE);WHITES 322/201
BLACKS 801/414 ASIANS 641/313
CPK ISOENZYMES CK-MB cTropnT
[**2185-10-11**] 10:27 4 <0.011
LPD ADDED [**10-11**] @ 10:58
[**2185-10-11**] 01:58 <0.011
<0.01
CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2185-10-24**] 05:58 7.8* 3.8 2.0
Brief Hospital Course:
[**2185-10-10**] MICU Course:
71 yo F with PMH DMI, CAD s/p MI and CABG, severe PAD/PVD with
fem-[**Doctor Last Name **] bypass in [**Month (only) **] who presented to OSH with ? dark stool
and found to be in DKA with a sugar >500 and
leukocytosis/bandemia likely from infected graft material. She
was started on an insulin drip and her anion gap resolved. She
had a red graft incision site oozing pus without dopplerable
pulses on her RLE. It was felt that she had a graft infection
and was transferred to the vascular surgery team for management.
[**Date range (3) 84213**]
Right groin was explored by Vascular surgery for purulent
drainage at the bedside. Tissue was opened at healed scar site
and purulent material was expressed. Wound was explored and
found to track. Site cleansed and dressed with wet to dry
dressing. Patient was transferred to VICU for probable surgery
in am. [**Last Name (un) **] was consulted for DKA. Continued on IVF and
insulin gtt. Lantus started after insulin gtt was stopped.
[**2185-10-13**] Patient was taken to the OR for excision of R femoral
infected graft with external iliac-profunda bypass with
cryovein, debridement, sartorius flap. Wound cultures pending.
IV abx continued. Intubated in the ICU overnight.
[**2185-10-14**]
Right foot cool to touch, no DP/PT signals. Patient having
ischemic pain. UA positive for yeast and blood. PICC placed and
placement confirmed. Discussion of possible additional operative
treatment. Better glucose management of insulin sliding scale.
[**2185-10-15**]
Right foot continues to be ischemia. Significant pain of the
right leg at rest. Plan to take back to OR for BKA.
[**Date range (3) 84214**]
Social work consult for coping, Pre-oped for BKA. Received 1
unit of PRBC and continued diuresis. Wound cultures positive for
beta stept group B
[**2185-10-18**]:
Taken to the OR for R BKA. Tolerated operation without
complications. Hemodynamically stable post op. Pain management
with PCA, Neurontin, Tylenol. Fluconazole 14 days for increasing
yeast and + UTI.
[**2185-10-19**]
Stable. Continued pain management. Nutrition following the
patient. [**Last Name (un) **] continues to follow patient
[**Date range (1) 84215**]-
Continued pain management. [**Last Name (un) **] continued to follow and tweak
insulin regimen. BKA site stable with some mild erythema, no
drainage. PT recommending Rehab. Per ID request patient on PCN
for 1 week po. Will be dc'ed on PCN and 2 additional weeks of
fluconazole for UTI. Discharged to Rehab [**2185-10-24**]. PICC d/c'ed
prior to transfer
Medications on Admission:
Acebutolol 400 mg once a day
Clopidogrel 75 mg once a day
Glyburide 15 mg qam and 5mg qpm
Lisinopril 10 mg once a day
Metformin 1,000 mg Extended twice a day
Aspirin 81 mg once a day
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. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for sbp<100;.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for sbp < 100, hr < 60.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for yeast overgrowth peri rectal
area, gluteal cleft.
11. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
13. Cromolyn 5.2 mg/Actuation Spray, Non-Aerosol Sig: One (1)
Spray Nasal Q6H (every 6 hours).
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
16. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
17. Penicillin V Potassium 500 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) for 7 weeks.
18. Lantus
5 units with dinner
19. Insulin sliding scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-150 mg/dL 6 Units 6 Units 8 Units 0 Units
151-199 mg/dL 7 Units 7 Units 9 Units 0 Units
200-239 mg/dL 8 Units 8 Units 10 Units 2 Units
240-279 mg/dL 9 Units 9 Units 11 Units 2 Units
280-319 mg/dL 10 Units 10 Units 12 Units 3 Units
320-360 mg/dL 11 Units 11 Units 13 Units 4 Units
> 360 mg/dL Notify M.D.
20. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) as needed for continued pain.
21. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for diuresis.
22. Lorazepam 0.25 mg IV Q6H:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] [**Hospital1 189**]
Discharge Diagnosis:
DKA
R groin wound infection
Graft infection
PMH:
DM
Cornonary Artery Disease
Peripheral Vascular Disease
Arterial ulcers
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING TRANSMETATARSAL AMPUTATION
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your BKA you
can not bear weight. You should keep this amputation site
elevated when ever possible
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise: You should work with PT and OT daily. Limit strenuous
activity for 6 weeks. Do not drive a car unless cleared by your
Surgeon. No heavy lifting greater than 10 pounds for the next 30
days.
.Try to keep leg elevated when able.
.BATHING/SHOWERING:
You may shower in a shower chair. No baths or soaking. You may
wash your incision(s) gently with soap and water. You will have
sutures/staples which are usually removed in 4 weeks. This will
be done by the Surgeon on your follow-up appointment.
WOUND CARE:
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS: Unless told otherwise you should resume taking all
of the medications you were taking before surgery. You will be
given a new prescription for pain medication, which can be taken
every three (3) to four (4) hours only if necessary.
.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
.
DIET:
.You should follow a diabetic diet. Poor appetite is expected
for several weeks and small, frequent meals may be preferred.
.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
.
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
.
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2185-11-21**] 3:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2186-1-2**] 1:15
Completed by:[**2185-10-24**]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,315
| 106,015
|
12726
|
Discharge summary
|
report
|
Admission Date: [**2134-4-19**] Discharge Date: [**2134-5-11**]
Date of Birth: [**2061-11-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Endoscopy
Sigmoidoscopy
Portacath removal
[**First Name3 (LF) **] catheter placement
[**First Name3 (LF) **]
History of Present Illness:
72M with pmh significant for metastatic rectal cancer was at
radiology clinic receiving scheduled imaging when blood pressure
at triage recorded 60/40. Recheck was 70/40. His port was
accessed and he was bolused with 300cc of IVF and transferred to
the ED. He denied syncope or lightheadedness but reported mild
SOB and fatigue. He reports having several days of diahrrea,
which began last wednesday [**4-14**]. His last dose of irinotecan and
panitumab chemotherapy was Monday [**2134-3-29**] (patient reports was
[**4-12**] but not recorded in OMR), and he reports always getting
diahrrea with his chemotherapy. He reports haveing watery bowel
movements roughly every 45 minutes since wednesday. HIs bowel
movements are not bloody or melanaic. He has been taking
immodium and diphenoxylate-atropine without improvement. Sunday
night, he reports acute worsening of his diahrrea, which
continued through Monday. EMS gave him another 500cc of NS prior
to arrival to the ED.
.
On arrival to the ED his vitals were 98.0 100/50 83 18 100%RA.
Cr was 1.3 from 1.1. Hct was 27.3. Mg was 0.8mg. He was guaiac
negative. CT torso was without PE or dissection, but did have
multiple stable pulmonary nodules, and a small right pleural
effusion. He also had stable metastatic disease. EKG was sinus
in the 70's. He was given 3L of NS and 4 grams of Mg.
.
Review of Systems:
(+) Per HPI
.
He is denying fevers, abdominal pain, chest pain, hematochezia,
melena.
Past Medical History:
Past Oncologic History:
Adenocarcinoma of the rectum
- [**6-/2131**]: The patient presented with a change in bowel habits
and was noted to have an abnormal rectal exam by his primary
care
physician, [**Name10 (NameIs) 39262**] [**Name Initial (NameIs) **] gastrointestinal evaluation.
- [**2131-7-23**] colonoscopy: Exophytic cancer of the rectum [**9-9**]
cm
above the anal margin. Polyp noted at the anorectal junction.
Biopsy: Invasive, moderately differentiated adenocarcinoma
arising in association with adenoma. Polyp: Adenoma with
high-grade dysplasia.
- [**2131-7-25**] rectal ultrasound: T3 posterior midline tumor with
luminal narrowing of the rectum.
- [**2131-8-2**] CT scan of the torso: Irregular, polypoid lesion
seen within the rectum, with multiple subcentimeter presacral
and
pericolic lymph nodes identified. Two pulmonary nodules seen in
the left lower lobe, the largest measuring 2.9 x 2.2 cm.
Multiple
low-attenuation lesions seen within the liver, the
largest of which may represent cyst, smaller lesions are not
fully characterized. Low-attenuation lesions seen within the
left kidney, possibly a cyst, although too small to
characterize.
Per report, a CT PET performed elsewhere demonstrated uptake in
the left base of the lung.
- [**2131-8-14**] to [**2131-9-25**]: Neoadjuvant chemoradiation with
continuous 5-FU at 225 mg/m2/day and radiation therapy five days
weekly.
- [**2131-12-10**]: Proctosigmoidectomy with stapled coloanal
anastomosis and diverting loop ileostomy. Pathology revealed
adenocarcinoma of the rectum, low-grade, with invasion into the
perirectal adipose tissue and metastasis to 7 of 13 regional
lymph nodes (T3N2). The resection margins were uninvolved.
- [**2132-1-28**] PET Scan: Interval progression of disease with an
increase in the size of the previously identified
lung metastasis. There is a new FDG-avid focus in segment 4A of
the liver which most likely represents metastasis.
- [**2132-2-13**]: Ileostomy takedown with simultaneous flexible
bronchoscopy and VATS with left lower lobe resection. Pathology
from the ileostomy stoma demonstrated no evidence of malignancy.
The left lower lobe wedge resection demonstrated an
adenocarcinoma, 4.1 cm, consistent with metastasis of rectal
origin. The pleural and apparent stapled margins were free of
malignancy.
- [**2132-2-14**]: Evaluation by the hepatobiliary surgery consult
team due to the finding on his recent PET scan of a likely liver
metastasis. It was felt that the lesion was amenable to surgical
resection, and it was planned that the patient would undergo two
cycles of chemotherapy prior to proceeding with hepatic
resection.
- [**2132-4-9**]: FOLFOX chemotherapy initiated. The patient completed
two cycles of therapy on [**2132-6-3**].
- [**2132-7-11**]: Hepatic resection of a 1.7cm segment 4a metastatic
lesion by Dr. [**Last Name (STitle) **].
- [**2132-10-22**]: Cycle 1 Day 1 5FU/LV for further adjuvant
chemotherapy. Oxaliplatin eliminated due to neuropathy. The
patient completed therapy in [**1-5**].
- [**2132-11-26**]: Hospital admission for SVC syndrome secondary to a
catheter-associated thrombus causing occlusion of the SVC and
bilateral brachiocephalic veins. The patient underwent TPA
infusion followed by venous angioplasty with balloon dilation
with resolution of symptoms. He was discharged on enoxaparin.
- [**2133-8-3**]: Initiation of ininotecan for recurrent disease.
- [**2134-2-8**]: Due to laboratory and radiographic evidence of
disease
progression, cetuximab was added to ininotecan; due to an
allergic reaction, cetuximab was changed to panitumumab on
[**2134-2-16**].
.
Other Past Medical History:
1. Hypertension.
2. Hyperlipidemia.
3. ASCVD, status post MI in [**2111**].
4. Status post appendectomy.
5. Diabetes
Social History:
The patient lives alone and is divorced. He has
three sons in their 40s. He is a construction inspector. He
denies alcohol use and drug use. He smoked one pack of
cigarettes daily for 30 years before quitting.
Family History:
The patient's paternal uncle had an abdominal
cancer, details unknown. His father died of an MI. His mother
died of [**Name (NI) 2481**] disease. He has two brothers who are well.
Physical Exam:
Admission:
GEN: awake, alert, NAD
VS: 97.6 110/46 88 19 100% 2L
HEENT: EOMI, MMM
CV: irregularly irregular, no m/g/r
PULM: crackles at RLL
ABD: well healed scars on abdomen, soft, NT, ND
LIMBS: no edema
SKIN: erythema and excoriation over left antecubital fossa.
Discharge:
GEN: NAD, aaox3
HEENT: MMM, oropharynx clear.
CV: RRR, No m/r/g
PULM: CTAB, decreased breath sounds at bases. Tunneled [**Name (NI) 2286**]
catheter noted on right chest, c/d/i
ABD: Soft, distended, NT, +BS.
EXTR: 2+ bilateral lower extremity edema, 2+ bilateral upper
extremity edema, left > right 2+ DP pulses bilaterally.
SKIN: blanching macules noted scattered across forearms and
upper back.
Pertinent Results:
Admission labs:
[**2134-4-19**] 11:35AM BLOOD WBC-2.8* RBC-3.30* Hgb-9.3* Hct-27.3*
MCV-83 MCH-28.3 MCHC-34.2 RDW-20.0* Plt Ct-283
[**2134-4-19**] 11:35AM BLOOD PT-14.0* PTT-35.5* INR(PT)-1.2*
[**2134-4-19**] 11:35AM BLOOD Glucose-199* UreaN-23* Creat-1.3* Na-139
K-4.0 Cl-106 HCO3-22 AnGap-15
[**2134-4-19**] 11:35AM BLOOD Calcium-8.3* Phos-2.4* Mg-0.8*
.
Discharge labs:
Micro:
[**4-20**]:
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2134-4-21**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
FECAL CULTURE (Final [**2134-4-22**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2134-4-22**]): NO CAMPYLOBACTER
FOUND.
.
[**2134-5-4**] 12:58 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2134-5-4**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2134-5-4**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2134-4-27**] 11:47 am CATHETER TIP-IV
**FINAL REPORT [**2134-4-29**]**
GRAM STAIN (Final [**2134-4-27**]):
TEST CANCELLED, PATIENT CREDITED.
INAPPROPRIATE SPECIMEN FOR GRAM STAIN.
WOUND CULTURE (Final [**2134-4-29**]):
STAPH AUREUS COAG +. >15 colonies.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2134-4-24**] 2:47 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2134-4-29**]**
Blood Culture, Routine (Final [**2134-4-29**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # 294-1510A
[**2134-4-23**].
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
STAPH AUREUS COAG +. SECOND MORPHOLOGY.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2134-4-26**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2134-4-26**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**4-19**] ECG:
Sinus rhythm with ventricular premature beat. Right
bundle-branch block. Since
the previous tracing of [**2132-11-27**] inferior lead Q waves are less
prominent.
.
[**4-19**] CT torso:
1. No evidence of pulmonary embolism or dissection. Multiple
small pulmonary
nodules are overall stable in size. Stable small right-sided
pleural
effusion.
2. Stable extent of metastatic disease in the abdomen.
3. Two small ventral wall hernias containing loops of small
bowel, but no
evidence of obstruction with oral contrast seen to the colon.
4. Cholelithiasis.
.
[**2134-4-26**] RUE ultrasound.
INDICATION: 72-year-old man with swollen left arm and left-sided
Port-A-Cath.
COMPARISON: None.
TECHNIQUE: Grayscale and Doppler evaluation of left upper
extremity.
FINDINGS: Grayscale and Doppler evaluation of the left internal
jugular,
subclavian, axillary, basilic, and brachial veins demonstrate
normal flow,
compressibility, and response to augmentation wherever
applicable. No
intraluminal thrombus was identified.
IMPRESSION: No evidence of DVT in the left upper extremity.
[**2134-4-27**] renal ultrasound:
INDICATION: 72 year old man with acute kidney failure and
sepsis.
COMPARISON: CTA chest performed [**2134-4-19**].
RENAL ULTRASOUND: The left kidney measures 10.9 cm. The right
kidney
measures 10.7 cm. There is no hydronephrosis, stone or mass in
either kidney.
The bladder is unremarkable.
IMPRESSION: Unremarkable renal ultrasound without evidence of
hydronephrosis.
Brief Hospital Course:
Mr. [**Known lastname 1683**] is a 72 yo M with h/o metastatic rectal CA and SVC
syndrome, now resolved on lovenox tx, who was admitted to OMED
on [**4-19**] with intractable diarrhea thought [**3-2**] chemo and
transferred to the [**Hospital Unit Name 153**] on [**4-24**] with BRBPR and hematemesis. GI
was consulted and an EGD was performed on [**4-24**] which showed
diffuse erythema/ulceration, in esophagus, stomach, duodenum.
This was thought due to irinotecan induced GI toxicity. They
recommended PPI and carafate slurry. They were concerned that
patient's whole GI tract was diffusely inflamed as was seen on
EGD and that the anastamotic site from his colectomy might be a
bleeding source; a flex sigmoidoscopy was done on as well and
showed as well diffuse ulceration and inflammation. HCTs and q6H
hemodynamics remained stable throughout his hospital course.
The patient was started on steroid enemas and mesalamine
suppositories to decrease inflammation. The steroid enemas were
discontinued, but the mesalamine suppositories were continued
through to discharge. In total, he received 3 units PRBCs and 2
units of FFP. Stool cultures revealed no evidence of infection.
.
On [**4-24**], the patient was found to have that 2/2 bottles of his
blood cultures drawn from his portacath were growing GPCs,
speciation showed MSSA. He was treated for this with IV
vancomycin, leaving the portacath and PICC in place. Daily
surveillance blood cultures were performed and he was noted to
clear his bacteremia on [**4-26**]. Infectious diseases was consulted
and the patient was switched to nafcillin with confirmation of
MSSA. The port-a-cath was removed which was the source of
infection.
The patient however despite aggressive crystalloid and colloid
(albumin, a further 2 units of blood) resuscitation then
developed sepsis related acute tubular necrosis. The patient
became anuric and nephrology was consulted. Hemodialysis was
initiated which the patient tolerated well, and a permanent
tunneled catheter line was placed on [**2134-5-7**]. The patient was
started on phosphate binders, nephrocaps and erythropoeitin
dosed at hemodialysis. The carafate was discontinued due to
risk of aluminum toxicity. The nafcillin was also changed to
Cefazolin dosed 2mg at each [**Date Range 2286**] session for ease of
administration and avoiding extra volume loading. Should the
patient miss [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2286**] session, extra doses of cefazolin should
be administered as needed. The patient was planned for a 28 day
course of cefazolin to be finished on [**2134-5-22**].
.
Other parts of his hospitalization are outlined by problem
below:
.
#Hypotension/Tachycardia: In setting of extensive diahrrea. Ct
torso is without PE or dissection. His BP initally recovered
with 500cc NS bolus. Once he had an episode of BRBPR, he became
tacycardic to the 140s, with BP 90s/60s. He was bolused NS and
given PRBC with improved HR to the 110s, and BP to 120s/80s.
.
#SVC syndrome: occurred in [**2132**]. s/p TPA infusion followed by
venous angioplasty with balloon dilation with resolution of
symptoms. He was initially treated with lovenox (dose
recalculated this admission, should be lower than his admission
dose), but this was held secondary to GI bleed. This was not
restarted at discharge given the patient's renal failure.
.
#Diarrhea - the patient continued to have diarrhea that was
controlled with titration of his anti-diarrheal medications.
Infectious sources were ruled out and the cause was likely
irinotecan-induced GI toxicity and radiation proctitis.
#Generalized anasarca - The patient was noted to have an
extremely low albumin on admission, likely related to poor
nutrition due to his GI pathology. Albumins ranged between 2.7
and 1.9. During volume resuscitation the patient became grossly
edematous, and albumin was administered to little effect. His
left upper extremity was noted to be more edematous than the
rest of his body, and a LUE ultrasound was acquired. This
demonstrated no evidence of clot. The patient slowly became
less edematous when [**Year (4 digits) 2286**] was initiated and ultrafiltration
was started.
Mr. [**Known lastname 1683**]' code status was confirmed as FULL CODE this hospital
admission.
Medications on Admission:
DIPHENOXYLATE-ATROPINE - 2.5 mg-0.025 mg Tablet - [**1-30**] Tablet(s)
by mouth q6hr as needed for diarrhea
ENOXAPARIN [LOVENOX] - 150 mg/mL Syringe - Inject 150 mg once a
day
LISINOPRIL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth daily
METOPROLOL SUCCINATE [TOPROL XL] - (Prescribed by Other
Provider) - 100 mg Tablet Sustained Release 24 hr - 1 Tablet(s)
by mouth daily
METRONIDAZOLE [METROGEL] - 1 % Gel - apply to rash twice a day
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
q6hr as needed for nausea
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth daily
LOPERAMIDE [IMODIUM A-D] - 2 mg Tablet - 2 Tablet(s) by mouth
q4he as needed for diarrhea
PYRIDOXINE - (OTC) - 50 mg Tablet - 2 Tablet(s) by mouth once a
day
Discharge Medications:
1. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for diarrhea.
2. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO every four
(4) hours as needed for diarrhea.
5. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating, gas.
9. 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.
10. Ondansetron 4 mg IV Q8H:PRN nausea
11. Prochlorperazine 10 mg IV Q6H:PRN nausea
12. CefazoLIN 2 g IV HD PROTOCOL
HD protocol, to be given during hemodialysis
13. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed for diarrhea.
14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
16. Heparin (Porcine) 1,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
Unit Injection PRN (as needed) as needed for line flush: DWELL
PRN line flush
[**Numeric Identifier **] Catheter (Tunneled 2-Lumen): [**Numeric Identifier **] NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
.
17. Insulin Lispro 100 unit/mL Solution Sig: Sliding scale units
Subcutaneous ASDIR (AS DIRECTED): 2 units for 101-150
4 units for 151-200
6 units for 201-250
8 units for 251-300
10 units for 301-350
12 units for 351-400.
18. Mesalamine 1,000 mg Suppository Sig: One (1) Suppository
Rectal DAILY (Daily).
19. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for dyspnea.
21. Epogen 10,000 unit/mL Solution Sig: Hemodialysis Protocol
Injection with each [**Numeric Identifier 2286**] session.
22. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Rectal cancer
Diarrhea
Sepsis
Acute Renal Failure
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Discharge Instructions:
You were admitted to the hospital with diarrhea. We believe the
diarrhea was a side effect of the chemotherapy you had received;
it was treated with 3 anti-diarrheal medications. You also have
a low blood pressure on admission, this was likely due to
dehydration in the setting of diarrhea, and it improved with
rehydration with IV fluids. Your diarrhea then became bloody,
and you also had an episode of vomit with blood in it. As a
result, you were transferred to the ICU. You had an upper
endoscopy and a sigmoidoscopy, which showed ulceration in your
esophagus, stomach and colon. This was thought to be due to the
chemotherapy and radiation that you have been receiving for your
colon cancer.
.
While admitted, you also had a severe bacterial infection that
got into your blood. This severely damaged your kidneys,
requiring you to be started on hemodialysis. You had a
permanent [**Location (un) 2286**] catheter placed and you will need to continue
getting [**Location (un) 2286**] 3 times a week.
You were started on several new medications when you were
admitted.
Nephrocaps 1 capsule daily
Phos-lo 667mg three times a day
mesalamine 1000mg suppositories once a day
Cefazolin 2g given with hemodialysis
pantoprazole 40mg daily
Erythropoetin given with hemodialysis
Your metoprolol was changed from 100mg once a day to 25mg three
times a day
Your lisinopril and enoxaparin have been discontinued.
Followup Instructions:
You need to follow up with your outpatient oncologists, Drs.
[**Last Name (STitle) **] and [**Name5 (PTitle) **] [**Name5 (PTitle) **] discuss any further treatment for you
rectal cancer.
Dr. [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] in Colorectal Cancer Clinic on
[**5-31**] at 10 AM. You can reach the office by calling [**Telephone/Fax (1) 22249**].
Provider: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2134-5-24**] 10:00
Completed by:[**2134-5-12**]
|
[
"707.03",
"558.2",
"530.21",
"V12.51",
"V15.82",
"197.0",
"995.91",
"250.00",
"414.01",
"532.40",
"401.9",
"E879.8",
"E849.7",
"412",
"707.22",
"707.07",
"196.9",
"584.5",
"E933.1",
"038.11",
"569.49",
"197.7",
"276.51",
"584.9",
"999.31",
"285.1",
"531.40",
"286.9",
"E879.2",
"V10.06",
"458.9",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"45.13",
"38.95",
"86.05",
"38.93",
"48.24"
] |
icd9pcs
|
[
[
[]
]
] |
19688, 19760
|
11970, 16273
|
328, 439
|
19854, 19854
|
6868, 6868
|
21398, 21998
|
5977, 6161
|
17127, 19665
|
19781, 19833
|
16299, 17104
|
19960, 21375
|
7242, 11947
|
6176, 6849
|
1829, 1917
|
277, 290
|
467, 1810
|
6884, 7225
|
19869, 19936
|
5607, 5730
|
5746, 5961
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,305
| 169,077
|
42885
|
Discharge summary
|
report
|
Admission Date: [**2143-6-30**] Discharge Date: [**2143-7-4**]
Date of Birth: [**2073-4-12**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Pigtail drain placement
History of Present Illness:
Patient is a 70 y/o man s/p an esophagectomy post op day 9.
Patient was discharged from hospital last night and was feeling
generally well. He began using his feeding tube and noticed that
he began coughing much more than at baseline. He turned off the
feeding tube and the coughing seemed to lessen. The patient
reports that he could not sleep at all last night because of his
persistent coughing. He reports that the sputum is mostly clear
with no blood. It occasionally appears "milky", particularly
after using the feeding tube. This coughing is much worse than
he
had experienced during his stay in the hospital. At times the
coughing is so severe that the patient has almost vomited from
the exertion. The patient states that he "feels warm" and tired.
His daughter and son-in-law (present upon interview), confirm
that he has been noticeably more lethargic since being
discharged.
His visiting nurse came this morning and observed the chest tube
wound was weeping and that the patient was short of breath. The
nurse called 911 and patient was brought to the ER. Of note, the
patient urinated once this morning and once in the ED (9PM). His
last bowel movement was this morning.
Past Medical History:
PMH: hypertension, obesity, small CVA([**2129**]), h/o GI bleed, dvts,
recent dx of PE, adenocarcinoma of the esophagus
PSH: splenectomy
Social History:
The patient is a retired [**Doctor Last Name 3456**]. He drinks socially. He quit
smoking over 15 years ago.
Family History:
Family history is negative for cancer or heart disease.
Physical Exam:
Vitals: T: 98.5 BP: 116/70 HR: 84 RR: 17 O2 Sat: 100% on oxygen
GEN: patient is alert and oriented, in no immediate discomfort
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: diffuse wheezes and crackles throughout the lungs, with
reduced breath sounds in the lower left back
ABD: Soft, distended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: 21 bilateral LE edema, LE warm and well perfused
Wounds: Midline [**Doctor Last Name **] appears intact, clean and dry, with
mild
erythema that does not extend more than 1 cm beyond the
[**Doctor Last Name **].
Chest tube wound (right axillary line) does not appear
erythematous but is extruding significant amounts of serous
fluid. All other wounds appear clean, dry and intact.
Pertinent Results:
[**2143-6-30**] 06:28PM PH-7.43 COMMENTS-PLEURAL
[**2143-6-30**] 06:20PM PLEURAL TOT PROT-3.1 GLUCOSE-103 LD(LDH)-189
AMYLASE-7 CHOLEST-41 TRIGLYCER-30
[**2143-6-30**] 06:20PM PLEURAL WBC-1217* HCT-2.5* POLYS-17* LYMPHS-4*
MONOS-1* MESOTHELI-10* MACROPHAG-68*
[**2143-6-30**] 04:00PM GLUCOSE-105* UREA N-38* CREAT-1.6* SODIUM-142
POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-23 ANION GAP-16
[**2143-6-30**] 04:00PM CALCIUM-8.4 PHOSPHATE-4.1 MAGNESIUM-2.2
[**2143-6-30**] 04:00PM WBC-15.0* RBC-2.92* HGB-8.3* HCT-26.6* MCV-91
MCH-28.5 MCHC-31.3 RDW-15.0
[**2143-6-30**] 04:00PM PLT COUNT-497*
[**2143-6-30**] 02:00AM GLUCOSE-92 UREA N-47* CREAT-2.0* SODIUM-136
POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
[**2143-6-30**] 02:00AM ALT(SGPT)-14 AST(SGOT)-15 ALK PHOS-80
AMYLASE-33 TOT BILI-0.3
[**2143-6-30**] 02:00AM LIPASE-33
[**2143-6-30**] 02:00AM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-4.9*
MAGNESIUM-2.1
[**2143-6-30**] 02:00AM WBC-16.8* RBC-2.67* HGB-7.5* HCT-25.1* MCV-94
MCH-28.2 MCHC-30.1* RDW-15.3
[**2143-6-30**] 02:00AM PLT COUNT-497*
[**2143-6-30**] 02:00AM PLT COUNT-497*
[**2143-6-30**] 02:00AM PT-13.7* PTT-29.8 INR(PT)-1.3*
[**2143-6-30**] 12:30AM LACTATE-1.4
[**2143-6-29**] 09:02PM URINE HOURS-RANDOM CREAT-145 SODIUM-73
POTASSIUM-31 CHLORIDE-42
[**2143-6-29**] 09:02PM URINE HOURS-RANDOM CREAT-145 SODIUM-73
POTASSIUM-31 CHLORIDE-42
[**2143-6-29**] 09:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2143-6-29**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2143-6-29**] 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2143-6-29**] 07:34PM LACTATE-1.1
[**2143-6-29**] 07:25PM GLUCOSE-101* UREA N-50* CREAT-2.4*#
SODIUM-137 POTASSIUM-5.1 CHLORIDE-98 TOTAL CO2-24 ANION GAP-20
[**2143-6-29**] 07:25PM estGFR-Using this
[**2143-6-29**] 07:25PM cTropnT-<0.01
[**2143-6-29**] 07:25PM cTropnT-<0.01
[**2143-6-29**] 07:25PM proBNP-351*
[**2143-6-29**] 07:25PM WBC-16.2*# RBC-3.30* HGB-9.4* HCT-30.2*
MCV-92 MCH-28.4 MCHC-31.0 RDW-15.1
[**2143-6-29**] 07:25PM PLT COUNT-551*#
[**2143-6-29**] 07:25PM PLT COUNT-551*#
CXR [**2143-7-3**]
IMPRESSION:
1. COPD.
2. Small residual effusions.
3. Moderate cardiomegaly
.
CT chest abd pel w/o contrast [**2143-6-29**]
IMPRESSION:
1. Post-surgical changes status post esophagectomy. no
mediastinal fluid
collection to suggest a leak.
2. New moderate left pleural effusion with adjacent
atelectasis.
.
Brief Hospital Course:
THe patient was admitted after experiencing shortness opf breath
and mild drainage from his right chest tube site. There were
reports in the ED that the patient also experienced a new cough,
but he denied this when we saw him. The patient's O2 saturation
was found to be 85%, and 91% on maximal nasal cannula oxygen
therapy. A non-rebreather mask was placed. A CT of his chest
showed left pleural effusion. The patient was admitted to the
ICU and had a pigtail placed. THE patient was monitored and his
symptoms began to improved. His diet was advanced and his tube
feeds were continued. THe patient's pigtail was discontined and
the patient came to the floor on HD 3. The patient continued to
require nasal cannula oxygen (1-2L) for O2 saturations less than
90% overnight during sleep. He was asymptomatic. On HD 4, the
patient felt bloated and received a suppository, to which he
responded well. His symptoms resolved. He is being discharged in
stable condition. He will receive home O2 therapy at night. We
encourage the patient to speak to his PCP about the possibility
of using a CPAP at night .
Medications on Admission:
Lasix, multivitamin, potassium, Nexium, Synthroid,
Zoloft, Klonopin, and another drug she cannot recall the name or
any dosages..
Discharge Medications:
1. atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
2. clonazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
3. DILT-XR 120 mg Capsule,Ext Release Degradable Sig: One (1)
Capsule,Ext Release Degradable PO once a day.
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours).
6. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. FerrouSul 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO
once a day.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): stop taking if having loose stools.
9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. triamterene-hydrochlorothiazid 37.5-25 mg Tablet Sig: One
(1) Tablet PO once a day.
11. Senna Concentrate 8.6 mg Tablet Sig: One (1) Tablet PO once
a day: stop taking if having loose stools.
12. OxyContin 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day.
13. oxycodone 10 mg Tablet Sig: One (1) Tablet PO three times a
day.
14. Home O2
2 L noctural only for documented stat of 88%. Respiratory
diagnosis: COPD
15. Tube Feeds
Replete full strength, rate of 60/hr, 14 hours a day. 3 months
Discharge Disposition:
Home With Service
Facility:
Allcare VNA
Discharge Diagnosis:
Symptomatic pleural effusion with hypoxemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
DISCHARGE INSTRUCTIONS:
You were admitted to the west 3 surgery service for cough and
chest tube site drainage.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new
medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may
not drive or operate heavy machinery while taking narcotic
analgesic
medications. You may also take acetaminophen (Tylenol) as
directed,
but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and
drink adequate amounts of fluids. Avoid strenuous physical
activity
and refrain from heavy lifting greater than 10 lbs., until you
follow-up with your surgeon, who will instruct you further
regarding
activity restrictions. Please also follow-up with your primary
care
physician.
[**Name10 (NameIs) 17779**] [**Name11 (NameIs) **]:
*Please call your surgeon or go to the emergency department if
you
have increased pain, swelling, redness, or drainage from the
[**Name11 (NameIs) **]
site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.
Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please
remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2143-7-11**] at 10:00 AM
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
Completed by:[**2143-7-5**]
|
[
"584.9",
"280.0",
"278.00",
"V12.54",
"V10.03",
"V12.51",
"401.9",
"511.9",
"285.29",
"244.9",
"V45.79",
"E878.8",
"V15.82",
"564.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
7969, 8011
|
5354, 6456
|
322, 348
|
8098, 8098
|
2754, 5331
|
9724, 10124
|
1870, 1928
|
6638, 7946
|
8032, 8077
|
6483, 6615
|
8272, 8360
|
1943, 2735
|
8392, 9701
|
263, 284
|
377, 1564
|
8113, 8224
|
1586, 1725
|
1741, 1854
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,982
| 128,020
|
23605
|
Discharge summary
|
report
|
Admission Date: [**2126-5-27**] Discharge Date: [**2126-6-6**]
Service: SURGERY
Allergies:
Plavix / Lipitor / Iodine Containing Agents Classifier /
Macrobid / Ticlid / Ambien
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Transfer for possible peripheral stent.
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Left aortobifemoral graft limb thrombectomy.
2. Left profunda endarterectomy with patch angioplasty using
Dacron patch.
History of Present Illness:
Ms. [**Known lastname 60414**] is an 82 year-old female with a history of CAD and
PVD who is being transferred to [**Hospital1 18**] for chest pain and a
possible peripheral stent.
Recently admitted to [**Location (un) 11248**] on [**5-13**] with an ulcer of her
left leg and severe LLE pain. Over the past few weeks, she has
had increasing left lower extremity pain. Where she had
previously been able to walk without issue, she began to require
a walker/cane. The pain progressed and she presented to Dr.
[**Last Name (STitle) 60415**] (vascular surgery) who prescribed antibiotics. She later
presented to her PCP (Dr. [**Last Name (STitle) 11250**] with complaints of
continued severe left leg pain. At that time, she was admitted
to an OSH and started on IV Cipro and Cefazolin. Dr. [**Last Name (STitle) 60415**]
recommended revascularization at that time, if conservative
therapy did not lead to an improvement.
On the day of the planned surgery ([**5-20**]), the patient
experienced chest pain. She was also hypotensive with an
elevated potassium; candesartan was decreased from 16mg to 8mg.
Troponins were negative.
Given that she was felt to be a high-risk surgical candidate,
she was transferred to [**Hospital1 18**] for further care
Past Medical History:
1. Coronary artery disease
a. CABG ([**2116**])
--> LIMA-LAD
--> SVG-OM1-OM2-D1 (known occluded)
b. PCI with stent to LMCA (outside institution)
c. NSTEMI ([**5-2**]) with PCI
--> LCX with 70% stenosis; stented with 3.0x28mm Cypher
[**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]. PCI ([**6-1**])
e. Current anatomy as follows:
- LMCA s/p stent
- LIMA-->LAD
- LCx s/p stent in [**5-2**]
- RCA totally occluded
- SVG-->OM1 (occluded)
- SVG-->OM2 (occluded)
- SVG-->D1 (occluded)
OTHER PAST HISTORY:
2. Peripheral vascular disease
a. aorto-bifemoral bypass
b. ? failed LLE bypass (per prior d/c summary left iliofem
bypass and anterior tib bypass noted in Dr. [**Last Name (STitle) **]??????s note)
3. Renal artery stenosis (right), severe
--> PCI ([**6-1**]) with 80% stenosis; stented with 5.0x18mm Ultra
RX
4. Carotid disease
- s/p Left CEA [**2116**]
5. s/p Stroke times two with residual right sided weakness
6. Hypertension
7. Hyperlipidemia
8. Chronic kidney disease: baseline SCr ~1.3-1.5
9. Anemia: baseline hct ~30
10. Hypothyroidism
11. s/p Left ORIF
12. s/p Ventral hernia repair x 4
13. s/p TAH
Social History:
Social history is significant for the absence of current tobacco
use (quit >30 years ago). There is no history of alcohol abuse
(drinks socially). She currently lives alone and is independent.
She is a widow and has two daughters.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS - T 98.2, BP 97/55, HR 68, O2 94% on room air
Gen: In good spirits, lying in bed in no distress.
HEENT: NCAT. Anicetic; mildy palor. JVP not elevated
CV: regular rate, rhythm, no mumurs heart, although heart sounds
were somewhat distant.
Chest: breathing easy with no wheeze/crackles
Abd: Soft, NTND. No HSM or tenderness.
Ext: LLE is cool with no palpable pulses (DP/PT) and not
doplerable. Has decreased ROM both active and passive and has
tenderness with slight touch. No hair distally. Sensation is
decreased to soft tough. Also with ulcer on aterior aspect of
shin on left (3x4cm). On RLE, pulses are doplerable (DP/PT) and
she has good ROM and sensation.
Pulses:
Right: Carotid 1+ Femoral 1+ Popliteal 1+ DP/PT doplerable
Left: Carotid 1+ Femoral 1+ Popliteal 1+ no PT/DP pulses
Pertinent Results:
[**2126-5-27**] 06:25PM BLOOD WBC-7.2# RBC-3.59* Hgb-11.1* Hct-33.9*
MCV-95# MCH-30.9 MCHC-32.7 RDW-14.0 Plt Ct-289#
[**2126-5-27**] 06:25PM BLOOD PT-12.5 PTT-31.1 INR(PT)-1.1
[**2126-5-27**] 06:25PM BLOOD Glucose-131* UreaN-47* Creat-1.2* Na-140
K-5.3* Cl-104 HCO3-28 AnGap-13
[**2126-5-28**] 02:00AM BLOOD ALT-9 AST-24 LD(LDH)-162 AlkPhos-140*
TotBili-0.2
[**2126-5-27**] 06:25PM BLOOD Calcium-9.2 Phos-3.4 Mg-2.3
CXR ([**2126-5-28**]):
Patient has had median sternotomy and coronary bypass grafting.
Heart is normal size. Pulmonary and hilar vasculature
unremarkable. The thoracic aorta is heavily calcified and
tortuous and somewhat irregular in shape making it difficult to
exclude aneurysm, particularly just above the thoracoabdominal
junction where the aortic contour is difficult to separate from
spinal osteophytes.
Very large lung volumes indicate emphysema or significant small
airways obstruction. A 7 mm wide oval opacity projecting over
the right fifth anterior rib could be a bone island or a small
lung nodule. Routine radiographs with shallow obliques
recommended for assessment. Lungs are otherwise clear. There is
no pleural abnormality.
CT HEAD ([**2126-5-28**]):
No intracranial hemorrhage or mass effect is identified.
Encephalomalacia and volume loss in the right frontal lobe from
remote infarction.
[**2126-6-4**] 1:35 PM
ART EXT SGL LEVEL
HISTORY: Recent aortobi-fem and the profunda to common femoral
patch angioplasty.
FINDINGS: There are no prior studies for comparison. The ABI on
the right based on the DP artery is 0.55 and on the left based
on the PT artery is 0.53. Doppler tracings demonstrate
monophasic waveforms at the tibial levels bilaterally. Volume
recordings demonstrate marked waveform widening and amplitude
loss, most notably at the metatarsal levels bilaterally, right
greater than left.
IMPRESSION: Limited study which demonstrates significant decline
in arterial inflow to the ankles bilaterally.
Brief Hospital Course:
1. Vascular disease:
Patient has significant vascular disease (CAD, PVD, renal artery
stenosis, carotid disease) and is here with worsening left lower
extremity pain worrisome for worsening PVD of the left lower
extremity. is s/p aorto-bifemoral bypass, but has significant
stenosis on MRI of [**6-1**] (nonvisualization of the left common
femoral artery and proximal superficial femoral artery due to
metallic artifact, though the left superficial femoral artery is
patent throughout its mid and distal course, then occludes at
the level of the popliteal artery. No straight line flow to the
foot).
it was decided to take the pt to the OR:
PROCEDURES:
1. Left aortobifemoral graft limb thrombectomy.
2. Left profunda endarterectomy with patch angioplasty using
Dacron patch.
She tolerated the procedure well. There were no compliacations.
Pt worked with PT. PT recommends rehab. pt dispo from vascular
standpoint is stable.
Pt was started on plavix post operative. It is noted that the pt
has
.
2. Pump:
Most recent echo showed moderately depressed (EF 40-45%). Is
currently euvolemic on exam.
- IVF pre-cath; will follow exam for signs of failure
- Holding [**Last Name (un) **]/Lasix for now
.
3. Rhythm:
In NSR. Will follow on telemetry.
.
4. Renal artery stenosis, Chronic kidney disease:
Is now s/p PCI in [**2124**] with 80% stenosis; was stented at that
time. Has a baseline SCr of 1.3-1.5.
- Pre-hydrate evening before cath is to be done
.
5. Hypertension:
- Continue metoprolol
- Holding [**Last Name (un) **]
.
6. Hyperlipidemia
- Continue zetia
.
7. Anemia: Baseline hct ~30; currently 33.9
- Follow hct and transfuse PRN
.
8. Hypothyroidism:
- Continue outpatient levothyroxine
Medications on Admission:
(on transfer):
1. Aspirin 325mg daily
2. Lopressor 25mg TID
3. Zetia 10mg daily
4. Nitro patch 0.2mg/hr
5. Lasix 20mg daily
6. Levothyroxine 88mcg daily
7. Regular insulin SS
8. Protonix 40mg daily
9. Estradiol 0.5mg daily
10. Colace 100 [**Hospital1 **]
11. Atacand 8mg daily
12. Calcium oyster shell 500mg [**Hospital1 **]
13. Ambien 5mg daily
14. Vitamin D 400mg [**Hospital1 **]
15. Nystatin powder TID
16. Miralax 17gm
17. Mucomyst 1200mg [**Hospital1 **]
18. Prednisone 20mg 4 times daily, started on [**5-27**] for dye
allergy
19. D5NS at 75cc/hr
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Estradiol 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
9. Polyethylene Glycol 3350 17 g (100%) Powder in Packet Sig:
One (1) Powder in Packet PO daily ().
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6-8H
(every 6 to 8 hours) as needed.
12. Candesartan 4 mg Tablet Sig: Two (2) Tablet PO daily ().
13. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
15. Insulin SS
Insulin SC Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-60 mg/dL 4 oz. Juice
61-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 0 Units
201-250 mg/dL 4 Units 4 Units 4 Units 0 Units
251-300 mg/dL 6 Units 6 Units 6 Units 2 Units
301-350 mg/dL 8 Units 8 Units 8 Units 4 Units
351-400 mg/dL 10 Units 10 Units 10 Units 6 Units
> 400 mg/dL Notify M.D.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 17921**] Center - [**Location (un) 5450**], NH
Discharge Diagnosis:
Primary
Left leg ischemia with rest pain.
agitation
Secondary
Dyslipidemia, HTN, Anemia: baseline hct ~30, Hypothyroidism,
Chronic kidney disease: baseline SCr ~1.3-1.5
Discharge Condition:
Stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Vascular Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-2**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 3121**]. Schedule an
appointment for 2 weeks.
Completed by:[**2126-6-6**]
|
[
"E937.8",
"244.9",
"440.23",
"412",
"285.21",
"V07.1",
"405.91",
"V45.81",
"996.74",
"E935.2",
"272.4",
"292.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.12",
"00.45",
"88.45",
"00.40",
"39.90",
"39.50",
"39.49",
"37.21",
"99.04",
"38.18"
] |
icd9pcs
|
[
[
[]
]
] |
10167, 10253
|
6127, 7830
|
329, 472
|
10469, 10478
|
4146, 6103
|
13323, 13464
|
3240, 3322
|
8435, 10144
|
10274, 10448
|
7856, 8412
|
10502, 12890
|
12916, 13300
|
3337, 4127
|
250, 291
|
500, 1750
|
1772, 2976
|
2992, 3224
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,604
| 161,464
|
15412+56642
|
Discharge summary
|
report+addendum
|
Admission Date: [**2161-3-1**] Discharge Date: [**2161-3-12**]
Date of Birth: [**2099-8-6**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 61-year-old
Caucasian male with a past medical history significant for
coronary artery disease status post CABG in [**2153**] and
myocardial infarction in [**2152**] and [**2160**], who is being admitted
for sudden onset of chest pain. The patient was recently
admitted to [**Hospital1 18**] on [**2161-2-11**] for treatment of
bilateral gangrenous feet. There was a plan for bilateral
below the knee amputations. However, the patient had
intermittent ventricular tachycardia during the
hospitalization and was started on amiodarone. The patient
was planned for cardiac catheterization prior to going
bilateral below the knee amputations and during the
catheterization, the patient had an acute ST elevation
myocardial infarction. The patient was treated with medical
management.
He was transferred to the CCU, where he continued to have
recurrent episodes of ventricular tachycardia. The patient
continued to be medically managed and was discharged to
[**Hospital **] Rehab. The patient is coming back on this current
admission two days after the last discharge to [**Hospital **] Rehab
with sudden onset of chest pain described as identical to his
anginal equivalent. The pain was brought on at rest and was
associated with shortness of breath and radiation to the
shoulder blades. There was no improvement with two
sublingual nitroglycerins and the patient's blood pressure
dropped into the 80s systolic.
The patient continued to complain of pain in the epigastric
region and described it as a squeezing sensation. He also
complained of nausea and vomiting for several days prior to
admission. He denies any palpitations, lightheadedness, or
other symptoms.
PAST MEDICAL HISTORY: Please see previous dictation summary
of admission of [**2161-2-11**] for further past medical
history, past surgical history including allergies.
MEDICATIONS ON ADMISSION:
1. Allopurinol 100 mg q.d.
2. Calcium acetate 667 mg t.i.d.
3. Aspirin 325 mg q.d.
4. Plavix 75 mg q.d.
5. Trazodone 100 mg q.h.s.
6. Pravastatin 20 mg q.d.
7. Klonopin 0.5 mg b.i.d.
8. Protonix 40 mg q.d.
9. Percocet prn.
10. Senna.
11. Amiodarone 400 mg b.i.d.
12. Mexiletine 150 mg b.i.d.
13. Multivitamin.
14. Insulin glargine 15 units q.h.s.
15. Humalog insulin-sliding scale.
VITAL SIGNS ON ADMISSION: Temperature 97.8, blood pressure
88/34, pulse 82, respiratory rate 16.
PHYSICAL EXAM: The patient is obese, lying in bed in no
apparent distress. Skin examination shows multiple scabs
with dry gangrene of bilateral feet especially of the right
lower extremity. Oropharynx is clear with no obvious JVD and
moist mucous membranes. Heart examination shows a normal S1,
S2 with a regular rate and rhythm with no murmurs
appreciated, but distant heart sounds. Lungs are clear to
auscultation anteriorly. Abdomen is benign. Extremities
showed trace edema of the bilateral lower extremities and
trace to 1+ dorsalis pedis pulses bilaterally. Neurologic
examination is grossly intact.
LABORATORIES ON ADMISSION: White count 10, hematocrit 34.1,
platelets 135. INR 1.4. Chemistries is significant for a
chloride of 93, bicarb of 30, BUN of 34, and creatinine of
5.2. Initial CK was 40.
Chest x-ray showed no evidence of CHF or pneumonia.
EKG shows low voltage with normal sinus rhythm at 80 beats
per minute. Axis is normal. QRS is mildly prolonged. There
are old ST depressions in leads V2 through V4.
SUMMARY OF HOSPITAL COURSE BY ISSUE:
1. Coronary artery disease: The patient has flat CKs and
elevated troponins, however, due to the fact that he had
failed revascularization on a previous cardiac
catheterization, there is no plan for recatheterization. It
is also likely that the elevated troponins were secondary to
the patient's elevated secondary to the patient's end-stage
renal disease rather than representing an acute event. The
patient was managed medically. His regimen was changed so
that beta-blocker was added. Carvedilol was started at a low
dose. He was continued on aspirin, Plavix, and statin.
The patient's beta-blocker dose is not able to be titrated up
due to borderline blood pressure. However, he did not have
any further significant chest pain, although he did complain
of occasional epigastric burning, which was not clearly
anginal. The patient was continued on current medical
management. There is no option for interventional procedure.
2. Congestive heart failure and fluid overload: On
admission, the patient was found to be approximately 15 to 20
kg above his dry weight. Renal service was consulted for
hemodialysis, and the patient underwent two hemodialysis
sessions. However, they were not able to remove significant
amounts of fluid due to the fact that there was concern for
ventricular arrhythmia and hypotension during dialysis. At
that point, the patient was transferred to the CCU for a CVVH
and removal of fluid through CVVH.
The patient received several days of CVVH with effective
fluid removal, however, he subsequently had a 22 beat run of
ventricular tachycardia. At this point, a CVVH was stopped.
The patient did not appear to be significantly fluid
overloaded after that point as he continued to receive
hemodialysis. His oxygenation was very good, and he did not
have any other signs of heart failure.
3. Rhythm: Patient continued to have significant ventricular
ectopy with intermittent runs of nonsustained polymorphic
ventricular tachycardia. As this was thought to be due to
his underlying ischemic heart disease, there is no
intervention that can be performed by Electrophysiology
service that would be effective. The patient was continued
on amiodarone and mexiletine. His mexiletine dose was
increased to 250 mg b.i.d, though he continued to have
intermittent short runs of NSVT.
4. End-stage renal disease: As previously mentioned, the
patient had a CVVH to decrease his weight to his goal weight
120 kg. However, this was stopped to ventricular arrhythmia.
The patient then underwent hemodialysis first with no fluid
removal, which he tolerated well and subsequently with fluid
removal of 1.6 liters on the second day, again which he
tolerated well without significant episodes of hypotension or
arrhythmia. The patient's CVVH catheter was removed by
Interventional Radiology.
5. Peripheral vascular disease: Patient was seen by Vascular
Surgery as he was awaiting bilateral knee amputations for his
dry gangrene of both feet. Due to his cardiac situation,
this was not undertaken during the hospitalization. Patient
is to followup with his vascular surgeon, Dr. [**Last Name (STitle) 1391**] after
discharge to be reassessed for possible surgery for the dry
gangrene.
6. Diabetes mellitus: The patient's diabetes was managed per his
outpatient regimen with insulin glargine, and Humalog sliding
scale.
7. Code status: The patient was full code on admission.
However, after discussion with him and his family, he was
made DNI only, but he did want to be resuscitated.
DISCHARGE STATUS: The patient is to be discharged to a
[**Hospital 3058**] rehab facility.
DISCHARGE CONDITION: Patient was in good condition. He is
afebrile, hemodynamically stable, and tolerating p.o.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Congestive heart failure.
3. End-stage renal disease.
4. Diabetes mellitus type 2.
5. Peripheral vascular disease.
6. Dry gangrene.
7. Ventricular tachycardia
8. Obesity
DISCHARGE MEDICATIONS:
1. Allopurinol 100 mg q.d.
2. Aspirin 325 mg q.d.
3. Plavix 75 mg q.d.
4. Trazodone 100 mg q.h.s.
5. Protonix 40 mg q.d.
6. Percocet 1-2 tablets p.o. q.4-6h. prn.
7. Amiodarone 400 mg b.i.d.
8. Mexiletine 250 mg q.12h.
9. Carvedilol 3.125 mg b.i.d.
10. Atorvastatin 80 mg q.d.
11. Klonopin 0.5 mg in the a.m. prn and 1 mg at bedtime.
12. Calcium acetate 1334 mg t.i.d. with meals.
13. Reglan 10 mg q.i.d. a.c./h.s.
14. Multivitamins one cap q.d.
15. Senna one tablet b.i.d.
16. Dulcolax prn.
17. Insulin glargine and Humalog insulin-sliding scale.
FOLLOW-UP INSTRUCTIONS AND DISCHARGE PLANS: Patient is to
followup with his primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44716**]
and with Vascular Surgery, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] in
approximately 2-3 weeks for further assessment of his
peripheral vascular disease and possible surgery.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 5709**]
MEDQUIST36
D: [**2161-3-12**] 23:58
T: [**2161-3-13**] 04:35
JOB#: [**Job Number 44717**]
Name: [**Known lastname 8195**], [**Known firstname **] Unit No: [**Numeric Identifier 8196**]
Admission Date: [**2161-3-1**] Discharge Date: [**2161-3-17**]
Date of Birth: [**2099-8-6**] Sex: M
Service: CCU
Continuation of the summary of the hospital course:
1. Coronary artery disease: Patient had one further episode
of chest pain on the day before scheduled dialysis, which was
relieved with Morphine. There were no EKG changes during the
chest pain. Patient did not have any further chest pain. He
was continued on his medical regimen of carvedilol, aspirin,
Plavix, and Lipitor.
Due to the patient's severe unintervenable coronary artery
disease, it would be expected that the patient would continue
to have intermittent episodes of chest pain, especially prior
to dialysis when he is fluid overloaded. As the patient's
coronary artery disease can be managed medically, recurrent
chest pain should be managed with medications and patient
would likely not require rehospitalization unless he was
unstable in any way.
2. Congestive heart failure: The patient was stable without
any signs of heart failure exacerbation. He was continued on
carvedilol. He received hemodialysis 3x a week for fluid
removal.
3. Rhythm: The patient continued to have ventricular ectopy
on telemetry, but did not have any significant runs of
nonsustained ventricular tachycardia during the last week of
admission. He was continued on mexiletin and amiodarone for
control of arrhythmias. Patient should be monitored on
telemetry during hemodialysis and the patient does desire
cardiac resuscitation should he have a ventricular arrhythmia
requiring such.
4. End-stage renal disease: The patient was tolerating
hemodialysis well without significant hypotension. Of note,
the patient's baseline systolic blood pressure ranges from
17-90 and is asymptomatic at those numbers. The patient
should continue to receive hemodialysis 3x a week.
5. Peripheral vascular disease: Upon discussion with the
Vascular Surgery service, the patient does not require
immediate surgical intervention. He is asked to followup
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Vascular Surgery approximately 2-3
weeks after discharge for re-evaluation of his dry gangrene
of the lower extremities and possible surgical intervention.
6. Right groin hematoma: Patient continued to have small
oozing from right groin hematoma, which was a complication of
a cardiac catheterization he had the previous admission.
Though this site did have some small amount of venous oozing
and mild tenderness, there was no signs of infection. The
patient's hematocrit remained stable suggesting there was no
significant active bleeding from the site.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Congestive heart failure.
3. End-stage renal disease.
4. Diabetes mellitus type 2.
5. Peripheral vascular disease with dry gangrene at both
lower extremities.
6. Ventricular tachycardia
Please see the prior dictated discharge summary for the
patient's discharge medications and follow-up plans.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3518**], M.D. [**MD Number(1) 3519**]
Dictated By:[**Name8 (MD) 3520**]
MEDQUIST36
D: [**2161-3-19**] 16:20
T: [**2161-3-20**] 05:26
JOB#: [**Job Number 8197**]
|
[
"427.1",
"998.12",
"440.24",
"250.60",
"414.8",
"585",
"428.0",
"424.0",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
7251, 7344
|
11621, 12210
|
7589, 9099
|
2048, 2443
|
9116, 11600
|
2546, 3158
|
163, 1851
|
3173, 7229
|
1874, 2022
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 128,437
|
22416
|
Discharge summary
|
report
|
Admission Date: [**2131-11-5**] Discharge Date: [**2131-11-9**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Prochlorperazine
Attending:[**First Name3 (LF) 7015**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Primary Care Physician: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 58273**] MD ([**Telephone/Fax (1) 7538**])
History of Present Illness: Mrs. [**Known lastname **] is a 26-year-old female
with DMI and multiple admissions for DKA who presents with
hyperglycemia.
Patient complains of nausea, vomiting for past day in addition
to low back pain and mild abdominal discomfort and increased
stool frequency (normal BM x 3 instead of BM x 1.) On her last
recent admission, her insulin regimen was changed to Lantus 28
(from 30 given hypoglycemia at times) and humalog [**Known lastname **]. The
patient noticed her blood sugar today of 400 with aforementioned
symptoms and reported to the hospital. She endorses taking her
insulin as prescribed with no missed doses. She denies dietary
non-compliance and usually carb counts at home. She denies sick
contacts and other symptoms such as fever, chills, dysuria,
cough. She denies difficulty obtaining her medications. She does
endorse recent increase in bowel movements that she does not
characterize as diarrhea. She endorses overall poor PO intake in
the past day. She overall attributes her hyperglycemia to her
chronic back pain.
She was recently admitted from [**2131-10-27**] to [**2131-11-1**] for
recurrent nausea and vomiting thought to be possibly
gastroparesis, uncontrolled type 1 diabetes mellitus with
complications, severe depression, anxiety, and possible panic
attacks, acute on chronic low back pain s/p prior MVA among
other somatic complaints. Given repeated admissions to the
hospital, psychiatry evaluated her for depression/anxiety, which
were thought play a large role in her symptoms and were also
obstructive to her obtaining proper outpatient primary care.
Given her psychiatric comorbidities leading to a negative cycle
of inability to access outpatient medical care, she was thought
to meet criteria for inpatient psych admission for symptoms
stabilization and was transferred to a crisis center to
faciliate voluntary psychiatric admission. The patient thought
the center was "depressing with black walls" and "full of crazy
people," and so she left.
Of note, she has had chronic back pain since an MVA in [**2124**] that
intermittently comes and goes, and for which she states she has
stated in the past that she takes 'her mother's percocet' but is
not prescribed anything by her PCP. [**Name10 (NameIs) **] currently endorses
stable back pain described as in the lower back with no specific
point and non-radiating. She denies motor/sensory
impairment/loss, saddle anesthesia, or urinary/fecal
incontinence.
.
In the ED, initial vs were 98.7 128 132/88 20 98%, AG 28.
Persistently tachycardic to 130. Got 12 units IV insulin. FS
remaining in upper 300s-400s, started on insulin gtt at 5
units/hr. Received 3 L NS in ED. UA and CXR performed. Current
VS: 138/92 129 20 100RA.
.
On the floor, the patient had a flat affect and answered
questions in short sentences. She appeared in no acute distress.
She was started on an insulin drip (2 units/hr regular IV). She
was noted to be tachycardic to the 130s and given a 500 NS bolus
followed by rapid fluid resuscitation. She only came to the
floor with one PIV and another access point was established.
.
Review of systems:
Review of 10 systems was negative except per HPI.
Past Medical History:
Past Medical History:
-Diabetes Type I: diagnosed age 16 in [**2120**] after her first
pregnancy. Most recent Hgb A1C 10.9 % ([**8-9**])
- Previous admissions for nausea/vomiting with h/o esophagitis
and with concern for diabetic gastroparesis on metoclopramide
- Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**]
- Stage I diabetic nephropathy
- Anxiety/panic attacks
- Depression
- Hyperlipidemia
- S/P MVA [**5-4**] - lower back pain since then. Per patient,
received oxycodone from her primary provider.
[**Name Initial (NameIs) **] [**Name Initial (NameIs) 58252**]
- G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section
in [**2122**], not menstruating secondary to being on Depo-Provera
- Genital Herpes
Social History:
She was born and raised in [**Location (un) 669**] but currently lives in her
own apartment. She is currently unemployed and received
disability. She has a 6 year old son. [**Name (NI) **] mother and sisters
live nearby. She denies tobacco, alcohol or illicit drug use.
Family History:
Her grandmother had diabetes. Otherwise non-contributory.
Physical Exam:
Vitals: T 98.8 HR 155 BP 160/93 RR 16 100 % RA
General: AA female, no acute distress, affect flat and downward
gazing during most of history
[**Name (NI) 4459**]: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardia and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: +vertical incision well healed with overlying keloid;
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: no TTP spinally or paraspinally. CNs [**1-12**] intact. [**4-4**]
strength in upper and lower extremities. 2+ reflexes in
patellar, achilles tendons. sensation grossly intact BL.
Pertinent Results:
I. Labs
A. Admission
[**2131-11-5**] 01:45PM BLOOD WBC-10.0# RBC-4.48 Hgb-12.8 Hct-41.0
MCV-92 MCH-28.7 MCHC-31.3 RDW-13.9 Plt Ct-253
[**2131-11-5**] 01:45PM BLOOD Neuts-84.5* Lymphs-13.3* Monos-1.0*
Eos-0.5 Baso-0.7
[**2131-11-5**] 01:45PM BLOOD Plt Ct-253
[**2131-11-5**] 01:45PM BLOOD Glucose-485* UreaN-24* Creat-1.1 Na-136
K-4.6 Cl-91* HCO3-17* AnGap-33*
[**2131-11-5**] 08:39PM BLOOD ALT-19 AST-14 LD(LDH)-156 AlkPhos-75
Amylase-71 TotBili-0.2
[**2131-11-5**] 08:39PM BLOOD Lipase-17
[**2131-11-5**] 08:39PM BLOOD CK-MB-2 cTropnT-<0.01
[**2131-11-5**] 08:39PM BLOOD Albumin-4.1 Calcium-8.6 Phos-3.2 Mg-1.9
[**2131-11-5**] 08:39PM BLOOD %HbA1c-10.3* eAG-249*
[**2131-11-5**] 01:45PM BLOOD HCG-<5
[**2131-11-5**] 08:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-11-5**] 09:21PM BLOOD Type-ART Temp-37.1 pO2-75* pCO2-43
pH-7.36 calTCO2-25 Base XS--1 Intubat-NOT INTUBA
[**2131-11-5**] 09:21PM BLOOD Lactate-1.6
[**2131-11-5**] 06:33PM BLOOD Lactate-1.9
B. Discharge
[**2131-11-9**] 06:35AM BLOOD WBC-4.9 RBC-4.33 Hgb-11.9* Hct-37.2
MCV-86 MCH-27.5 MCHC-31.9 RDW-14.0 Plt Ct-217
[**2131-11-9**] 06:35AM BLOOD Plt Ct-217
[**2131-11-9**] 06:35AM BLOOD Glucose-78 UreaN-12 Creat-0.9 Na-137
K-4.5 Cl-100 HCO3-28 AnGap-14
[**2131-11-9**] 06:35AM BLOOD Calcium-9.5 Phos-4.4 Mg-2.0
C. Urine
[**2131-11-5**] 06:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2131-11-5**] 06:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2131-11-5**] 06:50PM URINE UCG-NEG
[**2131-11-6**] 12:37PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
II. Microbiology
A. Urine
[**2131-11-6**] 12:37 pm URINE Source: CVS.
**FINAL REPORT [**2131-11-7**]**
URINE CULTURE (Final [**2131-11-7**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
B. Blood
[**2131-11-5**] 8:39 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
C. MRSA Screen
[**2131-11-5**] 8:17 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2131-11-8**]**
MRSA SCREEN (Final [**2131-11-8**]): No MRSA isolated.
III. Radiology
INDICATION: Nausea, vomiting, diarrhea and likely diabetic
ketoacidosis.
COMPARISON: [**2131-10-22**].
UPRIGHT AP AND LATERAL VIEWS OF THE CHEST: The cardiac,
mediastinal and hilar
contours are normal. Lungs are clear. Pulmonary vascularity is
normal. No
pleural effusion or pneumothorax is present. No acute osseous
findings are
seen.
IMPRESSION: No acute cardiopulmonary process.
#### Pending Studies
Blood culture ([**11-5**])
Brief Hospital Course:
Hospital course:
Patient is a 26-year-old female with diabetes mellitus type I
with frequent admissions for DKA and a history of chronic back
pain that was admitted to the ICU with low back pain, nausea,
and suspected diabetic ketoacidosis likely secondary to
medication non-adherence vs. gastroenteritis. Patient was placed
on an insulin drip with intensive monitoring and provided fluid
resuscitation with subsequent transition to SC insulin and
transfer to medical floor where [**Last Name (un) **] and the pain service
provided guidance on diabetic and pain management. During her
last admission, psychiatry had discussed a voluntary psychiatry
admission once medication issues stabilized given psychiatric
comorbidities leading to negative cycle of inability to access
outpatient medical care for symptom stabilization. However, the
patient preferred to return home. A multidisciplinary meeting
was held to address recurrent hospitalization with the patient
being discharged home with services after evaluation by the
aforementioned services.
.
# Diabetic ketoacidosis with diabetes type I (A1c 10.3 on
admission)
In the setting of elevated blood glucose, acidosis, and moderate
ketonuria, the patient was diagnosed with diabetic ketoacidosis
and admitted to the MICU for further management. The etiology
was thought to be non-adherence to medication regimen vs. viral
gastroenteritis. Acute pancreatitis, recent medication
changes/substance abuse, myocardial ischemic, infectious
etiologies were ruled out. Patient was maintained on insulin
drip with closed gap until transitioned to SC insulin with PO
intake. Patient also given fluid resuscitation. [**Last Name (un) **] consulted
and provided help with management. Patient subsequently taking
adequate PO, and discharged on 28 units of Lantus at night. Dose
is the same as prior recent admission given evidence of
hypoglycemia during recent hospitalization on higher dosage.
Patient will follow-up with [**Last Name (un) **] on discharge.
.
# Back pain:
Patient endorses chronic back pain in setting of motor vehicle
accident in [**2124**]. Patient stated on admission that usually takes
MSContin and IV Dilaudid during hospital admission for back pain
but takes nothing at home. Prior admission endorses "taking
mom's percocets." PCP denies prescribing such medications.
Patient had no red flag signs or symptoms such as weight loss,
IVDU, fevers, neurological deficits. CT imaging in [**11-7**] showing
no apparent pathology. Pain service consulted and recommended
conservative management given psycho-social comorbidities.
Patient started on tylenol and ultram, recommended PT as
outpatient, and consideration of MRI possibly as outpatient if
persistent complaint and if accompanied by neurological
involvement to differentiate discogenic pain vs. facet-mediated
or potential pars fracture from MVA.
.
# Nausea/vomiting with H. pylori gastritis
Patient has prominent nausea/vomiting with each episode of DKA.
Differential includes primary DKA process vs. viral
gastroenteritis. Patient also has history of H. Pylori
esophagitis and questionable history of gastroparesis although
studies at [**Hospital1 18**] indicate normal gastric emptying. Patient was
started on reglan TID and treated for H. pylori. She will
follow-up with GI.
Medications on Admission:
1. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. Lantus 100 unit/mL Solution Sig: Twenty Eight (28) units
Subcutaneous at bedtime.
6. Humalog 100 unit/mL Solution Sig: Per sliding scale units
Subcutaneous four times a day: Please resume your home insulin
sliding scale.
7. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain for 4 days.
(Patient states NOT taking)
9. acetaminophen 500 mg Capsule Sig: [**12-2**] Capsules PO four times
a day as needed for pain.
(Patient states NOT taking)
Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back pain.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*0*
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
Disp:*90 Tablet(s)* Refills:*2*
3. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 14 days.
Disp:*112 Capsule(s)* Refills:*0*
4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
5. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
14 days.
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO daily ().
9. insulin glargine 100 unit/mL Cartridge Sig: Twenty Eight (28)
UNITS Subcutaneous at bedtime.
Disp:*30 CARTRIDGES* Refills:*0*
10. insulin lispro 100 unit/mL Cartridge Sig: [**Month/Day (2) **] Subcutaneous
four times a day: Sliding scale insulin. Please check finger
sticks 4 times a day. .
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
1) Diabetic ketoacidosis
2) Type 1 diabetes mellitus
3) Possible viral gastroenteritis
4) Depression
5) Dehydration
6) H. Pylori gastritis
7) Nausea and vomitting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted for DKA or diabetic ketoacidosis. We treated you with
intravenous insulin and IV fluids in the ICU and you improved.
We had GI see you who will be treating you for a possible
inflammation/infection of your stomach with 2 weeks of
antibiotics. It is very important you finish these medications.
You were seen by psychiatry who recommended outpatient therapy
and psychiatric visiting nurses. You were also seen by [**Last Name (un) **]
who recommended returning to your regular dose insulin. We are
sending home visiting nurses who will visit you twice daily to
go over insulin and blood sugar. You were also seen by the pain
service regarding your back pain. If you develop back pain,
please remember to take tramadol and tylenol to treat your pain
and prevent high blood sugars. Please also follow with physical
therapy to treat your chronic back pain.
Please start the following medications:
1) Tramadol 50-100mg by mouth every 4 hours as needed for pain
2) Tylenol 1 gram every 8 hours as needed for pain.
3) Lidocaine patch apply to affected area daily
Per Gastroenterolgy recommendations, you were started on
H.Pylori treatment of:
1) Protonix 40mg po BID for 14 days
2) Levaquin 250mg po BID for 14 days
3) Amoxicillin 1g po BID for 14 days.
You will return to your original insulin regimen prior to your
hospitalization.
Followup Instructions:
You have an appointment with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] nurse [**First Name (Titles) **] [**Last Name (Titles) 3816**], [**11-13**] at 4:30pm at [**Last Name (un) 3911**], the [**Location (un) 1773**] of the [**Last Name (un) **]
Center. Contact number [**Telephone/Fax (1) 2384**]. It is critically important
for your health to make this appointment.
Please contact gastroenterology to set up a follow up
appointment regarding your gastritis. You can call them at
([**Telephone/Fax (1) 2756**]. Your home nurses can help you set this
appointment.
Please call the pain clinic to follow up regarding your back
pain at([**Telephone/Fax (1) 1652**].
|
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56,840
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42543+58538
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Discharge summary
|
report+addendum
|
Admission Date: [**2155-2-17**] Discharge Date: [**2155-2-21**]
Date of Birth: [**2075-11-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
aortic stenosis
Major Surgical or Invasive Procedure:
[**2155-2-17**] Aortic valve replacement (23mm [**Doctor Last Name **] pericardial)
History of Present Illness:
This 79 year old male with known aortic stenosis has been
followed for at least the last 10 years by his primary in New
[**Location (un) **] with serial echocardiograms. A little over a year ago
he had two syncopal episodes. The first occurred while in the
shower, the second while climbing up a flight of stairs. On
both occasions he became dizzy and weak prior to passing out.
Over the past six months he has had progressive dyspnea on
exertion, which has exacerbated more over the past three months.
He is now short of breath with performing daily activities and
is classified as NYHA class III. Due to his significant decline
he was referred for right and left heart catheterization. He is
also being referred to cardiac surgery for an evaluation of an
aortic valve replacement.
Past Medical History:
Aortic stenosis
Hypertension
Emphysema
probable obstructive sleep apnea
Prostate cancer (s/p radiation and hormonal therapy [**2150**])
s/p Cholecystectomy [**2141**]
s/p C5-C6 Cervical Disc Surgery [**Hospital1 2025**] [**2115**]
Glaucoma left eye s/p valve implant [**2135**]
Partial gastrectomy for ulcer disease [**2118**]
Social History:
Race:Caucasian
Last Dental Exam:Edentulous
Lives with:Wife
Contact: [**Name (NI) 1258**] (wife) Phone #[**Telephone/Fax (1) 92067**]
Occupation: retired police officer
Cigarettes: Smoked no [] yes [x] Hx:50 pack year history of
tobacco abuse, quit smoking in [**2134**]
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-28**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- 87 year old sister recently
had aortic valve surgery in [**2153-12-22**]. Nephew passed away
from heart failure at the age of 60.
Physical Exam:
Pulse:63 Resp:18 O2 sat:100/RA
B/P Right:91/71 Left:122/55
Height:5'[**52**]" Weight:180 lbs
General: awake, alert, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Mild wheeze bilaterally throughout
Heart: RRR [x] Irregular [] Murmur [x] grade _II_
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [x] _2+ isolated
bilateral ankle edema_ Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2155-2-17**] Echo: 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. The
ascending aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets are
moderately thickened. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is a very small pericardial
effusion.
POSTBYPASS: Biventricular systolic function remains normal.
There is a well seated, well functioning bioprosthetic in the
aortic position. No AI is visualized. The remaining study is
unchanged from prebypass.
.
[**2155-2-18**] 02:10AM BLOOD WBC-7.3# RBC-3.66* Hgb-10.9*# Hct-31.4*
MCV-86 MCH-29.9 MCHC-34.9 RDW-13.4 Plt Ct-125*
[**2155-2-19**] 04:45AM BLOOD WBC-8.4 RBC-3.49* Hgb-10.7* Hct-29.5*
MCV-84 MCH-30.6 MCHC-36.2* RDW-13.4 Plt Ct-119*
[**2155-2-19**] 04:45AM BLOOD Glucose-111* UreaN-20 Creat-0.9 Na-132*
K-4.0 Cl-100 HCO3-24 AnGap-12
[**2155-2-17**] 12:01PM BLOOD UreaN-19 Creat-0.8 Na-141 K-4.0 Cl-115*
HCO3-24 AnGap-6*
Brief Hospital Course:
Mr. [**Known lastname 92068**] was a same day admit and on [**2-17**] he was brought to
the Operating Room where he underwent aortic valve replacement.
Please see operative note for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later this day he was weaned from sedation,
awoke neurologically intact and extubated.
On post-op day one he was started on beta-blockers and diuretics
and gently diuresed towards his pre-op weight. Later this day he
was transferred to the telemetry floor for further care. Chest
tubes and epicardial pacing wires were removed per protocol. He
worked with Physical Therapy for strength and mobility.
He was trnasferred to [**Hospital1 6685**] Nursing & Reab in [**Location (un) 11333**], NH. for
further recovery prior to his return home. All follow up was
arranged and medications discussed.
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled [**Hospital1 **]
ALPRAZOLAM 0.5 mg [**Hospital1 **]/PRN
ATENOLOL 50 mg Daily
SYMBICORT 160 mcg-4.5 mcg/actuation HFA Aerosol Inhaler - 2
puffs inhaled [**Hospital1 **]
CAPTOPRIL 25 mg TID
DORZOLAMIDE 2 % Drops - 1 drop in the left eye twice a day
IRON INJECTION monthly at PCP office
POTASSIUM CHLORIDE 20 mEq [**Hospital1 **]
SIMVASTATIN 40 mg Daily
TERAZOSIN 10 mg Daily
SPIRIVA WITH HANDIHALER 18 mcg Capsule, w/Inhalation Device - 1
capsule inhaled daily
VITAMIN D Dosage uncertain
VITAMIN B COMPLEX Dosage uncertain
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. terazosin 10 mg Capsule Sig: One (1) Capsule PO at bedtime.
10. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for anxiety.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. flu vaccine [**2153**] (36 mos+)(PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose).
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 6685**] Nursing & Rehab in NH
Discharge Diagnosis:
Aortic stenosis
s/p Aortic valve replacement
Hypertension
Emphysema
probable obstructive sleep apnea
h/o Prostate cancer (s/p radiation and hormonal therapy [**2150**])
s/p Cholecystectomy [**2141**]
s/p C5-C6 Cervical Disc Surgery [**Hospital1 2025**] [**2115**]
Glaucoma left eye s/p lens implant [**2135**]
Partial gastrectomy for ulcer disease [**2118**]
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema-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**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2155-3-19**] at 1:30pm
Cardiologist: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2155-3-10**] at 1PM
Please call to schedule appointments with:
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 77484**] ([**Telephone/Fax (1) 77350**]in [**3-27**] 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:[**2155-2-21**] Name: [**Known lastname 14478**],[**Known firstname **] Unit No: [**Numeric Identifier 14479**]
Admission Date: [**2155-2-17**] Discharge Date: [**2155-2-21**]
Date of Birth: [**2075-11-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 741**]
Addendum:
Additional medications at discharge:
Lasix 40mg daily for 7 days
Potassium 20mEq daily for 7 days
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 14480**] Nursing & Rehab in NH
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2155-2-21**]
|
[
"424.1",
"365.9",
"492.8",
"V12.71",
"V70.7",
"458.29",
"327.23",
"401.9",
"V15.82",
"V10.46",
"525.10",
"V17.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9888, 10081
|
4339, 5232
|
327, 412
|
7731, 7902
|
2933, 4316
|
8742, 9788
|
2000, 2166
|
5880, 7236
|
7349, 7710
|
5258, 5857
|
7926, 8719
|
2181, 2914
|
9803, 9865
|
272, 289
|
440, 1225
|
1247, 1575
|
1591, 1984
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,057
| 174,850
|
4465
|
Discharge summary
|
report
|
Admission Date: [**2124-8-30**] Discharge Date: [**2124-9-5**]
Date of Birth: [**2044-1-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Differin / Coumadin / Adhesive Tape
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
[**2124-8-30**] Aortic valve replacement 25-mm Mosaic
tissue valve.
History of Present Illness:
80 yo male with known AS being
followed by serial echos. Has become symptomatic in past few
months and was referred for AVR. He presents today for surgical
management of his aortic valve stenosis.
Past Medical History:
aortic stenosis
avascular necrosis R hip
hypertension
hyperlipidemia
gastroesophageal reflux disease
prior ETOH dependen
Social History:
Lives with: wife
Occupation: works at supermarket deli 20h/week
Tobacco: quit 30 yrs. ago (20 pack year hx)
ETOH: 4 beers/day
Family History:
no FH of CAD
Physical Exam:
Pulse: 61 Resp: 16 O2 sat: 95%
B/P Left: 123/72
Height: 5'6" Weight: 175lb
General: NAD, WGWN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ (closure device s/p cath) Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit radiation of cardiac murmur vs. bruit
Pertinent Results:
[**2124-9-1**] 05:38AM BLOOD WBC-12.4* RBC-3.46* Hgb-11.1* Hct-31.6*
MCV-91 MCH-32.0 MCHC-35.0 RDW-13.5 Plt Ct-119*
[**2124-8-31**] 05:13AM BLOOD WBC-17.6*# RBC-3.75* Hgb-12.2* Hct-34.0*
MCV-91 MCH-32.5* MCHC-35.9* RDW-13.7 Plt Ct-147*
[**2124-8-30**] 01:10PM BLOOD PT-13.4 PTT-38.9* INR(PT)-1.1
[**2124-9-1**] 05:38AM BLOOD Glucose-117* UreaN-13 Creat-1.0 Na-135
K-4.0 Cl-101 HCO3-28 AnGap-10
PREBYPASS
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No spontaneous echo contrast is
seen in the body of the right atrium or right atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size is normal with normal free wall contractility. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the proximal descending thoracic aorta/distal
aortic arch. There are three aortic valve leaflets. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen.The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
POSTBYPASS
The patient is A-paced on a phenylephrine infusion.There is a
bioprosthetic aortic valve which appears well seated. The
peak/mean gradients across the valve are 19/8 mmHg at a CO of
3.91 L/min. The aorta is intact post decannulation. Dr.[**Last Name (STitle) **]
was notified in person of the results at the time of the study.
[**2124-9-5**] 04:30AM BLOOD WBC-6.4 RBC-3.21* Hgb-10.3* Hct-29.9*
MCV-93 MCH-31.9 MCHC-34.3 RDW-13.3 Plt Ct-286
[**2124-9-4**] 05:45AM BLOOD WBC-6.7 RBC-3.25* Hgb-10.5* Hct-30.1*
MCV-93 MCH-32.2* MCHC-34.8 RDW-13.4 Plt Ct-218
[**2124-9-5**] 04:30AM BLOOD Glucose-96 UreaN-21* Creat-1.0 Na-139
K-4.0 Cl-103 HCO3-27 AnGap-13
Brief Hospital Course:
The patient was brought to the operating room on [**2124-8-30**] where
the patient underwent aortic valve replacement with a 25mm
tissue valve. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical antibiotic prophylaxis.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. 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. He
did develop post-op a-fib briefly and converted to sinus rhythm
with amiodarone. 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 6 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to rehab (TCU, [**Hospital 1474**]
Hospital) in good condition with appropriate follow up
instructions.
Medications on Admission:
ASA 325 mg daily
metoprolol XL 50 mg daily
MVI daily
fish oil
simvastatin 10 mg daily
quinapril 5 mg daily
zolpidem 10 mg daily
omeprazole 20 mg [**Hospital1 **]
percocet 5/325 mg prn TID
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/temp.
10. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 7 days, then 400mg daily x 7 days, then
200mg daily until further instructed.
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
16. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. diphenhydramine HCl 25 mg Capsule Sig: [**11-27**] Capsules PO Q6H
(every 6 hours) as needed for itching.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1474**] Hospital TCU (Signature)
Discharge Diagnosis:
Aortic Stenosis
PMH:
avascular necrosis R hip
hypertension
hyperlipidemia
gastroesophageal reflux disease
prior ETOH dependency
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:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, [**Known lastname **], powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2124-9-28**] 1:00
Cardiologist Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] [**10-2**] @ 12:20 pm
Please call to schedule the following:
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 14331**] in [**2-28**] weeks
Completed by:[**2124-9-5**]
|
[
"424.1",
"272.4",
"V43.64",
"401.9",
"427.31",
"V58.66",
"458.29",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7067, 7139
|
3699, 4951
|
318, 388
|
7310, 7466
|
1655, 3676
|
8270, 8713
|
920, 934
|
5190, 7044
|
7160, 7289
|
4977, 5167
|
7490, 8247
|
949, 1636
|
262, 280
|
416, 616
|
638, 760
|
776, 904
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,694
| 176,812
|
34612
|
Discharge summary
|
report
|
Admission Date: [**2186-7-7**] Discharge Date: [**2186-7-11**]
Date of Birth: [**2123-5-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
Febrile neutropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 63 yo woman with metastatic breast cancer with
hepatic, pulmonary and bone mets who presented to the ED
yesterday evening [**2-15**] fever (100.8F) following therapeutic
paracentesis (2.5L). Prior to Thursday Ms. [**Known lastname **] had noted
fatigue since Sunday, but denied cough, SOB, changes in bowel
habits or urination. Fevers/chills were absent until Thursday
post-procedure
She is currently recieving 4th line chemotherapy with
Navelbine with ascites following 4 rounds. Also with leukopenia
(WBC 2.3) and neutropenia (483). Ascites has been
therapeutically tapped in [**6-26**] w/ 3L removed but with interval
worsening of ascites.
In the ED, initial vitals were T 99.0, HR 138, BP 118/69, RR 18,
O2 100% on RA. She triggered for tachycardia and received a
total of 4L IVF with minimal improvement. She had a clear CXR
and negative U/A. She also received 1 g IV vanco and 2 g IV
cefepime for febrile neutropenia and acetaminophen and motrin
for fever. The oncology fellow was consulted and recommended
against diagnostic paracentesis. Vitals on transfer were T 99.6
(Tmax in ED 100.4), HR 128, BP 122/88, RR 15, O2 sat 100% RA.
On the floor, patient endorses abdominal pain, dyspnea, and
malaise. She is somnolent and requests many questions be
referred to her daughter.
Past Medical History:
-Stage I breast cancer, diagnosed by biopsy [**2183-6-28**], (negative
mammogram in [**12/2182**]), on [**2183-8-4**] she had a right partial
mastectomy with sentinel node biopsy for invasive carcinoma of
the right breast (diagnosed by core biopsy) at [**Hospital 882**]
Hospital. The pathology report showed that one of five
radioactive lymph nodes contain a neoplastic cell in peripheral
sinus, pN0 (i+). ERA 40%, PRA 2%, HER2 1+ out of 3+, Ki67 25%.
-DM
-Hypercholesterolemia
Social History:
She denies the use of tobacco, alcohol, or illicit drug use
ever. She lives with her husband and 2 of her 5 daughters in
[**Name (NI) 3146**]. She is a homemaker.
Family History:
The patient's sister had a suprasellar epidermoid cyst diagnosed
[**8-15**] s/p right craniotomy [**11-15**]. CT brain showed it was a
suprasellar based mass extending into the sella measuring
1.8x1.4x2.2 cm which may represent dermoid or teratoma. MRI
showed suprasellar mass with fat and calcifications exerting
some mass effect on the optic chiasm which is likely dermoid or
teratoma.
Her mother had breast cancer at 37, and also had Crohn's disease
and a stroke, she died in her 70s. Her father had lymphoma and
died in his early 70s. Her sister has DM.
Physical Exam:
EXAM ON ADMISSION:
General: tired but oriented x3,
HEENT: Dry MM, oropharynx w/ mucosal bleeding
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: sinus tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: grossly distended abdomen w/ tenderness to palpation
GU:
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Exam on Discharge:
Vitals: Tmax 97.7, Tcurrent 96.8, BP 100/60, HR 88, RR 20, SO2
97 on RA
GEN: NAD, AOX3
HEENT: PERRL
Cards: RRR, No MRG
Pulm: Lungs CTAB (poor effort), no dullness to percussion
GI: Abdomen is distended and mildly tender to palpation in all 4
quadrants, no guarding or rebound tenderness
Extremities: Mild non-pitting edema in LE's bilaterally
Pertinent Results:
Admission Labs:
[**2186-7-6**] 11:20PM PT-16.4* PTT-24.9 INR(PT)-1.4*
[**2186-7-6**] 11:20PM PLT SMR-NORMAL PLT COUNT-204
[**2186-7-6**] 11:20PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+
[**2186-7-6**] 11:20PM NEUTS-21* BANDS-0 LYMPHS-45* MONOS-31* EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-1*
[**2186-7-6**] 11:20PM WBC-2.3*# RBC-3.70* HGB-10.8* HCT-32.7*
MCV-89 MCH-29.3 MCHC-33.1 RDW-19.5*
[**2186-7-6**] 11:20PM ALBUMIN-2.6*
[**2186-7-6**] 11:20PM LIPASE-32
[**2186-7-6**] 11:20PM ALT(SGPT)-46* AST(SGOT)-225* ALK PHOS-396*
TOT BILI-1.2
[**2186-7-6**] 11:20PM GLUCOSE-139* UREA N-13 CREAT-0.4 SODIUM-135
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15
[**2186-7-6**] 11:28PM LACTATE-3.1* K+-3.7
[**2186-7-6**] 11:28PM COMMENTS-GREEN TOP
[**2186-7-7**] 01:40AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2186-7-7**] 03:23AM LACTATE-3.2*
[**2186-7-7**] 07:14AM GRAN CT-1140*
[**2186-7-7**] 07:14AM PT-17.9* PTT-26.3 INR(PT)-1.6*
[**2186-7-7**] 07:14AM PLT SMR-NORMAL PLT COUNT-184
[**2186-7-7**] 07:14AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL SCHISTOCY-1+
[**2186-7-7**] 07:14AM NEUTS-41* BANDS-0 LYMPHS-33 MONOS-19* EOS-1
BASOS-0 ATYPS-0 METAS-4* MYELOS-2* NUC RBCS-2*
[**2186-7-7**] 07:14AM WBC-2.8* RBC-3.67* HGB-10.7* HCT-32.9* MCV-90
MCH-29.2 MCHC-32.6 RDW-19.1*
[**2186-7-7**] 07:14AM CALCIUM-8.6 PHOSPHATE-2.5* MAGNESIUM-1.5*
[**2186-7-7**] 07:14AM ALT(SGPT)-43* AST(SGOT)-199* LD(LDH)-996* ALK
PHOS-405* TOT BILI-1.8*
[**2186-7-7**] 07:14AM GLUCOSE-115* UREA N-13 CREAT-0.5 SODIUM-139
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
Imaging:
CXR [**2186-7-6**]:
FINDINGS: There is no pneumonia. There is no pleural effusion or
pneumothorax. Hilar, mediastinal, and cardiac silhouette within
normal
limits. There is a Port-A-Catheter with tip at the cavoatrial
junction. IMPRESSION: No pneumonia.
ECG
[**2186-7-6**]: Sinus tachycardia. Since the previous tracing no
significant change on previously noted findings.
[**2186-7-7**] Sinus tachycardia. Since the previous tracing no
significant change on previously noted findings.
Micro:
[**2186-7-6**] - BCX - NGTD
[**2186-7-7**] - BCX - NGTD
[**2186-7-7**] - MRSA Nasal Swab Screen - Negative
Discharge Labs:
[**2186-7-11**] 06:29AM BLOOD WBC-4.3 RBC-3.06* Hgb-8.9* Hct-28.0*
MCV-92 MCH-28.9 MCHC-31.6 RDW-18.4* Plt Ct-100*
[**2186-7-11**] 06:29AM BLOOD Neuts-52 Bands-0 Lymphs-16* Monos-30*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2186-7-11**] 06:29AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-2+ Schisto-1+
MacroOv-OCCASIONAL
[**2186-7-11**] 06:29AM BLOOD Plt Smr-LOW Plt Ct-100*
[**2186-7-11**] 06:29AM BLOOD Gran Ct-2484
[**2186-7-11**] 06:29AM BLOOD Glucose-116* UreaN-12 Creat-0.5 Na-137
K-4.0 Cl-105 HCO3-26 AnGap-10
[**2186-7-11**] 06:29AM BLOOD ALT-24 AST-95* LD(LDH)-310* AlkPhos-357*
TotBili-1.5
[**2186-7-11**] 06:29AM BLOOD Calcium-8.6 Phos-2.3* Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname **] presented with febrile neutropenia following
therapeutic paracentesis and was admitted to the medical ICU for
tachycardia unresponsive to fluids in the ED.
# Febrile Neutropenia. On arrival, the patient's ANC was < 500
and she was febrile to Tmax 100.4 in the ED. She was therefore
started on broad-spectrum antibiotic coverage with vancomycin
and cefepime. U/A and CXR were unremarkable, and blood cultures
obtained at admission showed no growth at this time. Diagnostic
paracentesis was considered to rule out the possibility of SBP,
but no suitable fluid pocket could be identified for safe
bedside paracentesis. Her fever resolved within 24 hours of
admission and she remained afebrile throughout the remainder of
her hospital stay.
#Tachycardia: The patient was noted to be tachycardic to
130s-140s on arrival to the ED; after 4L of IVF, her HR remained
in the 130s. 12-lead EKG was obtained which showed sinus
tachycardia. This was felt likely secondary to fever/infection,
as when her fevers resolved her heart rate decreased to
90s-100s. On review of her most recent clinic notes, her heart
rate was nearly always > 90 bpm, so HR in 90s to 100s was felt
to be her recent baseline.
#Abnormal LFTs:
Patient was noted to have a transaminitis as above. This was
felt possibly secondary to known liver metastases vs. toxicity
from recent chemotherapy. Transaminases trended down over the
course of this admission.
#Metastatic Breast Cancer:
Ms. [**Known lastname **] has undergone significant functional decline over the
past few weeks. Prior to this admission, she had planned to
visit [**Company 2860**] for a second opinion on treatment options and
discussion of her prospects for involvement in a clinical trial.
Her oupatient oncologist Dr. [**Last Name (STitle) **] was called to consult
during this admission, and was involved with her plan of care.
At this juncture, it was felt that the patient has a relatively
poor prognosis with life expectancy on the order of a few
months. Ms. [**Known lastname **] went out of the ICU to the oncology (OMED)
service on hospital day #2, where she remained afebrile and
normotensive and was discharged to home with services.
#DMII:
Metformin held while inpatient. Humalog ISS was implemented
during this stay.
Transitional Issues:
- Follow up blood cultures.
- Patient at higher risk for readmission due to reaccumulating
ascites and ongoing issues with pain (although under better
control than admission).
Medications on Admission:
diazepam 2mg 1-2x daily for insomnia/anxiety, simvastatin 40mg
once daily, paroxetine 20mg once daily, docusate 100mg twice
daily, OxyContin 30 mg [**Hospital1 **] PRN pain, Metformin 1000 mg [**Hospital1 **]
Discharge Medications:
1. OxyContin 30 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO twice a day as needed for pain:
Hold for sedation or Respiratory Rate < 12/min.
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
2. diazepam 2 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for Anxiety.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO once a
day.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
6. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
7. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Febrile Neutropenia
Hypotension
Tachycardia
Metastatic Breast Cancer
Pancytopenia
Type II Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **], you were admitted with fever and low blood
pressure. You were put on antibiotics, given fluids and given
some medicines to help with your blood pressure. We also found
that your white blood cell counts were low, but these have
improved since the day of your admission. During your stay your
blood pressure stabilized, you stopped having fevers and your
pain came under better control.
No changes were made to your medications.
Followup Instructions:
PCP [**Name Initial (PRE) **]:WEDNESDAY [**2186-7-19**] at 10:15am
Name: DR. [**First Name (STitle) **] TIBA, an associate of your PCP,
[**Last Name (NamePattern4) **].[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Doctor Last Name 79420**] since your PCP is unavailable next
week.
Location: [**Location (un) **] FAMILY HEALTH CENTER
Address: [**Street Address(2) 79421**] [**Apartment Address(1) 3745**], [**Location (un) **],[**Numeric Identifier 26335**]
Phone: [**Telephone/Fax (1) 78480**]
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2186-7-19**] at 3:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2186-7-19**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10280**], PA [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
|
[
"197.7",
"V10.3",
"288.00",
"197.0",
"272.0",
"198.5",
"E933.1",
"250.00",
"789.59",
"284.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
10247, 10322
|
6800, 9093
|
291, 297
|
10474, 10474
|
3710, 3710
|
11144, 12490
|
2347, 2907
|
9551, 10224
|
10343, 10453
|
9317, 9528
|
10657, 11121
|
6072, 6777
|
2922, 2927
|
9114, 9291
|
232, 253
|
325, 1647
|
3347, 3691
|
3727, 6055
|
2941, 3328
|
10489, 10633
|
1669, 2150
|
2166, 2331
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,565
| 137,080
|
895
|
Discharge summary
|
report
|
Admission Date: [**2188-7-19**] Discharge Date: [**2188-7-22**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 82 year old
male, who underwent a screening endoscopy and colonoscopy on
[**2188-7-18**]. During the procedure, polypectomy was performed on
a polyp seen in the left ascending colon. The patient was
discharged home and on the morning of admission, developed
brisk bright blood per rectum and syncope when he stood up
from his bed. He presented to the Emergency Department at
which time he was found to be hypotensive with a systolic
blood pressure in the 60's. He was immediately resuscitated
for hypovolemic shock.
The patient also underwent nasotracheal intubation in the
Emergency Room for airway protection.
PAST MEDICAL HISTORY: Significant for prostate cancer, basal
cell carcinoma, colonic polyp, hiatal hernia,
gastroesophageal reflux disease.
PAST SURGICAL HISTORY: Significant for bilateral inguinal
hernia repairs. Status post XRT for prostate cancer and a
previous transurethral resection of prostate.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: None.
SOCIAL HISTORY: There is no history of tobacco or ETOH use.
PHYSICAL EXAMINATION: The patient was intubated and sedated.
Heart rate was 90; blood pressure was 124/70. Chest is
clear. His heart is regular. His abdomen is nontender and
nondistended. There is bright red blood per rectum.
Bilateral lower extremity edema.
LABORATORY DATA: Initial laboratory results included a white
count of 10 and hematocrit of 22 which, after resuscitation,
was repeated and found to be 30; platelet of 343. BUN of 18;
creatinine of 0.9. INR of 1.0.
HOSPITAL COURSE: After undergoing the abovementioned
maneuvers in the Emergency Department, the patient was
transferred to the angio suite to undergo angiography. Prior
to angiography, the patient had a nasogastric tube lavage of
the upper gastrointestinal tract and was found to have no
evidence of bleeding. The patient underwent angiography of
the superior mesenteric artery and inferior mesenteric artery
and there was no active extravasation seen at that time. He
tolerated this procedure well. He was then transferred to
the Intensive Care Unit under the care of the surgical team.
Overnight, over his first night, the patient was transfused
for a total of six units of packed red blood cells and two
units of FFP. He remained hemodynamically stable and was
maintained on a ventilator overnight.
On hospital day number two, the patient was weaned and
extubated without incident. There were no further episodes
of bleeding and the patient's hematocrit remained stable at
30. The patient continued to do well with no evidence of
active bleeding.
On hospital day number three, the diet was advanced and the
patient was transferred to the floor.
The patient has continued to do well and has been followed by
the gastroenterology service. They will follow him as an
outpatient. His hematocrit remained stable and the patient is
now ready for discharge to home.
DISCHARGE DIAGNOSES:
Acute lower gastrointestinal bleed, presumed site of recent
polypectomy, Hemorrhagic shock, requiring blood
transfusion
History of prostate cancer.
Status post XRT and transurethral resection of prostate.
History of basal cell carcinoma.
Gastroesophageal reflux disease.
MEDICATIONS:
Protonic 40 mg p.o. q. day.
The patient will follow-up with Dr. [**Last Name (STitle) 6081**] in the
gastrointestinal clinic in one week and will call for an
appointment. The patient will also to continue to follow-up
with his primary care physician as appropriate.
CONDITION ON DISCHARGE: The patient is tolerating a diet,
with no evidence of active bleeding. The patient is
instructed to call should he become symptomatic once again.
[**Name6 (MD) 843**] [**Name8 (MD) 844**], M.D. [**MD Number(1) 845**]
Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.
MEDQUIST36
D: [**2188-7-21**] 05:44
T: [**2188-7-21**] 17:43
JOB#: [**Job Number 6082**]
|
[
"530.81",
"E878.8",
"998.11",
"V10.46",
"785.59",
"553.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.47",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
3049, 3613
|
1081, 1107
|
1670, 3028
|
913, 1054
|
1193, 1652
|
113, 748
|
771, 890
|
1125, 1170
|
3638, 4066
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,943
| 170,530
|
53442
|
Discharge summary
|
report
|
Admission Date: [**2115-11-1**] Discharge Date: [**2115-11-4**]
Date of Birth: [**2049-6-12**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Cardizem / Morphine / Vancomycin
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 66 year-old male with a history of diabetes,
hypertension and hyperlipidemia who presents with 1 day of
fever, dyspnea and confusion. The patient reports being in his
usual state of health until this AM when he began to feel weak.
He was concerned that he was becoming hypoglycemic and thus
drank some [**Location (un) 2452**] juice and checked his glucose (it was 180).
He rested and when his wife returned, he was found to be weak,
lethargic with fever and chills. Thus she called 911. On
arrival EMS noted the patient to be hypoxic to 89% and pale. Of
note the patient has been treated with dicloxacillin for the
last 10 days for a LLE injury that became infected. He
developed a rash prior to starting the antibiotics that was
located on his back, chest and arms. The patient nor wife can
recall any change that could cause the rash but do note that the
patient does frequently have rashes that occur for no clear
reason.
The patient was brought to the ER. Initial vitlas were t 101 BP
132/78 HR 130 RR 28 02 92% 4L. Per report cyanotic on arrival
of EMS, 02 sat 89%. In the ED the patient was given
levofloxacin and then found to have BP of 80s. IV fluids were
given and the patient responded with BP. Additionally, the
patient was given Vancomycin. The patient and wife report that
he immediately broke out in hives and became "red". The patient
was then given solumedrol, benadryl and pepcid with improvement
in the rash. He was placed on a NRB prior to transport
On arrival to the floor the patient is asymptomatic. He is more
alert and currently does not feel shortness of breath. He feels
that in the last hour he has felt significantly improved.
ROS: + nausea prior to admission, vomiting in ER with vancomycin
reaction. + constiption. Has had upper chest/back erythematous
rash. Intermittent LE edema r>L. The patient denies any weight
change, abdominal pain, diarrhea, melena, hematochezia, chest
pain, orthopnea, PND, cough, urinary frequency, urgency,
dysuria, , gait unsteadiness, focal weakness, vision changes,
headache.
Past Medical History:
DM-II on lantus (intermittently takes FS)
CAD s/p MI [**2096**]
HTN
Low back pain
glaucoma
impotence
current smoking
peripheral neuropathy
trivial MR
Obesity
Social History:
Smokes 1+ ppd, at least 50 pack years, no etoh, no IVDU, used to
work for the post office and the city. Lives with his wife in
[**Name (NI) 4310**]. On disability after having work related injury
Family History:
[**Name (NI) 46425**]
Mother-DM
Physical Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Chemistries:
[**2115-11-1**] 05:42PM GLUCOSE-184* UREA N-30* CREAT-1.6* SODIUM-137
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-24 ANION GAP-19
[**2115-11-1**] 05:42PM CALCIUM-9.7 PHOSPHATE-2.0* MAGNESIUM-1.8
[**2115-11-1**] 05:50PM LACTATE-3.8*
Hematology:
[**2115-11-1**] 05:42PM WBC-15.9* RBC-4.79 HGB-13.7* HCT-39.0*
MCV-82# MCH-28.6 MCHC-35.2*# RDW-15.0
[**2115-11-1**] 05:42PM NEUTS-87.7* LYMPHS-10.9* MONOS-0.5* EOS-0.6
BASOS-0.2
[**2115-11-1**] 05:42PM PT-14.5* PTT-23.9 INR(PT)-1.3*
Cardiac Enzymes:
[**2115-11-1**] 05:42PM BLOOD CK-MB-5
[**2115-11-1**] 05:42PM BLOOD cTropnT-0.05*
[**2115-11-1**] 05:42PM BLOOD CK(CPK)-252*
[**2115-11-2**] 12:15AM BLOOD CK-MB-16* MB Indx-4.2 cTropnT-0.09*
[**2115-11-2**] 12:15AM BLOOD CK(CPK)-378*
[**2115-11-2**] 02:37PM BLOOD CK-MB-19* MB Indx-2.6 cTropnT-0.15*
[**2115-11-2**] 06:01AM BLOOD CK(CPK)-500*
[**2115-11-2**] 09:11PM BLOOD CK-MB-15* MB Indx-2.5 cTropnT-0.16*
[**2115-11-2**] 09:11PM BLOOD CK(CPK)-603*
[**2115-11-3**] 04:00AM BLOOD CK-MB-13* MB Indx-2.5 cTropnT-0.17*
[**2115-11-3**] 04:00AM BLOOD CK(CPK)-514*
Imaging:
CT Chest w/o contrast [**2115-11-2**]:
1. Innumerable centrilobular nodules measuring up to 5 mm
throughout both
upper lungs. This is most likely infectious in etiology, and
could represent
bronchopneumonia. There is no area of confluent consolidation.
Needs F/U
after therapy.
2. Mild emphysematous changes bilaterally.
3. Mild atherosclerotic calcification.
4. Bulky appearance to the left adrenal gland, could represent
adrenal
adenoma. Adrenal protocol washout CT recommended.
Bilateral lower extremity ultrasounds [**2115-11-2**]:
No evidence of DVT of either leg.
CXR [**2115-11-1**]: no acute cardiopulmonary process
EKG: ECG: Sinus tachycardia at 128, ST depressions in I, II,
III, aVF, V5,V6. TWI in V4-V6 all new when compared to previous
[**2105**] (which was also tachycardic)
Microbiology:
[**2115-11-1**]: blood culture x 2 no growth to date
[**2115-11-2**]: urine culture no growth to date
[**2115-11-2**]: legionella antigen negative
Brief Hospital Course:
This is a 66 year old man with DM, HTN, CAD, Hyperlipidemia who
presented with confusion, lethargy, fever, and chills concerning
for infectious etiology. He was admitted to the ICU for
transient hypotension that resolved spontaneously. Blood and
urine cultures and legionella urine antigen were all negative.
Chest X-Ray was unremarkable. Chest CT was concerning for
possible bronchopneumonia although appearance is atypical. It
did show innumerable centrilobular nodules measuring up to 5 mm
throughout both upper lungs. This is most likely infectious in
etiology.
On presentation he had a new oxygen requirement but this was
quickly weaned to room air without shortness of breath. He
became afebrile with stable BP through out his stay. He was
placed on levofloxacin for five day course for fears of
community acquired pneumonia by the ICU team ( atypical and
unlikely presentation. His blood and urine cultures are negative
to date. His confusion/lethargy resolved prior to arrival to the
emergency room. He was noted to have elevated cardiac enzymes.
He has history of 95% LAD lesion treated with angioplasty in
[**2099**]. EKG on admission with ST depressions but in the setting
of tachycardia. EKG changes resolved upon arrival to ICU. CKs
have peaked and are tending down. Troponin currently 0.25.
There was low suspicion that this represents acute plaque
rupture given lack of symptoms but could represent demand
ischemia. He was treated with aspirin, atenolol, simvastatin.
I have explained all of the above to the patient and his wife on
2 separate occasions (yesterday and today). I advised him to
remain in hospital to obtain TTE or TEE, chemical myocardial
stress test, and CT of the abdomen ( adrenal enlargement on the
CT of the chest). I explained that he probably had a " minor
heart attack" that needs further testing and cardiology
consultation. He had unexplained fever, hypotension, confusion,
pulmonary nodules, and cardiac enzymes leak. He may need TEE to
R/O cardiac source of infection. In addition, he needs stress
[**Last Name (un) **]. In regards to the abnormal chest CT (multiple pulmonary
nodules on chest CT). No recent images for comparison. This
needs to be repeated after treatment with levofloxacin for
presumed pneumonia ( can not R/O cardiac emboli, or old fungal
infection). He is a smoker with risk of lung malignancy. He also
need CT abdomen for the adrenal enlargement seen on CT chest. He
needs outpatient cardiac and pulmonary consultations.
Again, I expressed the need for longer hospital stay and further
testing. He decided to leave with his wife and get all above
tests in the out patient setting. He understood the risk from
leaving the hospital prematurely.
Medications on Admission:
ASPIRIN - 325 MG TABLET (ENTERIC COATED) - UT DICT
ATENOLOL - 25 mg Tablet - 1 Tablet(s) by mouth once a day bp
DIAZEPAM - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia
DICLOXACILLIN - 500 mg Capsule - 1 Capsule(s) by mouth four
times a day
GLYBURIDE - 5 mg Tablet - 3 Tablet(s) by mouth once a day dm
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 by mouth once a day bp
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 60 units once
a day dm
LATANOPROST [XALATAN] - 0.005 % Drops - 1 gtt ou at bedtime
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - apply once a day as needed for for 12 hours per day
for low back pain
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day bp
METFORMIN - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day
dm
ROXICET - 5-325MG Tablet - TAKE 2 BY MOUTH EVERY 4 HOURS AS
NEEDED FOR FOR LBP
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day for
cholesterol
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply twice a day
affected area
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Diazepam 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 60
Subcutaneous at bedtime.
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
11. Glyburide 5 mg Tablet Sig: Three (3) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Fever.
Discharge Condition:
Excellent
Discharge Instructions:
you came because of fever, shortness of breath, confusion, and
almost passing out. your tests suggested infection (we did not
find the source yet) and stress on the heart "minor heart
attack". you felt well and decided to leave even though I
advised you to stay for more tests here in the hospital. You
need to have chemical stress test, Echocardiogram, CT of the
abdomen (adrenal protocol), and CT of the chest in 3 months. I
explained to you the need for these tests. you decided to have
them done in the out patient setting. Please return to the
hospital if you develop fever, shortness of breath, chest pain,
or any concerning symptoms. Do not take metformin for now as you
may need contrast study ( CT with contrast). Ask your doctor
when to resume it. follow up the results of the blood cultures
with your doctor as well.
Followup Instructions:
[**Last Name (LF) 1576**],[**First Name3 (LF) 1575**] [**Telephone/Fax (1) 1579**]. Please call to make appointment
this week to arrange for the above tests ASAP.
|
[
"305.1",
"518.89",
"724.2",
"357.2",
"V45.82",
"410.71",
"607.84",
"414.01",
"V58.67",
"E930.8",
"272.4",
"693.0",
"401.9",
"250.60",
"486",
"365.9",
"412",
"278.00",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10324, 10330
|
5681, 8397
|
333, 339
|
10381, 10393
|
3615, 4112
|
11269, 11435
|
2856, 2889
|
9467, 10301
|
10351, 10360
|
8423, 9444
|
10417, 11246
|
2904, 3596
|
4129, 5658
|
282, 295
|
367, 2441
|
2463, 2624
|
2640, 2840
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,876
| 184,032
|
2144
|
Discharge summary
|
report
|
Admission Date: [**2113-5-15**] Discharge Date: [**2113-5-19**]
Date of Birth: [**2066-3-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
increasing fatigue
Major Surgical or Invasive Procedure:
min. inv. MV repair [**2113-5-15**] (30 mm [**Doctor Last Name 405**]-[**Doctor Last Name **]
annuloplasty band and resection post. leaflet)
History of Present Illness:
47 yo female diagnosed with a murmur in [**2100**]. Initial echo
showed MVP with normal LV size and EF. Followed by serial echos
which have showed stable 2+ MR until most recent echo [**12-12**] that
showed a flail posterior leaflet, 3+ MR, and LAE. Referred for
surgical management.
Past Medical History:
MVP
PVCs
Social History:
lives with husband and 3 sons
project manager for Stop N Shop
never used tobacco
one drink per month
Family History:
NC
Physical Exam:
79.5 kg 67"
130/70 HR 60 RR 16 sat 100% RA
NAD
EOMI, PERRL, OP benign
neck supple, with no JVD, full ROM
CTAB without R/R/W
RRR with murmur presnet
soft, NT, ND + BS
warm, well-perfused, no edema or varicosities
alert and oriented x3, non-focal exam, MAE
bil. 2+ fem/DP/PTs
no carotid bruits
Pertinent Results:
[**2113-5-17**] 07:55AM BLOOD WBC-11.9* RBC-2.86* Hgb-8.8* Hct-25.7*
MCV-90 MCH-30.7 MCHC-34.1 RDW-12.9 Plt Ct-122*
[**2113-5-17**] 07:55AM BLOOD Plt Ct-122*
[**2113-5-17**] 07:55AM BLOOD Glucose-156* UreaN-11 Creat-0.6 Na-139
K-3.5 Cl-105 HCO3-28 AnGap-10
[**2113-5-17**] 07:55AM BLOOD Mg-2.2
Cardiology Report ECHO Study Date of [**2113-5-15**]
PATIENT/TEST INFORMATION:
Indication: Intraop minimally invasive mitral valve repair.
Evaluate valves, aorta, guide placement of coronary sinus
catheter.
Height: (in) 67
Weight (lb): 170
BSA (m2): 1.89 m2
BP (mm Hg): 130/70
HR (bpm): 60
Status: Inpatient
Date/Time: [**2113-5-15**] at 12:32
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW1-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Inferolateral Thickness: 0.6 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.2 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 55% to 65% (nl >=55%)
Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.3 cm (nl <= 3.4 cm)
Aorta - Arch: 2.5 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.1 cm (nl <= 2.5 cm)
INTERPRETATION:
Findings:
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. No atheroma in ascending aorta. Normal aortic arch
diameter. No
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Partial
mitral leaflet
flail. No MS. Moderate to severe (3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic
(normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
for the
patient.
Conclusions:
Pre bypass: No atrial septal defect is seen by 2D or color
Doppler. Left
ventricular wall thicknesses are normal. Biventricuar function
appears normal,
but given the extent of mitral regurgitation, the LV function
may be over
estimated. The left ventricular cavity is mildly dilated. Right
ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
There is partial mitral leaflet flail involiving primarily P2. .
Moderate to
severe (3+) eccentric mitral regurgitation is seen, directed
posteriorly.
Post bypass: Perserved biventricular function. LVEF >55%. Mitral
ring
prosthesis is insitu without evidence for mitral regrugitation.
Mitral
gradients are 7.3 mm Hg peak and 5.3 mm Hg mean. Cardiac output
measures 6.9
L/min (Index >3). There is no LVOT obstuction or systolic
anterior motion of
the mitral vlave leaflets. Aortic contours are intact. Remaining
exam is
unchanged. All findings are discussed with surgeons at the time
of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2113-5-17**] 09:35.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2113-5-16**] 9:17 AM
CHEST (PORTABLE AP)
Reason: r/o ptx
[**Hospital 93**] MEDICAL CONDITION:
47 year old woman s/p min. inv. MV repair and ct removal
REASON FOR THIS EXAMINATION:
r/o ptx
INDICATION: Chest tube removal.
PORTABLE CHEST: Cardiomediastinal silhouette appears unchanged.
Right vascular sheath is unchanged in position. Right-sided
chest tube has been removed and there is no evidence of
pneumothorax. Small right loculated effusion again noted. No
evidence of consolidation and pulmonary vasculature appears
unremarkable.
IMPRESSION: No evidence of pneumothorax status post removal of
right chest tube.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3904**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Brief Hospital Course:
Admitted [**5-15**] and underwent min. inv. MV repair with Dr.
[**Last Name (STitle) 1290**]. Transferred to the CSRU in stable condition on
propofol and phenylephrine drips. Extubated that evening, and
transferred to the floor on POD #1 to begin increasing her
activity level. CXR showed small bilat. pleural effusions, but
the pt. made excellent progress and was asymptomatic. Cleared
for discharge to home with VNA on POD # 4. Pt. is to make all
follow-up appts. as per discharge instructions.
Medications on Admission:
sotalol 40 mg [**Hospital1 **]
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 2 weeks.
Disp:*28 Capsule(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
s/p min. inv. MV repair
MR/MVP
PVCs
Discharge Condition:
stable
Discharge Instructions:
may shower over incisions and pat dry
no driving for 2 weeks or while on narcotics
no lotions, creams or powders on any incision
call for fever greater than 100.5, redness or drainage
no lifting greater than 10 pounds for 1 month
Followup Instructions:
see Dr. [**Last Name (STitle) 11487**] in [**2-7**] weeks
see Dr. [**First Name (STitle) **] in [**3-11**] weeks
see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2113-5-19**]
|
[
"997.3",
"427.31",
"E878.8",
"511.9",
"997.1",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"34.91",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7469, 7503
|
5926, 6424
|
340, 486
|
7583, 7592
|
1301, 1649
|
7870, 8093
|
965, 969
|
6505, 7446
|
5124, 5181
|
7524, 7562
|
6450, 6482
|
7616, 7847
|
1675, 5087
|
984, 1282
|
282, 302
|
5210, 5903
|
514, 799
|
821, 831
|
847, 949
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,237
| 117,156
|
45519
|
Discharge summary
|
report
|
Admission Date: [**2109-1-25**] Discharge Date: [**2109-1-31**]
Date of Birth: [**2032-11-24**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Lipitor
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Bright red blood per rectum.
Major Surgical or Invasive Procedure:
1. Upper endoscopy.
2. Colonoscopy.
History of Present Illness:
Ms. [**Known lastname 1968**] is a 76F with CAD s/p CABG on plavix, chronic angina
(unstable, sometimes with rest), DM presents following 3
episodes of BRBPR at home, filling toilet bowl. Also had
abdominal discomfort and mild nausea, no vomiting. Has had CP
for past few months, unchanged. Denies recent NSAID use. No F/C.
Has had a lower GI bleed previously in [**2107**], with colonoscopy
showing melanosis coli and grade 2 hemorrhoids. A previous upper
endoscopy performed for dyspepsia in [**2106**] was unrevealing.
.
In the ED, vitals were 96.7 103 207/84 16 100%RA. Had a clotty
red BM in the ED. 1st set of enzymes negative. CXR showed mild
congestion. She was given 2 SL nitroglycerin, 4 IV morphine, and
zofran. Her CP resolved after morphine and nitro x2, however she
became hypotensive to 80's 30 minutes following nitroglycerin.
Her BP subsequently responded to IVF. CT-A abdomen showed patent
vasculature no acute process. HCT at baseline (29.2). Ordered
for 2 units pRBCs in ED, got 1 of them in the ED. Access
obtained with 2 18-gauge peripherals. Most recent vitals 96.5 73
113/49 16 100% 3L.
Past Medical History:
Prior GIB while on aspirin
CAD s/p CABG [**15**]+ years ago
-- cardiac cath [**11-17**] showed patent LIMA and one SVG, with one
occluded SVG, diffuse disease of native vessels--> no
intervention
Hypertension
Dyslipidemia
Diabetes
Moderate Mitral Regurgitation
Moderate to severe tricuspid regurgitation
[**10-15**]-Right Rotator Cuff Surgery
GERD
Spinal Stenosis
Hysterectomy
Prior back surgery
Anemia
s/p cataract surgery
Social History:
She lives with her daughter. She denies use of tobacco or
alcohol,but smoked > 40 years ago. She is a retired [**Company 2676**]
technician. She is divorced with 5 children. She walks
unassisted.
Family History:
Denies any history of cancer, dm, htn.
Physical Exam:
T 96.5, BP 126/52, HR 83, RR 23, 100%3L
General: comfortable, no distress
HEENT: PERRL, EOMI
Neck No JVD
Pulm: Bibasilar crackles
CV: RRR, III/VI SEM
Abd +BS, soft, non-distended, mild tenderness LLQ. No
rebound/guarding
Extrem: no edema
Pertinent Results:
[**2109-1-25**] 09:30AM PT-13.8* PTT-34.0 INR(PT)-1.2*
[**2109-1-25**] 09:30AM PLT COUNT-243
[**2109-1-25**] 09:30AM NEUTS-64.7 LYMPHS-29.6 MONOS-4.0 EOS-1.6
BASOS-0.1
[**2109-1-25**] 09:30AM WBC-6.4 RBC-3.40* HGB-9.9* HCT-29.2* MCV-86
MCH-29.2 MCHC-34.0 RDW-14.1
[**2109-1-25**] 09:30AM CK-MB-NotDone cTropnT-<0.01
[**2109-1-25**] 09:30AM CK(CPK)-43
[**2109-1-25**] 09:30AM estGFR-Using this
[**2109-1-25**] 09:30AM GLUCOSE-190* UREA N-27* CREAT-1.0 SODIUM-139
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
[**2109-1-25**] 09:54AM LACTATE-1.3
[**2109-1-25**] 01:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2109-1-25**] 01:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2109-1-25**] 01:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.045*
[**2109-1-25**] 01:00PM URINE GR HOLD-HOLD
[**2109-1-25**] 01:00PM URINE HOURS-RANDOM
.
CXR ([**1-25**]): mild pulm edema, slightly improved from prior
.
CTA abdomen ([**1-25**]): 1. No acute process in the abdomen or
pelvis; specifically, no evidence of mesenteric ischemia. 2.
Stable hypodense lesion within the pancreatic body likely
represents a lipoma or interposed fat as this lesion is stable
from [**2106-12-3**] exam. If there is strong clinical concern, an MRCP
may be obtained. 3. Left renal hypodense cyst. 4. Colonic
diverticulosis, without evidence of diverticulitis. 5. Calcific
density at the pelvic floor, stable from [**2106**], likely represents
a stone within a urethral diverticulum.
.
Colonoscopy ([**1-28**]): Small internal hemorrhoids were noted. A
single diverticulum with small opening was seen in the sigmoid
colon. Diverticulosis appeared to be of mild severity. No old or
fresh blood was seen in the colon. Impression: Internal
hemorrhoids. Diverticulum in the sigmoid colon. No old or fresh
blood was seen in the colon. Otherwise normal colonoscopy to
cecum.
.
EGD ([**1-29**]): Duodenum: Normal duodenum. jejunum: Normal jejunum.
ileum: Not examined. Impression: Polyps in the pylorus.
Otherwise normal small bowel enteroscopy to proximal jejunum.
Brief Hospital Course:
Ms. [**Known lastname 1968**] is a 76F with DM, CAD, and h/o GIB who presents with
GIB and CP. She was admitted to the MICU for monitoring.
Hospital course is discussed below by problem:
.
1. Gastrointestinal bleed.
The history of BRBPR was more suggestive of a lower source. A
brisk upper bleed seemed less likely. Her baseline hct is 30,
and during this admission, it dropped to as low as 23.9. She had
small amounts of bright red blood in her stool, although nothing
to explain the 6 point hematocrit drop. A central line was
placed and she was transfused a total of 9 units PRBCs during
her six-day course in the unit. GI was consulted and performed
both upper endoscopy and colonoscopy, although no source of
active bleeding or old blood could be identified. The full
reports are provided above. She was started on IV proton-pump
inhibitor and her hematocrit stabilized in the low thirties on
the fifth hospital day, and remained stable with stable vital
signs. She was transferred to the floors on hospital day 6, and
her hematocrit followed twice daily. After transfer, she had no
more bloody bowel movements. Her Plavix has been held, and her
antihypertensives have also been held. She will follow-up in [**Hospital **]
clinic with Dr. [**First Name (STitle) 1356**] in one week.
.
2. Chest pain, coronary artery disease, history of CABG.
She has chronic chest pain, and is on 2 anti-anginal
medications. During this admission, she reported intermittent
episodes of angina. EKGs did not show acute changes and cardiac
enzymes were cycled and negative. Her ranolazine was continued
but her Imdur and SL nitros held for concern of precipitating
hypotension. She was transfused a total of 9 units PRBCs to keep
her hct above 25. As above, we have held her Plavix and
cardiovascular medicines at time of discharge given the recent
GI bleed. Her blood pressure has been well-controlled, despite
being off meds, with ranges in the 120s-140s/60-70s. She will
follow-up with her primary care where decision can be made
regarding resumption of her Plavix and CV meds.
.
3. Diabetes mellitus II.
We held her oral hypoglycemics and kept her on sliding scale
humalog insulin. She will resume her oral hypoglycemics after
discharge.
.
4. Hypertension.
As above, her metoprolol, Cozaar, Imdur and triamterene/HCTZ
were stopped in the setting of GI bleed. These can be resumed as
outpatient if her blood pressure warrants additional meds,
although during this admission her pressures have been
relatively well-controlled without.
.
5. Hyperlipidemia.
We continued her outpatient simvastatin.
.
Her diet was progressed as tolerated to diabetic, heart-healthy
diet. Pneumoboots were used for venous thrombosis prophylaxis.
Her code status is full code.
Medications on Admission:
Razolazine 500 [**Hospital1 **]
Plavix 75 daily
Omeprazole 20 daily
Simvastatin 20 daily
Triamterene/HCTZ 37.5/25 daily
Diltiazem ER 90mg [**Hospital1 **]
Metoprolol succinate 25 daily
Isosorbide mononitrate 120 daily
Losartan 100 daily
Glipizide 10 daily
Actos 30 daily
Insulin
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) 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. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
5. Pioglitazone 30 mg Tablet Sig: One (1) Tablet PO once a day.
6. Insulin Glargine 100 unit/mL Cartridge Subcutaneous
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Gastrointestinal bleed of undetermined origin
Acute blood loss anemia
.
Secondary Diagnoses
Coronary artery disease
Diabetes mellitus type II, uncontrolled with complications
Hypertension
Dyslipidemia
Gastroesophageal reflux
Discharge Condition:
Vital signs stable. Afebrile. Hematocrit stable.
Discharge Instructions:
You were hospitalized for treatment of gastrointestinal bleed.
You received nine transfusions of red blood cells. You also
underwent colonoscopy and upper endoscopy and we could not find
the source of the bleeding. Your red cell count has been stable
now for three days.
.
We have made the following changes to your medications:
1. We have held the Plavix.
2. We have held the triamterene/hydrochlorthiazide.
3. We have held the diltiazem.
4. We have held the metoprolol.
5. We have held the isosorbide mononitrate.
6. We have held the losartan.
Please do not restart these medicines until you follow-up with
your primary care provider.
.
Please note your follow-up appointments below: we have scheduled
appointments in [**Hospital **] clinic and primary care clinic.
.
Please call your doctor or return to the emergency room if you
notice any more bleeding, if you feel lightheaded or dizzy, or
if you develop any other symptoms that are concerning to you.
Followup Instructions:
1. Please schedule with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10273**], NP on next Wednesday,
[**2-6**] at 1:30PM at [**Hospital3 4262**] Group.
.
2. Please follow-up in [**Hospital **] clinic: Tuesday, [**2-5**] at 9:30
with Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) 1356**] at [**Last Name (NamePattern1) 439**] on the [**Location (un) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2109-2-5**] 9:30
.
3. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2109-2-18**] 11:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2109-1-31**]
|
[
"455.0",
"562.10",
"458.29",
"724.00",
"411.1",
"530.81",
"211.1",
"250.92",
"E942.4",
"V58.61",
"397.0",
"272.4",
"424.0",
"V45.81",
"578.1",
"790.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8331, 8337
|
4652, 7397
|
307, 345
|
8624, 8675
|
2477, 4629
|
9681, 10502
|
2163, 2203
|
7726, 8308
|
8358, 8603
|
7423, 7703
|
8699, 8999
|
2218, 2458
|
9028, 9658
|
239, 269
|
373, 1486
|
1508, 1933
|
1949, 2147
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,018
| 107,995
|
219
|
Discharge summary
|
report
|
Admission Date: [**2154-4-9**] Discharge Date: [**2154-4-18**]
Date of Birth: [**2084-12-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
BiPap
Intubation, extubation ([**2154-4-13**])
History of Present Illness:
69 year old male with history of HIV (CD4 116 [**2154-4-8**]), COPD
(2-4L at home), DVT on coumadin, hypertension, chronic lower
back [**Last Name (un) 2187**], osteoporosis who presents with respiratory distress.
The patient had been recently admitted 5/13-16/[**2153**] for COPD
exacerbation and treated with nebs, azithromycin, prednisone
(slow taper). The patient presented to the ED on [**2154-4-2**] for
dyspnea but left AMA before admission. He was sent to the ED on
[**2154-4-8**] but left AMA again, with prednisone and azithromycin
prescriptions which he never filled. He had seen Dr. [**Last Name (STitle) **] in
pulmonary clinic yesterday and had been non-compliant with
prednisone taper. He endorsed "exhaustion" at the appointment
but was stable 93% on 3.5L nasal cannula. The patient had also
been at [**Hospital **] Clinic with Dr. [**Last Name (STitle) 2185**] prior to Pulmonary
appointment.
.
The patient re-presented to the ED today with worsening dyspnea
and was brought in by EMS in respiratory distress (enroute CO2
50). He responded to nebulizers enroute and arrived looking very
uncomfortable, using accessory muscles. He was tight on
pulmonary exam with minimal breath sounds and speaking few word
sentences. The patient was started on BiPap (50%, PSV 15, PEEP
5), which he tolerated well. He was briefly weaned off to 4L NC
but decompensated, tripoding despite Methylprednisolone 125mg IV
X1, Azithromycin 500mg, more nebulizers and ativan 2mg IV.
.
ROS: Patient denies fevers/chills, nausea/vomiting, myalgias,
changes in bowel movement or urination.
Past Medical History:
* HIV (diagnosed [**2135**], s/p multiple HAART regimens, no history
of opportunistic infections, CD4 nadir [**2154-4-8**] 116)
* COPD (chornic O2 therapy at home 2-4L PRN, intubated recently
at [**Hospital6 **] and was DNR/DNI in the past)
* DVT (left lower extremity, [**2152-3-17**]; still on Coumadin therapy
- for sedentary lifestyle)
* h/o Rectal bleeding
* Chronic lower back pain s/p numerous back surgeries
* Hypertension
* Basilar aneurysm s/p clipping by Dr. [**Last Name (STitle) 1338**] ([**2134**])
* h/o substance abuse with cocaine
* Anemia of chronic disease
* Osteoporosis
* s/p ileocecetomy for ?cancer. SBO in [**2136**] with lysis of
adhesions
Social History:
Denies alcohol, smoking or illicit drugs (since [**2135**]). Previous
80 pack year smoker. Lives alone, uses wheelchair.
Family History:
Hypertension and throat cancer in brother (smoker)
Physical Exam:
Temp: 97.0 BP: 132/80 HR: 89 RR: 18 O2sat 100% on Bipap (15/5,
50%)
GEN: Pleasant, comfortable, NAD, mildly anorexic
HEENT: PERRL, EOMI, anicteric, MMM,
RESP: CTA b/l with good air movement throughout, ?prolonged
expiratory phase, barrel chested with increased AP diameter
CV: Regular rate, rhythm; S1 and S2 wnl, no murmurs/gallops/rubs
ABD: Nontender, nondistended, +BS, soft
EXT: No cyanosis/ecchymosis, [**11-18**]+ bilateral lower extremity
edema (symmetric)
SKIN: No rashes/no jaundice/no splinters
NEURO: AAOx3. CN 2-12 intact. Strength and sensation intact.
.
Discharge Exam:
No vitals (cmo)
Gen: Cachectic in NAD, no jaundice, no palor
HEENT: NCAT PERRL MMMs OP clear
Neck: No JVP elevation supple
Pulm: Very poor air movement wheezes throughout; no rhonci no
crackles
CV: RRR nml S1 S2 no m/r/g
Ab: +BS NTND
Ext: No edema
Neuro: Grossly intact AO x 3 responding appropriately to
questions
Pertinent Results:
[**2154-4-9**] 06:47PM O2-100 PO2-244* PCO2-53* PH-7.44 TOTAL
CO2-37* BASE XS-10 AADO2-426 REQ O2-73
[**2154-4-9**] 06:13PM LACTATE-1.9
.
CXR [**4-9**]:
Patchy opacity in left lung base, similar to the prior study,
which remains concerning for infection. Severe emphysema.
.
CXR [**4-13**]:
An endotracheal tube lies at the level of the
clavicular heads, appropriately positioned. A nasogastric tube
courses into the stomach. Severe emphysema is noted. The
cardiomediastinal silhouette is stable. There are small
bilateral pleural effusions. The left lower lobe opacity has
mildly improved and reflects resolving infection. No new focal
consolidation is appreciated.
.
Discharge Labs:
None
Brief Hospital Course:
69 year old male with history of HIV (CD4 116 [**2154-4-8**]), COPD
(2-4L at home), DVT on coumadin, hypertension, chronic lower
back [**Last Name (un) 2187**], osteoporosis who presents with respiratory distress.
.
# Respiratory Distress: Most likely due to ongoing COPD
exacerbation. Trigger unclear given lack of pneumonia on initial
CXR, no fevers/chills, productive cough. Patient has been
non-compliant with medications, however, since discharge; this
includes prednisone and antibiotics. ?compliance with nebulizers
and has supplemental O2 at home. The patient has had CTA
recently to rule out pulmonary emboli given ongoing dyspnea
despite therapy. He was treated with azithromycin for 5 days and
methylprednisolone. He intermittently required BiPap. A plan was
made to use bipap at night once the patient was able to leave
the ICU. However on the morning of [**4-13**] patient was anxious,
tachypneic and desatted and required intubation. The patient
was extubated on [**4-14**]. He did well overnight but subsequently
had further respiratory distress and his steroids were increased
to full burst. He ultimately decided to be DNR/DNI and came to
the understanding that he wasn't going to get better; the
patient decided to become CMO and was discharged to home hospice
after discussing with Palliative Care in-house.
- Continue long steroid taper at home (Prednisone 60mg X 7 days,
40mg X 7 days, 20 mg X7 days, 10mg X 7 days, off)
- Continue supplemental oxygen, albuterol and ipratropium nebs
- Continue MS contin and morphine liquid PRN for air hunger,
shortness of breath
- Continue lorazepam PRN for air hunger, shortness of breath,
anxiety
.
# HIV: Down trending CD4 count, ?due to acute illness. Continued
abacavir, lamivudine, fosamprenavir, and atazanavir. Continued
Bactrim SS daily. Patient does have history of Bactrim needing
to be held in [**10/2153**] for bone marrow suppression. The need for
ongoing HAART medication and PCP prophylaxis was discussed with
the patient. It was felt that he likely will not succumb to
HIV/AIDS or an opportunistic infection before he succumbs to his
end-stage COPD. However, taking these medications are not a
hardship for the patient and he would prefer not to risk
increasing HIV viral load and chance of opportunistic infection,
especially in the setting of ongoing steroids.
- The patient will be discharged home on hospice with
continuation of his HAART medications and Bactrim PCP
[**Name Initial (PRE) 1102**].
.
# DVT: LENI the day prior to admission as outpatient was
negative for DVT. Patient has been therapeutic and followed by
[**Hospital3 **] here at [**Company 191**]. He missed several doses of
Coumadin in the settting of being on Bipap and developed a
subtherapeutic INR. He was bridged with Lovenox. Anticoagulation
held [**4-13**] for concern for GIB but coumadin was resumed when hct
was stable for 24 hrs. Upon discharge home with hospice,
however, anticoagulation was discussed with the patient. As he
had a DVT in [**2152-3-17**] and ultimately completed treatment but was
continued given his sedentary/immobile nature, the indication
for ongoing anticoagulation and risk of DVT/PE is not high.
- Given this information, the patient chose to be discharged off
of coumadin. His primary care provider and the [**Name9 (PRE) 191**]
anticoagulation nurses were informed of his decision, and the
fact that he no longer needs INR checks.
.
#GIB: Patient noted to have guaic positive stool. T+S sent, PPI
started, PICC placed, transfused 1 unit of blood but did not
bump appropriately, so given 2nd unit. Hct then increased
appropriately and remained stable.
- PPI was stopped given the absence of frank melena on discharge
and to minimize medications for hospice.
.
# Multifocal atrial tachycardia: Seen in the ED during patient's
hospitalization [**2154-3-28**]. Patient was started on diltiazem in
this setting but did not have MAT last admission either. The
patient can continue on home diltiazem on discharge to prevent
discomfort from breakthrough tachycardia.
.
# Anemia: Slightly lower than baseline Hct close to 30.
Normocytic and previously thought due to chronic disease. HAART
medications may be contributing to marrow suppression. In
addition, pt noted to have guaic positive stools which are
discussed above.
.
# Hypertension: Stable, mildly hypertensive, continued [**Last Name (un) **]
diltiazem and doxazosin. -- doxazosin was stopped on discharge
for hospice to streamline medications.
.
# Osteoporosis: On Calcium and Vitamin D.
- These medications were stopped on discharge to streamline
medications.
.
# GERD: Admitted on famotidine. Stable, started on PPI as above
while intubated as famotidine can also interact with HIV
medications; also in setting of guaiac positive stools per
above.
- Famotidine was stopped on discharge to streamline medications.
.
# Other transitional issues:
- Continue home O2 as prescribed
- Oral suction as prescribed
- Maintain PICC with appropriate heparin flushes as a provision
for morphine infusion if patient's air hunger is refractory to
PO morphine elixir and he requires IV morphine
Medications on Admission:
* Atazanavir 400mg daily
* Fosamprenavir 1400mg twice daily
* Aspirin 325mg daily
* Abacavir 600mg daily
* Lamivudine 300mg daily
* Albuterol nebs every 2 hours PRN SOB, wheezing
* Ipratropium nebs every 6 hours
* Warfarin 3mg daily six times weekly, 2mg on Friday
* Doxazosin 2mg qHS
* Diltiazem 30mg three times daily
* Famotidine 20mg daily
* Bactrim 400-80 daily
Discharge Medications:
1. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
2. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
5. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours:
Standing.
Disp:*30 nebs* Refills:*2*
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for wheezing, shortness of breath.
10. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours): standing.
Disp:*30 nebs* Refills:*2*
11. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): x7days, 2 tablets daily X7d, 1 tab daily X 7d, half tab
daily X 7d, then off.
Disp:*46 Tablet(s)* Refills:*0*
12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for shortness of breath, air hungry, anxiety.
Disp:*60 Tablet(s)* Refills:*0*
13. MS Contin 15 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO every eight (8) hours.
Disp:*90 Tablet Extended Release(s)* Refills:*2*
14. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
Ten (10) mg PO q2h as needed for shortness of breath, air
hunger, pain.
Disp:*500 mL* Refills:*2*
15. Supplemental oxygen Sig: 1-5 liters once a day: via nasal
cannula, titrate to comfort PRN.
Disp:*1 tank* Refills:*2*
16. Admit to [**Hospital 2188**] Sig: One (1) once a day.
Disp:*1 unit* Refills:*2*
17. Maintain PICC at home
Maintain PICC at home with hospice for use with morphine
infusion if need for SOB, air hunger
18. heparin, porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 ML(s)* Refills:*2*
19. Oral suction
As needed for secretions
20. Supplemental Home Oxygen
Oxygen 5-10L as needed
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary: COPD exacerbation
Secondary: HIV, prior DVT on anticoagulation, chronic lower back
pain, anemia of chronic disease, osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with difficulty breathing. You were found to
be having a COPD exacerbation. You were treated with steroids
(oral and intravenous), antibiotics, nebulizers. You were also
put on a breathing machine called BiPap to make it easier for
you to breath. With your very sick lungs, you did become very
tired at one point, and were intubated to use a machine to help
you breath. Once you were extubated, we discussed your prognosis
and the severity of your condition with you. You made the
decision to change your code status to Do Not Resuscitate/Do Not
Intubate. The goals of your medical care was made for comfort.
.
You are being discharged home with hospice, who will oversee
your care going forward and address all of your symptoms with
the goal of making you comfortable.
.
It is important that you continue to take your medications as
directed. We made the following changes to your medications
during this admission:
--> Stop Coumadin and INR checks
--> Stop Aspirin
--> Stop Doxazosin
--> Stop Famotidine
--> Continue prednisone 60mg daily X 1 weeks, with a slow taper
--> Start Lorazepam as needed for shortness of breath, air
hunger, anxiety
--> Start MS Contin 30mg three times daily for air hunger
--> Start Morphine liquid 5-10mL every 2 hours as needed for air
hunger
--> Start Prednisone and take as directed according to the
prescribed taper
--> Continue Albuterol nebs every 4 hours standing
--> Continue Albuterol nebs every 2 hours as needed for
shortness of breath, wheeze
--> Continue Ipratropium nebs every 6 hours standing
.
Contact your hospice organization if you need help controlling
your symtoms.
Followup Instructions:
Please feel free to contact your hospice nurses and physicians
with any questions or concerns.
.
Also feel free to contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your new primary care
doctor, at [**Hospital3 **] at [**Telephone/Fax (1) 250**].
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2154-4-24**] at 10:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: WEDNESDAY [**2154-5-22**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"276.0",
"V58.61",
"V12.51",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
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] |
12305, 12356
|
4533, 9396
|
325, 374
|
12538, 12538
|
3815, 4488
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14374, 15296
|
2827, 2880
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10072, 12282
|
12377, 12517
|
9680, 10049
|
12714, 14351
|
4504, 4510
|
2895, 3464
|
3480, 3796
|
9417, 9654
|
265, 287
|
402, 1983
|
12553, 12690
|
2005, 2672
|
2688, 2811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,028
| 101,427
|
16706
|
Discharge summary
|
report
|
Admission Date: [**2163-1-17**] Discharge Date: [**2163-1-19**]
Date of Birth: [**2098-2-26**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
male with known ST elevation, MI, status post elective cath
complicated by hypotension and bradycardia who was
transferred to CCU for observation. The patient initially
presented to [**Hospital3 417**] Medical Center on [**2163-1-14**] with
chest pain radiating to the jaw. He was found to have
increased troponin of 1.76, was given Nitroglycerin and
remained pain free over the next three days at the outside
hospital on Aspirin, Plavix and Nitroglycerin prn. He was
then transferred to [**Hospital1 69**] for
elective catheterization on [**2163-1-17**]. The catheterization
showed double occlusion of PDA, no intervention was done.
The patient was transferred to post-op area where he became
hypotensive after continuous pressure to his groin was
applied in order to stop the bleeding from the femoral
artery. The patient was noticed to have groin hematoma and
angiocele was attempted. He was also given 40 mg of
Protamine in order to stop the bleeding. At this time he
became hypotensive. This was thought to be secondary to
vagal reflux. He was given IV fluids and Dopamine after
which he developed upper body pruritic rash. Because of the
concern for anaphylaxis secondary to dye Protamine, the
patient was given 120 mg of Solu-Medrol and Benadryl as well
as Promethazine and Pepcid. CT of the head and abdomen were
obtained in order to rule out retroperitoneal or head
bleeding. Both were negative. Vascular surgery was
consulted and the patient was transferred to the CCU.
PAST MEDICAL HISTORY: Significant for lung cancer. The
patient had left lung cancer in [**2147**] and right lung cancer in
[**2155**], both resected. He also had a brain metastasis thought
to be due to left lung cancer in [**2149**], prostatic cancer
diagnosed in [**2160**]. Also has a history of hypertension,
peripheral vascular disease and hypercholesterolemia.
ALLERGIES: No known drug allergies.
MEDICATIONS: On admission, Aspirin 325 mg, Lipitor 10 mg,
Lisinopril 20 mg, Serax [**11-14**] q 8 hours prn, Percocet 1-2
tabs q 4-6 hours, Dilantin extended release 400 mg q a.m.,
300 mg q p.m., Compazine prn, Simethicone prn, Lopressor 12.5
mg [**Hospital1 **].
SOCIAL HISTORY: The patient has a history of 30 pack year
smoking, quit in [**2162-2-26**], alcohol occasional use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Heart rate 64, blood pressure 141/65,
temperature 97.2, respirations 18, O2 saturation 98% on three
liters. General, no acute distress, somnolent, oriented
times two, oropharynx dry, mucosal membranes dry, sclera
anicteric. JVP at 6-7 cm of water. Regular rhythm and rate,
S1 and S2, no murmurs, rubs or gallops. Pulmonary exam clear
to auscultation anteriorly. Abdomen soft, nontender, non
distended. Extremities, moderate sized hematoma of the left
groin, dopplerable PT bilaterally and dorsal pedal pulse on
the right, foot only. Echocardiogram showed ejection
fraction more than 55% and basal inferior hypokinesis. White
cell count 10.2, hematocrit 39.5, platelet count 247,000,
sodium 137, potassium 3.9, chloride 106, CO2 19, BUN 15,
creatinine 0.6, glucose 166. ABG 7.26, 48, 113. EKG showed
ST elevations in V1 to V3, improved with Nitroglycerin.
Catheterization showed occluded left posterior descending
artery and non obstructive LAD with non dominant RCA.
HOSPITAL COURSE: The patient was admitted to the CCU for
observation and treatment of possible anaphylactic reaction.
Solu-Medrol and Nitro were continued over the next 24 hours.
The patient's mental status cleared the next morning. His
hematoma continued to ooze slowly and the patient was
transferred to the regular floor for observation of his
hematoma overnight. Duplex ultrasound of left femoral artery
was done and showed no evidence of pseudoaneurysm or an AV
fistula. Over the 24 hours prior to discharge his hematoma
remained stable with no symptoms or signs of bleeding. The
patient remained symptom free during his hospital stay. He
was discharged to home on [**2163-1-19**] in good condition on
cardiac diet, on the following medications.
DISCHARGE MEDICATIONS: Imdur 20 mg once a day, Dilantin 300
mg q p.m., 400 mg q a.m., Lopressor 12.5 mg [**Hospital1 **], Lisinopril
20 mg q d, Lipitor 10 mg q d, Aspirin 325 mg q d and
Nitroglycerin sublingual tablets prn. The patient is to
follow-up with his cardiologist, Dr. [**Last Name (STitle) 7047**] within 7 days
after discharge.
DISCHARGE DIAGNOSIS:
1. Myocardial infarction and profound vagal reaction.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**MD Number(1) 25755**]
Dictated By:[**Doctor Last Name 47224**]
MEDQUIST36
D: [**2163-1-19**] 10:52
T: [**2163-1-19**] 12:18
JOB#: [**Job Number 35439**]
|
[
"401.9",
"998.12",
"693.0",
"443.9",
"427.89",
"410.71",
"272.0",
"E934.5",
"995.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"37.22",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
2498, 2516
|
4299, 4618
|
4639, 4952
|
3535, 4275
|
2539, 3517
|
165, 1688
|
1711, 2363
|
2380, 2481
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,966
| 159,874
|
12749
|
Discharge summary
|
report
|
Admission Date: [**2161-11-9**] Discharge Date: [**2161-11-13**]
Date of Birth: [**2108-1-21**] Sex: M
Service: MEDICINE
Allergies:
adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 53 year old male with history of gastric bypass
and multiple other abdominal surgeries [**2-11**] nesidioblastosis
including pancreatectomy, splenectomy, gastrectomy and
thoracotomy, chronic TPN with indwelling PICC lines, cachexia,
multiple admissions to the intensive care units for PICC line
sepsis, and a recent fall from bed complicated by rib fractures
and hemothorax, which required chest tube drainage and
VATS/decortication for reaccumulation/loculation returns again
with fall from bed.
.
The patient reports an unwitnessed fall from bed on the day PTA,
and remained on the floor for approximately 20 hours. Notes that
when he woke up he had vomited, and he is concerned he may have
aspirated. He reports onset of 10 out of 10 sharp, pleuritic,
left-sided chest pain subsequent to the fall. Patient noted that
he did strike the left side of his face, left shoulder and elbow
with subsequent pain and decreased range of motion, left hip,
left knee, and left ankle. Patient remains able to ambulate but
is in excruciating pain. Thr patient's ROS is positive for
shortness of breath at rest, cough, nausea. He denies V/D,
seizure activity, neck pain, focal numbness or tingling,
dysuria, no abdominal pain, palpitations, lower back pain, GI
incontinence, or GU retention. He reports that the chest pain is
similar to the pain that the patient has had previously in the
setting of a hemopneumothorax from a fall with multiple rib
fractures.
In the ED, initial VS: 98 96 105/63 16 96%. Exam was significant
for superficial abrasion to nasal bridge with no septal
hematoma, pain with active and passive ROM over L
shoulder/elbow/hip/knee/ankle and normal neuro exam. Labs were
significant for WBC 42.2 (13% bands), CK 672, Cr 1.7 (baseline
1.0), initial lactate 7.3. FAST exam showed no e/o of PTX. L
shoulder/elbow/hip films and CT sinus showed no evidence of
fracture. CT Head showed no IC process. CXR showed likely large
LUL and moderate RUL opacity. Despite 2L IVF bolus in the ED,
MAPs remained 55-60, with SBP in 80s. There was attempted
placement of L subclavian, though they were unable to thread
wire. A RIJ was placed. The patient was started on levophed.
Repeat lactate was 2.9, ScV02: 64, CVP ranging [**8-19**] after total
5L NS. He made 100 cc urine/hour in the ED. He was given
vancomycin/zosyn X 1.
.
On arrival to the MICU,
.
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:
1. Roux-en-Y gastric bypass surgery with bile duct injury
complicated by stricture
2. S/P revision with total gastrectomy and
choledochojejunostomy.
3. S/P distal pancreatectomy, splenectomy, and ventral hernia
repair
4. Surgery for islet cell hyperplasia of the pancreas
5. MSSA endocarditis
6. recurrent line sepsis
7. circumferential abdominoplasty
8. hypoglycemia thought to be from nesidioblastosis
9. Osteomalacia [**2-11**] vitamin D deficiency
10. Vitamin B12 deficiency
11. Testosterone deficiency
12. Anemia of chronic disease
13. uvulectomy and tonsillectomy
14. lumbar spinal fusion at L4-L5
15. bilateral shoulder surgeries
16. right ankle fusion
17. hx of TB - treated with 4 drug therapy for 9 mo
18. ?eye infection - seen at MEEI and currently being treated
(needs clarification)
19. basilar migraines
Social History:
Denies IVDU, alcohol, or tobacco history. Worked as a CEO for
multiple companies until [**2152**]. Has an 17 yr old daughter and is
divorced.
Family History:
Significant for CAD in his father and a sister w/ SLE
Physical Exam:
Discharge PE:
Vitals: 97.4 115/80 61 18 95%RA
General: Thin man in NAD
HEENT: MMM
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: good air movement, clear b/l
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact, has some dyskinesia noted previously.
Pertinent Results:
Admission labs:
[**2161-11-8**] 10:15PM BLOOD WBC-42.2*# RBC-3.58* Hgb-10.1* Hct-34.0*
MCV-95 MCH-28.3 MCHC-29.7* RDW-15.9* Plt Ct-628*
[**2161-11-8**] 10:15PM BLOOD Neuts-82* Bands-13* Lymphs-1* Monos-3
Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2161-11-8**] 10:15PM BLOOD PT-14.2* PTT-31.2 INR(PT)-1.2*
[**2161-11-8**] 10:15PM BLOOD Glucose-247* UreaN-29* Creat-1.7* Na-134
K-5.2* Cl-101 HCO3-18* AnGap-20
[**2161-11-8**] 10:15PM BLOOD ALT-23 AST-34 CK(CPK)-672* AlkPhos-109
TotBili-0.4
[**2161-11-8**] 10:15PM BLOOD Calcium-8.7 Phos-4.0 Mg-1.6
[**2161-11-8**] 10:23PM BLOOD Lactate-7.3*
.
Immunoglobulins:
[**2161-11-12**] 06:10AM BLOOD IgG-1176 IgA-143 IgM-68
.
MICRO:
Blood cx [**2161-11-8**]: negative at time of discharge
[**11-10**]: C Diff positive by toxin (stool)
.
IMAGING:
TWO VIEWS OF THE CHEST [**2161-11-8**]:
The lungs are low in volume and show a new or substantially
worsening
heterogenous right upper lobe opacification and progression of
similart left upper lobe abnormality. Mediastinal fullness in
the right lower paratracheal region and bilateral hilar
enlargement have progressed since [**10-4**]. No pleural effusion or
pneumothorax is present.
IMPRESSION: Progressive bilateral pneumonia and concurrent
cardiac decompensation.
CT CHEST, [**2161-11-9**].
COMPARISON: Chest CTA study of [**2161-9-30**] and chest CT
of [**2161-9-29**]. Comparison is also made to chest
radiographs dating between [**2161-5-17**] and [**2161-11-9**].
TECHNIQUE: Volumetric, multidetector CT of the chest was
performed without
intravenous or oral contrast. Images are presented for display
in the axial plane at 5-mm and 1.25-mm collimation. A series of
multiplanar reformation images were also submitted for review.
FINDINGS: Since the prior chest CT of [**2161-9-30**], a left
hemothorax with loculated pneumothorax component has improved,
with resolution of blood contents and air contents. A residual
small, dependent left pleural effusion remains, with simple
fluid-attenuation characteristics. A small right pleural
effusion is also present and has slightly increased in size
since the prior study. Within the lungs, preexisting areas of
atelectasis in the left lower lobe adjacent to the pleural
effusion have improved, but extensive peribronchovascular
consolidation, more centrally in the left lower lobe is new.
Central consolidation in the left upper lobe and lingula has
progressed, and centrally distributed perihilar consolidation in
the right upper lobe is
mostly new. Basilar-predominant smoothly thickened interlobular
septa have
increased since the prior study. Scattered peribronchiolar
opacities in
superior segment right lower lobe are slightly improved compared
to the prior exam, and an area of opacity in the right middle
lobe on the prior exam has resolved. Although, the airways are
patent, note is made of mild narrowing and irregularity of the
lingular bronchus which in retrospect was present on the prior
study as well. The degree of narrowing, however, appears
improved compared to the earlier study of [**2161-9-29**].
Numerous subcentimeter mediastinal lymph nodes are largely
unchanged. There is likely bilateral hilar lymphadenopathy
present, difficult to measure in the absence of intravenous
contrast. Heart size is normal, and diffuse coronary artery
calcifications are present.
Exam was not specifically tailored to evaluate the
subdiaphragmatic region, but note is made of postoperative
changes in the upper abdomen and a persistent 4.2-cm diameter
fluid-density structure adjacent to the mid pole portion of the
left kidney, roughly similar in appearance to prior abdominal CT
scan, but incompletely imaged on this chest CT exam.
Healing lower left rib fractures are present at the
costovertebral junctions and possibly also at the L1 vertebral
body level. The thoracic fractures are at the T7 through T12
levels.
IMPRESSION:
1. Multifocal consolidations in both lungs, concerning for
multifocal
pneumonia. Coexisting pulmonary edema is likely, particularly in
the setting of smooth interlobular septal thickening with
basilar predominance.
2. Irregular narrowing of lingular bronchus, raising the
possibility of
intrinsic stenosis or extrinsic compression. Followup CT scan in
4 weeks
after completion of antibiotic therapy may be helpful to
document resolution of the pneumonia and to revaluate the
lingular bronchus. If interval chest radiographs fail to
demonstrate clearance of the consolidation, bronchoscopy may be
considered.
3. Improved left pleural effusion with residual small, simple
effusion
remaining. Slight increase in small right pleural effusion.
.
CXR:
[**11-12**]:
Marked improvement of pulmonary infiltrates during the last two
days examination interval. Remaining changes resemble those that
existed
previously when patient was treated for trauma and hemothorax.
The rather
extensive parenchymal infiltrates were identified on chest
examinations of
[**2161-11-8**], [**2161-11-9**], and [**2161-11-10**] and also documented on
chest CT of
[**2161-11-9**]. It is possible that this episode of extensive
infiltrates may
have been caused by aspiration, which however must have been
very massive
.
Discharge labs:
[**2161-11-13**] 05:55AM BLOOD WBC-13.5* RBC-3.70* Hgb-10.1* Hct-32.8*
MCV-89 MCH-27.2 MCHC-30.7* RDW-15.5 Plt Ct-715*
[**2161-11-11**] 07:00AM BLOOD PT-13.6* PTT-31.6 INR(PT)-1.2*
[**2161-11-12**] 06:10AM BLOOD Glucose-95 UreaN-8 Creat-1.0 Na-140 K-4.7
Cl-104 HCO3-28 AnGap-13
[**2161-11-11**] 07:00AM BLOOD Calcium-8.9 Phos-4.8*# Mg-1.9
[**2161-11-10**] 04:04AM BLOOD Lactate-1.7
Brief Hospital Course:
Summary: 53M history of gastric bypass and multiple other
abdominal surgeries, multiple admissions to the ICU for PICC
line sepsis, and a recent fall from bed complicated by rib
fractures and hemothorax admitted after a fall and subsequent
sepsis.
.
#. Sepsis: The patient was admitted with sepsis requiring IV
antibiotics and 12 hours of pressors in the ICU. He was
stabilized and transferred to the floor. He improved markedly,
with stable vitals and no O2 requirement by the time he was
transferred, approximately 24 hours after admission. It was
felt that the most likely source was pneumonia seen on CT. A
repeat CXR several days after admission showed marked
improvement in infiltrates seen initially. After an infectious
disease consult, it was decided to narrow antibiotics to 7d of
levofloxacin, and he was discharged after remaining afebrile for
24 hours on PO levo and flagyl. The flagyl was added after
stool was positive for C. Diff, though the patient was not
having loose stool or signs of megacolon.
.
# Thrombocytosis: His plt count trended up this admission.
Previous admissions had documented plt levels of nearly 1.5
million. On this admission, plts were below 800, and it was
felt that this was reactive thrombocytosis (similar to previous
admissions).
.
The remainder of his multiple medical conditions remained stable
during this admission, and his outpatient regimen was continued.
.
==
Transitional issues:
.
# Antibiotics: Will complete 7d course of levofloxacin, and 14
day course of flagyl for pna and c diff colitis respectively.
.
# Serum immunoglobulins were checked, and were within normal
limits.
.
# F/u CT: A CT scan done this admission suggested a follow-up
scan in ~1 month to assess for interval change. However, a
repeat CXR done several days later showed marked resolution in
the infiltrates, so it may be that this repeat scan is
unnecessary.
.
#) Vitamin D: The patient is currently taking Calcium
citrate-vitamin D3 as well as ergocalciferol. He noted this was
his outpatient regimen, so it was continued on discharge,
however may need follow-up as to whether it is necessary.
.
# Psychosocial issues: The patient has had a marked decline in
nutrition and weight over the past year. It is very possible
that underlying his extensive medical disease is an eating
disorder. This merits exploration, and it may be beneficial on
potential future admissions to have a nutrition consult and
strict calorie counts immediately upon admission, to monitor for
the presence of an eating disorder.
Medications on Admission:
1. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a
day).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
3. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) injection Injection once a month.
4. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
5. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO EVERY OTHER DAY (Every Other Day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed
Release(E.C.) PO three times a day.
9. lithium carbonate 450 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QHS (once a day (at bedtime)).
10. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
11. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig:
Three (3) Tablet Extended Rel 24 hr PO once a day.
12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for headache.
13. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO twice a day.
14. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
16. zonisamide 100 mg Capsule Sig: Three (3) Capsule PO at
bedtime.
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for Constipation.
21. thiamine HCl 250 mg Tablet Sig: One (1) Tablet PO once a
day.
22. calcium citrate-vitamin D3 315-250 mg-unit Tablet Sig: Three
(3) Tablet PO twice a day.
23. Centrum Silver Tablet Sig: Two (2) Tablet PO once a day.
24. vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.
25. Pro-Stat 101 15-101 gram-kcal/30 mL Liquid Sig: Thirty (30)
mL PO Three Times a Day with Meals.
Disp:*QS 1 month supply* Refills:*2*
26. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 1
months.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
27. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 1 weeks: Do not drink alcohol or operate
heavy machinery while on this medication. .
Disp:*QS 1 week supply* Refills:*0*
Discharge Medications:
1. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: One (1) Capsule, Ext Release 24 hr PO BID (2 times a
day).
2. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) Injection
once a month.
4. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
5. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO every other day.
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed
Release(E.C.) PO three times a day.
8. lithium carbonate 450 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QHS (once a day (at bedtime)).
9. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
10. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for headache.
12. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
13. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
19. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. calcium citrate-vitamin D3 315-250 mg-unit Tablet Sig: Three
(3) Tablet PO twice a day.
21. Centrum Silver Tablet Sig: Two (2) Tablet PO once a day.
22. Pro-Stat 101 15-101 gram-kcal/30 mL Liquid Sig: Thirty (30)
ml PO three times a day: With meals.
23. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
24. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 13 days.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
primary healthcare specialties
Discharge Diagnosis:
Pneumonia
Clostridium Difficile Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 39278**],
It was a pleasure seeing you again. You were admitted for an
infection, that required IV antibiotics in the ICU. You rapidly
improved, and were transferred to the floor. It is likely you
had a pneumonia, and a c diff infection (a bacteria in the
bowels, that usually happens when people are treated with
multiple antibiotics). This is a relatively common infection in
hospitalized patients, and it should improve quickly with the
antibiotic flagyl.
.
After speaking with your primary care doctor and the infectious
disease experts, it was decided that oral antibiotics are the
best choice. You should finish a 7 day total course of
levofloxacin, and a 14 day total course of flagyl. We have not
changed any of your other medications.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2161-11-18**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**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
Completed by:[**2161-11-13**]
|
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"300.00",
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"038.9",
"924.8",
"V45.4",
"314.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
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]
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17895, 17956
|
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354, 361
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389, 2756
|
4746, 9904
|
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|
3245, 4065
|
4081, 4225
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,988
| 181,254
|
38061+58189+58190
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2150-8-3**] Discharge Date: [**2150-8-7**]
Date of Birth: [**2071-10-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Ciprofloxacin / Iodine / Macrobid / Procaine Hcl / Keflex /
Flagyl / Penicillins / Bactrim / Doxycycline / Aspirin
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
Right craniotomy for SDH evacuation
History of Present Illness:
This is a 78 year old female transferred via med flight from
OSH, s/p fall from standing at approx 1600 this afternoon.
Witnesses say she tripped on the grass and fell back hitting her
head. No LOC. Taken to an OSH where she grew increasingly
combative. Head demonstrated large R SDH. She was intubated for
agitation, given 2 U FFP, 10mg Vit K, and transferred to [**Hospital1 18**].
Upon arrival she is intubated and sedated on propofol.
Past Medical History:
- Pulmonary Embolism ([**6-6**])
- Dysuria
- Diarrhea
- Orthostatic Hypotension
- Syncope
- Hypokalemia
- Tachycardia
- Leg edema
- Left ankle injury
- Left malignant lung lesion (Stage III NSCLC)
- s/p lobectomy LUL [**1-7**], chemo and XRT [**4-6**]
- Actinic Keratosis
- Irregular Heart Rate
- Vit D deficiency
- DM Type II
- GERD
- AAA (4.2 cm, followed by Dr. [**Last Name (STitle) 19141**]
- s/p hysterectomy
- s/p Chole
- s/p appendectomy
- Hyperlipidemia
- Hyperthyroidism
- Depression
- Insomnia
- HTN
- Fatty Liver Disease
- BBB
- Renal Cyst
- Hearing Deficit
- Diabetic Neuropathy
- Chronic Venous Insuffciency
- CVA
- Varicose Veins
- Diverticulosis
- ? NASH
- Smoker until [**1-7**]
Allergies:
Macrobid
Procaine
Keflex
Flagyl
PCN
Bactrim
Doxycycline
ASA
Cipro
Other Care:
[**Hospital 84984**] [**Hospital **] Homecare
[**Hospital1 2025**] Cancer Care
Social History:
Lives alone, Daughter lives next door. Diagnosed with depression
after loss of Husband 6 years ago. Previous smoker, quit [**1-7**].
No regular ETOH. Retired secretary/homemaker. Four adult
children.
Physical Exam:
On admission:
PHYSICAL EXAM:
O: T: 97.3 BP: 153/78 HR: 78 R:16 O2Sats: 100%
Gen: Intubated.
HEENT:NC, AT Pupils: PERRLA EOMs n/a
Neck: In C-Collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated. No commands.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally.
IX, X: Gag reflex present
Motor: When off Propofol, Moves all extremities equally and
purposefully.
Upon Discharge:
Mental status does intermittently change. At best she is AOx3,
interactive, verbal, speech is somewhat garbled, L pronator,
left sided weakness. PERRL, left facial droop.
When confused she is AOx1-2 (person, place), needs cues for
commands
Incision C/D/I
Pertinent Results:
Head CT [**2150-8-3**]:
Large bilateral subdural hematomas with approximately 7-mm
leftward midline shift and right uncal herniation.
Cspine CT [**2150-8-3**]:
No fracture or malalignment noted.
Abd/Pelvic CT [**2150-8-3**]:
No evidence of acute intra-abdominal process.
Diffuse osteopenia without acute fracture evident.
Abdominal aortic aneurysm, measurnig up to 4.8 cm in diameter.
Diverticulosis.
Head CT [**2150-8-4**]:
s/p right subdural hematoma evacuation with partially improved
mass effect
and leftward shift of midline structures.
Unchanged extensive left subdural hematoma.
The posterior aspect of the right craniotomy flap is depressed
by 2.5 mm
relative to the remainder of the parietal bone.
Head CT [**2150-8-5**]:
Continued improvement, with post-operative appearance and
decreased size of bilateral subdural collections and
post-surgical pneumocephalus.
BLE Ultrasound [**2150-8-5**]:
No DVTs
Head CT [**2150-8-7**]:
Stable appearance of R SDH, L SDH, and SAH. 5mm midline shift.
Brief Hospital Course:
78F admitted after sustaining a fall, a Head CT showed bilateral
subdural hematomas and subarachnoid blood. She was emergently
taken to the OR for a right craniotomy for evacuation of the
right subdural hematoma on [**2150-8-3**]. She remained in the ICU
overnight and was extubated on [**2150-8-4**]. She required Labetolol
and Lopressor IV to maintain her SBP < 160 and manage her
tachycardia.
On [**8-5**] she remained tachycardiac, it was unclear as to what her
past medical history was and her home meds. We received her
medical records from [**Hospital **] Hospital and the necessary changes
were made. Bilateral lower extremity ultrasound was done to
screen for DVTs which was negative. She was also noted to have
UOP of 200-300 cc per hour, urine lytes were normal but her
serum NA was 131. Patient failed a bedside swallow evaluation
and a NG tube was placed and she was made NPO.
On [**8-5**] her head CT and exam remained stable and she was
transferred to the Step Down Unit. On [**8-6**] her exam improved and
a repeat swallow evaluation was done and patient was cleared for
ground solids and nectar thick liquids. Her NG tube was
discontinued. Foley was discontinued and a UA was negative. Pt
was able to void post-removal. Physical and Occupational therapy
evaluated the patient and recommended acute rehab. Geriatrics
was consulted to help manage multiple medical issues which have
been controlled with current regimen.
On [**8-7**] AM, pt was more confused and required cues for commands.
A Head CT was done which remained stable. In the afternoon she
was alert and oriented and more interactive.
She was discharged to [**Hospital6 **] in [**Location (un) 4047**].
Medications on Admission:
Paxil 20mg Daily
Methimazole 5mg Daily
Ativan 1mg TID PRN
Klor-Con 40 CR- Daily
Coumadin
MAG-DELAY 535 (64 mg) [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Methimazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day).
4. Morphine Sulfate 1 mg IV Q4H:PRN Pain
5. Metoprolol Tartrate 5 mg IV Q6H:PRN SBP>160
Hold for HR < 60
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
9. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for agitation.
12. Potassium Chloride 20 mEq Packet Sig: Two (2) packets PO
DAILY (Daily): Hold for K > 5.
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for Pain.
17. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
19. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
20. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
21. Insulin Regular Human 100 unit/mL Solution Sig: Two (2)
units Injection ASDIR (AS DIRECTED): Sliding Scale.
22. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
Discharge Diagnosis:
Bilateral SDH
SAH
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:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, you will need approval from
your Neurosurgeon prior to starting.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 548**] in 4 weeks with a Head CT w/o
contrast. Please call [**Doctor First Name **] at [**Telephone/Fax (1) 2992**] to make this
appointment.
You will also need to have your staples removed 10 days
post-operatively. Please call [**Telephone/Fax (1) 2992**] to make this
appointment.
Completed by:[**2150-8-7**] Name: [**Known lastname 13495**],[**Known firstname 13496**] Unit No: [**Numeric Identifier 13497**]
Admission Date: [**2150-8-3**] Discharge Date: [**2150-8-7**]
Date of Birth: [**2071-10-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Ciprofloxacin / Iodine / Macrobid / Procaine Hcl / Keflex /
Flagyl / Penicillins / Bactrim / Doxycycline / Aspirin
Attending:[**First Name3 (LF) 2427**]
Addendum:
Lab values added
Pertinent Results:
[**2150-8-7**] 05:20AM BLOOD Glucose-90 UreaN-9 Creat-0.4 Na-131*
K-5.9* Cl-103 HCO3-22 AnGap-12
[**2150-8-6**] 03:32PM BLOOD Glucose-78 UreaN-17 Creat-0.6 Na-131*
K-4.2 Cl-98 HCO3-22 AnGap-15
[**2150-8-6**] 06:29AM BLOOD Glucose-110* UreaN-12 Creat-0.5 Na-131*
K-3.8 Cl-98 HCO3-25 AnGap-12
[**2150-8-5**] 01:17PM BLOOD Glucose-133* UreaN-10 Creat-0.6 Na-131*
K-3.3 Cl-94* HCO3-27 AnGap-13
[**2150-8-5**] 01:25AM BLOOD ALT-19 AST-18
[**2150-8-7**] 05:20AM BLOOD Albumin-3.2* Calcium-7.6* Phos-2.1*
Mg-1.1*
[**2150-8-6**] 03:32PM BLOOD Calcium-8.8 Phos-2.7 Mg-1.9
[**2150-8-6**] 06:29AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.1*
[**2150-8-5**] 01:17PM BLOOD Calcium-8.7 Phos-2.3* Mg-1.2*
[**2150-8-7**] 05:20AM BLOOD Phenyto-6.6* (corrected 15.7)
[**2150-8-6**] 06:29AM BLOOD Phenyto-10.0
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**]
Completed by:[**2150-8-7**] Name: [**Known lastname 13495**],[**Known firstname 13496**] Unit No: [**Numeric Identifier 13497**]
Admission Date: [**2150-8-3**] Discharge Date: [**2150-8-7**]
Date of Birth: [**2071-10-3**] Sex: F
Service: NEUROSURGERY
Allergies:
Ciprofloxacin / Iodine / Macrobid / Procaine Hcl / Keflex /
Flagyl / Penicillins / Bactrim / Doxycycline / Aspirin
Attending:[**First Name3 (LF) 2427**]
Addendum:
CT Head [**2150-8-3**]:
IMPRESSION: Large bilateral subdural hematomas with
approximately 7-mm leftward midline shift and right uncal
herniation.
The finding of a R uncal herniation is significant as it
indicates compression and the need for surgery to evacuate the
hematomas thus decompressing the brain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**]
Completed by:[**2150-9-14**]
|
[
"268.9",
"293.0",
"454.9",
"V58.61",
"852.21",
"V12.51",
"852.01",
"311",
"348.4",
"250.60",
"272.4",
"702.0",
"244.9",
"530.81",
"253.6",
"780.52",
"357.2",
"V10.11",
"441.4",
"785.0",
"E885.9",
"401.9",
"459.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
12318, 12518
|
3791, 5478
|
386, 424
|
7585, 7585
|
10526, 11309
|
9672, 10507
|
5657, 7457
|
7544, 7564
|
5504, 5634
|
7763, 9649
|
2047, 2227
|
338, 348
|
2486, 2743
|
452, 895
|
2283, 2470
|
2032, 2032
|
7600, 7739
|
917, 1785
|
1801, 2003
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,004
| 122,941
|
25497
|
Discharge summary
|
report
|
Admission Date: [**2154-7-5**] Discharge Date: [**2154-7-11**]
Date of Birth: [**2134-10-29**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
unrestrained rollover MVC
Major Surgical or Invasive Procedure:
1. Intramedullary fixation L femur shaft
2. L globe exploration/repair
3. L 1st metatarsal percutaneous pinning
4. L metatarsal ORIF
5. L scalp avulsion repair
6. Bilateral chest tube thoracostomy
History of Present Illness:
The patient is a 19 yo transferred to [**Hospital1 **] ED via [**Location (un) **] from
outside hospital after a ?speed rollover MVC. The patient was
unrestrained, and found unresponsive in the back seat of his
automobile. Injuries noted at the scene included L scalp
avulsion, Left lower extremity deformity. At the scene needle
decompression of L chest was performed, followed by L chest tube
placement. Upon arrival to the outside hospital, the patient was
responsive. Plain films showed L femoral shaft and L tib-fib
fractures. Prior to transfer, the patient became agitated and
was intubated to facilitate transfer. Of note, the patient had a
blood alcohol level of 152 on arrival.
Past Medical History:
asthma
Social History:
Occasional EtOH, denies tobacco/illicit substance
Family History:
Noncontributory
Physical Exam:
HR 110 BP 110/palp
GENERAL: sedated, intubated
HEENT - blown L pupil, R pupil 2mm and reactive. Large L
frontoparietal scalp avulsion with skull defotmity, 5 cm R scalp
avulsion
CHEST- CTA bilateral, L chest tube in place
CV - S1S2, RRR
ABDOMEN - soft, nondistended, normal rectal tone, heme negative
EXTR - L anterior mid shin laceration, L leg deformity with
pedal swelling
BACK - no spinal stepoffs
NEURO - moves upper extremities bilaterally, R lower extremity
Pertinent Results:
[**2154-7-5**] 07:25AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2154-7-5**] 07:25AM FIBRINOGE-258
[**2154-7-5**] 07:25AM PT-13.9* PTT-23.7 INR(PT)-1.3
[**2154-7-5**] 07:25AM PLT COUNT-377
[**2154-7-5**] 07:25AM WBC-21.2* RBC-4.33* HGB-13.3* HCT-37.2*
MCV-86 MCH-30.8 MCHC-35.8* RDW-11.9
[**2154-7-5**] 07:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2154-7-5**] 07:25AM ASA-NEG ETHANOL-152* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-7-5**] 07:25AM AMYLASE-73
[**2154-7-5**] 07:25AM UREA N-21* CREAT-1.2
[**2154-7-5**] 07:42AM GLUCOSE-128* LACTATE-4.6* NA+-147 K+-3.8
CL--106 TCO2-25
[**2154-7-5**] 07:54AM freeCa-0.90*
[**2154-7-5**] 07:54AM HGB-10.4* calcHCT-31 O2 SAT-99 CARBOXYHB-1
MET HGB-1
[**2154-7-5**] 07:54AM GLUCOSE-118* LACTATE-4.7* NA+-143 K+-3.2*
CL--114*
[**2154-7-5**] 07:54AM TYPE-ART PO2-454* PCO2-42 PH-7.19* TOTAL
CO2-17* BASE XS--11
Brief Hospital Course:
With the patient's multiple traumatic injuries, he was managed
by several consulting services. In general, the patient did
well. He was extubated, transferred to the floor and tolerating
a po diet on HD#3.
L SCALP AVULSION : The patient's scalp avulsion was repaired by
plastic surgery at the bedside in the ICU, with vigorous
debridement and washout prior to closure. The wound dressing was
changed daily with xeroform, and the patient had a short course
of prophylactic antibiotics while in the hospital.
MULTIPLE L ORBIT/GLOBE INJURIES- Ophthomology was consulted to
evaluate the patient's orbital trauma. The patient was deemed to
have a poor prognosis of visual function in this eye. He was
operated on by ophthomology on HD#1 during orthopedic repair of
his femoral shaft fracture. Exploration and repair of the globe
was performed. Repair of extensive orbital blow out fractures
was deferred until patient is more medically stable and had
decreased surrounding tissue edema, possibly as an outpatient.
Postoperatively, the patient was treated with IV antibiotics,
topical erythromycin ointment, and an eyeshield. His vision in
this eye had not changed as of discharge. Enucleation of the L
globe was considered and discussed with the family, with the
goal of preventing sympathetic opthalmia. However, in
consultation with the plastic surgery team, this was deferred as
it would likely make ORIF of his facial bone fractures more
difficult. He will follow up with ophthomology 1-2 weeks post
discharge to evaluate for repair of bony fracture.
BILATERAL PNEUMOTHORAX/PULMONARY CONTUSIONS/PNEUMOMEDIASTINUM -
The patient arrived with a L chest tube in place, and a R chest
tube was placed emergently in the T/SICU on HD#1. By HD#5, the
pneumothoraces had resolved, and the chest tubes were
discontinued. Thoracic surgery was consulted re: the patient's
pneumomediasinum, and per their reccomendations, fiberoptic
bronchoscopy was performed, showing no airway disruption. The
patient's respiratory status post-extubation was uneventful.
LEFT LOWER EXTREMITY FRACTURES: Orthopedics took the patient to
the OR on HD#1, where he had intramedullary fixation of his L
femur, debridement/washout of his L tibial fracture, and
percutaneous pin fixation of his L lisfrank fracture. The
patient tolerated these procedures well. Definitive operative
fixation of his metatarsal fractures was deferred for this
hospitalization. The patient will follow up 5d post discharge
with orthopedics for scheduling of repair.
C7/T1 VERTEBRAL FACET FRACTURES - The spine service managed the
patient's traumatic vertebral fractures. An spinal MRI was
performed which ruled out significant soft tissue injury to the
spinal cord or surrounding structures. The patient was
maintained on a cervical collar at all times for his fractures,
and operative management was deferred.
L SCAPULAR FRACTURE, RIGHT CLAVICULAR/1ST RIB FRACTURE - These
nonoperative injuries were managed conservatively throughout the
hospital stay. The patient has a sling on his R arm and will
require outpatient follow up of these injuries.
Medications on Admission:
None
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*3*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
3. 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:*0*
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
Disp:*1 bottle* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Erythromycin 5 mg/g Ointment Sig: 0.5 inch ribbon Ophthalmic
Q4H (every 4 hours): Alternate with Lacrilube Q 2 hours.
Disp:*1 tube* Refills:*2*
7. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic Q2H (every 2 hours): Apply to both eyes. .
Disp:*1 tube* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
S/P ROLLOVER MVC
1. L scalp avulsion, s/p operative repair
2. L globe rupture s/p operative repair
3. L retro-orbital and vitreous hemorrhage
4. L orbital blow out fracture (all walls)
5. L globe hyphema
6. L ocular lens subluxation
7. C7/T1 facet fracture
8. L scapular fracture
9. R distal clavicular fracture, displaced
10. R 1st rib fracture
11. L femoral shaft fracture, s/p ORIF
12. L tibial cortical defect
13. L metatarsal fractures (1,3,4,5) s/p repair
14. Bilateral pneumothorax, s/p chest tube
15. pneumomediastinum
16. Bilateral pulmonary contusions
Discharge Condition:
stable.
Discharge Instructions:
You may not bear weight on your left leg until you follow up
with orthopedics.
Continue to apply xeroform dressing changes to your scalp wound
2x daily.
Keep your eye shield in place. Apply topical ointments as
directed by ophthomology.
Wear your sling as prescribed. Follow PT reccomendations
regarding range of motion excercises and strength training for
your injuries.
You must wear your cervical collar at all times.
Followup Instructions:
Where: [**Hospital6 29**] ORTHOPEDICS Phone:[**Telephone/Fax (1) 5499**]
Date/Time:[**2154-7-16**] 8:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2154-7-16**] 8:40
You will need to follow up with ophthomology. Call today (([**Telephone/Fax (1) 7572**]) to schedule a follow up appointment.
You will need to follow up with Dr. [**Last Name (STitle) 363**] for your spinal
fractures. Call ([**Telephone/Fax (1) 11061**] to arrange for follow up.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"E816.0",
"805.07",
"871.2",
"285.9",
"873.42",
"873.0",
"802.6",
"825.25",
"821.01",
"958.7",
"518.5",
"801.02",
"379.23",
"921.3",
"802.4",
"823.90",
"860.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.58",
"45.13",
"38.93",
"34.04",
"99.04",
"38.91",
"33.22",
"86.22",
"16.82",
"79.66",
"96.71",
"79.15"
] |
icd9pcs
|
[
[
[]
]
] |
7039, 7086
|
2875, 5972
|
293, 492
|
7693, 7702
|
1841, 2852
|
8175, 8882
|
1322, 1339
|
6027, 7016
|
7107, 7672
|
5998, 6004
|
7726, 8152
|
1354, 1822
|
228, 255
|
520, 1209
|
1231, 1239
|
1255, 1306
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
212
| 189,635
|
1191
|
Discharge summary
|
report
|
Admission Date: [**2189-11-7**] Discharge Date: [**2189-11-10**]
Date of Birth: [**2127-3-5**] Sex: M
Service: NEUROLOGY
Allergies:
Amiodarone / Quinidine Gluconate / Pronestyl
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
ICH
Major Surgical or Invasive Procedure:
MRI/MRA
Echo
History of Present Illness:
HPI: 62yo RH M h/o HTN, Afib on coumadin, CAD s/p PTCA x 2 in
[**2178**] who was in USOH today when he began to have a mild
right-sided headache around noon, a/w some photophobia and
nausea. He was sitting at the computer half an hour later when
he
got up to go to [**Company 7546**] and noticed that his L foot was numb
and "wobbly". The foot felt weak, "like it was asleep". He
walked
but was tripping and went to get a banana, thinking that he
needed to eat something. He took his pulse which was regular and
went to drive to [**Company 7546**]. While driving though, he felt
confused and turned around. When he got home, he called his
daughter and asked her if his speech was slurred, thinking he
may
be having a stroke. It was not and he had no difficulty speaking
or comprehending what she was saying. She called 911 to get him
checked out and he was brought to an OSH.
There, the family noticed an increasing left facial droop. His
ankle felt better. Head CT showed an ICH and INR was 2.89 and
the
patient was given 3U FFP, vit K 5mg IM, labetalol 10mg IV x 1
and
dilantin 1g IV was started but d/c'd due to hypotension. The
patient was then transferred here.
At this point, the patient's only deficit, in addition to the
persistent L facial droop, is some numbness in his left hand
(all
five "tingling").
He has had no palpitations (has been in NSR since [**Month (only) 205**]), no
light-headedness. No neck pain. No diplopia or dysarthria or
dysphagia. He no longer feels disoriented.
He has had no LOC or convulsions and has smelled no bad odors.
No
visual symptoms or anything else out of the ordinary.
In our ED, he was seen by neurosurgery and neurosurgical
intervention deferred. He received proplex x 2 vials and FFP 2U.
Past Medical History:
As above, plus prostate CA s/p resection in [**2187**] (no further rx)
Social History:
works as plumber, quit smoking 30yrs ago after 15ppyr
history, no other drugs. Only occasional etoh.
Family History:
father died of MI at age 50, Mother alive and well 101
Physical Exam:
98.0 78 154/76 16 94%ra
Gen NAD, lying in bed, pleasant
CV RRR
Pulm ctab
Abd obese, nt/nd +bs
Ext no edema
NEURO
MS Awake, alert, fully oriented. [**Doctor Last Name 1841**] backwards, DSF 6. Language
fluent no errors, naming intact, reads no errors and repeats.
Neglects the left side of the cookie jar picture, even to
prompting. Bisects a line on the right. No apraxia. No
dysarthria.
CN
CN I: deferred
CN II: normal visual acuity, VFF no extinction. Pupils 4->2mm
b/l
and equal.
CN III,IV,VI: EOM full in all directions, no diplopia. Gaze
conjugate no deviation
CN V: intact to PP, LT both sides, no extinction
CN VII: L lower face is asymmetrical, droops with smile as well.
Eye closure [**6-12**]
CN VIII: hearing intact b/l, no nystagmus
CN IX,X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**6-12**]
CN XII: tongue midline, agile
Motor
No pronator drift, normal tone and bulk
D B T WE FE FF IP Q H DF PF
L 5 5 5 5 5 5 5 5 4+ 5 5
Sensory
Intact to LT, PP, JPS, vibration b/l. +extinction to LT in LE's,
none in UEs. Graphesthesia intact in both hands.
Coordination: ftn intact b/l, hts as well
Gait: deferred
Reflexes: 2+ throughout, toes up on L, down on R
Pertinent Results:
Labs
WBC 9.1, hct 38.7, plt 145
INR 1.8
SMA unremarkable (except for K 5.5 but hemolyzed)
EKG sinus rhythm
[**2189-11-7**] 11:19PM PT-14.1* INR(PT)-1.2*
[**2189-11-7**] 05:59PM GLUCOSE-107* UREA N-13 CREAT-1.1 SODIUM-136
POTASSIUM-5.5* CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
[**2189-11-7**] 05:59PM WBC-9.1 RBC-4.44* HGB-14.2# HCT-38.7* MCV-87
MCH-32.0 MCHC-36.8* RDW-14.1
NCHCT: There is a 2.7 x 1.6 cm focus of intraparenchymal
hemorrhage within the right thalamus, with subjacent edema,
and mass effect on the third ventricle. There is no shift of
normally midline structures. No other foci of intracranial
hemorrhage are identified. The ventricles are normal in
caliber.
The soft tissue and osseous structures are within normal limits.
The basal and ambient cisterns are not effaced.
Repeat MCHCT: No significant change in right thalamic
intraparenchymal hemorrhage compared to yesterday's study.
Brief Hospital Course:
Mr [**Known lastname 7547**] had no further events involving numbness/tingling while
in the hospital. Had a right thalamic intraparenchymal
hemorrhage on CT. At the outside hospital received 3U FFP, vit
K 5mg IM, labetalol 10mg IV x 1. INR had corrected to 1.8 by
the time of transfer to [**Hospital1 18**] and was given additional FFP.
Coumadin held during admission.
Seen by neurosurgery but no surgical intervention recommended.
Was reevaluated with f/u CT the next day which showed no
progression or sign of hydrocephalus.
Was at baseline at time of discharge and evaluated by PT/OT who
felt the patient was safe to go home.
Was discharged home with instructions to f/u with PCP and
neurology. Coumadin to be restarted at a later date given risk
of rehemorrhage.
Medications on Admission:
Coumadin 3mg po qhs
ASA 81
Zetia 10
Toprol XL 100mg po daily
MVI
Omega 3
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Outpatient Physical Therapy
3 sessions per week.
6. Outpatient Occupational Therapy
3 sessions per week
Discharge Disposition:
Home
Discharge Diagnosis:
Right thalamic cerebral hemorrhage
atrial fibrillation
high blood pressure
Discharge Condition:
stable, with mild sensory loss and weakness on left side
Discharge Instructions:
Please take all medications as prescribed. You will need to
start warfarin at some point in the near future (within a week
or so but definately after the MRI is performed). Please keep
all follow up appointments including: MRI and neuro f/u.
Followup Instructions:
Neurology Follow-Up:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2189-12-15**] 2:00
MRI Brain Appointment:
Provider: [**Name10 (NameIs) 7548**] [**Name11 (NameIs) **] [**Name12 (NameIs) 7549**] RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2189-11-20**] 1:45
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"401.9",
"V10.46",
"V45.82",
"432.9",
"790.92",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
5937, 5943
|
4561, 5335
|
310, 324
|
6062, 6121
|
3620, 4538
|
6414, 6904
|
2326, 2383
|
5459, 5914
|
5964, 6041
|
5361, 5436
|
6145, 6391
|
2398, 3601
|
267, 272
|
352, 2096
|
2118, 2191
|
2207, 2310
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
564
| 188,343
|
8908
|
Discharge summary
|
report
|
Admission Date: [**2174-8-6**] Discharge Date: [**2174-8-12**]
Date of Birth: [**2099-3-26**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
75 yo M with h/o CAD s/p IMI in [**2166**] with PTCA of the RCA, CHF
EF 30%, and recent endocarditis on vanco who presented with SOB
to [**Location (un) **], transferred here for concern for valvulopathy. He
was found to have O2 sats in the 60s at the NH and b/t LE edema.
He was sent to OSH ED where he improved on BiPAP and nitro gtt.
At OSH his CXR showed pulmonary congestion, but he also
received levofloxacin (3% bands).
.
In the ED the nitro gtt was stopped when he became hypotensive
to 70s/30s. Peripheral dopamine was started and a R SCL TLC was
placed. He recieved gentamycin 80 mg. The dopamine gtt was
quickly weaned off.
.
Of note, patient had his ICD battery changed on [**2174-5-12**].
Approx 2 weeks later he reported chills, anorexia, and nausea.
He presented to his PCP where blood cultures were drawn. These
were reportedly positive for Staph and pt was started on
vancomycin. Other records suggest that he was admitted on [**7-22**]
for endocarditis. The details of this are not available.
.
ROS: He reports "trouble cathching breath". Pt denies fever or
chills. Denied headache, congestion, cough. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
or abdominal pain. No dysuria. Has chronic arthritis. No
myalgias. No rash.
Past Medical History:
PCP [**Name Initial (PRE) 17863**] [**Telephone/Fax (1) 30963**], Cardiologist [**Doctor Last Name 11493**]
- CAD s/p prior IMI [**2161**] with PTCA of the RCA, recathed in [**2167**]
after a positive stress test and was found to have no
progression
- CHF with EF 30% - inferior and apical hypokinesis
- left bundle branch block and documented nonsustained VT
- + EP studys/p [**Hospital1 **]-v ICD placement in [**2171**]
- mild-moderate MR [**First Name (Titles) **] [**Last Name (Titles) 113**] in [**2171**]
- s/p pacemaker placement
- Hypertension
- Hyperlipidemia
- Diet controlled DM
- Former smoker, quit 33 yrs ago
- Arthritis
- s/p Appendectomy
- Hydrocele repair
- Gout
- "[**2138**]-repair of cerebral aneurysm" of carotid art
Social History:
He is widowed and a retired machinist from Polaroid. He drinks
rare alcohol. He lives at [**Location (un) 25576**] Center. Former smoker,
quit 33 yrs ago.
Family History:
non-contributory
Physical Exam:
Vitals: T: 101.8 P: 77 BP: 127/50 RR: 29 SaO2: 100%
on 70% open face mask
General: Awake, alert, mild resp distress.
HEENT: PERRL, EOMI, sclera anicteric. MMM, OP without lesions
Neck: supple, JVD to level of jaw. no carotid bruits
appreciated, 2+ carotid pulses
Pulm: lungs with exp wheezes, distant breath sounds, occ
crackles
Cardiac: RRR, distant S1/S2, no M/R/G appreciated
Abdomen: soft, NT/ND, + BS, no hepatomegaly noted.
Ext: trace edema b/t, warm
Skin: no Osler nodes, splinter hemorrhages. L arm with 1 cm
healing abrasion
Neurologic: Alert & Oriented x 3.
Pertinent Results:
ADMISSION LABS:
[**2174-8-6**] 10:50PM TYPE-ART PO2-98 PCO2-56* PH-7.36 TOTAL
CO2-33* BASE XS-3 INTUBATED-NOT INTUBA
[**2174-8-6**] 10:50PM O2 SAT-96
[**2174-8-6**] 04:55PM GENTA-2.8* VANCO-18.4
[**2174-8-6**] 12:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2174-8-6**] 12:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2174-8-6**] 12:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-<1
[**2174-8-6**] 07:25AM TYPE-ART PO2-89 PCO2-59* PH-7.33* TOTAL
CO2-33* BASE XS-2
[**2174-8-6**] 02:25AM LACTATE-1.4
[**2174-8-6**] 02:25AM HGB-9.2* calcHCT-28 O2 SAT-88
[**2174-8-6**] 02:15AM PT-14.7* PTT-29.8 INR(PT)-1.3*
[**2174-8-6**] 01:55AM GLUCOSE-145* UREA N-33* CREAT-2.1* SODIUM-139
POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-30 ANION GAP-14
[**2174-8-6**] 01:55AM CK(CPK)-58
[**2174-8-6**] 01:55AM cTropnT-0.06*
[**2174-8-6**] 01:55AM CK-MB-NotDone proBNP-[**Numeric Identifier 30964**]*
[**2174-8-6**] 01:55AM TSH-0.36
[**2174-8-6**] 01:55AM CORTISOL-17.5
[**2174-8-6**] 01:55AM VANCO-19.9
[**2174-8-6**] 01:55AM DIGOXIN-0.2*
[**2174-8-6**] 01:55AM WBC-12.9* RBC-3.18* HGB-8.9* HCT-27.7* MCV-87
MCH-28.1 MCHC-32.3 RDW-16.7*
[**2174-8-6**] 01:55AM NEUTS-67.8 BANDS-0 LYMPHS-9.2* MONOS-21.9*
EOS-0.6 BASOS-0.5
[**2174-8-6**] 01:55AM PLT SMR-VERY LOW PLT COUNT-72*.
.
MICROBIOLOGY:
Blood cultures from [**Date range (1) 30965**] NO GROWTH
Abscess culture: NO GROWTH TO DATE
.
<b>EKG:
[**Month (only) **]: V-paced, nl PR interval, LBBB, LAD
Admission: NSR, 1st degree AVB, LBBB, LAD, no Qs.
.
<b>Radiologic Data:
CXR [**8-6**]: Mild-to-moderate CHF. More confluent opacity in the
right lower lobe could represent asymmetric pulmonary edema;
however, a developing pneumonia cannot be excluded.
.
CXR [**8-6**]: There has been interval placement of a right subclavian
central venous catheter with the tip in the SVC. There is no
evidence of pneumothorax.
.
Cardiac Cath [**2167**]:
1. Coronary angiography of this right-dominant system revealed
no
hemodynamically significant CAD. The left main, LAD, and left
circumflex were without hemodynamically significant lesions.
The right coronary artery had mild luminal irregularities
throughout its length without hemodynamically significant
lesions.
2. Resting hemodynamic measurements revealed borderline
elevation of
the pulmonary artery systolic pressure at 30mmHg. The LVEDP was
within normal limits at 11mmHg. The CI was within normal limits
at 3.6 L/min/sq.m. There was no mitral stenosis. There was no
gradient on pullback across the aortic valve.
3. Left ventriculography revealed global hypokinesis with an
ejection fraction estimated at 35%. There was no mitral
regurgitation.
FINAL DIAGNOSIS:
1. No hemodynamically significant coronary artery disease.
2. Moderate systolic ventricular dysfunction.
.
[**Year (4 digits) 113**] [**2171**] OSH: ejection fraction of 30% with inferior and apical
hypoakinesis and mild to moderate mitral regurgitation
.
[**Year (4 digits) 113**] [**8-6**]:
1. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is moderate to
severe global left ventricular hypokinesis. Overall left
ventricular systolic function is moderately depressed. LVEF
2. The aortic valve leaflets are severely thickened/deformed.
There is moderate to severe aortic valve stenosis. Trace aortic
regurgitation is seen.
3. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
4. No evidence of endocarditis or abscess is seen.
.
TEE [**2174-8-9**]:
Conclusions:
No spontaneous [**Month/Day/Year 113**] contrast or thrombus is seen in the body of
the left
atrium or left atrial appendage. A patent foramen ovale is
present. A
left-to-right shunt across the interatrial septum is seen at
rest. Overall left ventricular systolic function is moderately
depressed. There are simple atheroma in the descending thoracic
aorta. There are simple atheroma in the abdominal aorta. There
are three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. No masses or vegetations are seen on the
aortic valve. There is moderate aortic valve stenosis. Mild to
moderate ([**12-6**]+) aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Mild to moderate ([**12-6**]+) mitral
regurgitation is seen. No vegetation/mass is seen on the
pulmonic valve. There is no clot or endocarditis on the pacer
wire. There is no pericardial effusion.
IMPRESSION: No echocardiographic signs of endocarditis. There is
no clot or endocarditis on the pacer wire. Moderate aortic
stenosis with mild to moderate aortic regurgitation. A PFO is
present with left to right flow. Moderately depressed systolic
function (EF 30-35%).
Brief Hospital Course:
<b>Assessment and Plan: 75 yo M with h/o CAD s/p IMI in [**2166**]
with PTCA of the RCA, CHF EF 30%, and recent endocarditis on
vanco who presented with SOB to [**Location (un) **], transferred here for
concern for valvulopathy.
.
Endocarditis: No records were initially available from the OSH.
He was maintained on vancomycin (PCN allergy) which was renally
dosed. He also received a TTE and a TEE which showed no
evidence of vegetation or abscess. His old PICC line was
removed and culture was sent. His WBC count trended down from
12.9 - 7. His OSH records were obtained on [**2174-8-9**], which showed
that he had Staph hominis bacteremia and an [**Date Range **] report that
raised the question of aortic valve endocarditis and AI. The
actual OCHO images were not able to be reviewed. All blood
cultures obtained were negative for growth. He will continue on
Vancomycin for a 6 week course (through [**2174-8-29**]). EP was
consulted; they feel that he does not need pacer wires changed
at this time, however would consider changing the wires should
he develop recurrent fevers or + blood cultures. He is to
continue his vancomycin to be dosed by outpatient oncology
clinic at [**Hospital3 7571**]Med Ctr. Dr. [**Last Name (STitle) 11493**] will also follow
his troughs. His goal trough is 15-20.
.
Ischemic cardiomyopathy: There were no EKG changes concerning
for ischemia. His initial troponin was 0.06. He was continued
on his ASA, statin, beta blocker. His ace was held for his
renal insufficiency. He did not have any chest pain or other
concerning symptoms during his admission.
.
CHF: [**Last Name (STitle) **] performed here showed an EF 30-35%: CXR on admission
was consistent with CHF exacerbation, and his BNP was [**Numeric Identifier 30964**].
The patient initially appeared labored with his breathing. He
was given lasix and his oxygenation and ventilation improved.
He diuresed well. There was a question of whether some of his
symtoms were due to his AI. An ABG was normal. We continued
his digoxin, bblocker, and statin.
.
Rhythym: He did have 1st degree AVB which was confirmed on
multiple EKGs. It did not progress, and he remained
asymptomatic. His amiodarone was continued.
.
AI: Apparently new over the last month. It was unclear whether
it was thought due to endocarditis. ECHP here did not show any
evidence of infection or vegetation. This issue remained stable
during admission.
.
Fever: Likely due to endocarditis as above. CXR was without
infiltrate. LUE extremity was erythematous. Fluctuance was
detected on exam. Surgery was consulted for possible I+D. The
PICC line was removed. His fevers resolved and he did not
experience any more during admission. Surgery drained his left
elbow abscess without complications. His abscess fluid was
cultred and was no growth upon discharge. Cultures remained
negative, and his WBC trended down.
.
Cellulitis: The patient has a recent history of cellulitis of
the L forearm, with a fluid collection that was previously
drained and grew Enterobacter, for which he was treated with
levofloxacin x 10 days. He was found to have a reaccumulation
of fluid over his l forearm during this admission which was
drained by surgery; the fluid was sterile.
.
Renal Failure: His creatinine remained elevated. His
medications were renally dosed. It was unclear what his
baseline Cr was. His epoetin was continued. His allopurinol
was held.
.
Anemia: Per old records, his anemia was chronic and ill defined.
We continued his outpatient epoetin. There were no signs of
active bleeding. He was re-started on protonix per old records
indicating history of gastritis. He was maintained on iron
replacement. He was given 2 units PRBCs during admission with
appropriate response.
.
Thrombocytopenia: Old records indicated a chronically low
count, thought to be due to MDS, although it was not proven
definitively. His platelet count remained in the 50-60's. He
has an outpatient hematologist who plans to pursue an outpatient
BM biopsy for work up of possible MDS.
.
Arthritis: We continued his steroids and plaquenil.
.
Diabetes Mellitus: We kept him on an insulin sliding scale.
.
Hypothyroidism: We continued synthroid at 25 mcg.
.
Code: He was full code during admission.
Medications on Admission:
Vancomycin 1.25 g Q40H
Levothyroxine 25mcg daily
Amiodarone 50mg daily
Digoxin 0.125 mg daily
Lasix 40mg daily
Toprol XL 100mg daily
Lipitor 10mg daily
Captopril 2.5mg three times per day
Hydroxychloroquine 200mg daily
Allopurinol 300mg daily
Folic Acid 1mg twice a day
Prednisone 2.5mg twice a day for arthritis
Multivitamin 1 tablet daily
Iron sulfate 325 daily
Epogen 40,000 QWeek
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 7571**]Hospital
Discharge Diagnosis:
Primary diagnosis: CHF exacerbation
Secondary diagnoses:
Cellulitis
CAD
CRI
arthritis
Discharge Condition:
Good- afebrile with normal WBC count.
Discharge Instructions:
During this admission you have been treated for CHF
exacerbation. Please continue to take all medications exactly
as prescribed.
You should adhere to a low salt diet. You should weigh yourself
every day; if you note a >3 pound weight gain in 2 days you
should call Dr [**Last Name (STitle) 11493**] right away.
If you notice increasing shortness of breath, fatigue, fevers,
night sweats, chest pain, or other symptom that is concerning to
you, please seek immediate medical attention.
You are to take vancomycin through [**2174-8-29**]. Pleaseis take 1g IV
every morning from [**Date range (1) 30966**]. On [**8-15**], please have a vancomycin
trough level prior to your AM dose. Goal trough 15-20. If
level <20, continue with daily qAM dosing. IF level >20, please
call Dr.[**Name (NI) 27809**] office to determine proper schedule. Check
follow up blood cultures 10 days after last dose of Vancomycin.
Please call Dr. [**Last Name (STitle) 11493**] with any questions.
Followup Instructions:
Dr [**Last Name (STitle) 11493**]: (Cardiology) Monday [**2174-8-15**] at 2:00 PM. ([**Telephone/Fax (1) 30967**]
.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2174-11-18**]
11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2174-11-18**] 12:00
.
|
[
"287.5",
"238.7",
"585.9",
"790.7",
"412",
"421.0",
"250.00",
"414.8",
"285.29",
"398.91",
"682.3",
"396.3",
"272.4",
"V45.02",
"244.9",
"401.9",
"041.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.01",
"38.93",
"88.72",
"99.04",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
12837, 12896
|
8125, 12402
|
291, 297
|
13025, 13064
|
3217, 3217
|
14090, 14477
|
2577, 2596
|
12917, 12917
|
12428, 12814
|
6008, 8102
|
13088, 14067
|
2611, 3198
|
12974, 13004
|
232, 253
|
325, 1621
|
3233, 5991
|
12936, 12953
|
1643, 2385
|
2401, 2561
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,783
| 194,351
|
625
|
Discharge summary
|
report
|
Admission Date: [**2119-9-19**] Discharge Date: [**2119-9-28**]
Date of Birth: [**2053-4-8**] Sex: M
Service: CARDTHOR
HISTORY OF PRESENT ILLNESS: This is a 63 year old gentleman
with known coronary artery disease who is status post
multiple percutaneous transluminal coronary angioplasties and
stents with brachy therapy to his right coronary artery, who
was admitted to [**Hospital6 3872**] on [**9-14**], after
three to four hours of chest pain and pressure. The patient
ruled out for a myocardial infarction. The patient underwent
repeat cardiac catheterization which showed a 40 or 50% left
main lesion, 70% left anterior descending lesion, 50% ramus
lesion, and a 30% right coronary artery lesion. The patient
was transferred to [**Hospital1 69**] for
operative treatment.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Status post percutaneous transluminal coronary
angioplasty and stent to right coronary artery.
3. Hypertension.
4. Hypercholesterolemia.
5. Diabetes mellitus diet controlled.
6. History of colon cancer status post sigmoid resection in
[**2104**].
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Enteric coated aspirin 325 mg p.o. q. day.
2. Protonix 40 mg p.o. q. day.
3. Plavix 75 mg p.o. q. day.
4. Hyzaar 100/25, one tablet p.o. q. day.
5. Zocor 20 mg p.o. q. day.
6. Nitropaste, one half inch q. four hours.
7. Clonidine patch 0.1 q. Friday.
REVIEW OF SYSTEMS: The patient denied cerebrovascular
accident, GI bleed; no cough and no current chest pain. The
patient underwent a carotid ultrasound on [**9-19**] and carotids
were within normal limits per report.
SOCIAL HISTORY: The patient denies tobacco use, occasional
ETOH use. The patient lives with his wife.
PREOPERATIVE PHYSICAL EXAMINATION: Pulse 88; blood pressure
136/84; respiratory rate 18; room air oxygen saturation 99%.
This is a pleasant gentleman in no apparent distress,
ambulating in the room. HEENT: Normocephalic, atraumatic.
Sclerae anicteric. Mucous membranes were moist.
Cardiovascular: Regular rate and rhythm without rub or
murmur. Respiratory: Breath sounds clear bilaterally
without wheezes, rhonchi or rales. Abdomen is soft, positive
bowel sounds, well healed lower abdominal surgical scar,
nontender, nondistended. No hepatosplenomegaly. No masses.
Pulses were equal in upper and lower extremities bilaterally;
lower extremities were without varicosities.
HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2119-9-19**]. The patient was
started on a Nitroglycerin infusion and remained chest pain
free. The patient was taken to the Operating Room with Dr.
[**Last Name (STitle) 70**] on [**2119-9-22**], for a coronary artery bypass graft
times three with a [**Doctor First Name 4796**] to left anterior descending,
saphenous vein graft to diagonal and saphenous vein graft to
ramus. Please see operative note for further details.
The patient was transferred to the Intensive Care Unit on
Neo-Synephrine and propofol infusion in stable condition.
The patient was weaned and extubated on his first
postoperative evening without difficulty. The patient was
restarted on his Plavix on postoperative day number one. The
patient had minimal chest tube drainage and chest tubes were
removed on postoperative day number one. The patient was
started on a beta blocker. The patient began ambulating with
Physical Therapy and the patient was started on Lasix.
On the evening of postoperative day number three, the patient
was noted to be in rapid atrial fibrillation on the monitor.
The patient was given intravenous Lopressor and amiodarone.
The patient converted into sinus rhythm and has remained in
sinus rhythm since the evening of postoperative day number
three.
On postoperative day number four, the patient was able to
complete a Physical Therapy Level 5, and by postoperative day
number nine, the patient was cleared for discharge to home.
CONDITION AT DISCHARGE: Temperature maximum 98.8 F.; pulse
70 in sinus rhythm; blood pressure 128/68; respiratory rate
14; room air oxygen saturation 95%. The patient is awake,
alert and oriented times three, ambulating without
difficulty, neurologically nonfocal. Heart is regular rate
and rhythm without rub or murmur. Lungs are clear
bilaterally. Abdomen is soft, nontender, nondistended.
Positive bowel sounds; the patient is tolerating a regular
diet, having normal bowel movement. Sternal incision:
Steri-Strips were intact. The incision is clean and dry
without erythema or drainage. The sternum was stable. The
left leg vein harvest site is without erythema or drainage.
LABORATORY: Hematocrit 26.5, potassium 4.7, BUN 17,
creatinine 0.9.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Enteric coated aspirin 325 mg p.o. q. day.
3. Plavix 75 mg p.o. q. day.
4. Niferex 150 mg p.o. q. day.
5. Amiodarone 200 mg p.o. q. day times one month.
6. Vitamin C 500 mg p.o. twice a day.
7. Lopressor 50 mg p.o. twice a day.
8. Zocor 20 mg p.o. q. day.
9. Lasix 20 mg p.o. q. day times seven days.
10. Potassium chloride 20 mEq p.o. q. day times seven days.
11. Percocet 5/325, one to two tablets p.o. q. four hours
p.r.n.
12. Tylenol 650 mg p.o. q. six hours p.r.n.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft.
3. Postoperative atrial fibrillation.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4797**], in one week.
2. The patient is to follow-up with his Cardiologist, Dr.
[**First Name (STitle) **], in one to two weeks.
3. The patient is to follow-up with Dr. [**Last Name (STitle) 70**] in four to
five weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2119-9-28**] 15:20
T: [**2119-9-28**] 17:42
JOB#: [**Job Number 4798**]
|
[
"414.01",
"V10.00",
"411.1",
"427.31",
"V45.82",
"401.9",
"272.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.68",
"36.15",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
5287, 5402
|
4748, 5266
|
2468, 3975
|
5426, 6070
|
1177, 1439
|
1802, 2450
|
3991, 4725
|
1459, 1660
|
169, 805
|
827, 1151
|
1677, 1779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,225
| 192,401
|
28428+57593
|
Discharge summary
|
report+addendum
|
Admission Date: [**2129-10-24**] Discharge Date: [**2129-11-18**]
Date of Birth: [**2063-2-2**] Sex: M
Service: HEPATOBILIARY SURGERY SERVICE
PART I OF DISCHARGE SUMMARY PLEASE SEE PART II
CHIEF COMPLAINT: Bile duct injury.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
male admitted to [**Hospital6 1708**] in [**2129-7-23**]
for 10 days of abdominal pain and right upper quadrant
tenderness. The patient had an open cholecystectomy on [**2129-8-19**] complicated by injury to the common bile duct. The right
and left hepatic ducts were clipped and a drain placed. The
patient had persistent bile leak and was sent to IR for
guided biliary drain placement. Only the left hepatic duct was
able to be accessed and drained. The patient also developed R PV
and R HV thrombosis. Complicated by sepsis, the
patient was treated with IV ceftazidime and gentamicin. Over
the past 5-6 days, the patient had increasing creatinine from
1.2 to 2 to 3. The patient also found to have a 4 cm
lobulated mass in the mid pole of the right kidney. Patient
was admitted to [**Hospital1 18**] for further work-up and treatment.
PAST MEDICAL HISTORY: Hypertension, cholecystitis,
hypercholesterolemia, renal mass.
PAST SURGICAL HISTORY: Open cholecystectomy.
SOCIAL HISTORY: He was visiting daughter here in the United
States. Patient lives in [**Country 11150**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Amlodipine 5 mg p.o. b.i.d.,
Dulcolax 10 mg p.o. once daily p.r.n., ceftazidime 1 gram
q.24 hours, Colace 100 mg p.o. b.i.d., gentamicin 60 mg
q.12h., heparin IV at 1450 U/h, Maalox [**1-24**] tbsp p.r.n. q.6h.,
Milk of Magnesia 30 mL p.o. once daily, Megace 800 mg p.o.
once daily, Toprol XL 100 mg p.o. once daily, oxycodone 5-10
mg p.o. q.6h., and Senokot 2 tabs p.o. b.i.d. p.r.n.
PHYSICAL EXAMINATION: On admission, vital signs were
temperature 99.6, heart rate 100, BP 196/58, respiratory rate
26, O2 was 100% on room air. The patient appeared jaundiced,
in no acute distress. Positive scleral icterus. Mucous
membranes were moist. Lungs were clear bilaterally with
decreased breath sounds in the right lower lobe. Heart: S1,
S2 was normal, with a regular rate and rhythm. Abdomen was
soft, nondistended, right upper quadrant tenderness, positive
bowel sounds, capped biliary drain, and a healed open
cholecystectomy scar. Extremities: Negative edema. Bilateral
dorsalis pedis pulses. Negative rashes. Neurologically, he
was alert and oriented x3. Cranial nerves grossly intact.
White blood cell count 9.7, hematocrit 26.1, platelet count
383, PT 15, PTT 27.1, and INR 1.3, sodium 132, potassium 4.6,
chloride 104, CO2 17, BUN 33, creatinine 2.5, glucose 104,
calcium 89, magnesium 2.1, phosphorus 4.4. It was noted on a
chest x-ray that he had a right pleural effusion. He was
wearing O2 two liters to be titrated to keep sat greater than
95%.
HOSPITAL COURSE: Initially, he was made n.p.o. and calorie
counts were started. Nutrition consult was obtained. Tube
feed recommendations were recommended due to patient's risk
for decreased p.o. intake and frequency of being n.p.o. for
procedures. The patient was started on Unasyn 1.5 grams IV
q.8h. Gentamicin was stopped. Patient had a left percutaneous
transhepatic catheter present. He also, of note, had a right
portal vein, right hepatic artery and right hepatic vein
thrombosis. The patient underwent cholangiogram on [**2129-10-25**]. Opacification of the ducts in the lateral segment of
the left lobe of the liver was noted. This was draining into
the first portion of the duodenum through a widely patent,
but slightly irregular tract. No leakage of the contrast
material occurred. A new 12 French biliary drain was placed
over the wire, and the wire was removed. On [**2129-10-26**],
he underwent an MRCP to evaluate the anatomy of the biliary
system, in particular the left biliary duct. Thrombosis of
the right portal vein with a nonocclusive thrombus was seen
within the proximal left portal vein with involvement of
segment [**Doctor First Name 690**] and IVb and proximal segment III involvement. The
right hepatic veins were thrombosed until 1.5 cm before its
junction with the IVC. The middle hepatic veins were
thrombosed until 3 cm before the junction with the IVC. The
left hepatic vein was widely patent. Three clips were
visualized in the porta hepatis. A clip was noted at the base
of the left hepatic duct, as well as a clip at the base of
the right hepatic duct, and a third clip just distal to the
common hepatic duct which was not seen. The common bile duct
was of normal caliber. There was mild right intrahepatic
biliary dilatation communicating with the subcapsular,
multiloculated bilomas. There was concern for infection. An
external-internal drainage catheter was seen entering the
periphery of the left lobe of the liver, coursing within a
left hepatic duct prior to exiting the intrahepatic biliary
system, then coursing through the hilum of the liver and
directly entering the duodenal bulb. Stenosis of the origin
of the gastroduodenal artery and the left hepatic artery with
patent flow distally was noted in the hepatic arteries. No
right proximal hepatic artery was seen. The distal peripheral
right hepatic artery branches were seen, but their feeding
arteries were not seen. Right renal carcinoma was noted
infiltrating the lower pole of the right kidney. The left
lateral lobe of the liver volume was 460 cc.
On [**2129-10-27**], he underwent a CT-guided drainage of the
subphrenic collection. This collection was perihepatic and
subphrenic seen on the MR [**First Name (Titles) **] [**2129-10-26**]. There was
successful CT-guided drainage, and a catheter placed within
the right subphrenic/perihepatic collection. Moderate right
pleural effusion was noted with adjacent atelectasis.
The patient was given oxycodone for pain on the right side of
his abdomen. He was maintained on IV heparin. It was noted
that he was short of breath with minimal exertion despite
wearing O2. A physical therapy consult was obtained to assist
with patient's decrease in endurance. On [**2129-11-1**], a
nasointestinal tube was placed, and tube feedings were
started. A nephrology was obtained for acute renal failure.
Recommendations included renally dosing all medications with
avoidance of nephrotoxic drugs. Patient was started on a
renal diet. A UA demonstrated red blood cells, a small amount
of bilirubin, 1+ protein, and muddy brown granular casts.
Gentamicin level was drawn; this was 3.7. Urine sodium was
47, and phenol was 1.47%. During this time, his vital signs
were stable, although he did experience a drop in his red
blood cell count from a baseline of 28.4 down to 24.2. He was
transfused with 2 units of packed cells on [**10-27**]. His
hematocrit increased to 30.7. His white blood cell count on
admission was 26.1. This trended down to 18.7. Bile culture
Gram stain was negative. Urine culture was negative. He did
experience some diarrhea after starting his tube feedings.
Stools were sent for C. diff, and these were negative. His
creatinine gradually improved from a baseline of 2.7 down to
1.2 and later decreasing further to 0.8. His LFTs improved
slightly after admission, but his alkaline phosphatase
continued to trend upward from a baseline of 313 up to 651.
His total bilirubin increased as high as 7.3 on hospital day
5. This trended down to 2.8 by hospital day 13. He was
maintained on IV normal saline for hydration. His urine
output improved with resolving acute renal failure. The
patient's appetite improved somewhat, and he was taking in an
increased amount of calories. Tube feeds were cycled using
Novasource Pulmonary at 70 cc/h x12h. which provided 1260
kcal. A repeat abdominal CT was done on [**11-2**] to assess
the subphrenic, perihepatic fluid collection. This
demonstrated a 10 x 4 cm subcapsular right hepatic collection
containing the drainage catheter, essentially unchanged in
appearance. There was a stable moderate to large right
pleural effusion with adjacent atelectasis. There was also
stable right renal cell carcinoma and bilateral renal cysts.
Around hospital day 10 and 11, it was noted that patient's
platelet count was dropping each day down as low as 88 on
hospital day 10. Patient's blood was sent for heparin
antibody. This returned positive. Heparin had been stopped
prior to the return of the result. His platelet count started
to trend back up. He was placed on lepirudin at 0.15/h. This
was titrated. On [**2129-11-3**], he underwent a PICC
placement with satisfactory position in the mid SVC. There
was interval increase in the size of the right-sided pleural
effusion. After 11 days of Unasyn, the patient was switched
to oral ciprofloxacin. On hospital day 14, it was noted that
the total bilirubin had increased. The capped left PTC was
opened. Total bilirubin decreased somewhat from 5.1 down to
3.3. The pigtail drain was draining approximately 25 cc/D. At
this point, the patient was ambulating better and taking in
approximately 1500 kcal orally. He was feeling better. Vital
signs were stable. Patient was progressing well with physical
therapy.
On [**2129-11-9**], he underwent abdominal CT with contrast
to evaluate for intraperitoneal bleeding. No evidence of
intraperitoneal hemorrhage was noted. He had a stable
perihepatic free-fluid collection. The right hepatic
collection containing the drainage catheter was largely
unchanged in appearance, and again a moderate to large right
pleural effusion with adjacent atelectasis was unchanged.
Patient was preopped for right hepatic resection with right
nephrectomy for bile duct injury and renal cell carcinoma,
right portal vein thrombosis and right hepatic vein
thrombosis. The patient was taken to the operating room by
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] on [**2129-11-11**]. Under general
anesthesia, he underwent right hepatic lobectomy, repair of
duodenum with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] patch, a Roux-en-Y hepaticojejunostomy
over a 12 French Silastic catheter, a right radical
nephrectomy with evacuation of a subphrenic hematoma, and Tru-
Cut biopsy of the left lobe of the liver. Please see
operative report for details. Patient received 14.4 liters of
crystalloid, 2 units of fresh frozen plasma, and 6 units of
packed red blood cells. Patient recovered in the PACU, he was
intubated, and he was transferred to the surgical intensive
care unit.
This is PART I of the discharge summary. Please see PART II.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12072**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2129-11-28**] 12:08:35
T: [**2129-11-28**] 13:36:25
Job#: [**Job Number 68958**]
Name: [**Known lastname **],[**Known firstname **] [**Last Name (NamePattern1) 11782**] Unit No: [**Numeric Identifier 11783**]
Admission Date: [**2129-10-24**] Discharge Date: [**2129-11-18**]
Date of Birth: [**2063-2-2**] Sex: M
Service: SURGERY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 48**]
Addendum:
Following his operation on [**2129-11-11**], Mr. [**Known lastname **] was transferred to
the ICU, still intubated, and with invasive cardiac monitoring.
He was on a phenylephrine drip because of hypotension. Within
the first few hours following his operation, it was noted that
Mr. [**Known lastname 11784**] abdomen was considerably tense and it was difficult to
ventilate him. Bladder pressures obtained were elevated,
suggesting a diagnosis of abdominal compartment syndrome. His
incision was reopened at the bedside to allow for pressure
relief, and an occlusive dressing was secured over the open
incision. However, Mr. [**Known lastname **] continued to remain in critical
condition, requiring vasopressor support, and with a large base
deficit (-19) and very low pH (7.0). An abdominal U/S was
obtained, which revealed a thrombosed Left portal vein. He was
then taken back to the operating room on [**11-12**], and [**Month/Year (2) **] a
portal vein thrombectomy, tru-Cut biopsy of the liver,
intraoperative ultrasound, left colectomy for ischemia,
andclosure of the abdomen with Silastic (please see Operative
note). The intraoperative biopsy revealed extensive necrosis.
Mr. [**Known lastname **] was transferred to the ICU following the operation in
stable condition. He remained intubated on AC support. He
continued to require vasopressor support. He required a large
amount of blood products, as well, including 7 units of FFP, 8
units of packed red blood cells, 2 units of platelets, and 1
unit of cryoprecipitate. He was coagulopathic with an INR > 2
and with an elevated PTT. He was in renal failure, making no
urine, and CVVH was started. Overnight, his pH normalized, and
we had more success oxygenting/ventilating him, without the use
of extreme vent settings. However, over the rest of his
hospital course, Mr. [**Known lastname **] would remain in critical condition. He
would continue to require vasopressor support. He continued to
remain intubated. His vent settings were adjusted daily, but
for the most part, again, without the use of extreme vent
settings. He received TPN for nutritional support. He
continued on broad-spectrum antibiotics, and antifungal
treatment. He continued to make no urine, and required
continuous CVVH. He continued to remain coagulopathic, and
required daily transfusions of blood products. As well, his
platelent count continued to trend downward, including a nadir
on the day of [**11-18**] of a value of less than 5. It should be
noted that throughout his hospital course, it was insured that
Mr. [**Known lastname **] received no heparin products, and the
hematology/oncology service was consulted regarding his platelet
drop. Several other consults followed Mr. [**Known lastname **] throughout his
hospital course, including the nephrology team for management of
his renal failure, and CVVH. The infectious disease team was
consulted following positive blood cultures and sputum cultures
for stenotrophomonas, and his antibiotic/antifungals were
adjusted according to their recommedations, which included a
regimen of tobramycin, meropenem, bactrim, vancomycin, and
caspofungin. On the day of [**2129-11-18**], Mr. [**Known lastname **] was taken to the
operating room for exploration of his abdomen, as the wound
continued to remain open to prevent abdominal compartement
syndrome and he continued to remain in critical condition. So on
[**11-18**], Mr. [**Known lastname **] [**Last Name (Titles) **] an exploratory laparotomy, right
hemicolectomy for ischemia, distal sigmoid colon resection for
ischemia, liver biopsy, abdominal washout and end ileostomy
(please see Operative note). Following the operation, Mr. [**Known lastname **]
was transferred back to the ICU in very critical condition. He
remained extremely hemodynamically unstable, requiring multiple
vasopressor support. He required a large amount of blood
products for a low hematocrit, coagulopathy, and again, a
platelet count less than 5. He was extremely acidotic, with a
pH down to 6.8. He required a bicarbonate drip. He suffered
from cardiac arrest several times throughout the day of [**11-18**],
ACLS protocal was initiated each time, including chest
compressions, and the use of atropine and epinephrine for
asystole. Unfortunately, Mr. [**Known lastname **] [**Last Name (Titles) 11785**] on the evening of
[**2129-11-18**], and he was pronounced dead.
Discharge Disposition:
[**Date Range **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2129-11-30**]
|
[
"567.29",
"568.0",
"427.1",
"401.9",
"998.2",
"038.3",
"995.92",
"452",
"576.2",
"584.5",
"286.6",
"287.5",
"557.0",
"998.59",
"569.83",
"729.73",
"189.0",
"518.5",
"998.12",
"570"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"97.05",
"51.37",
"55.51",
"96.72",
"87.54",
"99.62",
"46.21",
"38.95",
"46.71",
"99.04",
"99.07",
"45.76",
"45.91",
"50.3",
"99.05",
"39.95",
"54.91",
"45.75",
"50.11",
"96.6",
"99.06",
"54.59",
"99.15",
"99.60",
"38.07"
] |
icd9pcs
|
[
[
[]
]
] |
15675, 15849
|
1452, 1838
|
2925, 15652
|
1256, 1279
|
1861, 2907
|
228, 247
|
276, 1145
|
1168, 1232
|
1296, 1425
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,011
| 108,007
|
40009
|
Discharge summary
|
report
|
Admission Date: [**2139-12-9**] Discharge Date: [**2139-12-12**]
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]M with known metastatic colon cancer to lungs had reported
syncopal event on toilet at home, called EMS, went to [**Last Name (un) 1724**].
Mental status declined there requiring intubation. Head CT done
showed large right thalamic hemorrhage with likely underlying
mass. Transferred to [**Hospital1 18**] for further management.
Past Medical History:
colon cancer with lung mets, arthritis
Social History:
non smoker. armenian
Family History:
non- contributory
Physical Exam:
O: T: BP: 200/81 HR:86 R 18 O2Sats 96 vent
Gen: cachetic appearing, intubated, examined in ED
HEENT: Pupils:2mm NR
Lungs: ventilated
Cardiac: RRR
Abd: Soft
Extrem: Warm and well-perfused.
Neuro:
intubated, on propofol.
no eye opening. decerebrate posturing UEs, triple flexion
LEs,+cough/gag, + corneals
Toes upgoing bilaterally
Pertinent Results:
[**12-9**] Head CT: Right basal ganglia intraparenchymal hemorrhage
with 12mm leftward shift(previously 7mm) of midline structures.
There is intraventricular extention into the lateral, 3rd and
4th ventricles, which has increased since OSH CT.
Brief Hospital Course:
Pt admitted to the ICU with medical management for a large right
thalamic hemorrhage. The patient was treated with Mannitol and
decadron. The patient's prognosis was discussed in detail with
the family. He was made DNR per the family's request but was ok
to have chemical resuscitation. They wanted to await the arrival
of more family members from out of state, prior to making him
CMO. On [**12-11**] the family agreed to make the CMO. He died on [**12-12**].
Medications on Admission:
xeloda, hydrocodone
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Right thalamic hemorrhage
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2139-12-15**]
|
[
"431",
"V43.65",
"715.90",
"197.0",
"V43.64",
"331.4",
"198.3",
"250.00",
"V10.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2012, 2021
|
1450, 1913
|
275, 281
|
2090, 2099
|
1181, 1192
|
2151, 2186
|
778, 797
|
1984, 1989
|
2042, 2069
|
1939, 1961
|
2123, 2128
|
812, 1162
|
228, 237
|
309, 661
|
1201, 1427
|
683, 724
|
740, 762
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,798
| 154,920
|
648
|
Discharge summary
|
report
|
Admission Date: [**2197-5-9**] Discharge Date: [**2197-5-13**]
Service: MEDICINE
Allergies:
Penicillins / Amiodarone Hcl
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
bright red blood per rectum, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History of Present Illness: [**Age over 90 **] year old male with medical
history pertinent for CAD, Chronic Systolic CHF, CKD and DM who
presents with lower GI bleed. Patient began to feel ill and weak
yesterday evening and began to have diarrhea. Diarrhea was noted
to be mixed with bright red blood. He thinks that he had > 5
episodes yesterday. Also had multiple episodes of non-bloody
emesis yesterday. Patient denies associated symptoms including
chest pain, shortness of breath, abdominal pain. Patient denies
any travel outside of the country recently. He does report
ingesting egg salad on Sunday night which was apparently made
with 2 week old eggs. No one else consumed the egg salad and no
one else is sick in his family. This morning, he felt so weak
that he was not able to stand up-- felt like his legs could not
hold up his weight-- and so he asked his wife to call his PCP
who recommended that he come to the ED.
.
In the ED, patient was hemodynamically stable with BRBPR in
rectal vault. No active bleeding was noted. GI saw the patient
in the ED and reccomended admission with serial crits. Patient
was given kayelexate given elevated K on repeat chemistry and
given 2L IVF. On the floor, patient was found to be sitting on
sheets soaked in bright red blood. A trigger was called on
arrival. He remained hemodynamically stable with SBP in the 100s
and paced rhythm. MICU transfer was requested for closer
monitoring.
.
On arrival to the MICU, the patient complains of feeling hungry
and thirsty. He has SOB but notes that this is chronic for him
and unchanged. Denies chest pain, palpitations, abdominal pain,
dysuria, arthralgias, or myalgias.
Past Medical History:
HTN
CAD - s/p 3V-CABG and stenting
- MI [**03**] years ago
Congestive Heart Failure
- EF 40% on Echo [**2196-3-12**]
Severe Miral Regurgitation and Tricuspid Regurgitation
Atrial fibrillation
- s/p BiV pacemaker - [**Company 1543**]
- off Coumadin due to GI bleed history
Type II Diabetes Mellitus
Chronic Kidney Disease
Hypertension
GIB - has required transfusions, source unidentified after
capsule study
History of Colon Cancer [**2170**]
- s/p colectomy and ileoanal anastomosis, 7 wks radiation,
complication of radiation proctitis
History of ischemic colitis
BPH
Social History:
The patient lives at home with his wife, previously was in
[**Hospital 100**] Rehab. The patient used to work in oil and
air-conditioning business, in [**Location (un) 55**] (records note wife
herself with some degree of dementia) Tobacco: 50 pack-year
history, quit 56 years ago. Denies Etoh or illicit drug use.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Brother died of MI at 64, sister died of MI at
72. Mother died at 30 from complications from PNA. Father died
at 46 during cholecystectomy.
Physical Exam:
Vitals: T 98.7, BP 97/59, P 77, RR 20, SaO2 95% on RA
General: elderly male, frail, fatigued. Patient is awake, alert,
answers questions appropriately
HEENT: NCAT, EOMI, sclera anicteric, conjunctiva pale, dry MM
Neck: Thin, supple, no elevation in JVP appreciated
Chest: difficult exam secondary to shaking, no rales, rhonchi
appreciated
Cor: RRR, II/VI systolic murmur loudest at apex
Abdomen: + BS, Hyperactive bowel sounds, Soft, mild tenderness
to palpation in RLQ, no rebounding or guarding
Ext: no LE edema, feet cool bilaterally
Neuro: occasional tremor vs. small rigor (previously noted)
Pertinent Results:
[**2197-5-9**] 06:13PM UREA N-84* CREAT-2.9* SODIUM-137
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17
[**2197-5-9**] 06:13PM CK(CPK)-183*
[**2197-5-9**] 06:13PM CK-MB-4 cTropnT-0.10*
[**2197-5-9**] 06:13PM MAGNESIUM-2.9*
[**2197-5-9**] 06:08PM WBC-15.3* RBC-3.36* HGB-10.5* HCT-30.9*
MCV-92 MCH-31.4 MCHC-34.1 RDW-15.5
[**2197-5-9**] 06:08PM PLT COUNT-212
[**2197-5-9**] 06:08PM PT-15.3* PTT-31.6 INR(PT)-1.4*
[**2197-5-9**] 02:06PM K+-5.9*
[**2197-5-9**] 12:05PM GLUCOSE-171* UREA N-82* CREAT-2.9*#
SODIUM-133 POTASSIUM-6.0* CHLORIDE-93* TOTAL CO2-25 ANION
GAP-21*
[**2197-5-9**] 12:05PM estGFR-Using this
[**2197-5-9**] 12:05PM CK(CPK)-292*
[**2197-5-9**] 12:05PM cTropnT-0.09*
[**2197-5-9**] 12:05PM CK-MB-6
[**2197-5-9**] 12:05PM WBC-16.7*# RBC-3.73*# HGB-11.9*# HCT-35.0*
MCV-94 MCH-31.8 MCHC-33.9 RDW-15.7*
[**2197-5-9**] 12:05PM NEUTS-92.9* LYMPHS-3.0* MONOS-3.6 EOS-0.5
BASOS-0.1
[**2197-5-9**] 12:05PM PLT COUNT-242
[**2197-5-9**] 12:05PM PT-15.0* PTT-32.0 INR(PT)-1.3*
.
Labs: See OMR
.
STUDIES:
CXR:
Single bedside AP chest radiograph re-demonstrates multiple
sternotomy wires, vascular clips from previous coronary arterial
bypass graft and biventricular pacer with leads terminating in
appropriate position. Cardiomediastinal and hilar contours are
unchanged. Atherosclerotic calcification is noted at the aortic
arch. A left retrocardiac opacity is significantly improved
since [**2197-3-3**], though small opacity in that
distribution persists, likely atelectatic. Otherwise, the lungs
are clear. Visualized osseous and soft tissue structures are
unremarkable.
.
EKG: v-paced at 82 with PVC, ?peaked TW in V3-V5
Brief Hospital Course:
Briefly this is a [**Age over 90 **] year old male with CAD, Chronic Systolic
CHF, CKD, DM, h/o colon cancer s/p remote colectomy with
radiation proctitis with who initially presented with lower GI
bleed. Patient with previous history of lower GI bleed had
colonoscopy which demonstrated internal hemorrhoids, negative
capsule endoscopy and normal upper endoscopy in 4/[**2197**].
.
# Lower GI bleed - Patient is satus post colectomy with
radiation proctitis noted to have melena in the rectal vault in
the ED and then was found to be actively bleeding upon arrival
to the medicine floor. Patient was hemodynamically stable
however had multiple comorbid conditions. Patient had previous
bleed 4-5 months ago and had negative capsule endoscopy with
some internal hemorrhoids. Endoscopy was negative at that time.
Colonoscopy demonstrated internal hemorrhoids. Hct at initial
presentation was 35 which is well above his baseline crit of
mid 20s. Patient was hemodynamically stable but refused NGT
lavage. He was transfered to the MICU for closer monitoring of
his lower GI bleeding. In the MICU, patient was initially kept
NPO with Q8Hour hct which were stable. IV access was maintained
with two large bore IVs. Patient was also found to have a
leukocytosis with a WBC count of 16 and abdominal pain. He was
evaluated by GI. GI felt that the clinical picture was most
consistent with ischemic or infectious colitis and therefore
colonoscopy or endoscopy was not necessary. Patient did not
have any further episodes of bright red blood per rectum and his
Hct remained stable. He was transfered back to the floor where
[**Hospital1 **] Hct were checked. He was placed back on his home
cardioproctective medications slowlying including asa, beta
blocker, and ACE-I. Patient's Hct remained stable, his WBC
count trended to normal, and his abdominal pain resolved. He
was transitioned to a regular diet which he tolerated well.
.
# Hyperkalemia - Patient initially with elevated K on arrival of
6.0, however this was a hemolysed specimen. Repeat K was 4.7.
This elevated is likely secondary to acute on chronic renal
failure in the setting of lower GI bleed. Patient got kayelexate
in the ED which normalized his K. He never had any EKG changes.
.
#. Acute on Chronic Kidney Disease (Stage III): Cr on admission
2.9 which is above baseline values of 1.5-2.0. Likely related to
volume depletion in the setting of lower GI bleed. Potassium
elevated to 6.0 on admission repeat K 5.9. Previous K was
4.6-5.6. Initially patient's ACE I was held and his was treated
with gentle IVF. His Cr returned to its baseline of 1.5 by time
of discharge.
.
#. Chronic Systolic CHF, biventricular heart failure, EF 40%.
CAD s/p bypass graft. Patient followed by Dr. [**First Name (STitle) 437**] in
outpatient heart failure clinic. Patient maintained on aspirin,
torsemide, lisinopril and carvedilol as outpatient. Patient is
not on a statin. Patient with troponin of 0.10 on admission,
which is about at previous baseline especially given acute renal
failure. Cardiac enzymes were cycled which were stable. As GI
bleed stopped, patient was resumed on all of his home
medication.
.
# Atrial Fibrillation s/p PCM: Pt not anticoagulated with
coumadin secondary to history of GI bleed on low dose aspirin as
an outpatient. Patient started back on ASA after GI bleed was
attributed to ischemic colitis.
.
#. BPH: Patient continued on finasteride and flomax
.
#. Diabetes Mellitus II: patient continued on glipizide and ISS
.
#. Anemia, iron deficiency: Iron studies in [**Month (only) 404**] consistent
with iron deficiency. Patient has known history of guaiac +
stools, prior GI bleeding and now with frank melena.
Medications on Admission:
carvedilol 3.125 mg [**Hospital1 **]
digoxin 0.0625 mg every other day
finasteride 5 mg daily
gabapentin 100 mg up to three times a day as needed for shingles
pain
glipizide 5 mg daily
lisinopril 5 mg daily
pantoprazole 40 mg daily
Flomax 0.4 mg daily
torsemide 20 mg twice a day (reduced)
aspirin 81 mg daily
B complex vitamins daily
multivitamin daily
Colace daily
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day). Tablet(s)
2. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day:
Please start [**2197-5-14**].
Disp:*30 Tablet(s)* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Glipizide 2.5 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 100**] Senior Life
Discharge Diagnosis:
Ischemic colitis
Discharge Condition:
stable
Discharge Instructions:
You were admitted for bright red blood per rectum. You were in
the intensive unit for monitoring. You bleeding was attributed
to ischemic colitis. You were treated symptomatically. We
initially held your blood pressure medications. You can resume
all your medications except torsemide. Please start your
torsemide Sunday, [**2197-5-14**].
Please call you doctor if you have bloody stool, nausea,
vomiting, increased abdominal pain, fevers, chills, or any
questions or concers.
[**Month/Day/Year **] Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2197-7-24**]
2:30
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2197-7-24**]
3:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2197-9-20**] 2:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 3329**] [**5-18**]. 1pm
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"V45.02",
"584.9",
"578.9",
"424.0",
"041.11",
"428.0",
"707.07",
"V45.01",
"403.90",
"276.7",
"427.31",
"250.00",
"V45.82",
"414.00",
"V10.05",
"280.9",
"707.21",
"585.3",
"428.22",
"V45.81",
"557.9",
"440.20"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10605, 10667
|
5462, 9171
|
273, 279
|
10728, 10737
|
3770, 5439
|
2913, 3137
|
9588, 10582
|
10688, 10707
|
9197, 9565
|
10761, 11934
|
3152, 3751
|
195, 235
|
335, 1973
|
1995, 2566
|
2582, 2897
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,239
| 134,445
|
18877
|
Discharge summary
|
report
|
Admission Date: [**2186-7-14**] Discharge Date: [**2186-7-27**]
Date of Birth: [**2152-11-6**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 33-year-old
right-handed woman transferred from [**Hospital1 1474**] [**Hospital3 417**]
Hospital with having throbbing headaches and intermittent
photophobia and dizziness, worse in the morning and with
bending forwards, [**8-16**] in severity, starts in the neck and
wraps around to the frontal region and lasts all day,
progressively worse over the last four weeks.
PAST MEDICAL HISTORY:
1. GERD.
2. Cholecystectomy.
3. Bipolar disease.
4. Herniated disk at the L5-S1 level.
ADMISSION MEDICATIONS:
1. Wellbutrin 100 b.i.d.
2. Ibuprofen p.r.n.
3. Depo Provera.
4. Ativan 0.5 b.i.d. p.r.n.
5. Promex 40 mg q.d.
ALLERGIES: Codeine (rash).
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.8, BP 104/60, heart rate 56, respiratory rate 16,
saturations 98% on room air. General: The patient was
awake, alert, oriented times three, fluent speech, good
comprehension, able to name months of the year backwards.
Her cranial nerves were intact. HEENT: She did have some
uvular deviation to the left. Mild left facial asymmetry
with no evidence of excursion. Pupils were equal, round, and
reactive to light. She did have weakness in the left upper
extremity as well as left lower extremity. She had 4+ of the
deltoids, biceps, triceps, wrist extension, and wrist flexion
on the left side as well as [**3-10**]- in the IPs, quads, and
hamstrings. She was 5 in the [**Last Name (un) 938**], AT and plantar flexion on
the left. On the right side, she was [**4-10**] in the muscle
groups in the right upper extremity and [**3-10**]- in the right
upper extremity. Her reflexes were 3+ throughout. Her toes
were upgoing. She did have some spasticity but a negative
[**Doctor Last Name **]. Her sensation was intact to light touch throughout.
Her coordination was slightly slow on the left side and her
proprioception was decreased on the left side.
LABORATORY/RADIOLOGIC DATA: She had a head CT which showed
evidence of a right frontal parasagittal lesion which arises
from the corpus callosum and infiltrating in the left frontal
lobe.
HOSPITAL COURSE: On [**2186-7-18**], the patient was taken
to the OR for a right frontal craniotomy for excision of
tumor without intraoperative complications. The patient was
monitored in the Recovery Room overnight. She was awake,
alert, and oriented times three, following commands, had some
continued left facial droop, continued left-sided weakness.
She was a [**2-8**] in all muscle groups in the upper extremities
and lower extremities on the left side. The pupils were
equal, round, and reactive to light. Her EOMs were full.
She did have some periods of severe agitation and
hallucinating on the first night postoperatively.
She was medicated with Haldol and Ativan. She was
transferred to the ICU on postoperative day number one due to
drain placement. On [**2186-7-19**], she was seen by the Psychiatry
Service due to the severe psychosis while in the ICU.
Psychiatry assessment found the patient delirious and given
the acute onset following craniotomy as well as
disorientation, psychotic beliefs about Satan, there are
obviously concerns. They suggested holding Wellbutrin and
Ativan and minimizing narcotic use and starting Haldol 2 mg
IV t.i.d. and p.r.n. for agitation.
The patient was also started on lithium 300 mg p.o. b.i.d.
and concurrently is on Haldol 5 mg p.o. b.i.d. Psychiatry
continued to follow the patient throughout her hospital stay.
Her delirium resolved and her mood was stable on lithium and
Haldol. Her vital signs remained stable. She was
transferred to the regular floor on [**2186-7-22**] after her vent
drain was discontinued. Her vital signs have remained stable
throughout her hospital stay.
She was seen by Physical Therapy and Occupational Therapy and
felt to be safe for discharge home. She has been weaned down
on her steroid medication. She will be weaned down to 2 mg
p.o. b.i.d. over the course of a weeks time and follow-up in
the Brain [**Hospital 341**] Clinic on [**2186-8-14**]. She will return
to [**Hospital Ward Name 121**] V on postoperative day number ten for staple removal.
DISCHARGE MEDICATIONS:
1. Dilantin 100 mg p.o. t.i.d.
2. Lithium 300 mg p.o. b.i.d.
3. Haldol 5 mg p.o. b.i.d.
4. Protonix 40 mg p.o. q. 24 hours.
5. Tylenol 650 p.o. q. four hours p.r.n. headaches.
CONDITION ON DISCHARGE: Stable at the time of discharge.
She will return to [**Hospital Ward Name 121**] V on postoperative day number ten for
staple removal and follow-up in the Brain [**Hospital 341**] Clinic on
[**2186-8-14**] with Dr. [**First Name (STitle) **]. Her condition was stable at the time
of discharge.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2186-7-27**] 12:31
T: [**2186-7-27**] 12:34
JOB#: [**Job Number 51662**]
|
[
"292.12",
"530.81",
"E937.9",
"296.7",
"191.9",
"331.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
4327, 4509
|
2268, 4304
|
688, 855
|
870, 2251
|
573, 665
|
4534, 5112
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,914
| 104,336
|
20436
|
Discharge summary
|
report
|
Admission Date: [**2113-4-23**] Discharge Date: [**2113-4-26**]
Date of Birth: [**2040-6-17**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 72-year-old
white male with a history of diffuse large B-cell lymphoma
originally diagnosed in [**2108-9-12**]. He recently
travels from [**State **] to [**Location (un) 86**] area for evaluation by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] regarding possible enrollment in a clinical
trial. However, he was felt not to be a candidate for the
trial. He was treated with high-dose Solu-Medrol on [**2113-4-20**]
and [**2113-4-21**] on outpatient setting in hopes of temporization
of the disease so that they could safely return to the
[**State **] into the care of his primary Oncologist.
However, on the day prior to admission, he had sudden onset
of dizziness, graying, and blurring of his vision, and
lightheadedness along with some evidence of shortness of
breath and pleuritic chest pain. He called 911 and was
brought in by ambulance to the [**Hospital1 188**] Emergency Department. His symptoms were transient.
In the Emergency Department vital signs were, temperature
98.4, blood pressure 80/40, heart rate 70, and oxygen
saturation 99 percent on room air. In Emergency Department,
he reported that his voice was higher pitched than usual and
he noted increased nonproductive cough. He also complained
of increased left-sided neck pain. His neck pain resolved
without an intervention approximately 20 minutes after his
arrival. He denied any nausea, vomiting, palpitations,
fevers, chills, abdominal pain, hemoptysis, dysphagia, throat
pain, wheeze, or stridor.
In the Emergency Department, ultrasound showed a nonocclusive
thrombus in the right common femoral vein. CT scan of the
neck demonstrated a large lymphoma approximately 12.2 x 8 cm
with the left carotid arteries patent by encased by tumor.
He was seen in consultation by the ENT Service, who noted the
larynx and trachea deviated to the right, but no other
deviation of his anatomy. Given the rapid increase in size
of the mass, he was sent to the Medical Intensive Care Unit
for further monitoring of concern for possible airway
compromise. He was also seen by the Vascular Surgery
Service, who recommended a carotid ultrasound. Prior to
leaving the Emergency Department, he received allopurinol 300
mg p.o. x 1, Decadron 40 mg p.o. x 1, and Anzemet. He was
monitored over night in the Medical Intensive Care Unit and
was then discharged to the Pulmonary Transplant Unit.
REVIEW OF SYSTEMS: He denied fevers, chills, recurrent chest
pain, stridor, wheezing, cough, or hemoptysis. He denied any
changes in appetite, weight, or night sweats. No nausea,
vomiting, diaphoresis, constipation, dysphagia, or
odynophagia.
PAST MEDICAL HISTORY: Non-Hodgkin lymphoma, diffuse large B-
cell type, diagnosed in [**2108-9-12**], status post R-CHOP,
and XRT to the groin in [**2112-8-12**], status post DHAP in
8, [**2112**]. He is status post repeat cycles of R-CHOP in
[**10/2108**] and through 02/[**2109**]. Status post treatment with
Taxol, topotecan, and Rituxan from [**12/2110**] to 04/[**2111**].
Status post treatment with Rituxan and gemcitabine in [**4-/2112**]
to 07/[**2112**]. Status post repeat treatment with DHAP in
[**2113-3-3**] to [**2113-3-6**]. Status post two cycles of Rituxan
in [**2113-3-13**]. History of DVT and PE status post six weeks
of Coumadin therapy, originally diagnosed in [**2113-1-12**].
Coronary artery disease, status post CABG times four vessels
in [**2105**]. Status post transurethral resection of prostate.
History of shingles.
ALLERGIES: The patient was allergic to ciprofloxacin
resulting in hives, Vicodin resulting in dehydration, and
Humibid resulting in hives.
MEDICATIONS PRIOR TO ADMISSION:
1. Allopurinol 300 mg p.o. q.d.
2. Digoxin 0.25 mg p.o. q.d.
3. Aspirin 81 mg p.o. q.d.
4. Multivitamin one p.o. q.d.
5. Vitamin D.
6. Calcium carbonate.
7. Of note, he recently finished the course of Coumadin.
SOCIAL HISTORY: The patient lives with his wife in [**State **].
He is a former tobacco smoker, but quit 25 years prior to
admission. Denies any alcohol or IV drug use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Upon transfer: Generally, he is a
well-developed, well-nourished elderly male, breathing
comfortably in no acute distress. Head, neck exam was
remarkable for normocephalic and atraumatic. Pupils are
equal, round, and reactive to light. Extraocular eye
movements were intact. Sclerae anicteric. Oral mucosa
moist. No oropharyngeal lesions. Neck exam remarkable for a
large left-sided neck mass, thick 12 X 10 cm with deviation
in the trachea to the right. Pulmonary exam showed lungs to
be clear to auscultation bilaterally no adventitious breath
sounds. The patient also had a well-healed median sternotomy
scar. Cardiovascular exam was regular, rate, and rhythm and
normal S1 and S2 with no murmurs, rubs, and gallops. Abdomen
soft, nontender, nondistended with positive normal bowel
sounds. There is no evidence of hepatosplenomegaly.
Extremities exam showed bilateral lower extremity edema of
right greater than left. Distal pulses were full.
Extremities were warm and well perfused. Neurological exam
show cranial nerves II through XII are intact. The patient
is alert and oriented x 3.
PERTINENT LABS: X-rays and other studies on transfer to the
Pulmonary Transplant Service, the patient had a white blood
cell count with a WBC of 8.0 with 62 percent neutrophils, 28
percent lymphocytes, 9 percent monocytes, 0.2 percent
eosinophils, 0.2 percent basophils, hematocrit 35.6, and
platelets 210,000. Coagulations were also PT 14.4, PTT 87.9,
and INR 1.4. Serum chemistry showed sodium 138, potassium
4.2, chloride 102, bicarbonate 27, BUN 17, creatinine 0.8,
glucose 156, calcium 8.8, phosphorus 3.0, magnesium 1.9, and
uric acid 3.1. Three sets of cardiac enzymes were
unremarkable. LDH elevated at 341. Digoxin is 0.8.
Antibody typing screen was negative. Urinalysis negative.
Imaging showed a chest x-ray with cardiac size slightly
enlarged. There was slight elevation of left hemidiaphragm
with discoid atelectasis at the left base. There was a left-
sided Port-A-Cath tip that was present but difficult to
distinguish. A CT scan of the head without contrast
demonstrated no acute intracranial hemorrhage or evidence of
major vascular territorial infarct. The patient was noted to
have very prominent basilar artery. CT of the neck
demonstrated a large left-sided mass approximately 12.2 x 8.4
cm. There was marked right tracheal displacement with
questionable intraluminal tracheal mass. The tumor encased
the left common carotid but flow appeared patent. CT of the
chest demonstrated no evidence of pulmonary embolus. There
were noted a 10 mm precarinal node. As well, there were also
emphysematous changes at the lung bases. There were two
right-sided upper lobe pulmonary nodules, the largest 6 mm in
diameter. Lower extremity ultrasound showed no flow in the
right popliteal secondary to nonocclusive thrombus.
BRIEF SUMMARY OF HOSPITAL COURSE: Large B-cell lymphoma with
the left neck mass. The patient received IV Decadron and
Anzemet in the Emergency Department for preparation of the
second cycle of DHAP, which consisted of Decadron,
cytarabine, and cisplatin. He received a total four days of
therapy. This will be completed with vigorous hydration,
allopurinol, and serial checks of tumor lysis labs. He was
supported with blood products. On this regimen, the size of
his neck mass was decreased. He was felt stable for
discharge and travel back to [**State **] and with resume care
with his primary Oncologist there. It was reiterated to the
patient several times that at this time he was not a
candidate for moment in clinical trial regarding treatment
with Zevelin and in light of his rapidly progressive bulky
disease, or he might be never be a candidate for such
treatment.
Deep vein thrombosis. The patient was started on heparin and
Coumadin when he was in the Medical Intensive Care Unit, it
is unclear if the right deep vein thrombosis was old or new,
I have concern for pulmonary embolus. As the patient's CT
was negative, he was switched Lovenox and we will continue
this as an outpatient.
Dyspnea: CT was negative for PE. The patient ruled out for
MI. There were no signs or symptoms of airway compromise.
He was followed by the ENT Service while he was inhouse.
After chemotherapy was complete, his neck mass had decreased
in size somewhat. He remained without evidence of airway
compromise.
Chest pain: It is unclear that the patient's initial
symptoms were more consistent with transient ischemia versus
vasovagal episode. His chest pain resolved on the day of
admission. It was felt to be atypical in character and
unlike his previous coronary chest pain prior to his CABG, it
was felt to be less likely to be ischemic in nature.
Additionally, he ruled out for myocardial infarction. Two
sets of negative enzymes and his EKG remained unchanged. He
was instructed to continue digoxin and Lopressor.
DISCHARGE CONDITION: Stable. Afebrile. Hemodynamically
stable. No chest pain. No shortness of breath. Tolerating
well intake without nausea or vomiting. Ambulating
independently.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSES: Non-Hodgkin B-cell lymphoma.
Right lower extremity deep vein thrombosis.
History of pulmonary embolus.
Coronary artery disease, status post coronary artery bypass
grafting.
Status post transurethral resection of the prostate.
History of shingles.
DISCHARGE MEDICATIONS:
1. Compazine 10 mg p.o. q.4-6 hours as needed for nausea.
2. Reglan 10 mg p.o. q.i.d. a.c. and h.s.
3. Decadron 20 mg p.o. q.d.
FOLLOWUP PLAN: The patient was instructed to call his
primary Oncologist, Dr. [**Last Name (STitle) 54748**], for followup appointment
upon returning from [**State **].
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-699
Dictated By:[**Last Name (NamePattern1) 14378**]
MEDQUIST36
D: [**2113-6-20**] 17:16:41
T: [**2113-6-21**] 13:37:45
Job#: [**Job Number 54749**]
cc:[**Last Name (NamePattern1) 54750**]
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Dr. [**Last Name (STitle) 54751**], [**Hospital 54752**] Cancer Center
|
[
"786.59",
"786.05",
"453.8",
"202.88"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25"
] |
icd9pcs
|
[
[
[]
]
] |
9189, 9410
|
4234, 4252
|
9432, 9680
|
9703, 10424
|
7169, 9167
|
3832, 4045
|
4275, 5383
|
2577, 2804
|
153, 2557
|
5400, 7140
|
2827, 3800
|
4062, 4217
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,667
| 124,501
|
7494
|
Discharge summary
|
report
|
Admission Date: [**2187-10-6**] Discharge Date: [**2187-10-8**]
Date of Birth: [**2117-5-8**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfonamides / Vibramycin
Attending:[**First Name3 (LF) 2474**]
Chief Complaint:
nausea/vomiting, dark blood per rectum
Major Surgical or Invasive Procedure:
EGD and colonoscopy [**2187-10-7**]
History of Present Illness:
70yoF h/o duodenal ulcer, diverticulosis presented w/melena x1
day and nausea and vomiting of cranberry-like liquid. Symptoms
began in the last day. Does admit to mild epigastric tenderness.
Denies NSAID intake. Has not been on PPI recently.
In ED, 97.2 124 119/71 16 100% 3L, transfused 1uPRBC for hct 27
and admitted to the medical floor. Vital signs [**10-6**] on floor
sbp 112/70, hr 105 (up from baseline 80), 98% ra, afebrile,
+dark blood/brown stool in commode. Her AM hct returned at 23
despite 1u pRBC transfusion and the unit was called. An 18-gauge
pIV placed on L, 22-gauge on right, transfused 1L NS, 1uPRBC,
placed on NS IVF. GI ([**First Name4 (NamePattern1) 14992**] [**Last Name (NamePattern1) 9746**]) was aware.
On arrival to the MICU, denied any CP, SOB, LH, presyncope,
dizziness. Admitted to persistent mild epigastric pain. No
addt'l N/V. Last bloody BM 10am this morning.
Past Medical History:
1. Duodenal ulcer
2. Bipolarism (chronic, rapid-cycling) - not on meds
3. Hyperlipidemia
4. Meniere's disease
5. Fibromyalgia
6. Osteoporosis - fosamax stopped due to ulcer
7. Hypothyroidism
8. Asthma
9. DM II, diet controlled (last HgbA1c 6.2 [**5-/2187**])
10. L Nephrectomy after being hit by a truck (pedestrian vs.
truck)
11. IBS per patient
Social History:
- Denies EtoH, tobacco or illicit drug use
- Currently retired, worked as a teacher, librarian & instructor
- Lives alone with her cat
Family History:
- [**Name (NI) **] CA, father (died @ age 70's) & grandfather
- HTN, DM in Mother
- ?Blood CA in family
Physical Exam:
T 99 HR 105 BP 112/70, 145/80 RR 18 99% ra
SKIN: no rashes, no lesions
HEENT: NC/AT, Sclera Anicteric, EOMI, PERRL
CHEST: lungs CTAB, no wheezes/rhonchi/crackles
HEART: RRR, No Murmurs/Gallops/Rubs
BACK: No CVA Tenderness, No spinal tenderness
ABDOMEN: Obese/flat, no scars, NABS. Mild tenderness in
epigastric area. No rebound/guarding. Mild TTP over LLQ.
RECTAL: (per admit exam) guaiac positive with red blood per ED
EXT: No clubbing/cyanosis/edema. Good Pulses.
NEURO: anxious
Pertinent Results:
[**2187-10-6**] 05:50PM HCT-34.0*#
[**2187-10-6**] 09:39AM GLUCOSE-93 UREA N-31* CREAT-0.9 SODIUM-145
POTASSIUM-4.2 CHLORIDE-115* TOTAL CO2-25 ANION GAP-9
[**2187-10-6**] 09:39AM ALT(SGPT)-18 AST(SGOT)-17 LD(LDH)-126 ALK
PHOS-39 TOT BILI-0.4
[**2187-10-6**] 09:39AM CALCIUM-8.1* PHOSPHATE-2.6* MAGNESIUM-2.1
[**2187-10-6**] 09:39AM WBC-9.7 RBC-2.73* HGB-7.8* HCT-23.2* MCV-85
MCH-28.7 MCHC-33.9 RDW-16.2*
[**2187-10-6**] 09:39AM PLT COUNT-242
[**2187-10-5**] 11:26PM GLUCOSE-157* UREA N-29* CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2187-10-5**] 11:26PM estGFR-Using this
[**2187-10-5**] 11:26PM cTropnT-0.01
[**2187-10-5**] 11:26PM IRON-39
[**2187-10-5**] 11:26PM IRON-39
[**2187-10-5**] 11:26PM calTIBC-348 VIT B12-669 FOLATE-GREATER TH
FERRITIN-8.2* TRF-268
[**2187-10-5**] 11:26PM TSH-1.7
[**2187-10-5**] 11:26PM FREE T4-1.1
[**2187-10-5**] 11:26PM WBC-10.4# RBC-3.18* HGB-9.4* HCT-27.7* MCV-87
MCH-29.4 MCHC-33.8 RDW-14.3
[**2187-10-5**] 11:26PM WBC-10.4# RBC-3.18* HGB-9.4* HCT-27.7* MCV-87
MCH-29.4 MCHC-33.8 RDW-14.3
[**2187-10-5**] 11:26PM NEUTS-82.1* LYMPHS-15.1* MONOS-2.0 EOS-0.5
BASOS-0.3
[**2187-10-5**] 11:26PM PLT COUNT-291
[**2187-10-5**] 11:26PM PT-13.3* PTT-22.1 INR(PT)-1.2*
Brief Hospital Course:
70yoF with duodenal ulcer, hx of diverticulosis, bipolarism p/w
nausea, vomiting, blood per rectum.
.
1. GI bleed: Patient had a history of a GI bleed in [**2187-6-10**]
secondary to a duodenal ulcer. When the patient arrived to the
ED, she received 1Uprbcs and was transferred to the floor. She
continued to have bloody BM when going to the floor and was
quickly transferred to the ICU for closer monitoring. IN the
ICU, she recieved 3 additional units of prbcs. She was started
on an IV PPI. She was prepped for an EGD and colonoscopy which
was done on [**2187-10-7**]. The results of these studies showed a
healing duodenal ulcer and diverticuli with no clots or active
bleeding. She likely had a diverticuli bleed which stopped on
its own. GI recommended PPI [**Hospital1 **]. Hct was subsequently stable
and was placed on PO PPI [**Hospital1 **]. Her diet was advanced. UPon
discharge, she was tolerating a regular diet and Hct was stable.
PT will need Hct checked at her follow up appointment with her
PCP [**Last Name (NamePattern4) **] 3 days.
.
2. Bipolar - Patient was resumed on her home regimen.
.
3. Hyperlipidemia - Patient was continued on her home statin.
.
4. [**Name (NI) 27408**] Dz - Pt was continued on home regimen of Meclezine.
.
5. Hypothyroidism - Pt was continued on Synthroid per her home
regimen.
Medications on Admission:
1. Levothyroxine 37.5 mcg PO daily
2. Meclizine 12.5 mg PO TID
3. Albuterol 1-2 Puffs Inhalation Q6H PRN.
4. Lovastatin 20 and 40 mg PO daily alternating.
5. Hexavitamin 1 Cap PO daily.
6. Divalproex 125 mg Tablet, Delayed Release (E.C.) every other
day
7. Protonix 40 mg PO daily
8. Omega 3 [**Hospital1 **]
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
2. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO qOD (every
other day) ().
3. Divalproex 125 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO EVERY OTHER DAY (Every Other
Day).
4. Lovastatin 20 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER
DAY (Every Other Day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
7. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO three
times a day: continue home regimen.
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every 4-6 hours as needed for asthma: continue home
regimen.
9. Hexavitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI Bleed
Discharge Condition:
Improved
Discharge Instructions:
You were admitted to the hospital for a GI Bleed. You were
admitted to the intesive care unit for close monitoring. You
received a total of 4 Units of blood. In addition, you had a
procedure called an endoscopy and colonoscopy to look for the
source of bleed. You were found to have an ulcer in your
duodenum which was likely the cause of your bleed.
If you have any further episodes of bleeding from below,
lightheadness, chest pain, shortness of breath, palpitations,
nausea or vomiting, please return to the ER or call your PCP.
You have a follow up appointment with your new PCP Dr [**Last Name (STitle) 27409**] on
Thursday [**10-11**]. At that time, you will need to get some
blood work done.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2187-10-11**]
9:00
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7676**] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2187-10-12**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]
|
[
"386.00",
"V45.73",
"532.40",
"493.90",
"562.12",
"250.00",
"733.00",
"272.4",
"244.9",
"296.80",
"280.9",
"729.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6336, 6342
|
3757, 5094
|
338, 375
|
6401, 6412
|
2465, 3734
|
7164, 7614
|
1842, 1948
|
5454, 6313
|
6363, 6380
|
5120, 5431
|
6436, 7141
|
1963, 2446
|
260, 300
|
403, 1301
|
1323, 1672
|
1688, 1826
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,049
| 117,138
|
8112
|
Discharge summary
|
report
|
Admission Date: [**2118-9-4**] Discharge Date: [**2118-9-10**]
Date of Birth: [**2046-8-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
ST segment elevation myocardial infarction
Major Surgical or Invasive Procedure:
Heart Catheterization x2
Mechanical Ventilation
Intraaortic Balloon Pump
Thransvenous pacermaker wire
History of Present Illness:
72 year old man DM2, HTN, hyperlipidemia, A-fib (but not taking
coumadin for the past week), ASD, h/o PE s/p IVC filter
placement, mild LV global dysfunction, mod MR, mild RV
dysfunction, developed dizziness starting 8am (no chest pain).
Went to OSH ER at 10:45 am- by this time symptoms resolved.
Found to have ST elevation in inferior leads with reciprocal
changes in in Av1 and AVL, anterior leads. BP 90's HR 60's in
a-fib. ETA 30 minutes (from [**Hospital 882**] hospital). cath reealed
multivessesl sx- midLAD 80%, D1 80-90%, mLCx 95-99%, mRCA 100%.
C-[**Doctor First Name **] decided not to take to OR related to prior sternotomy and
chronic venous disease.
In CCU- bradycardic , hypotensive --> PEA arrest-->
fluids/dopamine--> hypertensive and tachy --> Vtach--> lidocaine
--> BP high, SVT --> pt was coded for > 1hr --> taken back to
cath lab--> rec'd three RCA stents, IABP, transvenous pacer.
Past Medical History:
1. chronic AFib/aflutter
2. ASD s/p repair [**2112**]
3. HTN
4. Hypercholesterolemia
5. DMII
6. previous DVT w/ recurrent PE; s/p filter placement in [**2095**]
c/b migration and urgent sternotomy w/ repair of atrial
perforations x2
7. Recurrent LE venous stasis ulcers s/p failed skin grafts to
site
Social History:
He lives with his sister and brother-in-law. Formerly worked
for [**Company 2318**]. Denies alcohol, drug, or tobacco use.
Family History:
n/c
Physical Exam:
Gen: critically ill, unresponsive
HEENT: vomiting
Cards: Irregular distant sounds
Pulm: Diffusely rhoncorous, on vent
Abd: soft, no HSM
Extrem: hemosideran deposition anterior tibia B.
Pertinent Results:
[**2118-9-4**] 03:00PM PT-16.9* PTT-62.2* INR(PT)-1.6*
[**2118-9-4**] 03:00PM GLUCOSE-126* UREA N-19 CREAT-1.3* SODIUM-138
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2118-9-4**] 05:30PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2118-9-4**] 05:30PM WBC-20.3*# RBC-3.55* HGB-11.1* HCT-33.9*
MCV-96 MCH-31.4 MCHC-32.9 RDW-16.0*
[**2118-9-4**] 09:42PM WBC-21.1* RBC-3.31* HGB-10.5* HCT-29.6*
MCV-89# MCH-31.8 MCHC-35.6* RDW-16.3*
[**2118-9-4**] 09:42PM CK-MB-196* MB INDX-12.0* cTropnT-10.02*
[**2118-9-4**] 09:54PM LACTATE-2.7*
[**2118-9-4**] 09:54PM TYPE-ART PO2-169* PCO2-38 PH-7.43 TOTAL
CO2-26 BASE XS-1
ECHOCARDIOGRAM [**2118-9-5**]
Conclusions:
The left atrium is moderately dilated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is moderately depressed. Resting regional wall motion
abnormalities include inferior akinesis and inferolateral
hypokinesis (estimated ejection fraction ?40%). The right
ventricular cavity is dilated. Right ventricular systolic
function appears depressed. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic root is mildly dilated.
The ascending aorta is mildly dilated. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) 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 [2+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared to the prior study of [**2118-9-4**], findings are similar.
Aortic
regurgitation now may be slightly more prominent.
CARDIAC CATHETERIZATION [**2118-9-4**]
COMMENTS:
1) Initial angiography was unchanged from previous
catherization. The
RCA had a 100% mid vessel occlusion with collaterals to the
distal
vessel from the left system. The LAD and CX had high grade
lesions.
2) Successful PTCA, thrombectomy, and stenting of the distal,
mid, and
ostial RCA with multiple Cypher stents. A 2.75x16 mm Taxus was
deployed
in the distal RCA and was postdilated with a 2.75 mm NC balloon.
Overlapping 3.0x16 mm and 3.5x28 mm Taxus stents were placed in
the mid
RCA and the 3.5 mm stent was postdilated with a 3.5 mm NC
balloon. A
3.5x16 mm Taxus stent was placed in the ostial RCA and
postdilated with
a 4.0 mm NC balloon. Final angiography revealed <10 % residual
stenosis, no dissection, and TIMI 3 flow. (see PTCA comments)
3) Successful placement of an IABP and transvenous pacemaker
given the
bradycardic arrest and cardiogenic shock.
4) Resting hemodynamics revealed severely elevated right and
left sided
filling pressures, moderate pulmonary hypertension, and normal
cardiac
outputs.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Cardiogenic shock with severely elevated left and right sided
filling
pressures with normal cardiac outputs on IABP support.
3. Acute inferior myocardial infarction, managed by acute ptca,
temporary pacemaker, and IABP.
4. PTCA of RCA vessel with multiple drug eluting stents.
Brief Hospital Course:
72yo M with multiple cardiac risk factors presented with STEMI,
found to have 3VD awaiting CABG, became HD unstable, coded >
1hr, brought back to cath lab and received four taxus stents to
RCA. Patient was stabilized in the CCU on two pressors,
intraortic balloon pump and transvenous pacer wire. These were
all weened over the course of 4 days. Through discussions of
risks and benefits with CT surgery, the patient's family, and
primary cardiologist Dr. [**Last Name (STitle) 73**] it was decided to not undergo
CABG for multivessel disease. The family decided on DNR/DNI code
status at that time. With the patient stable off IABP and
pressors he was extubated on [**2118-9-9**] however developed pulmonary
edema and increased oxygen requirement. Was placed on BiPAP as
temporizing measure. Further discussion with family confirmed
DNR/DNI status, and they later decided to make the patient
comfort measures only. Morphine drip was titrated for comfort
and air hunger. The patient was pronounced dead at 11:25am on
[**2118-9-10**].
Medications on Admission:
Sotalol 80 PO TID
Amlodipine 5mg daily
Coumadin
glyburide 2.5 PO twice daily
fosamax
zestril 5
lipitor 10
HCTZ 25
Tamsulosin 0.4
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
ST elevation MI
Discharge Condition:
Pt Expired
|
[
"427.31",
"427.5",
"585.9",
"V12.51",
"428.21",
"401.9",
"518.81",
"507.0",
"578.0",
"997.1",
"410.21",
"785.51",
"414.01",
"599.0",
"443.9",
"250.00",
"584.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.72",
"93.90",
"96.04",
"37.61",
"37.78",
"00.40",
"99.07",
"36.07",
"37.23",
"00.17",
"99.69",
"00.48",
"88.56",
"00.66",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6734, 6743
|
5491, 6526
|
357, 460
|
6802, 6815
|
2104, 5128
|
1878, 1883
|
6706, 6711
|
6764, 6781
|
6552, 6683
|
5145, 5468
|
1898, 2085
|
275, 319
|
488, 1395
|
1417, 1719
|
1735, 1862
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,562
| 178,104
|
36181
|
Discharge summary
|
report
|
Admission Date: [**2153-10-27**] Discharge Date: [**2153-11-14**]
Date of Birth: [**2115-5-8**] Sex: M
Service: SURGERY
Allergies:
Demerol / Phenergan
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Splenic artery aneurysm.
Major Surgical or Invasive Procedure:
[**10-27**] - Exploratory laparotomy, splenectomy with distal
pancreatectomy, retroperitoneal exploration and control of
arterial and venous bleeding and abdominal packing for damage
control surgery
[**10-29**] - Exploratory laparotomy, removal of 20 laparotomy packs,
control of superficial bleeding and partial abdominal closure
[**10-31**] - Abdominal washout and closure of open abdomen
History of Present Illness:
This middle-aged Asian male presents unresponsive and intubated
with having been found down in his garage. He was brought to
[**Hospital3 **] ED where they did a CT scan finding blood in his
abdomen. He was brought up to [**Hospital1 1170**] and in shock, arriving with a blood pressure 60. With
aggressive resuscitation, we were able to get his blood pressure
up in the 110-120 region. He had the CT scan with him. There
was no contrast in that scan as far as IV contrast and also the
issue of his being found down was not clear. His abdomen at that
time was not terribly distended and he had a small amount of
blood in his abdomen. Based on that, we felt it is probably
necessary that we make sure that he had not suffered
intracranial hemorrhage since his INR, which had been reported
back, was nearly 2 and so he was quickly taken to CT scan for a
head scan and a C-spine scan when he again became hypotensive.
He was, therefore, taken to the OR as a STAT transfer
Past Medical History:
PMH: diabetes, hepatitis B
PSH: liver transplant for hepB ([**Hospital3 **] ~ 5 yrs ago)
Social History:
Married (wife [**Location (un) **].
Lives in [**Location 5110**] w/ wife and 2 children (5&2). Is a
stay-at-home dad; wife is manicurist.
Came from [**Country 3992**] 8 yrs ago. Has 2 siblings (brother & sister)
here.
Buddhist
Family History:
NC
Pertinent Results:
[**2153-10-27**] 11:58PM GLUCOSE-422* UREA N-18 CREAT-1.3* SODIUM-144
POTASSIUM-6.0* CHLORIDE-109* TOTAL CO2-13* ANION GAP-28*
[**2153-10-27**] 11:58PM CALCIUM-13.9* PHOSPHATE-6.8* MAGNESIUM-1.4*
[**2153-10-27**] 11:58PM WBC-1.8* RBC-2.21* HGB-6.9* HCT-20.2* MCV-91
MCH-31.4 MCHC-34.4 RDW-14.2
[**2153-10-27**] 11:58PM PLT COUNT-99*
[**2153-10-27**] 11:58PM PT-18.1* PTT-133.8* INR(PT)-1.7*
[**2153-10-27**] 10:31PM TYPE-ART TEMP-34.4 O2-100 PO2-451* PCO2-32*
PH-7.05* TOTAL CO2-9* BASE XS--21 AADO2-251 REQ O2-48
INTUBATED-INTUBATED VENT-CONTROLLED
[**2153-10-27**] 08:46PM ALT(SGPT)-19 AST(SGOT)-28 ALK PHOS-10* TOT
BILI-0.3
[**2153-10-29**] LIVER OR GALLBLADDER US
IMPRESSION:
1. Dilation of the common duct, measuring 9 mm.
2. Patent vessels within the right lobe of the liver. The left
lobe could
not be well evaluated due to patient positioning and overlying
bandages.
3. Right pleural effusion.
Brief Hospital Course:
[**10-27**] Transferred to [**Hospital1 18**] from [**Hospital3 **] w/ imaging c/w
hemoperitoneum. The day prior to arrival, was complaining of
stomach pain & later collapsed while helping friend work on his
car. At [**Hospital1 18**], found to be unresponsive, intubated, and
hypotensive. Volume resuscitation was temporarily successful.
Taken to OR as STAT transfer for ex-lap, splenectomy with distal
pancreatectomy & packing. Received 24 units PRBCs, 8 units FFP,
1 unit cryoprecipitate intraopa and peri-op. Post-op,
necessitated pressor support including levophed and epinephrine.
Patient was started on IV vancomycin, levofloxacin and flagyl.
[**10-28**] Patient was kept intubated/sedated with IV resuscitation,
ventilator and vasopressor support. A plastic surgery
consultation was obtained for epidermolysis of the left hand
dorsum. His arm was splinted below the elbow in extension with
xeroform and dry gauze dressing to the wound.
[**10-29**] Taken back to OR for exploratory laparotomy, removal of 20
laparotomy packs, control of superficial bleeding and partial
abdominal closure. The patient began to develop acute renal
failure with a creatinine of 3.6 up from 1.6. His LFTs were also
found to be rising. A transplant hepatology consult was
obtained. This rise was felt to be secondary to shock liver from
hypoperfusion.
[**10-30**] Continued to stabilize and resuscitate with IV fluids.
Patient was weaned off pressors. His creatinine and LFTs were
followed carefully. Adequate urine output.
[**10-31**] Takeback to OR for abdominal washout and closure of open
abdomen. Antibiotic regimen changed to vancomycin and zosyn.
[**11-1**] Tube feeding started, sedation weaned
[**11-2**] Vent weaned from CMV to CPAP. Antibiotics stopped.
[**11-3**] Vent wean continued. Self-extubated with immediate
re-intubation.
[**11-5**] Tube feeds advanced to goal.
[**11-6**] Extubated
[**11-7**] Off all drips/O2/sedation. Drinking/eating ground diet
without issue. [**Last Name (un) **] Biabetes center consulted for elevated
sugars. He was started on an insulin regimen which required
adjustment throughout his stay.
[**11-8**] Transferred from TSICU to floor.
On [**11-10**] he developed fevers and was pan cultured and empirically
started on Vanco and Zosyn. His blood and urine cultures grew
E.coli resistant to Ampicillin, Cipro and Bactrim so Augmentin
was started; the Vanco and Zosyn were stopped.
[**11-11**] He underwent abdominal imaging which revealed a perihepatic
abscess which was subsequently drained by Interventional
Radiology. Culture of the fluid was sent which had no growth,
the catheter continued to drain bile and was eventually removed
on day of discharge.
[**11-12**] Fevers defervesced and patient doing well.
He was discharged to home on [**11-14**] with services. Specific
instructions for follow up were provided.
Medications on Admission:
FK [**1-6**], hepsera 10', lamivudine 100', RISS
Discharge Medications:
1. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
2. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*qs Patch 72 hr(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
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. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Adefovir 10 mg Tablet Sig: One (1) Tablet PO qday ().
Disp:*30 Tablet(s)* Refills:*2*
7. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Glargine insulin Sig: Twenty Five (25) Units at bedtime.
Disp:*2 vials* Refills:*2*
9. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY
(Daily): Apply to left antecubital fossa daily as directed.
Disp:*1 Jar* Refills:*2*
10. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 13 days.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Splenic artery hemorrhage
Acute blood loss anemia
Secondary diagnosis: Diabetes
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills,
headache, dizziness, very hih or low blood sugars, shortness of
breath, abdominal pain, nausea, vomiting, diarrhea and/or any
other symptoms that are concerning to you.
Take all of your medications as prescribed and be sure to
complete your entire antibiotic course as instructed.
Followup Instructions:
Follow up next week with Dr. [**Last Name (STitle) **], call [**Telephone/Fax (1) 2359**] for an
appointment. You will also need to be scheduled for an
outpatient CTA (CT scan to look at your arteries). Please inform
the office when you call to make your appointment to schedule
this test.
Follow up with [**Last Name (un) **] Diabetes Asian American Clinic in the next
week, call [**Telephone/Fax (1) 58905**] for an appointment.
Follow up in [**Hospital 3595**] clinic for your left hand/arm in 1 week,
call [**Telephone/Fax (1) 5343**].
Follow up with your primary care doctor in [**12-6**] weeks, you will
need to call for an appointment.
Completed by:[**2153-11-21**]
|
[
"997.5",
"041.4",
"998.0",
"276.9",
"E928.9",
"V42.7",
"997.4",
"998.2",
"E878.8",
"584.5",
"518.5",
"276.2",
"913.2",
"250.00",
"442.83",
"599.0",
"790.7",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.62",
"99.07",
"96.59",
"54.59",
"52.52",
"99.05",
"41.5",
"39.31",
"99.04",
"96.72",
"96.6",
"39.98",
"96.04",
"99.09",
"07.44",
"50.61",
"38.87"
] |
icd9pcs
|
[
[
[]
]
] |
7255, 7310
|
3033, 5899
|
304, 696
|
7434, 7515
|
2090, 3010
|
7910, 8588
|
2067, 2071
|
5998, 7232
|
7331, 7381
|
5925, 5975
|
7539, 7887
|
240, 266
|
724, 1695
|
7402, 7413
|
1717, 1807
|
1823, 2051
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,957
| 114,920
|
50557
|
Discharge summary
|
report
|
Admission Date: [**2132-8-2**] Discharge Date: [**2132-8-4**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Epistaxis and hypotension
Major Surgical or Invasive Procedure:
L nares cauterized
History of Present Illness:
85 year old man with CAD s/p CABG and CHF who was admitted
with recurrent epistaxis. He was transferred to the MICU for
hypotension. He first had epistaxis one week ago and went to [**Hospital **]
clinic on [**7-24**] where he was cauterized. Five days later, he
presented to [**Hospital1 18**] ENT on [**7-29**] for recurrent epistaxis and was
packed by ENT consult. Two nights ago, he presented to the ED
again for epistaxis and was cautarized. He has not bled since.
In the ED, his vitals were 96.8, HR: 46, BP:167/74, RR:20, O2
95%RA.
He was kept overnight in the ED then admitted to the Medicine
team in the morning. He recieved all his BP meds including
metoprolol, lisinopril, lasix and imdur. At the time, he was
also straining to move his bowels. His SBP dropped from 120's to
80's over the course of the morning. His vitals were: 96.5,
88/40, 50, 94%RA. He remained asymptomatic; making urine,
ambulating and mentating. He recieved 650cc's of NS without
improvement, and given his h/o CHF, he was then transferred to
the MICU for closer monitoring and care. In the MICU the pt
received an additional 1L NS in boluses and 1L NS over 10 hrs
with improvement in his SBPs to the 120-140s. This am, he had an
episode of L sided chest pressure without SOB, diaphoresis, n/v,
lightheadedness, palpitations. Stated this was his anginal
equivalent which occurs 1-2xs/week. EKG was without any new
ischemic changes and pain relieved with SL nitro. Was transfused
2 units pRBC for Hct 23.9 which bumped to 28.7. Transferred to
floor for further care.
Baseline, he can walk 1 flight of stairs and would get SOB.
Baseline [**2-9**] pillow orthopnea. He has occasional chest pain and
relieves it with nitro.
Past Medical History:
-CAD: Severe 3 vessel disease s/p 3v CABG [**2108**](SVG=>D1=>LAD,
SVG=>OM1=>OM3, SVG= >AM). SVG=>D1=>LAD was stented [**2128**]. Repeat
cath [**7-11**] showed inoperable disease. During admit [**10-11**], had CP
a/w some dynamic ST segment depressions in anterior leads,
medically managed with aspirin, plavix, ACE, imdur, and
betablocker. LVEF >55% on Echo done [**12/2131**]
-Incarcerated paraesophageal hernia s/p laparoscopic repair with
fundoplication in [**10-11**]; associated gastric outlet obstruction
resolved with surgical repair
-Lower gastrointestinal bleed secondary to hemorrhoids and
colonic polyps, admit [**2129-11-20**]
-Hypertension with mild symmetric LVH
-Afib, first noted post-op during [**10-11**] admission post op after
paraesophageal hernia repair, converted to NSR on 11/[**2131**]. Off
coumadin [**2-8**] significant bleeding issues.
-Hyperlipidemia
-Diabetes type II
-By MRI/MRA: left posterior parietal infarct, chronic
periventricular microvascular ischemic changes, moderate disease
resulting in 60-70% stenosis of the right precavernous and
cavernous ICA
-s/p bilateral carotid endarterectomy
-Peripheral vascular disease status post left toe amputation
-History of prostate cancer status post radiation therapy
-Cataracts
Social History:
Never smoked
No illicit drugs
He denies alcohol use
Walks with walker at home, recently limited by SOB. Followed by
[**Hospital 119**] [**Name (NI) 2256**] [**Name (NI) 269**], PT, OT. Lives with his wife [**Name (NI) 1446**], has
son [**Name (NI) **] who is active in his care.
Family History:
History of MI in mother (death 89), father (death 67).
Physical Exam:
Vitals
97.5, 145/60, 57, 15, 100% room air
GEN- NAD, pleasant, cooperative
HEENT- MMM, OP clear, pale conjunctiva, no signs of active
bleeding
NECK- JVP 9 cm above sternal notch
CV- Normal S1 and S2. Soft apical holosystolic murmur. No S3.
PULM- Bibasilar crackles at bases, no rhonchi or wheezes
EXT- 1+ edema, 2+ pulses posterior tibialis and dorsalis pedis
bilaterally
Pertinent Results:
HCT 23.9 on [**2132-8-3**] 0600 improving to 28.7 on [**2132-8-3**] [**2055**]. HCT
stable at 27.2 on [**2132-8-4**]
Troponin T negative x two
proBNP 1798 on [**2132-8-2**]
EKG on [**2132-8-2**]
Probable ectopic atrial rhythm. Occasional atrial premature
beats. Right
bundle-branch block. Probable old inferior wall myocardial
infarction.
Prolonged QTc interval. Low QRS voltage in the precordial leads.
Compared to the previous tracing of [**2132-7-29**] atrial ectopy is
new. Otherwise, no significant diagnostic change.
Brief Hospital Course:
Briefly, 85 year old man with CAD s/p CABG and CHF who was
admitted with recurrent epistaxis, transferred to the MICU for
hypotension. He first had epistaxis on one week ago and went to
[**Hospital **] clinic on [**7-24**] where he was caudarized. Five days later, he
presented to [**Hospital1 18**] ENT on [**7-29**] for recurrent epistaxis and was
packed by ENT consult. Two nights ago, he had to come to the ED
again for epistaxis and was cautarized. He has not bled since.
In the ED, his vitals were 96.8, 46, 167/74, 20, 95%RA.
.
He was then admitted to the Med team in the morning. He recieved
all his BP meds including metoprolol, lisinopril, lasix and
imdur. At the time, he was also straining to move his bowels.
His SBP dropped from 120's to 80's over the course of the
morning. His vitals were: 96.5, 88/40, 50, 94%RA. He remained
assymtomatic; making urine, ambulating and mentating. He
recieved 650cc's of NS without improvement, and given his h/o
CHF, he was then transferred to the MICU for closer monitoring
and care. In the MICU the pt received an additional 1L NS in
boluses and 1L NS over 10 hrs with improvement in his SBPs to
the 120-140s. This am, he had an episode of L sided chest
pressure without SOB, diaphoresis, n/v, lightheadedness,
palpitations. Stated this was his anginal equivalent which
occurs 1-2xs/week. EKG was without any new ischemic changes and
pain relieved with SL nitro. Was transfused 2 units pRBC for Hct
23.9 which bumped to 28.7. Transferred to floor for further
care.
.
Baseline, he can walk 1 flight of stairs and would get SOB.
Baseline [**2-9**] pillow orthopnea. He has occasional chest pain and
relieves it with nitro.
[**2132-8-4**]
Patient had episode of bradycardia during the night of [**2132-8-3**].
Went down to 22, patient was aymptomatic and sleeping
comfortably. Heart rate rose back into baseline of 50s, blood
pressure was 140/44. Tele otherwise unremarkable. Decision was
made to continue with metoprolol due to his significant coronary
disease. Blood pressure have held, systolic in the 120s-130s for
the past 24 hours. Patient is not a candidate for
revascularization or surgery, needs optimal medical management.
No signs of epistaxis s/p cautery in the emergency room. Patient
is stable and decision for discharge was made today.
Medications on Admission:
MEDICATIONS ON TRANSFER FROM FLOOR:
# Aspirin 81 mg PO DAILY
# Clopidogrel Bisulfate 75 mg PO DAILY
# Metoprolol 25 mg PO TID
# Lisinopril 20 mg PO DAILY
# Furosemide 20 mg PO DAILY
# Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
# Nitroglycerin SL 0.3 mg SL PRN
# Clindamycin 300 mg PO Q6H
# Sodium Chloride Nasal 2 SPRY NU TID
# Mupirocin Nasal Ointment 2% 1 Appl NU [**Hospital1 **] Duration: 5 Days
# Pantoprazole 40 mg PO Q24H
# Atorvastatin 40 mg PO DAILY
# FoLIC Acid 1 mg PO DAILY
# Ferrous Sulfate 325 mg PO DAILY
# Insulin SC (per Insulin Flowsheet)
# Atropine Sulfate 1 mg IV ASDIR
Discharge Medications:
1. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Dorzolamide-Timolol 2-0.5 % Drops Sig: Two (2) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day).
Disp:*2 bottles* Refills:*2*
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Mupirocin 2 % Ointment Sig: One (1) application Topical
twice a day for 2 days.
15. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 3 days.
Disp:*24 Capsule(s)* Refills:*0*
16. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
17. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*2*
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] [**Hospital 2256**]
Discharge Diagnosis:
CAD- severe 3 vessel disease s/p CABG in [**2108**], LAD stent placed
[**2128**], repeat cath [**7-/2131**] showed inoperable disease
Diastolic heart failure- EF 65-70%
Hypertension
Atrial fibrillation- converted, off coumadin due to bleeding
problems
Paraesophageal hernia- s/p fundplication
Epistaxis
chronic anemia
Chronic lower GI bleed
Diabetes type 2
Hyperlipidemia
PAF
h/o CVA
s/p bilat CEA
h/o prostate ca s/p radiation
cataracts
PVD- s/p left toe amputation
Discharge Condition:
Good
Patients blood pressures holding in the 120-130s systolic
Heart rate in the 50s, baseline
No active bleeding
Discharge Instructions:
You were admitted to the hospital to monitor your blood
pressure which was found to be low during the event of a
prolonged nosebleed.
Continue to use Ocean nasal spray to both nares 4 time a day.
Just allow the fluid to drip into your nose to keep your nose
moist.
Clindamycin is an antiboitic. Please continue for 2 more days.
Continue all medicines as prior to this admission.
Contact Dr [**First Name (STitle) **] [**Telephone/Fax (1) **] if you have nose discomfort or
concerns about bleeding.
Followup Instructions:
Dr [**First Name (STitle) **] on Wednesday [**8-6**] 2:15 at [**Location (un) 55**] Office
[**Telephone/Fax (1) **]
Please follow up with you primary care doctor Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1609**]
within 1-2 weeks. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1609**]. Her phone number is [**Telephone/Fax (1) 2740**]
|
[
"458.8",
"V15.3",
"578.9",
"428.30",
"784.7",
"250.00",
"427.31",
"285.1",
"427.89",
"V10.46",
"593.9",
"428.0",
"401.9",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"21.03"
] |
icd9pcs
|
[
[
[]
]
] |
9313, 9382
|
4630, 6932
|
243, 264
|
9893, 10009
|
4077, 4607
|
10566, 10944
|
3612, 3668
|
7587, 9290
|
9403, 9872
|
6958, 7564
|
10035, 10543
|
3683, 4058
|
178, 205
|
297, 2005
|
2027, 3299
|
3315, 3596
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,527
| 112,574
|
2347
|
Discharge summary
|
report
|
Admission Date: [**2150-5-16**] Discharge Date: [**2150-5-22**]
Date of Birth: [**2093-6-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
56 with history of tonsillar cancer (post XRT in [**2140**], post
trach/PEG, recurrent aspiration PNA) presents from [**Hospital1 1099**] rehab with hypotension. Of note, he was just recently
admitted to [**Hospital1 18**] for septic shock in [**2-21**] and to [**Hospital1 2177**] in [**5-3**] for
the same problem. Over the past 6 months he has had recurrent
aspiration and has been ventilator dependent.
.
He presented to the ED with hypotension. He was transferred for
BP in 70-80. He was given fluid bolus at [**Hospital3 672**] with no
response and hence transferred here. He was also reported had
change in mental status. His initial vitals were T101.8 P120
BP84/50. He was given 1L NS, flagyl, levaquin, 1L LR and 1u
PRBC. He refused central line twice in the ED. Sepsis protocol
was thus not initiated. He was also found to be profoundly
anemic, with leuckocytosis and severe diarrhea with is guiac
positive.
Past Medical History:
Head and Neck Ca s/p XRT 96 (PEG/Trach)
history of recurrent aspiration pneumonias.
Recent discharge from [**Hospital1 2177**]
IDDM, Hep C, hz IVDU, Anxiety, PTSD
history of pericarditis ([**12-24**] hospitalization)
history of MRSA pneumonia
history of pseudomonas
Social History:
has 2 daughters
[**Name (NI) **] has been in hospitalized setting since [**2149-10-20**],
prior to this he was living at home with aunt. [**Name (NI) **] was a former
drug abuse counsellor
Family History:
noncontributory
Physical Exam:
bp117/76 p110 on AC, 400x12 40% FiO2, PEEP=5, 99%
Gen: severe cachexia
HEENT: dry MM, pallor
Abd: diffusely tender
Lungs: diminished BS bilaterally
CV: RRR, nl s1/s2, no m/r/g
Extr: Left thigh swollen and tender
Pertinent Results:
Admission Labs:
[**2150-5-16**] 07:40PM WBC-44.5*# RBC-1.65*# HGB-5.0*# HCT-15.7*#
MCV-95 MCH-30.0 MCHC-31.5 RDW-16.7*
[**2150-5-16**] 07:40PM NEUTS-68 BANDS-18* LYMPHS-4* MONOS-5 EOS-0
BASOS-0 ATYPS-1* METAS-3* MYELOS-1*
[**2150-5-16**] 07:40PM PLT SMR-NORMAL PLT COUNT-315#
[**2150-5-16**] 07:40PM PT-12.9 PTT-33.2 INR(PT)-1.1
[**2150-5-16**] 07:40PM GLUCOSE-66* UREA N-21* CREAT-0.9 SODIUM-142
POTASSIUM-5.0 CHLORIDE-109* TOTAL CO2-26 ANION GAP-12
[**2150-5-16**] 07:40PM ALT(SGPT)-22 AST(SGOT)-44* CK(CPK)-68 TOT
BILI-0.5
.
CT LOW EXT W&W/O C BILAT [**2150-5-17**] 12:59 PM
CT LOWER EXTREMITY: The left adductor magnus muscle is expanded
to 7.3 x 7.1 cm, with high-density fluid consistent with blood.
The right adductor muscle, at the same level measures 2.5 x 3.0
cm. The hematoma extends to the level of the pubic symphysis
superiorly, and to the distal femur/knee inferiorly.
Additionally, high-density fluid fills the gluteus maximus
muscle posteriorly. Fat stranding is seen throughout the imaged
left leg. On post-contrast imaging, there was no evidence of
arterial active bleed. There are diffuse vascular
calcifications. Air is seen within the bladder, without a
visualized Foley catheter in place.
BONE WINDOWS: Mild degenerative changes are seen. There is no
visible disruption of the cortex, periosteal reaction, or sinus
tract within the left femur to indicate osteomyelitis.
Degenerative changes are seen along the pubic symphysis,
bilateral hips. There are diffuse vascular calcifications.
IMPRESSION:
1) Large left hematoma, without CT evidence of active bleeding.
If arterial source is clinically suspected this should be
evaluated with conventional angiography.
2) No bony changes to suggest the presence of an abscess, or
osteomyelitis.
3) Air within the bladder, without presence of Foley catheter.
Reasons for this could include recent instrumentation, recent
removal of Foley catheter, versus infectious etiology.
CHEST (PORTABLE AP) [**2150-5-16**] 5:37 PM
PORTABLE AP CHEST RADIOGRAPH: The study is extremely limited
secondary to difficulty with patient positioning. There is an
opacity in the left lower lobe, which may represent pneumonia.
There is a small left pleural effusion. The remainder of the
lung fields is unchanged from prior study. A tracheostomy tube
is seen with the tube tip approximately 6 cm above the carina.
The soft tissue and osseous structures are unchanged from prior
study.
IMPRESSION: Limited study. There appears to be an opacity in the
left lower lobe, which may represent pneumonia. Additionally,
there appears to be a small left pleural effusion. Recommend
repeat evaluation with PA and lateral chest radiographs.
PORTABLE ABDOMEN [**2150-5-16**] 11:13 PM
There is paucity of the air throughout the abdomen. Air is
probably noted in the ascending and transverse colon and
rectosigmoid. No evidence of obstruction. No evidence of toxic
megacolon.
There is probably a small bilateral pleural effusion. Patchy
opacity is seen in the left lower lobe. If clinically indicated,
please evaluate with chest x-rays. The free air is not well
examined on this supine abdominal film.
IMPRESSION: No evidence of obstruction.
Brief Hospital Course:
56yo M with tonsillar cancer, recurrent aspiration penumonia,
ventilator dependent, diabetes who presented with sepsis and
acute hematocrit drop with goal of care comfort measures only
#ID:The patient initially presented with leukocytosis, fever,
18% bandemia but with lactate 1.9 with possible sources
including cdiff, LLL PNA, and UTI. Initial CXR was clear. His
stool cultures were pending but he had diarrhea in the setting
of recent antibiotics and thus flagyl for possible Cdiff was
started. The pt and his family subsequently requested comfort
measures only and specified that all antibiotics, additional
IVs, blood draws etc be discontinued for comfort. After this
decision was made, pt's sputum culture was found to have
klebsiella sensitive to only imipenum and meropenum and
pansensitive pseudomonas resistant only to ciprofloxacin. Stool
cultures and Cdiff were negative. No antibiotics were continued
on discharge (patient was made CMO after discussion with patient
and family), and he was discharged to hospice.
.
#anemia- The patient was found to be anemic believed to be
secondary to a hematoma in the left medial thigh. The etiology
remains unclear but it may have been related to a femoral stick
at an outside hospital. His initial hct in the ED was 15. He was
transfused 2 units pRBC's with an increase to 24. A CT scan of
his left thigh showed a hematoma with suspected ongoing bleed
based on appearance. A source was not localized. His repeat Hct
was 21. A pressure gauze was placed on his left leg and he was
transfused an additional 2 units for suspected ongoing bleed.
Vascular surgery was consulted as well for potential surgical
intervention, however family wished for no invasive procedures,
only supportive care.
.
#respiratory : The patient was initially continued on outpatient
ventilatory settings. He was treated prn with anti-anxiety
medications. On [**5-18**], a family meeting was held with the
patient's daughter ([**Name (NI) 12230**]) and an aunt who agreed that the
patient would want the ventilator to be discontinued as well. He
tolerated this well and was placed on a trach maskl. He
maintained o2 sats in the high 90-100 range.
.
#FEN: Pt was initial kept NPO. Pt expressed that he was a hungry
and a desire to eat/drink. He was started on bolus tube feeds
through his J tube.
#code-DNR/DNI/CMO. Had family meeting on [**5-17**] and [**5-18**] where
daughter and aunt agreed that the patient would not aggressive
measures at this time. This includes intubation, pressors, IVs,
lab draws, antibiotics. They are agreeable to IV only for pain
meds in the case he loses IV access. The patient cannot take PO
MSO4 (including liquid form). After transfer to the floor,
palliative care was consulted. He was ultimately discharged to
hospice care.
#Communication -aunt very involved with his care although
daughters
are official healthcare proxy.
daughter [**Name (NI) 12231**] [**Known lastname 12232**] [**Telephone/Fax (1) 12233**]
[**Name2 (NI) **]ter [**First Name8 (NamePattern2) 12234**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 12235**]
Medications on Admission:
On admission:
Zosyn
SQ heparin
Fentanyl TP
Vancomycin
MVI
Vitamin C
Zyprexa
Protonix
Fe supplements
Discharge Medications:
1. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
2. Ativan 2 mg/mL Solution Sig: 1-5mg Injection every 4-6 hours
as needed for aggitation.
3. Haldol 5 mg/mL Solution Sig: 0.5-1 Injection every 4-6 hours
as needed for aggitation.
4. Morphine Sulfate 2 mg/mL Solution Sig: 2-10mg Injection q3h
as needed for pain.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Tonsillar cancer
Aspiration pneumonia (klebsiella and pseudomonas)
Discharge Condition:
Maintaining o2 sat from 95-100%
Discharge Instructions:
Pt is comfort measures only.
-no IVF, lab draws, antibiotics. He is DNR/DNI.
Followup Instructions:
None
|
[
"V10.01",
"482.1",
"070.70",
"995.91",
"998.12",
"250.00",
"V44.1",
"038.9",
"V44.0",
"008.45",
"507.0",
"482.0",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8915, 8930
|
5282, 8382
|
326, 333
|
9041, 9074
|
2062, 2062
|
9199, 9207
|
1793, 1810
|
8532, 8892
|
8951, 9020
|
8408, 8408
|
9098, 9176
|
1825, 2043
|
275, 288
|
361, 1281
|
2078, 5259
|
8422, 8509
|
1303, 1571
|
1587, 1777
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,144
| 178,652
|
42181
|
Discharge summary
|
report
|
Admission Date: [**2165-11-2**] Discharge Date: [**2165-11-13**]
Date of Birth: [**2081-6-10**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2071**]
Chief Complaint:
Congestive Heart Failure, Non-ST elevation Myocardial Infection,
Urinary Tract Infection
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 year old female per record has a history of colon cancer
recent diagnosis of pneumonia presenting from an outside
hospital with congestive heart failure, NSTEMI, and urinary
tract infection. Patient is confused and unable to answer
questions, history obtained from chart from [**Hospital3 **] and
from husband. She was recently admitted to [**Hospital3 **]
[**2165-10-25**] for lethargy and PNA, had been hospitalized prior to
that for R colectomy for colon Ca c/b cholecystitis s/p
cholecystecomty and also had G tube placement. PNA treated with
oral abx and dc'ed to rehab with anticipation that G tube would
be removed in near future.
.
She was sent to [**Hospital3 **] again on [**2165-11-2**] from rehab for
shortnss of breath, nasal congestion and desat to 70s, improved
to 93% with O2 by NC. the onset was 2 days prior to
presentation. The patient characterizes increased shortness of
breath at rest. SOB is exacerbated by activity; relieved with
rest. At the outside hospital, her room air saturation was noted
to be in the 70s and she was tachypneic, placed on O2 by NC.
.
In regard to associated symptoms, the patient denies chest pain,
cough, headache or change in vision, neck stiffness, abdominal
pain, focal numbness tingling or weakness, dysuria or urinary
frequency although patient appears to be altered and knows she
is in a hospital but does not know why, thinks she lives at home
with her husband and is not sure of the year.
.
In the ED, noted to have physical exam with stigmata of CHF
including symmetric lower extremity edema, crackles in the bases
bilaterally, +JVD. Give 40 mg IV lasix at outside hospital ED
and received vanc and zosyn for evidence of UTI on UA. Troponin
noted to be elevated at 0.15, Cr 1.9, Hct 33.3. She was given
heparin bolus and gtt for concern for NSTEMI as well with EKG
showing a flutter at 85 and TWI in lateral leads, no prior. BNP
ordered in ED and is pending. Also received duonebs with some
improvmeent in dyspnea. Initial ED VS 96.1 86 113/71 24 98% 2l
at [**Hospital1 18**].
.
Currently, patient denies any complaints although she is
breathing very quickly and appears uncomfortable. Husband notes
that she has been increasingly forgetful over the last few
months but has been confused in that she is not sure entirely of
what day it is, where she is at all times. She also has
occasinally been very agitated and angry while at rehab. After
first operation in [**9-22**] for colon cancer, she started getting
more confused. Per husband, mental status at baseline today. He
thought she had been improving, denied any complaints in the
last couple of days, but while he was vistiting her today she
suddenly started breathing very hard. No fevers, but has had
cough and congestion for the last about 7 days, was recently
admitted for PNA and had been on a course of keflex. Lower
extremity edema has been presented since [**9-22**] and has not
worsened. Husband denies any other symptoms.
Past Medical History:
Hyperlipidemia, Hypertension, Hypothyoridism, Vertigo, Anemia
(on B12 and iron), history of MRSA, Colon CA s/p R colectomy c/b
cholecystitis s/p cholecystectomy in [**9-/2165**], Anorexia with
G-tube placed [**2165-10-28**], Anxiety, "only one kidney works" per
husband
Social History:
-Tobacco history: former smoker quit 30 yrs ago, started as
teenager 1 ppd until 40 years old
-ETOH: denies
-Illicit drugs: denies
lives at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Healthcare Center ([**Telephone/Fax (1) 91474**], but lived
at home prior to [**9-22**]
Family History:
[**Name (NI) **] brother died of MI at 71, brother with pancreatic cancer
in 70s. Mother died of pernicious anemia at 44, fathr died 57
from strokes. Sister died at 59 died of kidney failure. Has a
living and brother and sister. [**Name (NI) **] family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: 95.6 146/75 85 40 100% 2L
GENERAL: WDWN F breathing heavily. Oriented to hospital,
[**Month (only) 359**], self but not to year or president. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with elevated JVP
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: No chest wall deformities, scoliosis or kyphosis. Appears
to be working hard to breathe, +bilateral crackles at bases,
wheezes throughout
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits, G tube in place with
no drainage
EXTREMITIES: 3+ pitting edema to knees, +venous stasis changes
on shins. No femoral bruits.
SKIN: No ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
Admit Labs:
[**2165-11-2**] 08:00PM BLOOD WBC-7.8 RBC-3.79* Hgb-10.6* Hct-33.3*
MCV-88 MCH-28.0 MCHC-31.9 RDW-17.7* Plt Ct-230
[**2165-11-2**] 08:00PM BLOOD Neuts-69.8 Lymphs-24.6 Monos-3.9 Eos-1.5
Baso-0.2
[**2165-11-2**] 08:00PM BLOOD PT-12.8 PTT->150 INR(PT)-1.1
[**2165-11-2**] 08:00PM BLOOD Glucose-98 UreaN-22* Creat-1.9* Na-139
K-4.6 Cl-108 HCO3-20* AnGap-16
[**2165-11-2**] 08:00PM BLOOD CK(CPK)-48
[**2165-11-2**] 08:00PM BLOOD Albumin-2.2* Calcium-7.7* Phos-4.7*
Mg-1.4*
.
CXR [**2165-11-2**]:
UPRIGHT AP VIEW OF THE CHEST: The heart size is mildly enlarged.
There is
mild-to-moderate pulmonary edema with perihilar haziness and
vascular
indistinctness. Additionally, small-to-moderate sized layering
bilateral
pleural effusions are present, greater on the left than on the
right. Dense opacification in the retrocardiac region may
reflect compressive atelectasis. Infection, however, is not
excluded. Diffuse calcification of the aorta is present. There
is no pneumothorax. Right PICC tip terminates within the mid
SVC. No acute osseous abnormalities are seen.
IMPRESSION:
Mild-to-moderate pulmonary edema. Small-to-moderate sized
bilateral pleural effusions, left greater than right.
Retrocardiac opacity may reflect compressive atelectasis though
infection cannot be excluded.
.
EEG [**2165-11-6**]:
FINDINGS:
CONTINUOUS EEG: The initial part of this recording (eight
minutes) is
performed on the Natus EEG system. This shows continuous
bilateral
frontally maximal high voltage sharp and slow wave discharges at
2 Hz.
The discharges are of higher amplitude over the right
hemisphere. EEG
is then continued on the Apropos system at 1 a.m. The patient
had
received intravenous lorazepam in the interim. The recording
shows a
[**6-18**] Hz posterior dominant rhythm with diffuse frontally maximal
semi-rhythmic delta activity. There are frequent high voltage
bilateral
sharp and slow wave discharges, sometimes in brief periodic runs
at
0.5-1 Hz. EEG is disconnected between 2 and 3 a.m. At 4:30 a.m.,
there
is recurrence of the 2 Hz high voltage sharp and slow wave
discharge
pattern in bursts lasting three to five minutes. This then
resolves
until 5 a.m. when the high voltage sharp and slow wave
discharges recur
at 1.5 Hz lasting until 6:50 a.m., resolving for several minutes
and
then continuing until the end of the study at 7 a.m.
SPIKE DETECTION PROGRAMS: There are 1,009 automated spike
detections
predominantly for the high voltage spike and slow wave
discharges
described above, as well as EMG and electrode artifact.
SEIZURE DETECTION PROGRAMS: There are 11 automated seizure
detections
predominantly for electrode and movement artifact. There are
several
prolonged electrographic seizures, as described above.
PUSHBUTTON ACTIVATIONS: There are no pushbutton activations.
SLEEP: The patient progresses from wakefulness to stage II, then
slow
wave sleep at appropriate times with no additional findings.
CARDIAC MONITOR: Shows a generally regular rhythm with an
average rate
of 60-70 bpm.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of initial continuous 2 Hz high voltage sharp and slow wave
discharges
consistent with generalized nonconvulsive status epilepticus.
There is
slight predominance of the ictal rhythm over the right
hemisphere. This
pattern improved after intravenous lorazepam and intravenous
levetiracetam, but then recurred several hours later and lasted
until
the end of the study. Between electrographic seizures,
background
showed a slow posterior dominant rhythm and diffuse delta
activity
indicative of moderate diffuse cerebral dysfunction which is
etiologically non-specific. There were frequent bifrontal sharp
and
slow wave discharges.
.
MRI of the brain w/o contrast ([**2165-11-9**])
CLINICAL INFORMATION: Patient with CHF and myoclonic status
which is now
settled following medication adjustment, confused but otherwise
nonfocal exam, question evidence of hypoperfusion accounting for
seizures.
TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and
diffusion axial
images of the brain were acquired.
FINDINGS: FLAIR images demonstrate multiple foci of T2
hyperintensity in the periventricular and subcortical white
matter. There is moderate
ventriculomegaly seen with mild dilatation of the temporal
horns. The
findings are indicative of brain atrophy. The diffusion images
demonstrate no evidence of acute infarct. In addition, the
diffusion images demonstrate no evidence of areas of restricted
diffusion to indicate watershed infarcts or global cerebral
hypoperfusion.
IMPRESSION: No acute infarcts are seen. Brain atrophy and small
vessel
disease are noted.
.
Discharge Labs:
[**2165-11-13**] 05:15AM BLOOD WBC-10.2 RBC-3.10* Hgb-9.1* Hct-27.9*
MCV-90 MCH-29.3 MCHC-32.6 RDW-18.5* Plt Ct-354
[**2165-11-13**] 05:15AM BLOOD Glucose-126* UreaN-54* Creat-2.1* Na-146*
K-3.7 Cl-106 HCO3-38* AnGap-6*
[**2165-11-9**] 06:10AM BLOOD ALT-17 AST-23 AlkPhos-122* TotBili-0.1
[**2165-11-13**] 05:15AM BLOOD Phos-2.3* Mg-2.0
[**2165-11-7**] 02:32AM BLOOD T4-3.4* T3-48* calcTBG-0.87 TUptake-1.15
T4Index-3.9*
[**2165-11-7**] 02:32AM BLOOD TSH-25*
[**2165-11-6**] 08:45PM BLOOD Ammonia-8*
[**2165-11-12**] 04:53AM BLOOD Valproa-49*
Brief Hospital Course:
Primary Reason for Hospitalization: Mrs. [**Known lastname **] is an 84 year old
female with a history of HTN, colon cancer s/p colectomy c/b
cholecystitis s/p laparascopic cholecystectomy, HLD, p/w
dyspnea, UTI, elevated troponin, evidence of fluid overload on
physical exam and who developed status epilepticus.
.
# Goals of Care: Several days into the hospitalization a family
meeting was held with patient's husband and daughter present.
They expressed that the patient would want to be at home rather
than repeatedly hospitalized as she has been for the past 2
months. Currently the plan is to get the patient to rehab for a
fixed amount of time (2 weeks maximum) to see whether the
patient can gain any strength to be more functional. The
secondary purpose would be for the family to get a better idea
of how to care for the patient at home. After a week or so of
rehab the patient would go home with hospice. She will continue
to receive medical care but interventions will focus on things
that will improve her comfort and ability to interact with the
environment. Therefore controlling seizures and avoiding
pulmonary edema will be tantamount. If her care transitions to
hospice, we recommend discontinuing Atrovastatin, multivitamins,
ferrous sulfate. We also recommend only giving free water and
food by gastric tube for comfort.
.
# Status Epilepticus: On [**11-6**] patient became more
encephalopathic, not interacting when her family visited on
[**11-6**]. Thus a head CT and EEG were performed with the latter
demonstrating polyspike and wave discharges at
1Hz with evidence of status epilepticus (myoclonic
encephalopathic type). The patient was treated with IV lorazepam
and Keppra with delayed hypotension into the 70s systolic and
maintained pressures in the 80-90s resulting in transfer to the
ICU under neurology on [**11-7**]. Her hypotension settled on
transfer and she did not require pressor support. She improved
initially from a behavioral and EEG perspective after cessation
of cefepime and initiation of Keppra however had persistent
epileptiform discharges and episodic seizures on [**11-7**]. She was
loaded with IV sodium valproate, changed AEDs to IV and started
standing dose and gave additional dose overnight into [**11-8**] due
to persistent seizures. No seizures on [**11-8**] and keppra
increased to 1g [**Hospital1 **]. The etiology is likely multifactorial. An
MRI was performed which showed many nonspecific findings but no
clear etiology for the seizures.
.
# NSTEMI vs Demand Ischemia: Patient is a poor historian due to
dementia and delirium so it was difficult to illicit if patient
was having CP sysmptoms prior to transfer from OSH. Patient at
OSH had troponin elevation 0.43 prior to transfer with EKG
changes. On Presentation to [**Hospital1 18**] ED, trops were 0.15 to 0.14,
CKMB 8->6. In the setting of renal failure and fluid overload
with CHF exacerbation patient thought to have NSTEMI. Patient
had dynamic EKG changes upon evaluation of OSH EKG and EKG taken
[**Hospital1 18**] ED. She was noted to have new TWI in V4-V6, and ST
elevation in V3 in comparison to previous EKG on the [**10-25**].
Patient was treated with maximal medical therapy including
heparin drip. The plan originally was for possible outpatient
cath when patient's overall medical condition improved however
that plan changed as goals of care changed.
.
#Pneumonia: Patient was being treated at OSH prior to admission
for Pneumonia. She was noted to have evidence of fluid overload
but concern for LLL infiltrate per OSH CXR. Patient had
productive cough, but no elevation in WBC or fever. She was
placed on Vanc/Cefpimie (D1 [**2165-11-3**]). After several days the
patient's presentation appeared more consistent with CHF
exacerbation rather than PNA therefore antibiotics were
dicontinued. In addition there was concern that cefepime could
have lowered the seizure threshold.
.
# Acute systolic CHF exacerbation (EF=40%): Patient was
hypervolemic on exam with elevated JVP, lower extremity edema,
and dypsnea also with concerning CXR with pulm edema. She did
not have previously have documented CHF, but per rehab notes was
recently started on lasix 20mg daily. Her BNP was 70,000 on
presentation. She was diuresed aggresively with IV lasix before
being transitioned to PO torsemide. She was also treated with
Metoprolol, lisinopril, and spironolactone.
.
# CKD: Cr was 2.0 prior to discharge which was at recent
Baseline per OSH records.
.
# Anemia: Patient has an unclear baseline, but patient on
presentation was hemodynamically stable. Her HCT was trended and
she was continued on her home B12 and iron supplementation
.
# HTN: Patient's medications were changed to lisinopril,
metoprolol, spironolactone, and torsemide as above.
.
# Dementia: Pt on presentation from OSH had altered mental
status and was A&Ox1 (only to person). Per family report patient
has had memory issues over the last year but did not carry a
diagnosis of dementia. Pt had a CT head [**2165-10-25**] at OSH which
demonstrated no acute intracranial process, atropy and
mircovascular leukoencephalopathy (proogresed from [**2162-1-18**]).
She also had an MRI during this admission that showed many
nonspecific findings. The patient's med list was reconciled to
reduce deliriogenic meds including stopping meclizine and ativan
(unless needed for status epilepticus). Seroquel was stopped
because patient's agitation was able to be controlled adequately
with redirection and comforting.
.
# HLD: Patient was on simvastatin at home, changed to
atorvastatin 80mg given possible NSTEMI.
.
# Vertigo: Patient had no symptoms therefore meclizine was
stopped to avoid inducing delirium
.
# Anorexia: Patient had history of poor PO intake, recent G tube
placed at OSH. She was taking mirtazapine however this was
discontinued when it appeared to be worsening her mental status
and possible also her seizures.
.
# Hypothyroidism: Patient's levothyroxine was increased because
of very elevated TSH and low T4 and T3.
.
.
TRANSITIONAL ISSUES:
- TSH should be rechecked in [**4-17**] wks after increase in
levothyroxine dose if consistent with goals of care at that
point
Medications on Admission:
Keflex 500 mg TID (last day to be [**11-4**])
lactobacillus [**Hospital1 **]
Kcl 20 mEq daily
levothyroxine 75 mcg daily
simvastatin 20 mg daily
vitamin B12 250 mcg daily
lorazepam 0.5 mg Q6H PRN
ferrous sulfate 325 mg daily
heparin 5000 units TID
meclizine 12.5 mg Q8H PRN dizziness
tramadol 50 mg Q6H PRN
remeron 15 mg QHS
albuterol nebs PRN
multivitamin
hctz 25 mg daily
labetolol 200 mg [**Hospital1 **]
lasix 20 mg daily
seroquel 25 mg [**Hospital1 **]
seroquel 25 mg Q6H prn
nitropaste PRN
Tube feeds: free water flush 200 mL Q6H, jevity 1.2 cal 50
mL/hr, on at 8 pm of at 6AM, hold durng the day
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
5. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for Dizziness.
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. valproic acid (as sodium salt) 250 mg/5 mL Syrup Sig: One
(1) PO Q8H (every 8 hours).
11. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Tube feeds
Tubefeeding: Nepro Full strength;
Starting rate:35 ml/hr; Do not advance rate Goal rate:35 ml/hr
Residual Check:q4h Hold feeding for residual >= :200 ml
Flush w/ 50 ml water q6h
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] Continuing Care Center - [**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnoses:
Acute on Chronic Diastolic Heart Failure
Healthcare Associated Pneumonia
Non convulsive seizure
Secondary Diagnoses:
hypothyroidism
pneumonia
vertigo
anemia, unclear etiology, on B12 and iron supplements
HTN
MRSA hx
Colon Ca s/p R colectomy c/b cholecystitis s/p cholecystectomy
in [**9-/2165**]
G tube placed [**2165-10-28**]
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to the hospital because you were found to have
a pneumonia. You were also found to have increased fluid
buildup around your lungs, thought to be secondary to problems
with your heart.
Your hospital course was complicated by seizure activity. We
treated you with medication to control the seizures, you will
need to continue to take these medications to prevent seizures
in the future.
You also suffered a heart attack and were taken for cardiac
catheterization. There was stent placed, and optimal medical
management was started.
The following changes were made to your medications:
START Aspirin
INCREASE Levothyroxine
DISCONTINUE Simvastatin
DISCONTINUE Lorazepam
DISCONTINUE Tramadol
DISCONTINUE Remeron
DISCONTINUE Hydrochlorothiazide
DISCONTINUE Labetalol
DISCONTINUE Furosemide
DISCONTINUE Seroquel
START Atorvastatin
START levetiracetam
START Valproic Acid
START Torsemide
START Lisinopril
START Metoprolol
START Spironolactone
Followup Instructions:
Please follow up with your primary care provider as needed
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 2073**]
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69,022
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Discharge summary
|
report
|
Admission Date: [**2188-8-6**] Discharge Date: [**2188-8-10**]
Date of Birth: [**2108-5-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
RUQ pain, transferred from another hospital for evaluation of
cholangitis, pancreatitis
Major Surgical or Invasive Procedure:
ERCP [**2188-8-7**]
History of Present Illness:
Mr. [**Known lastname 83296**] is an 80 year old gentleman with a PMH significant
for DM 2, HTN, afib, CHF, and emphysema admitted to the MICU for
gallstone pancratitis and renal failure. The patient was
transferred from the OSH after developing acute abdominal pain
last night. This was associated with 4 episodes of NBNB emesis
and shortness of breath. At the OSH, labs were notable for
lipase of 3353 and Tbili of 2.1. CT demonstrated multiple
gallstones, a dilated CBD, and a stone in the ampulla. The
patient was then transferred to the [**Hospital1 18**] for surgical and ERCP
evaluation.
.
In the [**Hospital1 18**] ED, VS 97.4 68 134/75 18 94%2L nc. Patient
underwent an additional CTAP confirming a stone in the ampulla
and a dilated CBD, received 2L NS IVF, and pain medications. He
also received 4 units FFP for an INR of 2.3 and was evaluated by
surgery and ERCP with plan for ERCP. He was then transferred to
the MICU for further management.
.
Upon admission to the MICU, he is resting comfortably without
complaints. States that his abdominal pain is well controlled.
Denies any CP/SOB, f/c/s, n/v/d, orthopnea, PND, or increased
lower extremity swelling.
Past Medical History:
Gallstone pancreatitis
DM 2
HTN
CHF
AFib on coumadin
Emphysema (not on supplemental O2)
Social History:
Drinks 5 beers three times weekly. Tobacco - quit 30 years ago.
Denies IV, illicit, or herbal drug use. Lives with wife.
Family History:
DM 2, both parents with AAA
Physical Exam:
Gen: Age appropriate male in NAD
HEENT: Perrl, sclerae anicteric. MMM, OP clear without lesions,
exudate or erythema. Neck left base with 2x2 cm mass consistent
with lipoma.
Pulm: CTAB
CV: Irregular S1+S2
Abd: Mild TTP in epigastrum. +bs. No rebound or guarding
Ext: Trace edema bilaterally.
Pertinent Results:
[**2188-8-6**] 12:05PM PT-24.3* PTT-30.1 INR(PT)-2.3*
[**2188-8-6**] 12:05PM PLT COUNT-249
[**2188-8-6**] 12:05PM NEUTS-88.2* LYMPHS-7.6* MONOS-3.9 EOS-0.2
BASOS-0.1
[**2188-8-6**] 12:05PM WBC-8.4 RBC-4.18* HGB-11.3* HCT-37.1* MCV-89
MCH-27.1 MCHC-30.6* RDW-15.2
[**2188-8-6**] 12:05PM ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-4.6*
MAGNESIUM-2.2
[**2188-8-6**] 12:05PM LIPASE-6600*
[**2188-8-6**] 12:05PM ALT(SGPT)-216* AST(SGOT)-380* ALK PHOS-350*
TOT BILI-2.3*
[**2188-8-6**] 12:05PM GLUCOSE-212* UREA N-67* CREAT-3.1*
SODIUM-146* POTASSIUM-4.8 CHLORIDE-107 TOTAL CO2-28 ANION GAP-16
[**2188-8-6**] 05:59PM PT-18.8* PTT-28.7 INR(PT)-1.7* (s/p 2 units
FFP)
CTAP:
1. Multiple gallstones and choledocholithiasis with dilatation
of the common bile duct up to 1.3 cm. In the appropriate
clinical setting, these findings raise concern for gallstone
pancreatitis. No evidence of acute cholecystitis.
2. Fatty liver.
3. Multiple bilateral cystic renal lesions measuring up to 4.4
cm. Recommend non- emergent ultrasound for further evaluation.
.
ECG: afib, RBBB.
Brief Hospital Course:
#Gallstone pancreatitis: Upon admission to [**Hospital1 18**], the patient
was urgenly taken to ERCP. A sphincterotomy was performed and
[**5-11**] irregular black pigmented stones were removed from the
biliary tree. A large amount of biliary sludge was visualized.
Following the procedure, the patient improved dramatically with
a decrease in liver function tests and pancreatic enzymes. The
patient was kept NPO and hydrated with IVF until he was free of
pain. Ins and outs were carefully monitored as the patient had
a history of congestive heart failure. The patient started a
seven day course of ciprofloxacin and flagyl
# Renal failure: The patient presented with an elevated BUN and
creatinine, representing acute on chronic kidney failure
secondary to dehydration. Serial renal function tests were
monitored with eventual return to the patient's baseline
creatinine of around 3.0 (as per patient's primary care
physician).
# Respiratory distress: The patient initially failed extubation
following ERCP. Respiratory failure was likely multi-factorial
including sedation, obstructive disease due to COPD, and
possible pulmonary edema (hx. of CHF compounded by 3rd spacing
of pancreatitis). As there is no prior CXR available for
comparison, it was difficult to assess whether the patient has
another contributing underlying pulmonary process. Pulmonary
function improved and the patient was extubated without
incident. Pulmonary toilet was encouraged with incentive
spironmetry. The patient received ipratropium and albuterol as
needed.
#Hypernatremia/ hyperchloremia: Patient developed mild
hypernatremia due to fluid administration. Once the patient's
diet was advanced, the hypernatremia resolved
# DM 2: The patient's oral hypoglycemic medications were
initially held while the patient was kept NPO. He remained
normoglycemic with sliding scale insulin.
# HTN: Patient's blood pressure remained stable with home dose
of metoprolol
# Afib: on longterm anticoagulation, coumadin held for ERCP.
Patient restarted coumadin when INR become sub-therapeutic.
Rate was adequately controlled with AV nodal blockade on home
metoprolol.
He was transferred out of the ICU on [**2188-8-9**]. After his
pancreatic enzymes normalized, he was given a clear liquid diet
and tolerated this without issue. On [**2188-8-10**], he was advanced to
a regular diet and tolerated this without issue. He looked very
well, and was pain-free. He was therefore discharged home with
instructions to follow up with Dr. [**Last Name (STitle) **] within the next 2
weeks for interval cholecystectomy. He is to complete a 7-day
course of antibiotics in the interim.
Medications on Admission:
Glipizide 20 mg daily
Lasix 80 mg daily
Coumadin 4 mg daily
Propanolol 120 mg daily
Amlodipine 5 mg daily
Allopurinol 100 mg daily
Actos 15 mg daily
Simvastatin 40 mg daily
Spireva 1 puff daily
Alubterol prn
Quinapril 40 mg daily
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
4. Propranolol 120 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Actos 15 mg daily
Glipizide 20 mg daily
Quinapril 40 mg daily
Spireva 1 puff daily
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Acute cholecystitis
Choledocholithiasis
Discharge Condition:
Stable
Discharge Instructions:
You may resume all your pre-hospital medications.
You may resume your pre-hospital activity level as tolerated.
Please call your doctor or return to the ER for any of the
following:
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* You experience return of abdominal pain, nausea, vomiting, or
yellowing of the eyes (jaundice)
* 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.
* 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.
Followup Instructions:
You must have your gall bladder removed in the near future. Call
Dr.[**Name (NI) 10946**] office to make an appointment to see him and
schedule your operation. His office phone number is
[**Telephone/Fax (1) 9**].
Completed by:[**2188-8-10**]
|
[
"428.0",
"276.0",
"574.61",
"492.8",
"576.1",
"577.0",
"427.31",
"V58.61",
"403.90",
"250.00",
"585.9",
"584.9",
"276.2",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85"
] |
icd9pcs
|
[
[
[]
]
] |
7141, 7147
|
3339, 6003
|
397, 419
|
7254, 7262
|
2247, 3316
|
7992, 8236
|
1891, 1920
|
6283, 7118
|
7168, 7233
|
6029, 6260
|
7286, 7969
|
1935, 2228
|
270, 359
|
447, 1626
|
1648, 1737
|
1753, 1875
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,497
| 137,753
|
50297
|
Discharge summary
|
report
|
Admission Date: [**2138-7-9**] Discharge Date: [**2138-7-14**]
Date of Birth: [**2075-10-19**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Cough and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 62 year old man with mild developmental delay,
mild OCD, and hypertension who presented to the ED from his
group home complaining of fever and cough. The history is
limited due to his somewhat limited ability to communicate.
He apparently developed a cough two days prior to admission.
Today he was seen by an advanced practice nurse, probably at the
group home, and was noted to be febrile to 101.6, tachycardic to
127 and with an oxygen saturation of 90% on room air. He was
sent to the ED where his initial vitals were 100.8 128 125/85 20
94%. He had a leukocytosis, profuse, productive cough, and a
possible right lower lobe consolidation on a chest xray. He was
treated with morphine, azithromycin, ceftriaxone, and tylenol.
He was given 3L NS.
On arrival to the MICU, he complained of a "cold" and continued
to repeat that he was "just getting over a cold". He states that
he sometimes has sharp pains all over his body. He says that he
had a sore throat before his cough.
Past Medical History:
GERD
Mental retardation
Rash and other nonspecific skin eruption
Colonic polyps
Vitreous detachment
Onychomycosis
Hypertension
Hypertriglyceridemia, essential
MENTAL/BEHAVIOR PROB NOS
Social History:
He lives at a group home due to his cognitive delay and history
of behavioral problems. [**Name (NI) **] has never smoked. No etoh or ilicit
drug use.
Family History:
No history of developmental delay
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
VS - 97.7 133/57 92 18 94% on RA
General: alert, oriented, awoken very easily from sleep
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Decreased expiratory rhonchi in all lung fields, no
end-expiratory wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, no focal deficits
Pertinent Results:
Blood Counts
[**2138-7-9**] 05:15PM BLOOD WBC-12.4*# RBC-3.93* Hgb-12.7* Hct-38.5*
MCV-98 MCH-32.4* MCHC-33.0 RDW-12.7 Plt Ct-157
[**2138-7-11**] 03:21AM BLOOD WBC-11.3* RBC-3.46* Hgb-11.3* Hct-35.1*
MCV-101* MCH-32.7* MCHC-32.3 RDW-12.8 Plt Ct-119*
[**2138-7-13**] 06:40AM BLOOD WBC-5.4 RBC-3.26* Hgb-10.8* Hct-33.5*
MCV-103* MCH-33.1* MCHC-32.1 RDW-13.2 Plt Ct-146*
Chemistry
[**2138-7-9**] 05:15PM BLOOD Glucose-110* UreaN-16 Creat-0.6 Na-141
K-3.8 Cl-100 HCO3-32 AnGap-13
[**2138-7-13**] 06:40AM BLOOD Glucose-93 UreaN-16 Creat-0.5 Na-145
K-3.5 Cl-108 HCO3-30 AnGap-11
Micro
[**2138-7-10**] 2:41 am URINE Source: CVS.
**FINAL REPORT [**2138-7-10**]**
Legionella Urinary Antigen (Final [**2138-7-10**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
[**2138-7-10**] 11:59 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Antigen Screen (Final [**2138-7-10**]):
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
Interpret all negative results from this specimen with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Recommend new sample be submitted for confirmation.
Reported to and read back by DR [**First Name8 (NamePattern2) 104899**] [**Last Name (NamePattern1) **] [**2138-7-10**] AT
15:30.
CXR - [**7-10**]
IMPRESSION: New retrocardiac opacity which is concerning for
pneumonia, and could be better evaluated with dedicated upright
and lateral chest
radiographs.
CXR - [**7-11**]
Improving left lower lobe opacity. Considering rapid
development and rapid improvement, aspiration is a likely
possible cause. However, followup radiographs with PA and
lateral technique would be helpful as well as clinical
correlation to exclude an infectious pneumonia.
TTE - [**7-10**]
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with thinning and hypokinesis
of the mid to distal inferior and inferolateral segments and of
the distal anteroseptum and apex. Right ventricular chamber size
and free wall motion are normal. Interventricular septal motion
is 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. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Regional left ventricular systolic function
suggestive of multivessel CAD. No significant valvular
abnormality seen.
Brief Hospital Course:
This is a 62yo male w mild developmental delay, hypertension who
presented to the ED from his group home with fever, cough, found
to have R lower lobe consolidation, treated for community
acquired pnuemonia with subsequent improvement
.
#Bacterial Pneumonia with reactive airway disease flare: The
patient's bacterial pneumonia was most likely secondary to
aspiration. No sputum cultures were able to be sent. Urine
legionella antigen, nasopharyngeal viral screen were negative.
Patient was treated with PO levofloxacin and weaned off
supplemental oxygen. To rule out an aspiration cause, he had a
speech and swallow evaluation that was unremarkable. Given
significant wheezing on exam, he was treated with a two week
course of prn albuterol and inhaled corticosteroids. He
completed a 5d course of levofloxacin prior to discharge.
.
#Hypertension: The patient's home lisinopril and
hydrochlorothiazide were held in setting of acute ilnness, but
restarted at discharge. Continued home aspirin.
.
#Behavioral Issues NOS: Stable. The patient was continued on his
home clozapine, divalproic acid/delayed release, and
benztropine.
.
# Chronic constipation: The patient's was maintained lactuose
and psyllium for constipation. He also received colace/senna.
.
#?Allergies: Patient received loratidine PRN.
.
Transitional Issues
- Code status: Full
- HCP: Brother [**Name (NI) **] ([**Telephone/Fax (1) 104900**]
- [**Name2 (NI) **]umonia and post-infection wheezing - treated with
levofloxaxin, discharged with scripts for prn albuterol and 2
weeks of inhaled fluticasone
- TTE showed regional left ventricular systolic function
suggestive of multivessel CAD, PCP was [**Name9 (PRE) 82414**] via letter
- Should follow-up with his regular physician [**Name Initial (PRE) 176**] 2 weeks of
discharge
Medications on Admission:
clozapine 200mg qpm
clozapine 100mg qAM
divalproic acid/delayed release 652mg [**Hospital1 **]
MV
colace 100mg [**Hospital1 **]
benztropine 1mg [**Hospital1 **]
albuterol inh 2 puffs prn qid prn
hctz 25mg daily
senna one tab daily
aspirin 81mg daily
robitussin prn
lisinopril 10mg daily
ferrous sulfate 325mg daily
lactulose 15cc daily
claritin 10mg qhs
physillium prn
tylenol prn
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
2. Aspirin 81 mg PO DAILY
3. Benztropine Mesylate 1 mg PO BID
4. Clozapine 200 mg PO HS
5. Clozapine 100 mg PO DAILY
6. Divalproex (DELayed Release) 652 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Guaifenesin [**5-22**] mL PO Q6H:PRN cough
9. Multivitamins 1 TAB PO DAILY
10. Senna 2 TAB PO BID
11. Claritin *NF* 10 mg Oral qhs
12. Hydrochlorothiazide 25 mg PO DAILY
13. Lactulose 15 mL PO DAILY
14. Lisinopril 10 mg PO DAILY
15. Loratadine *NF* 10 mg ORAL QHS
16. Omeprazole 20 mg PO BID
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash
18. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
RX *Flovent HFA 110 mcg/actuation 2 puffs(s) inhaled twice a day
Disp #*1 Inhaler Refills:*0
19. Albuterol Inhaler [**1-13**] PUFF IH Q6H:PRN wheezing
RX *albuterol sulfate 90 mcg 1-2 puffs inhaled every six (6)
hours Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary
Community-acquired pneumonia
Post-infection reactive airway
Secondary
Mild developmental delay
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
You were admitted to the [**Hospital1 69**]
for pneumonia and difficulty breathing. We treated your
pneumonia with antibiotics (Levofloxacin). You had some
wheezing on exam so we started you on a two week course of
inhalers.
Thank you very much for allowing us to participate in your care.
Best wishes with your recovery.
Followup Instructions:
You should follow-up with you regular primary care physician
[**Name Initial (PRE) 176**] 2 weeks of your discharge
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD Phone:[**Telephone/Fax (1) 608**]
Date/Time:[**2138-9-8**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD Phone:[**Telephone/Fax (1) 608**]
Date/Time:[**2138-9-16**] 1:45
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone:[**Telephone/Fax (1) 3294**]
Date/Time:[**2138-9-19**] 4:30
Completed by:[**2138-7-22**]
|
[
"317",
"493.92",
"275.3",
"401.9",
"507.0",
"564.00",
"786.50",
"312.9",
"428.22",
"276.0",
"799.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9242, 9299
|
6078, 7879
|
321, 327
|
9460, 9460
|
2973, 6055
|
9990, 10591
|
1762, 1797
|
8311, 9219
|
9320, 9439
|
7905, 8288
|
9613, 9967
|
1812, 2423
|
2439, 2954
|
265, 283
|
355, 1369
|
9475, 9589
|
1391, 1577
|
1593, 1746
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,237
| 141,156
|
48405+59087
|
Discharge summary
|
report+addendum
|
Admission Date: [**2156-5-2**] Discharge Date: [**2156-5-10**]
Date of Birth: [**2086-7-24**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is a 69 year old
male with a history of squamous cell carcinoma at the base of
the tongue, status post surgical neck dissection on [**2156-4-1**], status post chemo radiation therapy with residual
disease. He now presents to [**Hospital6 2018**] with fevers, change of mental status and generalized
weakness for one day. During his initial presentation he
also was complaining of difficulty breathing, swelling on
"the inside of his throat" that has been progressing over
hours. The patient then complained of pain in the right side
of his neck and continued shortness of breath.
REVIEW OF SYSTEMS: Review of systems also revealed a
persistent right frontal/temporal/occipital headache rated
1.5 out of 10. He denies chest pain, denies abdominal pain,
denies nausea and vomiting, diarrhea and denies dysuria.
PAST MEDICAL HISTORY: 1. History of squamous cell carcinoma
of the right basal tongue, status post selective neck
dissection on [**2156-4-1**]; 2. Hypercholesterolemia; 3.
Depression; 4. Status post tonsillectomy; 5. Status post
hemorrhoidectomy.
MEDICATIONS ON ADMISSION: Ciprofloxacin times one week for
sinusitis, Duragesic 25, Neurontin 600 once a day, Zocor 10
mg once a day, Trazodone 100 mg once a day, Roxicet 2 tsp 4-6
hours, Celexa 40 mg once a day, Nystatin Swish and Swallow.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has a past alcohol use history.
The patient also has a past history of tobacco use which
stopped four months ago.
PHYSICAL EXAMINATION: Physical examination on presentation
revealed temperature recorded at 102.6, blood pressure
111/64, heartrate 140, respiratory rate 20, 98% on room air.
In general, the patient appeared sleepy and malaised. Head
and neck examination revealed head normocephalic and
atraumatic. Pupils were small and reactive. Ear, nose and
throat examination failed radiation changes in the anterior
and lateral neck, no fluctuance and scar was present. Chest,
crackles were heard at the left lung base. Heart
examination, regular tachycardiac, no murmurs, rubs or
gallops. Gastrointestinal, soft, nontender, nondistended and
bowel sounds were present. Genitourinary examination
revealed no costovertebral angle tenderness, no suprapubic
tenderness. Musculoskeletal extremity examination revealed
no spinal or paraspinal tenderness. Skin revealed no rash
and the patient was alert and oriented times three.
LABORATORY DATA: Admission laboratory data revealed white
blood cell count of 11.5, hematocrit 30.4, platelets 316,
sodium 141, potassium 4.8, chloride 98, carbon dioxide 30,
BUN 39 and creatinine of 1.0 with a glucose of 177. Chest
x-ray taken in the Emergency Room revealed no evidence of
pneumonia.
HOSPITAL COURSE: In the Emergency Department, the patient
became hypotensive, 87/40 with continued fevers to 102 and
received 7 liters of normal saline and was placed on
Vancomycin, Levofloxacin and Flagyl in the Emergency
Department. The lumbar puncture was performed in the
Emergency Room and during this lumbar puncture he became
dyspneic complaining of neck swelling, throat closure and was
taken to the Operating Room for emergency intubation which
was unsuccessful secondary to questionable airway edema and
emergently had his old closed tracheostomy sites accessed by
endotracheal tube and was admitted to the Medicine Intensive
Care Unit. His Medicine Intensive Care Unit course was
notable for ventilator support until [**5-6**] when
Otorhinolaryngology changed the endotracheal tube to a
tracheostomy and the patient weaned to a tracheostomy mask.
Pressure support was continued with Neo-Synephrine. Levophed
was required transiently for hypotension and one episode of
sinus bradycardia to the 30s which was responsive to
Atropine. He was hemodynamically stable since [**5-4**] and
was ruled out for an myocardial infarction.
The patient continued to be treated on Vancomycin,
Clindamycin, Levofloxacin for presumed postoperative
otorhinolaryngology infection, however, blood, urine and
cerebrospinal fluid cultures from admission remained negative
and computerized tomography scans of the neck and chest did
not reveal any abscesses. However, the computerized
tomography scan of the neck did show some marked edema
posterior and of the hypopharynx with a questionable right
density versus aneurysm of the right jugular vein versus
jugular ectasia but normal flow by ultrasound and no further
concern for septic thrombophlebitis. Vascular Surgery
consults suggested likely extraluminal hematoma. Right
Port-A-Cath was removed on [**5-4**] without complications. On
[**5-3**] he was transfused 2 units of packed red blood cells
due to a hematocrit of 23 and bloody airway secretions and on
[**5-7**] was transferred to the floor where he remains
hemodynamically stable and successfully weaned to a
tracheostomy mask on [**5-6**]. Since transfer to the floor
the patient has had no complaints and notes a slight
sensation of throat swelling but denies any shortness of
breath. He continued to have secretions around the
tracheostomy and will continue on antibiotics for a total of
ten days.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home with a
home physical therapy consult and home safety evaluation and
will follow up with Otorhinolaryngology. The patient was
discharged with instructions to remain NPO. He was to
continue nutrition per gastrostomy tube of 8 cans of ProMod
with fiber.
DISCHARGE MEDICATIONS:
1. Gabapentin 600 mg per gastrostomy tube q. 8 hours
2. Levofloxacin 500 mg per gastrostomy tube once a day for
five days
3. Clindamycin 300 mg per gastrostomy tube q. 6 hours for
two days
4. Nystatin Swish and Swallow 5 ml by mouth four times a day
for ten days
5. Ibuprofen 400 mg per gastrostomy tube q. 8 hours prn pain
6. Zocor 10 mg per gastrostomy tube once a day
7. Celexa 40 mg per gastrostomy tube once a day
8. Trazodone 100 mg per gastrostomy tube at night once a day
DISCHARGE DIAGNOSIS:
1. Respiratory distress
2. Infection
3. Status post tracheostomy
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2156-5-9**] 15:03
T: [**2156-5-9**] 15:28
JOB#: [**Job Number 46560**]
Name: [**Known lastname 16422**], [**Known firstname 657**] E Unit No: [**Numeric Identifier 16423**]
Admission Date: [**2156-5-2**] Discharge Date: [**2156-5-12**]
Date of Birth: [**2086-7-24**] Sex: M
Service: Medicine
ADDENDUM: This is an addendum to a Discharge Summary dated
[**2156-5-10**].
The patient continued to have low-grade fevers with
temperatures ranging from 98.9 to 100.4. It was felt that
the patient should remain in house until these fevers were
trending down or if he became afebrile for 24 hours.
During this time, the patient did not complain of any more
headaches. He did not complain of any fevers or chills. No
shortness of breath or chest pain. No abdominal pain. No
muscle pain. He stated that his tracheal secretions
decreased in amount and became less purulent. He completed
his 10-day course of antibiotics on clindamycin and
levofloxacin.
Otolaryngology continued to follow and requested outpatient
follow up with Dr. [**Last Name (STitle) **] after one week from
discharge for possible tracheostomy revision. Tube feeds
were initially switched to bolus feeds to accommodate
outpatient care. The family requested the patient to remain
on continuous tube feeds. However, the patient stated that
he would like to continue boluses, and the family and the
patient agreed to a 12-hour infusion at nighttime and one can
of ProMod with fiber during the day.
Also throughout his stay, the patient stated he had
difficulty sleeping and was given Ambien 10 mg by
percutaneous endoscopic gastrostomy tube, which improved his
sleep considerably.
On [**5-11**], he continued to have slight fevers with a
temperature maximum of 100.1 during the day. Cultures were
obtained. A chest x-ray obtained at that time revealed no
infiltrates. Urine cultures, blood cultures, and Clostridium
difficile toxin were pending. The family was instructed by
Respiratory Care with regard to tracheostomy instructions.
MEDICATIONS ON DISCHARGE:
1. Gabapentin 600 mg per G-tube q.8h.
2. Nystatin 5 mL swish-and-swallow p.o. q.i.d. (times 10
days).
3. Ibuprofen 400 mg per G-tube q.8h. p.r.n. for pain.
4. Zocor 10 mg per G-tube q.d.
5. Celexa 40 mg per G-tube q.d.
6. Trazodone 100 mg per G-tube q.h.s.
7. Pantoprazole 30 mg per G-tube q.d.
8. Ambien 10 mg per G-tube q.h.s.
A prescription for a feeding tube pump was given.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: The patient was sent home with home
physical therapy and home safety evaluation.
DISCHARGE FOLLOWUP: He was to follow up with
Dr. [**Last Name (STitle) **] in one week. [**Hospital6 1346**]
will visit for tracheostomy care and tracheostomy
instructions. Humidification was ordered for suctioning as
necessary, and a request for tracheostomy kit and associated
supplies were administered.
[**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**]
Dictated By:[**Name8 (MD) 1554**]
MEDQUIST36
D: [**2156-5-12**] 13:08
T: [**2156-5-25**] 14:20
JOB#: [**Job Number 16424**]
|
[
"V10.01",
"998.2",
"263.9",
"038.9",
"276.5",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.71",
"96.04",
"31.74",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
5680, 6169
|
6190, 8503
|
8529, 8928
|
1277, 1531
|
2921, 5325
|
1698, 2903
|
8943, 9080
|
785, 997
|
9102, 9657
|
169, 765
|
1020, 1250
|
1548, 1675
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,876
| 171,840
|
35577
|
Discharge summary
|
report
|
Admission Date: [**2150-4-10**] Discharge Date: [**2150-5-14**]
Date of Birth: [**2131-5-15**] Sex: F
Service: MEDICINE
Allergies:
Tylenol
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
lightheadedness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
18 year old woman with pmh significant for anorexia, last
menstrual period was at 12 yrs old, presenting with dizzyness
and lightheadedness since yesterday. She reported increased
weakness over the past two weeks. She reports eating 800
calories per day, consisting of ensure, peanut butter, and
protein shakes. She also drinks [**2-6**] cans of sparkling water
daily. On presentation to the ED she was bradycardic with HR
40-50's, and hypotensive with SBP 70-80's. EKG showed low
voltage with prolonged Qtc to 465. She was given 1L NS, and a
banana bag. FS was 30 and she was given an amp of D50. Echo was
performed and did not show effusion.
.
She was transferred to the ICU given her hypotension and
bradycardia.
.
Review of systems is otherwise negative, denying chest pain,
dyspnea, dysuria, abdominal pain,
Past Medical History:
Anorexia nervosa
Social History:
Denies EtOH, tobacco, drug use. Pt is youngest of 3 children
born to English mother and Lebanese father, born in [**State 2690**].
Parents reports multiple moves during pt's childhood. When pt,
mother and sister moved to US (approx 6 years ago), father and
brother moved to [**Country 22390**], where they still live. Parents report
significant conflict in their marriage, with frequent arguments.
Parent's report pt has always been an A student, but never made
friends after moving to US at age 12. They report prior to that
move, pt was well adjusted and had many friends. Although she
has missed significant amts of school over the years, pt started
12th grade this year and has been attending school until today.
Family History:
maternal cousin with bipolar disorder
Physical Exam:
GENERAL: Cachectic, in NAD
HEENT: Normocephalic, atraumatic. Conjunctival pallor, MMM.
CARDIAC: Regular bradycardia, Normal S1, S2. No murmurs, rubs or
[**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
WBC 1.4
Hct 29
Plt 201
K 3
AST 249
ALT 395
Bili 1.3
Brief Hospital Course:
18F with anorexia, presenting with hypotension and bradycardia.
Anorexia: Patient's BMI on admission was 10.1, weighing 59
pounds with height 5'3''. Her K, PO4, and Mg were normal at
presentation. Complications associated with her anorexia
included bradycardia HR 45 with prolonged QTc, hypotension
75/40, elevated transaminases (? focal hepatic necrosis),
leukopenia, anemia, and hypoglycemia. She was also hypothermic
and remained on a warming blanket. Other sources of hypotension
and bradycardia, including sepsis, hypovolemia, hypoadrenal
state, or myocardial infarction were investigated and were
unrevealing. Psychiatry evaluated the patient upon admission and
found her not to have capacity to declare her code status as
DNR/DNI, and she was therefore made full code. Nutrition
evaluated the patient and immediately placed her on the eating
disorder protocol. According to protocol, she was written for
neutraphos 2 packets twice daily, in addition to multivitamins
with minerals and thiamine. Her lytes were checked twice daily
to monitor for electrolyte abnormalities associated with
refeeding syndrome. Her first night of admission to the ICU,
she remained hypoglycemic with FSBG in 30-40's, she therefore
received 2 amps of D 50 and was started on a D5 1/2NS @50cc/hr.
She refused her first solid meal the evening of admission, and
was given ensure supplements for breakfast the following day.
She was subsequently transferred to the medical service for
further management. She received Ensure tid as part of her
eating disorder protocol, along with electrolyte repletion. She
complied with the eating disorder protocol and started eating
solids by the time of the discharge.
Pancytopenia/Neutropenia: This was secondary to impaired bone
marrow response in the setting of her severe malnutrition. Iron
studies, vitamin B12, folate, TSH were evaluated for etiologies
of anemia and she was found to have anemia of chronic disease.
She was not hypothyroid, and did not have vitamin B12 or folate
deficiencies. She was initially maintained on neutropenic
precautions but after discussion with hematology this was not
felt to be necessary as her neutropenia was due to malnutrition
and not malignancy/chemotherapy and therefore did not confer the
same infectious risk. Her WBC and absolute neutrophil count
increased as she continued to gain weight.
Coagulopathy: INR 1.5 on admission, thought secondary to vitamin
K deficiency.
Elevated liver enzymes: At highest, ALT was 580, AST of 410.
Of note, patient with history of tylenol overdose in prior
suicide attempt. The patient has a history of transaminitis
when she is severely malnourished - this is most likely due to
focal hepatic necrosis, a phenomenon described in severe
anorexia nervosa. Trended downward during the admission with
concurrent weight gain.
Hypotension: Patient with baseline systolic BP in the 70s to
80s. She fell while taking a warm shower on [**4-12**], felt to be due
to peripheral vasodilation in the setting of the warm shower.
Otherwise, she had no events related to her blood pressure and
was not symptomatic.
Pericardial Effusion: The patient had a moderate pericardial
effusion on her TTE without evidence of tamponade.
Lower extremity edema: she developed 2+ LE pitting edema
attributed to her poor nutritional state, with associated
hemosiderin deposition and capillary rupture in the subcutaneous
tissues of the ankles and feet, and blistering of the dorsal
surfaces of her feet, and significant pain in her feet with
walking. Elevation, teds stockings, and ibuprofen were
recommended, aquaphor and sarna lotion helped her symptoms. The
pain improved with this conservative treatment and she was
ambulating normally at discharge.
Medications on Admission:
none
Discharge Medications:
1. Therapeutic Multivitamin Liquid Sig: One (1) dose PO
daily ().
2. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet
Sig: Two (2) Powder in Packet PO TID (3 times a day).
3. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Location (un) 10059**]
Discharge Diagnosis:
Anorexia
Hypoglycemia
Hypotension
Hypokalemia
Hypophosphatemia
Status post fall
Discharge Condition:
good, stable, not lightheaded/orthostatic, not on neutropenic
precautions
Discharge Instructions:
You were evaluated for lightheadedness and low blood pressure
that were due to your severe malnutrition from your anorexia.
You were placed on the eating disorder protocol and gained
weight. Your white blood cell count was very low from
malnutrition but improved as you gained weight.
You will be followed by the doctors at the eating disorder
program. You acknowledged understanding that if you refuse
treatment, you may be sent back to the hospital.
Followup Instructions:
Follow up as directed by your providers at the eating disorder
program; you should have ongoing psychiatric followup as well as
a primary care physician. [**Name10 (NameIs) **] may call [**Hospital3 **] at
[**Telephone/Fax (1) 250**] to schedule an appointment with a new primary care
physician if you do not already have one.
|
[
"261",
"288.00",
"284.1",
"285.9",
"307.1",
"275.3",
"423.9",
"251.2",
"276.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6730, 6809
|
2603, 6353
|
284, 290
|
6933, 7009
|
2527, 2580
|
7510, 7840
|
1929, 1968
|
6408, 6707
|
6830, 6912
|
6379, 6385
|
7033, 7487
|
1983, 2508
|
229, 246
|
318, 1133
|
1155, 1173
|
1189, 1913
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,799
| 131,042
|
49566
|
Discharge summary
|
report
|
Admission Date: [**2158-11-6**] Discharge Date: [**2158-11-13**]
Date of Birth: [**2088-11-7**] Sex: M
Service: MEDICINE
Allergies:
Tape / Lipitor
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Shortness of breath, dizziness
Major Surgical or Invasive Procedure:
Upper endoscopy
RIJ
History of Present Illness:
69 YO m h/o CAD s/p MI and stent, mechanical [**First Name3 (LF) 1291**] x 2, VT s/p ICD
placement and multiple GIBs who presents following an episode of
shortness of breath, diaphoresis and dizziness at home. The
patient was in his usual state of health until three weeks ago
at which time he noticed inreasing shortness of breath with
exertion (at baseline he can walk to the mailbox and back and
recently he has had pain with limited movement around his
house). Over the past four days he has noted increasing anginal
episodes for which he has used nitroglycerin 5 times. He has
also noticed black colored stools over the past four days. On
the morning of presentation he was preparing food and he became
lightheaded, diaphoretic and short of breath and felt as if he
would pass out but did not lose consciousness or fall down.
During this episode he did not experience any chest pain,
nausea, vomiting, or abdominal pain. Recently he denies any
fevers or chills. He denies any episodes of ICD firing. He
denies hematochezia, hematemasis or BRBPR.
.
In the ED the patient was chest pain free. He was found to have
a hematocrit of 23.7, a troponin of 0.06, was guaiac positive
with a negative NG lavage. EKG revealed a ventricularly paced
rhythm at 68 bpm. He received aspirin 325 mg, protonix IV and 2
units PRBCs. He underwent central line placement secondary to
poor IV access and coumadin was held for supratherapeutic INR
.
Transferred to MICU for further management.
Past Medical History:
1. Status post St-[**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 1291**] and redo (96 and 99) for AS/AI, on
Coumadin
2. CAD status post CABG X 2, s/p multiple PTCA/stents, last in
[**2156-6-8**]
3. History of GI bleeds (prior endoscopies with gastritis, and
duodenal AVMs seen on capsule endoscopy [**6-11**])
4. Status post PPM/AICD [**8-/2156**] for VT
5. CHF with EF 30%
6. SLE with history of lupus nephritis
7. s/p thyroidectomy
8. Anemia
Social History:
Former smoker (h/o 1.5 PPD x 30 years, quit [**2132**])
Occasional ethanol. Denies illicit drug use. Lives with his
wife, daughter and grand-daughter. Wife helps him with
medications. Fomer truck driver.
Family History:
Mother, father and sister died from liver failure. Father
alcoholic but mother and sister were not. His sister died 1 year
ago with liver failure and lupus.
Physical Exam:
MICU Physical Exam:
Vitals: T: 98.1 HR: 67 BP 123/83 RR 16 O2: 100% on RA
General: Alert, oriented, no distress
HEENT: EOMI, PERRL, sclera anicteric, oropharynx clear
Neck: JVP difficult to assess. CVL bleeding profusely.
CV: RRR, prominent valvular click
Resp: CTAB, no wheezes, rales, ronchi
GI: soft, non-tender, non-distended, + BS, no HSM
GU: no foley
Ext: WWP, 1+ pulses, good capillary refill, 2+ edema in LLE, 1+
in RLE, no clubbing or cyanosis.
Neuro: grossly intact
Pertinent Results:
[**Year (4 digits) **]:
[**2158-11-6**] 09:30AM BLOOD WBC-5.1 RBC-2.82*# Hgb-7.9*# Hct-23.7*#
MCV-84 MCH-28.1 MCHC-33.4 RDW-22.7* Plt Ct-230
[**2158-11-6**] 09:30AM BLOOD PT-37.8* PTT-49.0* INR(PT)-4.2*
[**2158-11-6**] 09:30AM BLOOD Glucose-106* UreaN-74* Creat-2.0* Na-137
K-5.1 Cl-106 HCO3-17* AnGap-19
[**2158-11-6**] 09:30AM BLOOD CK(CPK)-87
[**2158-11-6**] 09:30AM BLOOD cTropnT-0.06*
[**2158-11-7**] 10:26AM BLOOD Lactate-1.2
.
EGD [**10/2158**] per GI note:
EGD showed mild petechiae in prepyloric region and mild
duodenitis. No active bleeding.
.
Brief Hospital Course:
Impression: The patient is a 69-year-old male with a history of
CAD s/p MI and stenting, mechanical [**Year (4 digits) 1291**] x 2, VT s/p ICD
placement and GIB who presents with GIB and found to have
duodenitis.
.
1. GIB: The patient was admitted with a GI bleed in the setting
of a supratherapeutic INR. On the night of admission he
received FFP to reverse his anticoagulation. On hospital day 2
he underwent upper endoscopy which failed to reveal a discrete
bleeding source but showed mild duodenitis. He required a total
of 5 units PRBC over the course of three days before his
hematocrit stabilized. Cardiac enzymes were mildly elevated on
admission and peaked at a troponin of 0.11 and in the setting of
blood loss and reduced renal function this was thought to be
most likely secondary to demand ischemia. On admission the
patient was also noted to have an elevated creatinine kinase
which continued to rise on hospital days 2 and 3 out of
proportion to his elevation in cardiac enzymes. It was decided
to stop the patient's statin and upon doing so his CKs
immediately began to trend down. The patient's Coumadin and
aspirin were restarted on hospital day 5 for anticoagulation in
the setting of a mechanical aortic valve.
.
2. Anemia: Patient was guaiac positive with dark brown stool in
the ED with a negative gastric lavage. Patient has a history of
ileal AVM diagnosed in [**2156**] after experiencing a similar episode
of bleeding. His baseline hematocrit is 30-32 but was 38 on
[**2158-10-20**]. He had a negative colonoscopy in [**2156**] and a normal
EGD in [**Month (only) 116**] of this year. Possible etiologies include rebleeding
AVM vs. duodenal ulcer. Lower GI etiologies less likely given
lack of BRBPR. Patient received FFP and blood transfusions.
Patient's INR was 4.2 on admission and Coumadin was held. Upper
endoscopy showed duodenitis. He was treated with transfusions
plus Lasix to limit volume overload, PPI [**Hospital1 **], serial HCT checks.
Coumadin and aspirin were restarted on HD 5 for anticoagulation
in the setting of a mechanical valve.
.
3. Chest Pain: Patient has had increasing anginal episodes over
the past week relieved with nitroglycerine. Most likely
secondary to decreased hematocrit causing demand ischemia.
Troponin was 0.06 on admission and peaked at 0.11. EKG
unrevealing secondary to paced ventricular rhythm. Treated with
BB, statin, Imdur, NTG. Aspirin was initially held until
patient stabilized. Elevated creatinine kinase which continued
to rise on hospital days 2 and 3 out of proportion to his
elevation in cardiac enzymes. It was decided to stop the
patient's statin and upon doing so his CKs immediately began to
trend down.
.
4. Mechanical AV: Reluctant to fully reverse his anticoagulation
secondary to his mechanical valve. Coumadin was held and his
INR trended down slowly. The patient's Coumadin and aspirin were
restarted on hospital day 5 for anticoagulation in the setting
of a mechanical aortic valve. Antibiotics given for prophylaxis
for EGD.
.
5. Elevated Creatinine: Baseline creatinine is 1.5-1.6. On
admission was slightly elevated at 2.0 likely secondary to blood
loss. At the time of discharge creatinine was at baseline.
.
6. Hypertension: Stable
- Continue Imdur, Metoprolol
.
7. Hyperlipidemia: Lipitor, Lopid. On admission the patient was
also noted to have an elevated creatinine kinase which continued
to rise on hospital days 2 and 3 out of proportion to his
elevation in cardiac enzymes. It was decided to stop the
patient's statin and upon doing so his CKs immediately began to
trend down.
.
8. Hypothyroidism
- Continue Levoxyl
Medications on Admission:
Allopurinol 100 mg daily
Ambien 10 mg prn insomnia
Aspirin 81 mg daily
Ambien CR 6.25 mg--1 tablet(s) by mouth once a day
Coumadin
Coumadin 3MG
Diovan 160 mg daily
Folic acid 1MG daily
Imdur 60 mg daily
Lasix 40MG daily
Levoxyl 125MCG daily
Lipitor 40MG daily
Lopid 600MG [**Hospital1 **]
MVI
NTG 0.4MG PRN
Protonix 40MG [**Hospital1 **]
Pyridoxine HCL 50MG daily
Toprol XL 25 mg daily
Aranesp
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*180 Tablet(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) for 2 days.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day. Tablet Sustained
Release 24HR(s)
12. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
13. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Imdur 60 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
15. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual prn as needed for chest pain: Take as directed for
chest pain. Seek medical attention of chest pain persists.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Outpatient [**Hospital1 **] Work
INR, HCT
[**Hospital1 **] work for [**2158-11-14**]
Discharge Disposition:
Home
Discharge Diagnosis:
GIB from duodenitis/gastritis
CAD
[**Month/Day/Year 1291**] on Coumadin
ARF
HTN
Hypothyroidism
Discharge Condition:
stable, anticoagulated, hematocrit stable.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please come back to the emergency room, if you have black or
blood stools or vomiting or if you have any chest pain, that
does not resolve with nitroglycerin.
.
We were holding your statin because of an elevated CK. You
should rediscuss starting your statin with your PCP.
.
Please take all your medications as directed. You have been
started on gembirozil since your lipitor is being held. Your
diovan dose is now half (80mg daily instead of 160mg daily).
You should rediscuss increasing the dose with your PCP. [**Name10 (NameIs) 2172**]
lasix dose has been cut in half for low BP. Please reevaluate
medication changes with your PCP.
.
Check your INR TOMORROW [**2158-11-14**] and have your PCP look at the
results after it is drawn. Continue to have your INR checked
regularly.
Followup Instructions:
Please follow up with your primary care doctor:
Provider: [**Name10 (NameIs) 10531**],[**Name11 (NameIs) **] ([**First Name9 (NamePattern2) **] [**Location (un) **]) [**Location (un) **] INTERNAL MEDICINE
(NHB) Date/Time:[**2158-11-27**] 11:45
.
You also have the following appointments available:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) 708**]:[**Telephone/Fax (1) 435**]
Date/Time:[**2158-12-18**] 2:30
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2038**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2159-6-8**] 10:30
.
Have your INR checked tomorrow morning [**2158-11-14**]. Continue to have
your INR checked with your PCP on [**Name Initial (PRE) **] regular bassis.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"584.9",
"285.1",
"582.81",
"710.0",
"V43.3",
"244.9",
"535.51",
"535.61",
"585.9",
"428.0",
"V45.81",
"V58.61",
"276.2",
"403.90",
"V45.02",
"790.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9520, 9526
|
3807, 7453
|
306, 327
|
9665, 9710
|
3226, 3784
|
10646, 11534
|
2556, 2714
|
7898, 9497
|
9547, 9644
|
7479, 7875
|
9734, 10623
|
2749, 3207
|
236, 268
|
355, 1832
|
1854, 2318
|
2334, 2540
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,863
| 185,982
|
32664
|
Discharge summary
|
report
|
Admission Date: [**2166-12-10**] Discharge Date: [**2167-1-2**]
Date of Birth: [**2123-9-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilantin
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
vomiting/confused
Major Surgical or Invasive Procedure:
1/24 L MCA coiling and EVD placement
History of Present Illness:
HPI: (history obtained from boyfriend)
43 year old female presents to the ER today after feeling sick
since Saturday. She vomited on Saturday and the family thought
she had a virus. The patient refused to eat and seemed confused
today so her boyfriend called 911. She was brought to [**Hospital1 18**]
where
a CT scan shows a left frontal ICH with extension in the
ventricles. The patient does report a headache currently. She
does not have any dizziness, numbness, tingling anywhere.
Past Medical History:
PMHx:unknown
Social History:
Social Hx: works as a tech in this hospital
Family History:
unknown
Physical Exam:
PHYSICAL EXAM:
T:98.8 BP:125/64 HR:54 RR:20 O2Sats:99% 3L NC
Gen: Patient is sleepy, confused as to why she is here.
HEENT: Pupils: PERRL EOMs-intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, flat
affect.
Orientation: Oriented to person, place, and year. She thought is
was [**11-6**].
Language: Speech is slowed.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 1 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**3-23**] throughout except hamstrings on
right [**2-21**]. No pronator drift.
Sensation: Intact to light touch bilaterally.
Pertinent Results:
CT head:
Preliminary Report !! Wet Read !!
(Findings just rev'd, w/Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 3271**], in detail.)
Lrg, acute parench bleed, centered L frontal deep [**Male First Name (un) 4746**], w/sign
assoc vasogen edema. Process appears centered on 12 mm round,
rel
hyperdense lesion: ?aneurysm/?mass.
Bld dissects into ventric chain, w/early [**Last Name (un) **] hydroceph and dil
temp horns. Min shift of midline; no evid herniation.
Labs:
PT: 13.4 PTT: 23.6 INR: 1.1
Na 142 Cl 106 BUN 25 Glu 112
K 4.0 CO2 22 Cr 0.6
WBC 15.7 Hbg 14.3 Hct 39.5 Plts 323
N:83.8 L:11.9 M:3.6 E:0.3 Bas:0.4
Brief Hospital Course:
A/P: 43 yo woman with left MCA aneurysm rupture.
.
Hospital course:
.
Patient was admitted from ED to Neuro ICU for q1 hour neuro
checks. She had CTA/MRA/MRI which showed evolving L IPH of L
basal ganglia and frontal lobe with IVH and evidence of
obstructive hydrocephalus. She had a L MCA coiling performed
and an external ventricular drain placed on [**12-11**]. Started on
cefazolin as prophylaxis for the drain. She remained intubated
until POD 3. She spiked a temperature on POD3. Pan cultures and
CSF sent. CSF was concerning for infection with 250 WBCs.
Started on empiric Vancomycin and Ceftriaxone. Infectious
disease was consulted and recommended cipro and c.diff checks.
Continued to spike temps over her hospitalization and multiple
blood, csf, and urine cx have been negative except for two urine
cx's that grew GPR and Lactobacillus. UTI's treated
appropriately but continued to spike fevers. MRI was not
concerning for infection. Eventually it was decided to hold abx
for a presumed drug fever. After stopping antibiotics patient
remained afebrile. She had hyponatremia and leukopenia on labs.
Patient was fluid restricted and started on salt tabs.
Patient's hct then steadily declined no source defined - guaiac
negative. Her neuro exam markedly improved and was doing very
well with physical therapy. Patient was transferred to medicine
service for workup of anemia and treatment of metabolic issues.
.
On the medicine service:
.
# Leukopenia: The patient had a leukopenia on transfer. An ANC
was checked when the WBC dropped to 1.8, with an ANC of 700.
Etiology of leukopenia was likely lab error versus medication
effect (Keppra, vancomycin). She will have her WBC monitored as
an outpatient.
.
# Anemia: On the day of transfer from neurosurgery, she was
noted to have a 10-point hct drop from 30 to 20. This drop was
from lab error, as the repeat check was 26%. Hemolysis labs
were negative and reticulocytes were normal with an retic index
of 1.8. There was no sign of bleeding and she was guaiac
negative.
.
# Aneurysm rupture: Was stable on transfer. Coil stable without
new pathology seen on MRI/MRA [**12-24**]. Patient's memory and weakness
deficits were improving daily per boyfriend's report. The
nimodipine was discontinued on [**1-2**] and the keppra was continued
(will be on this until 1 month follow-up with neurosurgery. She
was discharged on Plavix 75 mg po qday and aspirin for coil per
neurosurgery directions. She was asked to arrange a follow-up
MRI/MRA in one month and then see Dr. [**First Name (STitle) **] after that.
.
# Right-hand weakness/Cognitive deficits: Improving per patient
and boyfriend. Only minimal weakness noted on exam with wrist
extensors, all other strength was equal bilaterally. Patient is
right handed and was still having significant difficulty writing
at the time of discharge. Per OT notes, the patient's RUE
function was improving and recommended outpatient rehab as soon
as appropriate. Concerning the cognitive function, she was not
at baseline at the time of discharge. She had improved during
her hospitalization but experienced delayed responses and
speech. She was discharged with plans for outpatient OT, PT and
speech therapy.
.
# Anorexia: Patient reported having no appetite since the
aneurysm bleed, but eating because she knows she needs to eat.
Likely related to the aneurysm rupture, and should improve with
time. Considered an appetite stimulant and suggested starting as
an outpatient is appetite did not improve. Did not appear to be
secondary to depression. She was encouraged to take in high
calorie, smaller meals supplemented with ensure. Weight was
stable.
.
# DVT: Right calf vein DVT at the level of the peroneal vein
seen on doppler on [**12-24**]. On transfer to medicine was on ASA,
plavix, and SQ heparin. Neurosurgery requested that she not be
started on coumadin for now, but aggreed to theraputic lovenox
for a course of [**1-22**] months. She will continue lovenox until her
neurosurgery follow-up visit and the issue of coumadin
transition can be discussed at that time.
Medications on Admission:
Medications prior to admission: unknown
Discharge Medications:
1. Outpatient Occupational Therapy
2. Outpatient Physical Therapy
3. Outpatient Speech/Swallowing Therapy
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*1*
7. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 80mg syringe
Subcutaneous Q12H (every 12 hours).
Disp:*60 80mg syringe* Refills:*1*
8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Outpatient Lab Work
CBC
LFTs
Within 1-2 weeks. Have results send to: REYMOND,[**Last Name (un) 76114**] K
[**Telephone/Fax (1) 76115**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
1. Left MCA aneurysm rupture
2. Deep Vein Thrombosis
3. Hyperglycemia
4. Hyponatremia
5. Adverse reaction to antibiotics (cephalosporins)
6. Anemia
7. Leukopenia
8. Anorexia
Discharge Condition:
Improved: Vital signs stable, right hand weakness improving,
cognitive function improving.
Discharge Instructions:
You were admitted to the hospital for a ruptured brain anurysm.
The aneurysm was coiled and the bleeding was stopped. You
developed post-op fever and were treated with antibiotics for
suspected infection. These antibiotics were stopped when you
developed a rash. The rash was likely due to ceftriaxone or
ceftazidime, both of which are part of a group of medications
called cephalosporins. You should not take cephalosporins for
infection in the future. Your cognitive deficits have improved
since the aneurysm bleeding was stopped and your right arm/hand
weakness is improving.
You were started on an antiseizure medication (Keppra) due to
the bleed and will need to take this until directed to stop by
your neurosurgeon. For the coil, you were also started on
aspirin and plavix. You will continue to the aspirin
indefinetely. You will take the plavix for one more week and
then can stop this medication. It was discovered that you
developed a DVT in your right leg. You were started on a blood
thinning medication (lovenox) and will need to take this until
directed to stop.
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**First Name (STitle) **] TO HAVE AN ANGIOGRAPHIC STUDY PERFORMED IN ONE MONTH TO
ASSESS YOUR ANEURYSM. YOU WILL NEED TO SCHEDULE AN APPOINTMENT
TO MEET WITH HIM AFTER THIS IMAGING STUDY HAS BEEN PERFORMED.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST. YOU
WILL/WILL NOT NEED AN MRI OF THE BRAIN WITH OR WITHOUT
GADOLIDIUM
Please follow-up with your primary care doctor in [**11-19**] weeks
regarding your hospitalization.
You should have a CBC and LFTs drawn at you follow-up
appointment with your PCP.
Completed by:[**2167-1-10**]
|
[
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"599.0",
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icd9cm
|
[
[
[]
]
] |
[
"02.2",
"88.41",
"00.65",
"03.31",
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"39.72",
"00.44",
"00.45",
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] |
icd9pcs
|
[
[
[]
]
] |
7837, 7894
|
2883, 2934
|
300, 339
|
8121, 8214
|
2220, 2220
|
10679, 11300
|
968, 977
|
7063, 7814
|
7915, 8100
|
6999, 6999
|
2951, 6973
|
8238, 10656
|
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7031, 7040
|
243, 262
|
367, 854
|
1525, 2201
|
2229, 2860
|
1295, 1509
|
876, 890
|
906, 952
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,031
| 179,956
|
6720
|
Discharge summary
|
report
|
Admission Date: [**2172-9-30**] Discharge Date: [**2172-10-5**]
Date of Birth: [**2089-4-20**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
S/P Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
83 yo male w/ PMHx sig for HTN, DM, ESRD on HD who
has dialysis yesterday evening and had a fall at home w/ LOC. Pt
does not remember fall. This AM he had frontal HA and emesis.
Pt brought to an OSH where CT head showed frontal IPH and small
SAH.
Past Medical History:
Coronary Artery Disease
End Stage Renal Disease - requires Hemodialysis
Type I Diabetes Mellitus
Hypertension
History of colon cancer
Cataracts
Appendectomy
Cholecystectomy
Social History:
Denies tobacco. Admits to occasional ETOH. Former Soviet [**Hospital1 1281**]
Naval Captain.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: T 97.6; BP 136/46; P 69; RR 14; O2 sat 99% RA
General: lying in bed wearing a c-collar
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.
Neurological Exam:
Mental status: (per daughter) A & O x3, Able to say MOYB. Fluent
speech with no paraphasic or phonemic errors. Adequate
comprehension. Follows simple and multi-step commands.
Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**6-15**]
XII: Tongue midline without fasciculations.
Motor: Normal bulk. Normal tone. No pronator drift. Full
strength
Sensation: intact to light touch
Reflexes: 1+ symmetric Toes mute.
Coordination: FNF intact.
Pertinent Results:
[**2172-10-4**] 07:40AM BLOOD WBC-5.7 RBC-3.22* Hgb-10.7* Hct-31.1*
MCV-97 MCH-33.2* MCHC-34.4 RDW-16.9* Plt Ct-163
[**2172-9-30**] 06:35PM BLOOD Neuts-84.3* Lymphs-10.2* Monos-4.7
Eos-0.5 Baso-0.2
[**2172-10-4**] 07:40AM BLOOD Plt Ct-163
[**2172-10-4**] 07:40AM BLOOD Glucose-107* UreaN-39* Creat-4.9* Na-139
K-4.3 Cl-97 HCO3-31 AnGap-15
[**2172-10-1**] 04:23AM BLOOD ALT-13 AST-16 AlkPhos-107
[**2172-10-4**] 07:40AM BLOOD Calcium-8.3* Phos-4.3 Mg-2.0
[**2172-10-1**] 04:23AM BLOOD Triglyc-95 HDL-41 CHOL/HD-3.3 LDLcalc-75
Brief Hospital Course:
Mr [**Known lastname **] was admitted to the neurosurgery service for close
neurological checks and follow up head CTs. Head CT showed right
inferior frontal lobe with
cortical breakthrough and small amount of adjacent subarachnoid
and subdural
hematoma. He had an MRI and MRA of his brain due to a question
of anuerysm an MRA showed no evidence for aneurysm or clot.
There is atrophy of the right and left PCOMs. Other intracranial
vessels are normal in appearance. There is no stenosis or
occlusion. An MRI showed chronic left cerebellar hemispheric
infarct and periventricular white matter ischemic disease. An
MRI C-Spine was done due to his fall and questionable CT finding
no evidence for ligamentous tear
was noted and he had no pain. Neurologically he remained
awake,alert and orientated X3, full motor strength, and
following commands. He was found to have orthostatic hypotension
his family was advised to have 24 hour supervison and to sit the
patient up slowly. We advised going to rehab but the family
wanted to bring the patient home and promised this care.
Medications on Admission:
Protonix 40 mg q day, Renal caps 1 cap q day,
Aggrenox 1 cap [**Hospital1 **], Provigil 200 mg q day, Avapro 150 mg qod &
75
mg qod, Renagel 400 mg tid, Lexapro 20 mg q day, Metoprolol 50
mg
q day, Lantus 20 units in AM, Alprazolam
Discharge Medications:
1. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO q day ().
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Use if taking pain medications.
Disp:*60 Capsule(s)* Refills:*0*
6. Irbesartan 150 mg Tablet Sig: 0.5 Tablet PO qod ().
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA
Discharge Diagnosis:
Right frontal IPH with adjacent SAH and SDH
Discharge Condition:
Neurologically stable
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, and
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered.
You must have 24 hour supervision when you get out of bed
You must slowly move from a sitting to a standing position
CALL YOUR SURGEON 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.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with
Dr.[**First Name (STitle) **] to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2172-10-5**]
|
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icd9cm
|
[
[
[]
]
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[
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icd9pcs
|
[
[
[]
]
] |
4954, 4988
|
2484, 3558
|
328, 335
|
5076, 5100
|
1935, 2461
|
6230, 6490
|
936, 979
|
3840, 4931
|
5009, 5055
|
3584, 3817
|
5124, 6207
|
994, 1242
|
1261, 1261
|
280, 290
|
363, 613
|
1454, 1916
|
1276, 1438
|
635, 809
|
825, 920
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,482
| 168,651
|
4623
|
Discharge summary
|
report
|
Admission Date: [**2117-2-25**] Discharge Date: [**2117-3-4**]
Service: [**Location (un) **]
HISTORY OF PRESENT ILLNESS: This is an 89 year old female
with a history of atrial fibrillation, congestive heart failure,
and recent admission for pancreatitis/syncope, now presents with
hypotension and hypothermia. The patient was recently discharged
one day prior to admission to an [**Hospital3 **] center with
[**Hospital6 407**] after being treated for pancreatitis.
Today the patient noticed some dizziness in the morning. After
the dizziness, she later developed some abdominal pain. She did
fall, collapsed, and then called Life Line. She was brought to
the Emergency Department by the emergency medical services with
blood pressure 60s/palpable. She was hypothermic with rectal
temperature of 94. In the Emergency Room the patient had
significant abdominal pain and diarrhea which was nonbloody
and guaiac negative. She received 2 liters of normal saline
with appropriate increase in blood pressure to systolics of
120s to 160s and temperature to 97.3 rectally. The white count
was markedly increased as well as the hematocrit and creatinine
from baseline.
PAST MEDICAL HISTORY: Syncope status post DDD pacer placed
in [**2116-12-26**], atrial fibrillation without anticoagulation,
congestive heart failure with a [**2116-3-25**] echocardiogram
revealing an ejection fraction of 45%, 3+ mitral regurgitation
and 2+ tricuspid regurgitation, hypertension, coronary artery
disease with myocardial infarction in [**2111**] with the [**2117-2-23**]
stress ushering fixed inferior defect, chronic renal
insufficiency with creatinine of 1.4 to 2 and diverticulitis,
asthma and vertigo.
ALLERGIES: Sulfa
MEDICATIONS ON ADMISSION: Medications at home were
Amiodarone 200 mg p.o. q.d., Hydrochlorothiazide 25 mg p.o.
q.d., Toprol XL 25 mg p.o. q.d., Aspirin 325 mg p.o. q.d.,
Protonix 40 mg p.o. q.d., Evista 60 mg p.o. q.d., Lipitor 10
mg p.o. q.d., Multivitamin one tablet p.o. q.d., Folate 1 mg
p.o. q.d., Thiamine 100 mg p.o. q.d., Singulair 10 mg p.o.
q.d., Combivent 2 puffs q. 6 hours.
SOCIAL HISTORY: The patient lives in an [**Hospital3 **]
center with [**Hospital6 407**] services.
PHYSICAL EXAMINATION: Physical examination at the time of
admission is temperature 97.3 with heartrate of 60 to 70,
blood pressure 120 to 160/60 to 80, respiratory rate 12,
oxygen saturation 97% on room air. Generally, this patient
is in no acute distress with skin warm and dry. Head, eyes,
ears, nose and throat, oropharynx clear with mucous membranes
that are dry. Neck is supple without lymphadenopathy or
jugulovenous distension. Cardiovascular, regular rate and
rhythm, normal S1 and S2, II/VI systolic ejection murmur.
Lungs are scattered rhonchi bilaterally. Abdomen, soft, mild
distention with diffuse tenderness with left lower quadrant
greater than left upper quadrant. There are normoactive
bowel sounds. Stools, guaiac negative per Emergency
Department nursing. Extremities, no edema, palpable distal
pulses.
LABORATORY DATA: Laboratory studies on admission revealed
white count 30 with 79% neutrophils, 3% bands, 18%
lymphocytes with a hematocrit of 49.1, platelets 277, sodium
137, potassium 5.7, chloride 99, bicarbonate 22, BUN 32,
creatinine 2.4, glucose 144, INR 1.3, PTT 30.9, PT 13.8. ALT
38, AST 77, alkaline phosphatase 109, total bilirubin 0.8,
amylase 214, lipase 167, LDH 620, lactate 3.8, troponin 0.3.
Urinalysis showed 0-2 white blood cells, 0 red blood cells,
1.01 and urine culture pending. Chest x-ray showed no acute
cardiopulmonary processes. KUB showed no signs of
obstruction, nonspecific bowel/gas pattern. Computerized
tomography scan of the abdomen/pelvis showed colonic wall
thickening at the splenic flexure with minimal stranding and
small amount of free fluid which is consistent with ischemia
versus infection. Electrocardiogram was AV paced.
HOSPITAL COURSE: 1. Gastroenterology - Ischemic colitis and
pancreatitis, the patient was initially NPO. She was rehydrated
with 8 liters of intravenous fluids while in the Medicine
Intensive Care Unit. She was also given intravenous proton pump
inhibitors twice a day. She was also covered with Ampicillin,
Levofloxacin and Flagyl. Though Surgery felt that she was a good
surgical candidate, the patient did not desire surgery at this
time. Stool guaiac continued to be negative while in the
Medicine Intensive Care Unit. It did become positive when she
was transferred to the Medical Floor after spending one day in
the Medical Intensive Care Unit. Her lactate level did decrease
down to 1.6 from 2.8 with intravenous hydration. We continued
hydration. Her pancreatic enzymes decreased down to an amylase
of 77 and lipase of 27 with triple antibiotic and intravenous
fluids. The patient's systolic blood pressure was kept in the
140s to 150s for intestinal perfusion. Her abdominal examination
did improve with less tenderness to palpation on examination.
She was then advanced to clear liquid diet while being supported
with total parenteral nutrition for nutrition. She did well on
the clear liquid diet without any problems with pain or excessive
blood per rectum. All antihypertensives were held so that her
systolic blood pressure could be kept up. Surgery recommended a
full ten day course of the Ampicillin, Levofloxacin and Flagyl.
2. Pulmonary - The patient had a lot of problems with wheezing
that was secondary to her asthma. Her chest x-ray did not show
any evidence of congestive heart failure that may be causing any
cardiac wheezes. She was given Flovent and Combivent inhaler.
Given that she could not fully utilize these inhalers correctly,
she was given Atrovent nebulizers on a scheduled q.i.d. basis.
She was also given Albuterol nebulizers but that was kept as prn
because it has caused some tachycardia.
3. Infectious disease - The patient's leukocytosis did decrease
down from 43 to 16 with triple antibiotic. She was given a full
ten day course of these antibiotics. One out of four blood
cultures did grow gram positive cocci on [**2117-2-28**] but this
was felt to be a contaminate. Blood cultures were drawn on [**2117-3-2**] but there has been no growth to date.
4. Hematology - The patient's hematocrit did drop down to 27.5.
Hemolysis laboratory data were checked but found to be negative,
given the normal LDH at 379, total bilirubin of 0.6 and
haptoglobin of 91. Her anemia was then attributed to some blood
loss in her stool secondary to the ischemic colitis. Given her
coronary artery disease history, she was given 1 unit of packed
red blood cells and responded appropriately from 27.5 to 31.9.
The patient also had some thrombocytopenia going down to 101. Her
Pepcid was discontinued after she started eating food. Also her
subcutaneous heparin was discontinued and Pneuma boots were
placed instead. Her platelets did then increase back up to 107.
DISCHARGE DIAGNOSIS:
1. Ischemic colitis
2. Pancreatitis
3. Asthma
4. Leukocytosis
5. Anemia
6. Thrombocytopenia
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 250 mg p.o. q. 48 hours to end on [**2117-3-7**]
2. Flagyl 5 mg p.o. t.i.d. to end on [**2117-3-7**]
3. Ampicillin 500 mg p.o. t.i.d. to end on [**2117-3-7**]
4. Atrovent nebulizer q. 6 hours
5. Flovent 110 mcg 2 puffs inhaler b.i.d.
6. Combivent 2 puffs inhaler q. 6 hour
7. Albuterol nebulizer q. 6 hours prn
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To rehabilitation center.
FOLLOW UP: The patient is to follow up with primary care
provider in two weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 4270**]
MEDQUIST36
D: [**2117-3-3**] 18:47
T: [**2117-3-3**] 20:00
JOB#: [**Job Number 19620**]
|
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48,970
| 197,400
|
12400
|
Discharge summary
|
report
|
Admission Date: [**2105-1-2**] Discharge Date: [**2105-1-5**]
Date of Birth: [**2048-2-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Upper GI Bleed
Major Surgical or Invasive Procedure:
[**2105-1-5**] esophageal gastro duodenoscopy ([**Month/Day/Year **])
History of Present Illness:
56M with hx prostate ca s/p radical prostatectomy, GERD
(biannual [**Month/Day/Year **]), distant hx ulcer p/w coffee ground emesis and
melena.
.
Pt states that 5 days ago felt mild nausea with little episode
of vomiting and fatigue which resolved. Then last night
developed severe n/v/d. He states that the first couple of
episodes of vomiting were normal, however the vomit then turned
to coffeegrounds around 3AM. Likewise, the diarrhea started as
normal liquid stools and then became black. He feels weak with
chills, but denies CP, SOB. He endorses only mild discomfort in
his abdomen. He has a granddaughter who had n/v/d last week. He
denies liver disease. Took 2 tabs advil today but none
yesterday, no aspirin, no etoh. 400mg ibuprofen daily for back
pain. Had an episode of vomiting blood 20y ago bc of a "bad
esophagus". He says he drank [**12-15**] a bottle of kaopectate and took
some vitamin water. Currently he feels generally weak and
nauseous. Not actively vomiting, no active diarrhea.
.
In the ED inital vitals were, T 97.6, HR 103, BP 115/60, RR 18,
100% on RA. Vomited small amount of bright red blood in ED. NG
lavage showed coffee grounds, didn't clear. Guaiac positive
brown. Still nauseous. WBC 16, Hct 48, T&S. 2 x 18g PIV, started
on protonix bolus and drip, given 1L. GI consulted and
recommended ICU admission, possible [**Month/Day (2) **] in AM.
.
On arrival to the ICU, initial vitals were T100.4, BP 123/87,
R14, 98RA. He feels fatigued with mild nausea but no recent
vomiting since 3 pm. On ROS, mentions some fevers, chills over
past 24 hours with abdominal pain, but no dysuria, hematuria,
rashes, skin changes, dizziness, or lightheadedness.
Past Medical History:
LOW BACK PAIN
OBESITY UNSPEC
BENIGN NEOPLASM - SKIN UPPER LIMB INCLUDING SHOULDER
Mental Health Visit - AMRS
ESOPHAGEAL REFLUX
CHEST PAIN
ANGINA PECTORIS
CORONARY ARTERY DISEASE
HEADACHE
ACNE
HYPERCHOLESTEROLEMIA
Social History:
Retired Sherriff's department worker
Etoh: 10 years ago would drink upwards of case a day, now a few
beers a week.
tobacco: quit 64d ago
Family History:
Brother - Myocardial Infarction
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T100.4, BP 123/87, R14, 98RA
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, discomfort diffusely with deep palpation,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE PHYSICAL EXAM
afebrile, BP remained 120s/80s, saturaing 100% RA
exam unchanged, especially:
no abdominal tenderness or distension
good capillary refill and pulses 2+ DP and radial bilaterally
Pertinent Results:
ADMISSION LABS:
[**2105-1-2**] 05:06PM BLOOD WBC-16.4* RBC-5.81 Hgb-16.7 Hct-48.1
MCV-83 MCH-28.8 MCHC-34.8 RDW-12.7 Plt Ct-270
[**2105-1-3**] 02:11AM BLOOD PT-19.4* PTT-29.3 INR(PT)-1.8*
[**2105-1-3**] 02:11AM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-139
K-3.6 Cl-107 HCO3-24 AnGap-12
[**2105-1-2**] 05:06PM BLOOD ALT-33 AST-22 AlkPhos-74 TotBili-0.5
.
HEMATOCRIT TREND:
[**2105-1-2**] 05:06PM BLOOD WBC-16.4* RBC-5.81 Hgb-16.7 Hct-48.1
MCV-83 MCH-28.8 MCHC-34.8 RDW-12.7 Plt Ct-270
[**2105-1-3**] 02:11AM BLOOD WBC-9.1 RBC-5.09 Hgb-14.5 Hct-41.8 MCV-82
MCH-28.5 MCHC-34.7 RDW-12.8 Plt Ct-231
[**2105-1-3**] 09:10AM BLOOD Hct-41.6
[**2105-1-3**] 09:21PM BLOOD Hct-39.8*
[**2105-1-4**] 06:40AM BLOOD WBC-6.1 RBC-4.60 Hgb-13.0* Hct-37.9*
MCV-82 MCH-28.2 MCHC-34.2 RDW-12.6 Plt Ct-222
.
MICRO:
[**2105-1-3**] C. DIFF NEGATIVE
[**2105-1-3**] STOOL CULTURE PENDING, NO GROWTH TO DATE
.
IMAGING:
[**2105-1-5**] [**Month/Day/Year **]: Procedure: The procedure, indications, preparation
and potential complications were explained to the patient, who
indicated his understanding and signed the corresponding consent
forms. A physical exam was performed. The patient was
administered moderate sedation. Supplemental oxygen was used.
The patient was placed in the left lateral decubitus position
and an endoscope was introduced through the mouth and advanced
under direct visualization until the third part of the duodenum
was reached. Careful visualization of the upper GI tract was
performed. The procedure was not difficult. The patient
tolerated the procedure well. There were no complications.
Findings: Esophagus:
Lumen: A small size hiatal hernia was seen.
Mucosa: Normal mucosa was noted.
Stomach:
Mucosa: Mild erythema and friability of the mucosa was noted in
the stomach. These findings are compatible with mild gastritis.
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Small hiatal hernia
Normal mucosa in the esophagus
Mild erythema and friability in the stomach compatible with mild
gastritis
Normal mucosa in the duodenum
Otherwise normal [**Month/Day/Year **] to third part of the duodenum
Recommendations: Daily PPI for 4 weeks.
Follow up as per inpatient team.
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSES are listed in the impression
section above. Estimated blood loss = zero. No specimens were
taken for pathology
.
[**2105-1-5**] RIGHT UPPER QUADRANT ULTRASOUND:
Preliminary Report
COMPARISON: No previous studies available for comparison.
FINDINGS: The liver is normal in echogenicity and echotexture.
No focal
liver lesions identified. No intra- or extra-hepatic duct
dilation. There is normal hepatopetal flow within the portal
vein. The gallbladder is normal in appearance without evidence
of cholelithiasis. The pancreas is not completely visualized due
to overlying bowel gas. The visualized portions of pancreas are
normal. The spleen is top normal in size measuring 12.5 cm.
Both kidneys are normal in size and echogenicity. The right
kidney measures 10.5 cm. The left kidney measures 14 cm. There
is no evidence of hydronephrosis, renal lesion, or stone.
The aorta is normal in caliber throughout. The visualized
portions of the IVC are normal. There is no free fluid.
IMPRESSION:
1. Borderline splenomegaly.
2. The remainder of the study is normal.
Brief Hospital Course:
Mr. [**Known lastname 38582**] is a 56 year old male with history of
gastroesophageal reflux disease (GERD) who presented with 24
hours of severe vomiting and diarrhea which progressed to
hematemesis with coffee ground emesis. The coffee grounds did
not clear with nasogastric lavage and so he was admitted to the
MICU for observation and [**Known lastname **] found mild gastritis.
.
ACTIVE ISSUES:
# Hematemesis: Because his coffee ground emesis did not clear
with nasogastric lavage, he was initially admitted to the MICU.
However, he remained hemodynamically stable and with hematocrit
which went from 48 on presentation to 41 --> 41 --> 41. He was
started on intravenous PPI; however, because he was so stable
this was changed to pantoprazole 40 mg orally daily. The GI
team was consulted and they felt that his initial hematocrit was
hemoconcentrated from 24 hours of vomiting and diarhhea and that
he actually had a very stable blood volume. He had an [**Known lastname **]
performed on hospital day 3 which found only mild gastritis.
There was suspicion for [**Doctor First Name **]-[**Doctor Last Name **] tear given the time course
of vomiting and then hematemesis, however, tears were not found.
He did not ever require blood transfusion. In house
anticoagulation was with pneumoboots instead of chemical
prophylaxis in the setting of this GI bleed. He should continue
the pantoprazole 40 mg daily for 4 weeks.
.
# Viral gastroenteritis: The initial cause of his GI illness
was probably norovirus, contracted from his granddaughter with
similar symptoms. This is supported by the time course of
illness and his symptoms. His C. diff and stool cultures were
negative. His symptoms resolved and he had good PO intake
before discharge.
.
# Leukocytosis: Likely from gastroenteritis. Resolved with
conservative management.
.
# Elevated INR: His INR on admission was 1.8 He received
vitamin K 5 mg PO with improvement in his INR before the [**Doctor Last Name **].
In the setting of decreased albumin, the elevated INR might
represent decreased synthetic function of the liver in a
cirrhotic patient. He does have a significant drinking history
although he claims his outpatient GI doctor monitors liver
function every 1-2 years and has always been normal. He
underwent a RUQ ultrasound which showed no evidence of
cirrhosis.
.
CHRONIC ISSUES:
# Low back pain: He reported that his pain was at baseline. He
was continued on oxycodone 5-10 mg q4 hours prn pain. His
ibuprofen was stopped due to upper GI bleed. Instead, he was
given a prescription for acetaminophen 325-600 mg q6H prn pain.
He was told that this would be better to take at least 3 times a
day for chronic pain with oxycodone as breakthrough.
.
# Communication: Patient, wife [**Name (NI) **] [**Telephone/Fax (1) 38583**]
# Code: confirmed full
.
TRANSITIONAL ISSUES:
- There is a chart history of coronary artery disease and
hyperlipidemia, however he was not taking medications as an
outpatient for risk modification. The patient denies having a
history although prior notes do list it as a problem. [**Name (NI) **] have
this followed by PCP with lipid checks and consider starting
statin and aspirin. ASA was not started in-house given concern
for GI bleed.
- Please follow-up with his symptoms of GERD and ensure that he
is doing well with the pantoprazole.
Medications on Admission:
Ibuprofen 800 mg Oral Tablet TAKE 1 TABLET EVERY 8 HOUR
CIALIS TABLET 20MG PO (TADALAFIL) 1 tablet one hour before sex
PRILOSEC OTC TABLET DR 20MG PO (OMEPRAZOLE MAGNESIUM) 1 tab po
qd 30 min. before first meal. Disp 2 x 14 tabs pk.
ROXICODONE TABLET 5MG PO (OXYCODONE HCL) [**12-15**] po q 3-4 h prn pain
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day for 4 weeks.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Cialis Oral
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: Maximum daily dose 2 grams.
Disp:*120 Tablet(s)* Refills:*0*
4. bismuth subsalicylate 262 mg/15 mL Suspension Sig: Fifteen
(15) ML PO TID (3 times a day) as needed for heartburn for 7
days.
Disp:*qs ML(s)* Refills:*0*
5. Roxicodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Gastritis
.
SECONDARY DIAGNOSIS
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 38582**],
.
You were admitted to the hospital because you were vomiting
blood. The GI doctors performed [**Name5 (PTitle) **] [**Name5 (PTitle) **] (inserted camera down
your esophagus to look at the esophagus and stomach) which
showed gastritis.
.
The following changes were made to your medications:
- START pantoprazole 40 mg by mouth daily for 4 weeks
- STOP taking ibuprofen for pain, this can irritate your stomach
and promote ulcer formation
- START acetaminophen 325-650 mg by mouth up to three times
daily for chronic back pain. The maximum daily dose is 2 grams.
.
It is also very important that you keep all of the follow-up
appointments listed below.
.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Name: [**Last Name (LF) 38584**],[**First Name3 (LF) **] P.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 3530**]
When: Tuesday, [**1-13**], 3:30 PM
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
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59,886
| 178,881
|
38489
|
Discharge summary
|
report
|
Admission Date: [**2108-3-21**] Discharge Date: [**2108-3-28**]
Service: MEDICINE
Allergies:
Codeine / Valium
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F with CHB, known 13 cm AAA non-op per vascular presented to
[**Hospital3 **] with abdominal pain where CT scan showed large
(10.6 cmper report)AAA with concern for endovascular leak and
was transferred to [**Hospital1 18**] forfurther management. In the ED her
initial vitals were: In the EW, initial vitals were: T 97, HR
30, BP 180/90, RR 26, O2 99%. In the EW, she was hypertensive
and mantained on nicardipine drip from OSH. She was also given
morphine, zofran and was given a dose of zosyn for a UTI.
.
Upon arrival to the ICU her initial vitals were: HR 33 BP 146/43
RR 12 O2 sat 99%. She is sleepy and hard of hearing. She is only
able to provide limited history. She states she has not been
eating well and has some pain in her anterior abdomen. Her
daughter states that she recently had a UTI 10 days ago which
was treated with an antibiotic though she does not recall which
one. She says that her abdominal pain worsened after then and
also noted elevated blood pressures >200 routinely. She also
reports a cough that had been productive.
.
Of note she was admitted to [**Hospital1 18**] [**Date range (1) 69877**] for similar reasons
at that time it was documented that the patient did not want any
further intervention and would prefer Be DNR/DNI and mostly
focus on comfort. However the daughter insisted that she have
further interventional procedures. Ethics and social work had to
be involved. Now the patient is not alert enough to state her
wishes and her daughter insists that she reversed her decision
and want to be full code.
.
Past Medical History:
1. Bradycardia, complete heart block status post pacemaker
placement 20 years ago.
2. PPM noted to be nonfunctional and was taken out at [**Hospital3 **]. The patient developed recurrent hematoma and right-sided
system implanted. PPM then later noted to be infected and
right-sided system taken out. Now with no pacer present but
left-sided leads in place.
3. Bleeding/clotting problems, question of an ITP or factor
deficiency.
4. CAD.
5. Hypertension.
6. Diabetes.
7. Gallstones.
8. Valvular heart disease.
9. Breast cancer status post mastectomy/radiation.
10. Legally blind.
11. Hip fracture status post ORIF.
12. AAA status post endovascular repair in [**2097**]. Recently noted
to have sac expansion.
13. Thrombocytopenia, thought to be ITP, also noted to have
factor XIII deficiency per daughter report.
Social History:
Was wheelchair bound but is mostly bed bound now. She has not
been able to perform ADLS. She lives with her daughter in
[**Name (NI) **]; her daughter is reluctant to not pursue all options
for the patient. Ms. [**Known lastname 34763**] was married or about 60 years to
her husband, and has 4 children present today during the
interview (3 daughters). Remote tobacco use (former smoker who
quit 30 years ago), no history of alcohol or illicit substances.
Family History:
noncontributory, no h/o AAA
Physical Exam:
ADMISSION EXAM
Vitals: T:97 HR 33 BP 146/43 RR 12 O2 sat 99%
General: Sleepy but arousable, A&Ox1, no acute distress
HEENT: Sclera anicteric, dMM, oropharynx clear, EOMI
Neck: supple, JVP difficult to appreciate, no LAD
CV: Brady but regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Mildly diminished BS at bases otherwise clear to
auscultation bilaterally, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
does have large frim mass in central adbomen without pulsation
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Discharge Exam:
VS: 98.4, 142/59 (111-142/46-59), 44 (40s), 20, 98%2L
General: awake, interactive, improved MS from previously, hard
of hearing, A&Ox2, no acute distress, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, right eye
with significant cataract (blind), left eye pupil minimally
reactive to light, hearing aid in left ear
Neck: supple, JVP minimally elevated, no LAD
CV: regular rate and rhythm, normal S1 + S2, [**1-23**] early systolic
murmur over LUSB, no rubs, gallops noted
Lungs: rales 1/3 up the lungs posteriorly, no wheezes/rhonchi.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
does have large firm mass in central abdomen without pulsation
GU: foley in place with minimal clear yellow urine in bag
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. [**12-19**]+
sacral edema and left arm with 1+ edema. Sensation intact to
light touch and temperature, toes moves bilaterally. No edema of
feet or lower legs.
Skin: old ecchymoses on forearms, thin fragile skin, stage I
wound on coccyx (3 x 2 cm intact non-blanchable erythema)
Pertinent Results:
ADMISSION LABS:
[**2108-3-21**] 10:30AM WBC-11.2* RBC-3.26* HGB-10.5* HCT-33.2*
MCV-102* MCH-32.2* MCHC-31.6 RDW-15.6*
[**2108-3-21**] 10:30AM NEUTS-77.0* LYMPHS-21.0 MONOS-1.3* EOS-0.4
BASOS-0.3
[**2108-3-21**] 10:30AM PLT COUNT-44*
[**2108-3-21**] 10:30AM PT-11.0 PTT-29.1 INR(PT)-1.0
[**2108-3-21**] 10:30AM GLUCOSE-92 UREA N-30* CREAT-1.1 SODIUM-133
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-19* ANION GAP-16
[**2108-3-21**] 10:30AM ALT(SGPT)-14 AST(SGOT)-38 ALK PHOS-52 TOT
BILI-0.3
[**2108-3-21**] 10:30AM LIPASE-30
[**2108-3-21**] 10:30AM ALBUMIN-2.8* CALCIUM-8.6 PHOSPHATE-3.9
MAGNESIUM-1.7
[**2108-3-25**] Vitamin B12: 1043
Urine studies:
[**2108-3-21**] 10:45AM URINE BLOOD-MOD NITRITE-POS PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
[**2108-3-21**] 10:45AM URINE RBC-2 WBC->182* BACTERIA-MOD YEAST-NONE
EPI-1 TRANS EPI-<1
[**2108-3-21**] 10:45AM URINE WBCCLUMP-MANY MUCOUS-RARE
[**2108-3-24**] 05:41PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2108-3-24**] 05:41PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2108-3-24**] 05:41PM URINE RBC-2 WBC-36* Bacteri-FEW Yeast-NONE
Epi-5 TransE-<1
[**2108-3-24**] 11:33AM URINE Hours-RANDOM UreaN-354 Creat-76 Na-28
K-39 Cl-16
Creatinine trend: 1.1->1.3->1.7->1.8->1.8->2.0->2.3->2.2->2.5
GFR: 21->18 ([**3-27**]->[**3-28**], day of discharge)
.
Discharge Labs:
[**2108-3-27**] 12:46PM BLOOD Hct-28.9*
[**2108-3-27**] 06:25AM BLOOD PT-11.8 PTT-31.6 INR(PT)-1.1
[**2108-3-28**] 06:20AM BLOOD Creat-2.5*
[**2108-3-27**] 06:25AM BLOOD Calcium-7.1* Phos-6.0* Mg-2.0
.
Micro:
[**2108-3-21**] Urine culture negative
[**2108-3-21**] MRSA screen negative
[**2108-3-22**] blood culture negative
[**2108-3-23**] blood culture NGTD
[**2108-3-24**] 5:41 pm URINE Source: Catheter.
**FINAL REPORT [**2108-3-26**]**
URINE CULTURE (Final [**2108-3-26**]):
YEAST. 10,000-100,000 ORGANISMS/ML.
[**2108-3-24**] 10:57 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2108-3-27**]**
GRAM STAIN (Final [**2108-3-25**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
RESPIRATORY CULTURE (Final [**2108-3-27**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
Imaging:
[**2108-3-21**] ECG: Baseline artifact. Probable underlying sinus rhythm
with complete heart block and ventricular escape rhythm.
Compared to the previous tracing of [**2108-1-15**] no definite change.
TRACING #1
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
46 0 154 566/541 0 -64 -44
.
[**2108-3-21**] Sinus rhythm with complete heart block and ventricular
escape rhythm. Compared to the previous tracing no change.
TRACING #2
Read by: [**Last Name (LF) **],[**First Name3 (LF) **]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
34 232 152 630/[**Medical Record Number 85639**] 23
.
[**2108-3-21**] CXR: FINDINGS: Single portable view of the chest is
correlated to CT scan of the abdomen from earlier the same day
performed at an outside hospital. There are bibasilar opacities,
larger on the left than on the right which partially silhouette
the hemidiaphragms. There is engorgement of the central
pulmonary vasculature and indistinct pulmonary vascular markings
seen peripherally. Cardiac silhouette appears enlarged.
Degenerative changes noted at the right shoulder and
acromioclavicular joint. Surgical clips seen in the left axilla.
Partially visualized abdominal aortic stent. IMPRESSION:
Findings suggestive of congestive failure. Left greater than
right basilar opacities compatible with effusion and underlying
atelectasis although component of infection is not excluded.
.
[**2108-3-22**] ECG: Sinus rhythm with complete heart block and slow
ventricular escape rhythm with right bundle-branch block and
left anterior fascicular block morphology. Compared to the
previous tracing of [**2108-3-21**] no diagnostic interim change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
38 420 148 558/[**Telephone/Fax (2) 85640**]
Brief Hospital Course:
[**Age over 90 **]F with CHB, known 13 cm AAA non-op per vascular presented to
[**Hospital3 **] with abdominal pain where CT scan showed known
AAA with concern for endovascular leak and was transferred to
[**Hospital1 18**] for further management.
.
# Goals of care: Family meeting held this admission with the
patient, 3 children, cardiology, palliative care, social work,
and renal. See OMR note from palliative care. Briefly, patient
clearly stated she did not want a pacemaker placed. Patient and
family are aware of the limitation of what can be offered given
the risks and benefits of various interventions with her
comorbidities (no pacemaker, no dialysis, no AAA intervention).
Palliative care and social work have set up home hospice for the
patient with the goal of managing her symptoms at home (SL nitro
x3 for abdominal pain, then consider morphine. Call the hospice
nurses with management questions prior to considering bringing
her to the hospital). Although the patient was DNR inhouse (not
medically indicated), the daughter insists she be full code at
home. This is not incompatible with hospice. The patient would
like to live at home with medical managment and optimization of
her clinical status (i.e. blood pressure control) as well as
symptomatic control (for her abdominal pain and anxiety) given
the limitations of treatment of her significant medical problems
(i.e. no invasive procedures). The daughter is adamant that the
patient should continue to be managed aggressively and has been
having a very difficult time accepting that a pacemaker is not
an option (despite the fact that her mother has said she does
not want this herself). It is our hope that with hospice care
and good PCP oversight, her care can be effectively addressed in
the outpatient setting and hospitalizations can be avoided given
our limited therapeutic options.
.
# AAA/abd pain: Has known AAA that was evaluated by vascular on
last admission in [**Month (only) 956**]. At that time the aneurysm was 10x13
cm and vascular recommended non-operative management. The report
of the CT does not suggest AAA is enlarging though this has not
been confirmed. Vascular was re-consulted in the ED who again
recommended medical management. BP was very elevated on
presentation which may be related to her symptoms. Her blood
pressure was lowered to 140 systolic per vascular surgery
recommendations as below and her abdominal pain resolved. She
had no recurrence of abdominal pain while here and was
instructed to try nitroglycerin SL at home, as this has worked
in the past.
.
# Hypertension/Hypertensive urgency: Presented to an outside
hospital with BP >200. She was started on nicardipine gtt prior
to transfer. On admission here her blood pressure was still
elevated >170. Her nicardipine gtt was changed to nitro and her
home medications were restarted. She still required the nitro
gtt to maintain her blood pressure at the goal of 140 so her
amlodipine was increased to 10 mg daily and isosorbide
monnonitrate 60 mg daily was started. Her blood pressure
ultimately better controlled on the following regimen:
amlodipine 10, Imdur 60mg ER daily, hydralazine 50mg TID.
However, in controlling her blood pressure, she developed
[**Last Name (un) **]/ATN and oliguria. Ultimately her SBP goal was >120 and <140,
which was maintained well on the above regimen.
.
# [**Last Name (un) **]/oliguria: Patient was admitted with a creatinine of 1.1
which slowly increased as her blood pressure came under better
control. On day 4 of hospitalization, Cr was 2.0 and patient was
oliguric with 90cc out in 8hrs. FeUrea 20%. Renal was consulted
and felt that her kidney injury was likely due to her improved
blood pressure control, and her BP in the recent months has been
much higher at baseline. As a result, her renal perfusion
decreased and she developed [**Last Name (un) **]. She did not respond to a fluid
challenge, suggesting that she has developed some ATN as a
result. It is also possible that her AAA is causing some
decreased renal perfusion and resultant renal stenosis, however
given that there were no plans for intervention, a renal artery
US was not pursued. Lisinopril was stopped and goal SBP >120 was
maintained. The patient's creatinine continued to rise (see
pertinent results section) as expected with ATN and was
essentially stable in the 3 days prior to discharge (Cr
2.3->2.2->2.5, GFR 21 (with Cr 2.2) ->18 (with Cr 2.5) on
discharge). The expected course of ATN is that it will rise,
plateau and then fall, however given that the patient is [**Age over 90 **],
with multiple comorbidities and previous [**Last Name (un) **], it is unclear how
much her renal function will recover. Renal discussed with the
patient and her daughter that she is not a dialysis candidate.
The patient is going home with hospice, however the family would
like her to continue to be managed medically. It was agreed that
the patient will have weekly creatinine checks for
prognostication, and not for management as there is nothing to
be done concerning her renal function.
.
# Complete heart block: The patient has been in complete heart
block for years and stable without pacemaker. She has had
pacemaker in the past which had to be removed and replacement
attempt was complicated by significant bleeding and infection
and was subsequently unsuccessful. Has been evaluated at >4
hospitals and all have declined further intervention. Of note,
during last admission, the patient stated she would not want the
procedure. She does have pacemaker leads in place from the prior
pacemaker which would be easier to access, but it is unknown if
these leads are still functional. EP was reconsulted and again
declined to offer the procedure given patient's comorbidities
and persistent complications with from the last procedure. A
family meeting was held, and the patient clearly outlined again
that she would not want a pacemaker or any further invasive
procedures.
.
# UTI: Patient has had a UTI that has been unsuccessfully
treated with cipro and macrobid in the past. Prior to admission,
she had also recently received amoxicillin. On admission, UA
showed + Leuks, + Nitrates, >182 WBC, moderate bacteria. She was
started on vanc and zosyn in ED for possible PNA, with UTI
coverage. Urine culture from [**2108-3-20**] at OSH grew klebsiella
pneumonia, sensitive to amoxicillin, ceftriaxone, cefazolin
(resistant to cipro, bactrim, levoflox). The patient's
vanc/zosyn were discontinued and she was switched to
ceftriaxone. Patient received antibiotics from [**3-21**] to [**3-26**]. Urine
cultures x 2 at [**Hospital1 18**] have been negative for bacteria >10K. WBC
peaked at 12.5 on HD #2 and trended down to 9.8 prior to
discharge.
.
# Cough: Per patient's daughter the patient has been having
productive cough. CXR showed pulmonary edema and possible
consolidation. However, she did not have fevers or a cough,
though did appear to have sinus congestion. She initially
received vanc/zosyn but these were stopped and antibiotics were
switched to cover her UTI as above. Patient received antibiotics
from [**3-21**] to [**3-26**]. Sputum culture grew gram positive cocci in
pairs, found to be commensal flora. Patient remained afebrile.
WBC down to 9.8 on discharge.
.
# LUE swelling: Patient developed swelling of her left forearm.
Platelets were between 20-40s throughout the admission, making
DVT unlikely and prohibiting DVT any treatment. Patient was
treated symptomatically with elevation of her arm and warm
compresses. IV was moved to right arm.
.
# Bleeding disorder/thrombocytopenia: This has been a chronic
issue for Ms. [**Known lastname 34763**]. The etiology of her bleeding disorder
is unclear. It may be ITP but this is less likely to cause
bleeding complications. Throughout admission, plts ranged
between 20-40s. Hematocrit remained stable around 30.
.
# Macrocytosis: MCV 107. B12 was noted to be 1043. Patient was
given folate and a MV.
.
Transitional Issues:
Home hospice has been set up. Patient will be full code at home,
but is DNR in the hospital as it is not medically indicated.
Weekly creatinine checks for **prognostication**, and not for
management as there is nothing to be done concerning her renal
function. She is not a dialysis candidate.
Patient has been set up with PCP [**Name Initial (PRE) 648**].
Goal is to manage this patient at home with the help of hospice
and PCP [**Name Initial (PRE) 37798**].
Medications on Admission:
citalpram 10mg daily
tramadol 50 mg Q4prn
lisinopril 30 mg daily
Lasix 40 mg daily
carafate 1 gm TID
culturelle 1 daily
prevacid 30 mg daily
nystatin tid
amlodipine 5 mg daily
.
Recent abx:
augmentin 500 Q12 hrs x 10 days [**2-25**]
macrobid x7 days [**2-16**]
cipro x5 days in [**Month (only) **]
Discharge Medications:
1. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Pain.
3. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
4. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Culturelle 10 billion cell Capsule Sig: One (1) Capsule PO
once a day.
6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
8. hydralazine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
9. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Capsule(s)* Refills:*2*
10. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual twice a day as needed for abdominal pain: take at the
onset of abdominal pain, and repeat in 5 minutes if not
improved.
Disp:*60 tablets* Refills:*2*
12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
** as well as hospice medications **
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Primary:
abdominal pain
hypertensive urgency
urinary tract infection
acute renal failure
Secondary:
abdominal aortic aneursym
complete heart block
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 34763**],
It was a pleasure taking care of you during this admission. You
were admitted initially from the other hospital given abdominal
pain and concerning for the abdominal aneursym. You were seen by
the vascular surgeons who felt that it was not safe or indicated
for you to have surgery. You were initially in the ICU for
optimal blood pressure control on a nitroglycerin drip. Your
blood pressure improved and we took care of you on the
cardiology floor with new medications to optimize your blood
pressure. You were treated with antibiotics for a urinary tract
infection, which were completed here, and repeat urine culture
showed that you no longer had a urinary tract infection. As your
blood pressure improved, your kidneys stopped functioning as
well. We had the kidney doctors [**Name5 (PTitle) 788**] [**Name5 (PTitle) **], who think that the
kidney function will eventually plateau and potentially get
better, though the timing of this is still unsure at this time.
amd it may be that your kidney function does not significantly
improve. Unfortunately, you are not a dialysis candidate.
We discussed at length your daughter's concerns for pacemaker
placement. The cardiologists do not feel a pacemaker will
improve your condition and would not be willing to place one.
After discussion with the cardiologists, palliative care, and
social work, you expressed to us that you did not want a
pacemaker anyway. We agreed that the likely complications and
risks far exceeded any potential for benefit of a pacemaker.
After further discussion with the palliative care team, the
cardiology team, and the nurses here, you decided that you
preferred to be at home with more help. The palliative care team
helped to arrange home hospice to help with services at home.
The following medications were changed during this admission:
- STOP Lasix
- STOP Lisinopril
- STOP recent antibiotics, including - augmentin, macrobid, and
cipro (you finished antibiotics here for your urinary tract
infection)
- START Isosorbide mononitrate ER 60mg by mouth daily
- START Hydralazine 50mg by mouth three times daily
- START Calcium acetate 1334 mg by mouth three times daily
- START Morphine if needed for pain, as directed by the hospice
nurses
- START Acetaminophen 650mg by mouth three times daily
- START Nitroglycerin 0.3mg sublingual as needed for abdominal
pain; can repeat every 5 minutes for a total of 3 doses if
continued pain
- START Docusate sodium 100mg by mouth twice daily
- INCREASE Amlodipine to 10mg by mouth daily
Followup Instructions:
Please follow-up with your primary care doctor as below. You
will also follow-up with the hospice nurses who will be in close
contact with your doctors.
Name: SIRAKOV,DIMITRE T.
Location: [**Hospital **] MEDICAL GROUP
Address: [**Apartment Address(1) 85641**], [**Hospital1 **],[**Numeric Identifier 59034**]
Phone: [**Telephone/Fax (1) 24335**]
Appointment: Thursday [**2108-4-5**] 2:30pm
|
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icd9cm
|
[
[
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[] |
icd9pcs
|
[
[
[]
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19470, 19572
|
9282, 17229
|
247, 253
|
19775, 19775
|
4944, 4944
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|
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|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,013
| 196,057
|
2164
|
Discharge summary
|
report
|
Admission Date: [**2129-6-30**] Discharge Date: [**2129-7-6**]
Service: MICU
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is an 88 year old
female with a history of COPD and coronary artery disease who
had a recent long hospitalization for shortness of breath
presumed to be secondary to COPD and had chest pain of
unclear etiology. She now presents early this morning after
calling EMS in respiratory distress. EMS noted that she was
wheezing, using respiratory accessory muscles and slightly
diaphoretic, although oriented. She was given albuterol and
Atrovent nebs with some decrease in her level of distress.
Her O2 sats were noted to be 98% at that time. In the
emergency room she was again noted to be wheezing and had
worsening PO2 that did not improve with nonrebreather or
BiPAP. The patient had ABG performed which revealed pH of
7.22, PCO2 89, PO2 18 in room air. The patient was
subsequently intubated and admitted to the MICU.
PAST MEDICAL HISTORY: Coronary artery disease status post
CABG in [**2121**]. Negative P-thal in [**2128-10-13**]. Negative
pain MIBI recently. COPD on 0.5 liters of O2 at home at
baseline. Left bundle branch block. Hypertension. Pleural
plaques. History of PPD positive. History of PE.
Peripheral vascular disease. Chronic renal insufficiency.
Insulin dependent diabetes mellitus.
MEDICATIONS: Include aspirin 81 mg q.d., Combivent two puffs
q.i.d., Coumadin dose unknown, Flovent 220 two puffs b.i.d.,
Isordil 20 mg t.i.d., Lasix 40 mg q.d., Lipitor 10 mg q.d.,
lisinopril 40 mg q.d., Prilosec 20 mg q.d., verapamil 80 mg
t.i.d.
SOCIAL HISTORY: The patient is from [**Country 3587**] and speaks
Portuguese only.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission blood pressure was
209/102, pulse 115. Patient sedated with endotracheal tube
in place with clear secretions coming from the oropharynx.
Neck: there was no JVD, no bruits of the carotids. Pulmonary
exam showed good air movement on the vent, no wheezing at
this time. Cardiovascular tachycardic, PMI prominent, no
murmurs. Abdomen soft, nontender, good bowel sounds.
Extremities had trace lower extremity edema, no palpable
cords. Skin warm and dry. Numerous areas of ecchymosis. On
neuro exam the patient was sedated, moving all four limbs
spontaneously.
LABORATORY DATA: On admission white count was 13.7,
hematocrit 39.9, platelets 323. SMA-7 was 141, 4.8, 101, 27,
25, creatinine 1.7, glucose 124. PTT 34.8, INR 1.4. The
patient had an initial ABG on room air of 7.22, PCO2 89, PO2
18, bicarb 38. The patient had repeat ABG once intubated
with pH of 7.34, PCO2 55, PO2 470, bicarb 31. Lactate was
2.3. EKG revealed sinus tachycardia with old bundle branch
block, rate 157. Chest x-ray revealed old pleural
parenchymal disease in the left lower lobe and left middle
lobe, mild CHF.
HOSPITAL COURSE:
1. Hypoxia. The patient was admitted in respiratory arrest
and found to be hypoxic. The patient was subsequently
intubated secondary to respiratory arrest. The patient did
well on the vent, maintaining good O2 saturations. The
patient was able to be extubated. The patient was intubated
on [**2129-6-29**], and was subsequently extubated on the 21st,
doing well, maintaining good O2 sats throughout her stay.
2. COPD. Patient admitted with most likely COPD
exacerbation leading to respiratory arrest leading to
intubation. The patient was started on IV Solu-Medrol for
COPD flare. The patient also received Atrovent and albuterol
nebulizers p.r.n. and continued MDI. After extubation the
patient's oxygenation improved markedly. The patient's IV
Solu-Medrol was switched to p.o. prednisone and the patient
was discharged on a prednisone taper as well as Combivent MDI
and Flovent MDI.
3. Cardiac. The patient was admitted with shortness of
breath, questionable mild CHF on exam. The patient had runs
of SVT in the MICU which were consistent with atrial
tachycardia. The patient was started on amiodarone 200 mg
q.d., however, after discussion with cardiology and the
primary care physician, [**Name10 (NameIs) **] patient's amiodarone was
discontinued prior to discharge. The patient had no
subsequent runs of SVT after her transfer from the MICU to
the medicine floor.
4. Hypertension. The patient was admitted with blood
pressure in the 200/100 range. The patient was on lisinopril
40 mg q.d., Isordil 20 mg t.i.d., verapamil 80 mg t.i.d. The
patient's verapamil was increased to 120 mg t.i.d. The
patient was also started on hydralazine as well as Isordil,
Zestril 40 mg q.d. Beta blockers avoided secondary to COPD.
The patient's blood pressure responded with the increased
dose of verapamil and hydralazine. The patient's blood
pressure was under control upon discharge.
5. Cardiac ischemia. The patient ruled out for MI. The
patient had three sets of negative cardiac enzymes. The
patient has left bundle branch block at baseline. The
patient was considered for cath, but she refused. The
patient had an echo which was essentially normal with no
evidence of any regional wall abnormalities that were new.
The patient was discharged on aspirin and Lipitor.
6. Chronic renal insufficiency. The patient was admitted
with a creatinine clearance of 30 ml per minute, question of
renal artery stenosis which was not worked up. The patient's
creatinine remained stable throughout her stay.
7. Diabetes. The patient's blood sugars remained stable on
insulin sliding scale and NPH 5 in the morning and 2 in the
evening.
8. GI. Patient with a history of abdominal pain. The
patient has had an extensive workup which was essentially
normal including MRCP and MRA to rule out mesenteric
ischemia.
9. ID. The patient was found to have a urinary tract
infection on [**2129-6-27**], and was started on a three day
course of ciprofloxacin 200 mg q.d.
DISPOSITION: The patient was transferred from the MICU to
the floor on [**2129-7-4**], and subsequently discharged home
on [**2129-7-6**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. COPD exacerbation leading to respiratory arrest and
intubation.
2. Supraventricular tachycardia.
DISCHARGE MEDICATIONS: Same as on arrival with the addition
of increase of verapamil to 120 mg t.i.d., increase of Lasix
from 20 to 40 mg q.d. Hydralazine 10 mg q.i.d. was added.
The patient was sent home on a prednisone taper starting at
40 mg p.o. q.d.
FOLLOWUP: The patient will follow up with Dr. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) 8499**] upon discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], M.D. [**MD Number(1) 11525**]
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2129-10-13**] 18:02
T: [**2129-10-16**] 09:44
JOB#: [**Job Number 11545**]
|
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icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,485
| 120,044
|
33522
|
Discharge summary
|
report
|
Admission Date: [**2143-4-3**] Discharge Date: [**2143-4-18**]
Date of Birth: [**2060-3-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dypsnea on exertion
Major Surgical or Invasive Procedure:
[**2143-4-4**] Cardiac Catheterization
[**2143-4-8**] Aortic Valve Replacement([**Street Address(2) 17167**]. [**Male First Name (un) 923**] tissue), Mitral
Valve Replacement([**Street Address(2) 11599**]. [**Male First Name (un) 923**] tissue), and Single Vessel
Coronary Artery Bypass Grafting(saphenous vein graft to
posterior descending artery).
History of Present Illness:
This is a 83 year old female with known aortic stenosis. She was
relatively asymptomatic until three days prior to admission at
outside hospital when she developed worsening shortness of
breath with exertion. She required diuresis and was transfused
with PRBC for a hematocrit of 26%. She has a history of AVMs.
Outside ECHO showed and [**Location (un) 109**] of 0.64cm2 with 3+ mitral
regurgitation. Her LVEF was estimated at 55%. She was stablized
on medical therapy and transferred to the [**Hospital1 18**] for further
evaluation and treatment.
Past Medical History:
- Congestive Heart Failure, Aortic Stenosis, Mitral
Regurgitation
- Hypertension
- Type II Diabetes Mellitus
- Iron Deficiency Anemia
- History of AVMs
- Degenerative Joint Disease
- s/p Total Hip Replacement
- s/p Carpal Tunnel Surgery
- s/p Appendectomy
- s/p Hysterectomy
Social History:
Denies tobacco history. Admits to 2 glasses of wine per night.
She currently lives with her daughter.
Family History:
Daughter with MI at age 50. Mother and Father died of CAD in
their 70's.
Physical Exam:
PREOP EXAM
Vitals: 144/70, 84, 20, 96%RA
General: WDWN elderly female in NAD
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD. Transmitted murmur noted bilaterally.
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, 4/6 systolic ejection murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 1+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2143-4-18**] 05:20AM BLOOD WBC-7.1 RBC-2.77* Hgb-7.5* Hct-23.4*
MCV-84 MCH-27.0 MCHC-32.0 RDW-15.3 Plt Ct-257
[**2143-4-17**] 05:40AM BLOOD WBC-7.0 RBC-2.73* Hgb-7.5* Hct-23.3*
MCV-85 MCH-27.3 MCHC-32.1 RDW-14.4 Plt Ct-230
[**2143-4-16**] 05:35AM BLOOD Hct-23.3*
[**2143-4-15**] 05:45AM BLOOD WBC-5.9 RBC-2.78* Hgb-7.7* Hct-23.8*
MCV-85 MCH-27.7 MCHC-32.5 RDW-14.3 Plt Ct-212
[**2143-4-13**] 06:40AM BLOOD WBC-7.1 RBC-2.85* Hgb-8.0* Hct-24.4*
MCV-86 MCH-28.1 MCHC-32.8 RDW-14.8 Plt Ct-189
[**2143-4-17**] 05:40AM BLOOD PT-14.2* PTT-28.3 INR(PT)-1.2*
[**2143-4-18**] 05:20AM BLOOD Glucose-97 UreaN-20 Creat-1.2* Na-135
K-4.1 Cl-101 HCO3-22 AnGap-16
[**2143-4-17**] 05:40AM BLOOD Glucose-106* UreaN-26* Creat-1.4* Na-133
K-4.3 Cl-98 HCO3-22 AnGap-17
[**2143-4-16**] 05:35AM BLOOD UreaN-23* Creat-1.2* K-4.8
[**2143-4-15**] 05:45AM BLOOD Glucose-93 UreaN-20 Creat-1.2* Na-133
K-4.4 Cl-101 HCO3-24 AnGap-12
[**2143-4-4**] 05:00PM BLOOD ALT-10 AST-16 AlkPhos-64 TotBili-0.3
CHEST (PA & LAT) [**2143-4-18**] 10:41 AM
CHEST (PA & LAT)
Reason: lead placement
[**Hospital 93**] MEDICAL CONDITION:
83 year old woman s/p dual chamber pacemaker
REASON FOR THIS EXAMINATION:
lead placement
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: S/P dual-chamber pacemaker.
Comparison is made with prior study, [**2143-4-16**].
New left transvenous pacemaker leads terminate in the standard
position in the right atrium and right ventricle. Mild
cardiomegaly is stable. Moderate bilateral pleural effusions
with associated bibasilar atelectases are unchanged. There is
engorgement of the pulmonary vasculature without overt CHF.
Patient is post median sternotomy. There is no pneumothorax.
[**Known lastname 77722**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77723**]
(Complete) Done [**2143-4-8**] at 2:40:09 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2060-3-30**]
Age (years): 83 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: AVR/MVR/CABG
ICD-9 Codes: 786.05, 786.51, 799.02, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2143-4-8**] at 14:40 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3318**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine: AW3
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.4 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *3.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *37 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 21 mm Hg
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Mild (1+) AR.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Severe mitral annular calcification. Moderate to severe (3+) MR.
TRICUSPID VALVE: Mild to moderate [[**1-30**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Right ventricular chamber size and free wall motion
are normal. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are severely
thickened/deformed. There is severe mitral annular
calcification. Moderate to severe (3+) mitral regurgitation is
seen. There is no pericardial effusion.
Post-CPB: Patient is AV-Paced, on no infusions. Well seated
aortic and mitral prostheses are seen with no AI, no MR and no
perivalvular leaks. Residual mean aortic valve gradient is 9,
mitral is 7. Good biventricular systolic fxn. Aorta intact.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted and underwent extensive cardiac
surgical evaluation. Cardiac catheterization confirmed aortic
stenosis and mitral regurgitation. Coronary angiography showed
single vessel coronary artery disease. Other workup included
transthoracic echocardiogram, carotid ultrasound and vein
mapping which showed suitable greater saphenous vein. Please see
result section for more extensive findings of the above studies.
Her preoperative course was otherwise uneventful. She remained
stable on medical therapy and was eventually cleared for
surgery. On [**4-8**], she underwent aortic and mitral valve
replacements along with coronary artery bypass grafting surgery.
For surgical details, please see seperate dictated operative
note. Given her inpatient hospital stay was greater than 24
hours, she required perioperative antibiotic coverage with
Vancomycin. Following the operation, she was brought to the
CVICU for invasive monitoring. Within 24 hours, she awoke
neurologically intact and was extubated without incident. She
initially required atrial pacing for postoperative junctional
rhythm/sinus node dysfunction. Over several days, rhythm
progressed to junctional with rate in the 40-60's per minute.
External pacemaker was set to VVI. She tolerated a junctional
rhythm with blood pressures in the 90-100mmHg. All nodal agents
were withheld. Her CVICU course was otherwise uneventful, and
she transferred to the SDU on postoperative day three. While in
a junction rhythm, she experience oliguria. She was therefore
atrial paced again with improvement in urine output. Given her
persistent sinus node dysfunction, the EP service was eventually
consulted for evaluation for potential permanent pacemaker.
Initial recommendations were to continue atrial pacing at a
lower rate. After several days of observation, there was no
improvement in her sinus node dysfunction. It was therefore
decided to proceed with permanent pacemaker implantation on
[**4-17**]. She should continue on antibiotics for 2 more days and
follow up with the device clinic in one week as per her
discharge instructions. She was found to have atrial
fibrillation under her pacemaker and was started on coumadin.
She was ready for discharge to rehab the following day.
Medications on Admission:
Simvastatin 20 qd, Xanax prn, Fioricet prn, Norvasc 10 qd,
Nifedipine XL 60 qd
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg 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 DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
7. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks: then reassess need for diuresis.
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 2 days.
12. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day for 2
days: Check INR [**4-20**], dose for goal INR [**3-3**] for atrial
fibrillation.
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
- Chronic Systolic Congestive Heart Failure, Aortic Stenosis,
Mitral Regurgitation, Coronary Artery Disease - s/p AVR, MVR,
CABG
- Postop Sinus Node Dysfunction/Junctional Rhythm
- Hypertension
- Type II Diabetes Mellitus
- Anemia
Discharge Condition:
Stable
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**5-4**] weeks, call for appt
Dr. [**First Name (STitle) **] in [**3-3**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**3-3**] weeks, call for appt
Completed by:[**2143-4-18**]
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icd9cm
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30,344
| 196,989
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47406
|
Discharge summary
|
report
|
Admission Date: [**2189-1-31**] Discharge Date: [**2189-2-9**]
Date of Birth: [**2109-3-22**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
Hip fracture
Major Surgical or Invasive Procedure:
Intertrochanteric hip fracture on the right
PICC placement (now removed)
History of Present Illness:
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
.
79 yo M w/ [**Last Name (un) 309**] Body Dementia, Type II DM, hx of mechanical
falls presented from NH s/p unwitnessed fall c/b hip fracture.
Patient has altered mental status and hallucinations at baseline
and is able to report that he "tripped" and fell and broke "his
bones."
.
Upon arrival to the ED: VS T97.4 HR 92 BP 145/83 99% RA. Pt
underwent HIP xray that was significant for fracture. CT head,
CT c-spine, b/l shoulder films and L foot xr were negative for
fracture or bleed.
.
Pt was seen and evaluated by surgery and was admitted with plan
to undergo hip arthroplasty. Patient underwent right
intertrochanteric fx repair yesterday and was extubated in the
OR. Patient was kept in the PACU overnight because of agonal
breathing, copius secretions and lethargy. He was given
flumazenil as he was thought to be lethargic secondary to
overuse of benzodiazepenes. He was satting 99-100% on 35% shovel
mask this am. His blood pressure also dropped to 80s systolic
overnight but came up without bolus after they suctioned him.
His crit also dropped 10 points overnight after the surgery and
he is currently on his 2nd bag of prbcs. This am, patient is
lethargic but arousable. He falls asleep while asking questions.
Patient was oriented x 3- knew name, that it was [**Hospital1 **] and year was
[**2188**]. Complains of pain in the right hip, right shoulder and
headache. Otherwise, denies cp, dizziness, sob, abd pain,
nausea, etc.
Past Medical History:
DM2
asthma
dyslipidemia
gait disorder
vertigo
CRI (baseline 1.1-1.3)
Mild dementia- ?[**Last Name (un) 309**] Body Dementia
s/p recent mechanical fall
s/p CCY
s/p hernia repair
s/p b/l blepharoplasty
Social History:
Tob 40 pack yrs, smokes a cigarette now only occasionally ETOH.
Pt lives in an [**Hospital3 **] facility. He has a daughter who
lives in the area. His wife recently died in [**Month (only) 359**], since that
time, patient has been seen several times by his gerontologist
for confusion and hallucinations.
Family History:
non-contributory
Physical Exam:
VS: T 99 BP 99/50 HR 87 RR 16 O2 sat 98% on 35% shovel mask WT
184lbs
GEN: Elderly man, lethargic, eyes closed, arousable, making very
loud gurgling noises
HEENT: NC, lac over right eye brow w/o erythema, could not
assess EOM, PERRL, Dry MM, OP clear
NECK: Supple, No [**Doctor First Name **], no JVD
RESP: very loud upper airway girgling, difficult to hear lung
sounds
CV: RRR, S1S2
ABD: Soft, NT, ND
EXT: R Shoulder; Swollen, ecchymotic with no palpable
deformities;
L foot: ecchymoses on toes and dorsum of foot
R hip: dressing covering wound, clean/dry/intact, no pain on
palpation, thigh does not feel tense, cannot appreciate hematoma
NEURO: lethargic but arousable, oriented x 3; moving all
extremities but would not cooperate with CN testing, strength or
sensation assessment
Pertinent Results:
[**2189-1-31**] 03:00AM BLOOD WBC-14.4*# RBC-4.39* Hgb-13.9* Hct-40.8
MCV-93 MCH-31.7 MCHC-34.2 RDW-14.6 Plt Ct-218
[**2189-1-31**] 05:31PM BLOOD WBC-15.8* RBC-3.83* Hgb-11.9* Hct-36.0*
MCV-94 MCH-31.1 MCHC-33.0 RDW-14.6 Plt Ct-247
[**2189-2-2**] 12:51PM BLOOD WBC-12.3* RBC-2.84* Hgb-9.2* Hct-25.7*
MCV-90 MCH-32.4* MCHC-35.8* RDW-15.6* Plt Ct-116*
[**2189-2-3**] 04:30AM BLOOD WBC-8.4 RBC-2.56* Hgb-8.3* Hct-22.9*
MCV-90 MCH-32.6* MCHC-36.4* RDW-15.9* Plt Ct-109*
[**2189-2-8**] 06:00AM BLOOD WBC-9.9 RBC-3.12* Hgb-9.7* Hct-28.9*
MCV-93 MCH-31.2 MCHC-33.7 RDW-15.5 Plt Ct-242
[**2189-2-9**] 05:41AM BLOOD WBC-8.5 RBC-3.07* Hgb-10.0* Hct-29.0*
MCV-94 MCH-32.5* MCHC-34.4 RDW-16.3* Plt Ct-255
[**2189-1-31**] 07:32AM BLOOD PT-12.0 PTT-26.7 INR(PT)-1.0
[**2189-2-3**] 04:30AM BLOOD PT-25.9* PTT-61.0* INR(PT)-2.6*
[**2189-2-6**] 02:59AM BLOOD PT-13.7* PTT-27.9 INR(PT)-1.2*
[**2189-2-7**] 06:43AM BLOOD PT-13.4 PTT-27.0 INR(PT)-1.1
[**2189-1-31**] 03:00AM BLOOD Glucose-180* UreaN-22* Creat-1.1 Na-139
K-3.9 Cl-100 HCO3-31 AnGap-12
[**2189-2-6**] 02:59AM BLOOD Glucose-116* UreaN-18 Creat-0.7 Na-143
K-3.6 Cl-110* HCO3-25 AnGap-12
[**2189-2-9**] 05:41AM BLOOD Glucose-169* UreaN-18 Creat-0.6 Na-138
K-3.6 Cl-103 HCO3-30 AnGap-9
[**2189-1-31**] 03:00AM BLOOD Calcium-9.6 Phos-2.5* Mg-2.1
[**2189-2-3**] 04:30AM BLOOD Albumin-2.4* Calcium-7.9* Phos-2.6*
Mg-1.9
[**2189-2-9**] 05:41AM BLOOD Calcium-8.1* Phos-1.9* Mg-1.9
[**2189-2-1**] 05:00PM BLOOD Hapto-151
[**2189-1-31**] 03:00AM BLOOD TSH-2.5
[**2189-2-1**] 02:58PM BLOOD Type-ART pO2-71* pCO2-44 pH-7.44
calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2189-2-4**] 02:23PM BLOOD Type-ART Temp-36.4 pO2-60* pCO2-39
pH-7.47* calTCO2-29 Base XS-4
.
Hip unilat (2 view): IMPRESSION: Intertrochanteric fracture of
the right femur.
.
CT C-spine IMPRESSION: No acute fracture or malalignment of the
cervical spine.
.
CT Head: IMPRESSION: No intracranial hemorrhage or fracture.
Aside from mild right frontal scalp swelling, no appreciable
change compared to [**2188-7-18**].
.
Shoulder plain film: IMPRESSION: No fracture or dislocation of
the shoulders.
.
CT Pelvis: CT PELVIS WITHOUT INTRAVENOUS CONTRAST:
There is colonic diverticulosis without evidence of
diverticulitis. There is a catheter within the urinary bladder
as well as free air likely related to the recent
catheterization. There is no significant pelvic lymphadenopathy.
There is no free fluid in the pelvis.
MUSCULOSKELETAL:
There is a dynamic hip screw in the right femur. There is also
evidence of a recent fracture through the femoral neck. There is
extensive edema of the subcutaneous tissues of the right thigh
along with multiple pockets of air and small pockets of fluid,
likely related to the recent surgical intervention at the right
hip.
CONCLUSION:
1. Edema of the subcutaneous tissues of the right thigh along
with pockets of air and fluid between the facial planes, most
likely related to recent right hip operation.
2. No retroperitoneal hematoma or free fluid in the abdomen or
pelvis.
3. Multiple large bilateral renal hypodensities, some of which
are cysts, and others are not accurately characterized given the
lack of intravenous contrast. A renal ultrasound would be
helpful for further evaluation.
.
[**2-4**] CT Head (done for change in mental status) - IMPRESSION: No
intracranial hemorrhage.
.
[**2-9**] knee (3 views): FINDINGS: No comparisons. No acute fracture
or dislocation is seen. No lucent or sclerotic lesion is noted.
Minimal medial compartment joint space narrowing is seen.
Enthesophyte is noted at the insertion of the quadriceps tendon
on the patella. Soft tissues are otherwise unremarkable.
IMPRESSION:
Mild degenerative change of the right knee including medial
compartment joint space narrowing.
.
[**2-9**] RLE u/s: no DVT (per verbal conversation with radiologist).
Brief Hospital Course:
# Respiratory: Post op course complicated by increased
respiratory secretions, on exam patient appears to be
aspirating. Some of respiratory difficulty post-op thought to be
due to oversedation. He was electively intubated for airway
protection for head CT, able to be extubated after imaging.
Respiratory difficulties seemed to be due to mental status
fluctuations and aspiration. Speech and swallow felt patient
should be NPO (see below). Patient responded well to pulmonary
toilet measures such as suctioning and nebulizers. At discharge
lungs were clearing and suctioning requirement was down to
q4hrs.
.
#Dysphagia. Pt evaluated by speech and swallow, considered
unsafe for PO intake given altered mental status and poor
swallow. Had OG tube placed and PEG placement. At discharge he
was tolerating tube feeds well. He is unlikely to be able to
take POs given his mental status and aspiration risk.
.
#Altered mental status. Unclear etiology. Has [**Last Name (un) 309**] body
dementia, predilection for waxing/[**Doctor Last Name 688**] mental status, worsened
in setting of acute illness, exact precipitant unknown. Not
hypercarbic, no bleed on head CT. No known infection. Once
transferred out of ICU on floor mental status began to clear.
Per daughter mental status waxes and wanes to begin with. To
some degree this was felt to be due to day-night reversal and he
was given trazodone in an attempt to correct this. His
lorazepam was stopped at the recommendation of the geriatrics
service.
.
#. Hip fracture: s/p right intertrochaneteric hip repair.
Patient is doing well after hip fracture repair. He should have
physical therapy at rehab. He was started on calcium and vitamin
D. He should receive lovenox 30mg SC bid for 1 month. Followup
with orthopedics for staple removal scheduled.
.
#Anemia - baseline HCT in 40s, post op, levels have been
variable. Has required a total of 4 units PRBCs, no obvious
source of bleeding. CT x 2 did not reveal hematoma in leg or
abd/pelvis. Guaiac negative. HCT stable at time of discharge.
Had some hematuria during hospital course which resolved without
intervention.
.
#Thrombocytopenia. Had Plt drop from peak of 247 to nadir of
103, and increased to 255 at discharge. HIT ab negative,
evaluated by heme-onc who felt this was drug-induced
thrombocytopenia likely due to cefazolin. He is safe to have
heparin and lovenox.
.
#. DM: held Actos during hospitalization and covered with
insulin sliding scale. .
.
#. [**Last Name (un) 309**] body dementia: avoided antipsychotics (typical and
atypical) and anti-cholinergics. At baseline patient
hallucinates per old records. He may have small doses of
zyprexa (1.25mg) if needed per geriatrics.
.
#. Hypercholesterolemia- d/c'ed zetia per geriatrics.
.
# Right knee intermittent
no fracture on plain films. Orthopedics felt likely
osteoarthritis. Planned to see how he does with physical
therapy and if he has peristant pain to consider CT of knee and
further orthopedic evaluation. If osteoarthritis, he may need
steroid injection.
.
# R leg swelling:
most likely due to hematoma after hip fracture (has large
ecchymotic area on posterior right leg). No DVT on ultrasound
[**2-9**].
.
# Code status
Patient remained DNR but allowed brief intubations during his
hospital stay.
Medications on Admission:
RISS
Vit D/calcium
colace
Zetia (now discontinued)
Actos
tylenol PRN
albuterol and atrovent nebs
Dulcolax PRN
Milk of Magnesia
ASA 81
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q4H (every 4 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: per SS
units Subcutaneous four times a day.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
6. Acetaminophen 500 mg Capsule Sig: [**12-31**] Capsules PO four times
a day as needed for pain.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
12. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 1 months.
13. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary:
Hip fracture
Drug-induced thrombocytopenia due to cefazolin
[**Last Name (un) 309**] Body Dementia
Discharge Condition:
Mental status waxes and wanes, suctioning requirement reducing
(now at q4hrs), complains of intermittent knee pain but no
fracture on plain film.
Discharge Instructions:
You were admitted for a hip fracture. During the course of your
admission you developed difficulty breathing and low platelets.
This required a brief stay in the ICU. The difficulty breathing
was most likely due to oversedation and intubation. The low
platelets were most likely due to cefazolin, an antibiotic.
.
You are being discharged back to [**Hospital 100**] Rehab.
.
Please seek medical attention if your breathing worsens, if you
have worsening knee pain, if you have fevers, discharge from
your wound, or any other new or concerning symptoms.
Followup Instructions:
Please followup with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of orthopedics
[**Telephone/Fax (1) **]
Tuesday 26th at 11:40am - [**Hospital Ward Name 23**] building ([**Hospital Ward Name **]) [**Location (un) 1385**].
.
If the knee continues to be a problem, please see an orthopedic
surgeon of your choice, you may need to have a CT of the knee,
please discuss with the orthopedic surgeon.
Please followup with Dr. [**Last Name (STitle) **] as needed
|
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"787.20",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"38.93",
"44.32",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11895, 11960
|
7149, 10445
|
282, 357
|
12112, 12260
|
3306, 5164
|
12864, 13345
|
2467, 2485
|
10630, 11872
|
11981, 12091
|
10471, 10607
|
12284, 12841
|
2500, 3287
|
230, 244
|
385, 1904
|
5173, 7126
|
1926, 2127
|
2143, 2451
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,969
| 159,746
|
6089
|
Discharge summary
|
report
|
Admission Date: [**2191-5-16**] Discharge Date: [**2191-5-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
new left sided neck mass
Major Surgical or Invasive Procedure:
Excision of deep left neck mass
Novo7 infusion
History of Present Illness:
83-year-old male with 20-year history of Waldenstrom's
macroglobulinemia and acquired [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease. In
[**3-12**], he developed new onset left anterior cervical
lymphadenopathy. MRI scan confirmed the presence of a single 2.8
cm Left Level II JD lymph node. He denies odynophagia,
dysphagia, hemoptysis, voice changes, fevers, chills, or night
sweats. He has had no recent URIs or other significant ENT
complaints.
Past Medical History:
Type II diabetes: diet controlled
Waldenstrom's macrogammaglobulinemia
acquired [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 23871**] disease
Hypertension
Gout
BPH
Social History:
Wife diet three months ago. Smoked pipe for about thirty years,
occasional cigar, occasional EtOH, no drugs
Family History:
Mother with diverticulosis, father with stroke, brother had MI
at age 36 yrs.
Physical Exam:
Gen: elderly male, NAD
HEENT: anicteric, pale conjunctiva, OMM slightly dry, OP clear,
neck supple, left neck incision with overlying steri strips, No
evidence of active bleeding
Cardiac: RRR, no M/R/T appreciated
Pulm: CTA bilaterally
Abd: NABS, soft NT/ND, no masses
Ext: No C/C/E, warm with 2+ DP bilaterally
Pertinent Results:
[**2191-5-16**]
GLUCOSE-140 UREA N-26 CREAT-1.3 SODIUM-142 POTASSIUM-3.9
CHLORIDE-104 TOTAL CO2-29
CALCIUM-8.5 PHOSPHATE-3.9 MAGNESIUM-1.4
WBC-6.8 RBC-2.92 HGB-10.4 HCT-30.4 MCV-104 MCH-35.7 MCHC-34.4
RDW-17.4
PLT COUNT-81
PT-9.4 PTT-40.8 INR(PT)-0.6
DIAGNOSIS:
1. Left neck mass, excisional biopsy (A-D): Metastatic
poorly-differentiated squamous cell carcinoma.
2. Left neck mass #2, excisional biopsy (E-I): Metastatic
poorly-differentiated squamous cell carcinoma.
Note: The tumor cells are negative for CK-7, CK-20 and TT-1,
consistent with squamous cell carcinoma.
Brief Hospital Course:
84 year old male with acquired [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23872**] disease in the
setting of Waldenstrom's macroglobulinemia admitted for
excisional cervical lymph node biopsy.
1) Excisional lymph node biopsy/Post-op bleeding: The patient
underwent excisional biopsy of 2.8 cm left lymph node on
[**2191-5-16**]. He received 90 mcg/kg novo7 pre-op, followed by 20
mcg/kg over 5 hours in PACU. However, ~ 3 minutes after
infusion, bleeding recurred at the incision site. He was
admitted tho the MICU for closer monitoring and intravenous [**Last Name (un) 11083**]
7. He also received desmopressin X1, and thrombin impregnated
surgicel pads were placed on the wound. His JP drain was removed
on [**2191-5-19**] following bolus of [**Last Name (un) 11083**] 7. The [**Last Name (un) 11083**] 7 infusion was
stopped [**2191-5-20**] without recurrence of bleeding, and he was
transferred to the general medical floor.
2) Squamous Cell Carcinoma: The pathology of the lymph node was
consistent with metastatic squamous cell carcinoma, unknown
primary. Hematology-oncology was consulted, who recommended an
outpatient PET scan. Per ENT, the risk of blind biopsies of the
nasopharynx in the setting of acquired [**First Name5 (NamePattern1) **] [**Last Name (Prefixes) **]
deficiency is unacceptably high. The patient will be discharged
to follow-up with oncology as an outpatient
3) Hypertension: Once the patient was transferred to the general
medical floor and there was no further evidence of active
bleeding, his home anti-hypertensives were resumed.
4) Type II diabetes: The patient was maintained on an insulin
sliding scale while in-house. His diabetes is diet-controlled at
home.
5) Code: Full Code
Medications on Admission:
Cardura 4 mg PO daily
Proscar 5 mg PO daily
Atenolol 25 mg PO daily
Folic acid 1 mg PO daily
Allopurinol 300 mg PO daily
Dyazide 37.5/25 PO daily
Lisinopril 40 mg PO daily
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 2 days.
Disp:*4 Capsule(s)* Refills:*0*
2. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Cardura 4 mg Tablet Sig: One (1) Tablet PO once a day.
4. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a
day.
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. Proscar 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: s/p excisional biopsy of left neck mass
Secondary: Waldenstrom's macrogammaglobulinemia, acquired [**First Name5 (NamePattern1) **]
[**Last Name (Prefixes) 4516**] disease, hypertension, gout, benign prostate
hypertrophy, metastatic small cell carcinoma
Discharge Condition:
stable
Discharge Instructions:
1. Please call if fever greater than 101.5, if increased redness
around wound, if discharge from wound, if increased bleeding
from wound or fullness in neck.
2. Please do not immerse wound in bath, swimming, or sauna for 2
weeks.
3. Please do not drive while taking narcotics.
4. Please follow up with primary care provider concerning
hospitalization.
Followup Instructions:
1) Oncology
Please follow-up with your primary oncologist on [**2191-5-24**] as
previously scheduled.
- if you wish to transition your care to [**Hospital3 **] oncology,
please call to make an appointment with thoracic oncology clinic
via [**First Name4 (NamePattern1) 8771**] [**Last Name (NamePattern1) 19276**] ([**0-0-**])
- your oncologist should schedule you for an outpatient PET scan
- your oncologist will likely schedule you for follow-up with
radiation oncology
2) ENT
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Where: LM [**Hospital Unit Name 40**] (ENT) Phone:[**Telephone/Fax (1) 41**] Date/Time:[**2191-5-31**] 2:00
3) Hematology: Please call to make an appointment with your
outpatient hematologist (Dr. [**Last Name (STitle) 2805**] [**Telephone/Fax (1) 22**]) to be seen
within 2 weeks following discharge.
4) Primary care
Please follow-up with your primary care physician (Dr. [**Last Name (STitle) 23873**]
[**Telephone/Fax (1) 23874**]) within 1 week following discharge
- you should have your hematocrit (red blood cell) and platelet
count checked at that time to ensure stability (HCT 32.2,
platelets 102 at time of discharge)
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2191-12-12**]
|
[
"273.3",
"287.5",
"998.11",
"274.9",
"199.1",
"250.00",
"401.9",
"286.3",
"196.0",
"286.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.06",
"40.21"
] |
icd9pcs
|
[
[
[]
]
] |
4904, 4910
|
2215, 3957
|
286, 335
|
5217, 5225
|
1608, 2192
|
5626, 7006
|
1182, 1261
|
4179, 4881
|
4931, 5196
|
3983, 4156
|
5249, 5603
|
1276, 1589
|
222, 248
|
363, 840
|
862, 1041
|
1057, 1166
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,437
| 153,086
|
49425
|
Discharge summary
|
report
|
Admission Date: [**2110-9-17**] Discharge Date: [**2110-9-18**]
Service: MEDICINE
Allergies:
Ergotamine / Hydralazine / Paxil
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
Dyspnea and fatigue
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
85 year old female with chief complaint of tachypnea and
coughing-up blood. Pt has had a cough for about 1 week and had
been more fatigued. She has also been having constipation for
several days and last night while having a BM began coughing.
With this had tachypnea and coughing up bright red blood last
night (about a tsp mixed with mucus) and then flet better. She
was going to her PCP this AM and had another episode of
hemoptysis in the car. At her PCP, [**Name10 (NameIs) **] was hypoxic to 85 on RA,
with a baseline of 96% with no oxygen at home. She was
tachypneic to 40s. She was sent to the ER.
.
In the ED, initial vs were: T -98.2. HR- 68, BP- 164/54, O2- 93
on RA. Patient was given ASA 325mg, Vanco 1g, and Ceftriaxone 1
g IV.
She had one episode of about a tsp of hemoptysis mixed with
mucus. She was placed on a non-rebreather and was sating 100%.
She was changed to a nasal canula. She was at MS A&O x 1. She
had an EKG that showed LVH, new V4-V6 ST depressions which cards
thought was strain. She had a negative UA. CXR showed a new left
effusion compared to [**2108**]. No nebs were given. Again became
tachypneic with HTN 180s. EKG showed larger ST depressions in
lateral leads and STE in V1-V2. Cards thought this was still
related to strain. CTA was done that showed no PE, but did show
PNA in LLL and left effusion. She was started on BIPAP and
transferred to the ICU. VS at transfer: HR 63 BP 133/46 RR 19 O2
100 BIPAP 15/5 FIO2 60%. Pt is DNR/DNI.
.
.
ROS: (pt unable to answer most questions)
+ Fatigue
- for chest pain, SOB, dysuria, diarrhea, abdominal pain, HA,
rash
Past Medical History:
-COPD, no home oxygen, sats 93-97% at her PCP, [**Name10 (NameIs) **] meds
-Gait instability
-Dementia
-Hypertension
-Hypercholesterolemia
-History of rheumatic fever- Moderate-severe AS (area
0.8-1.0cm2). Moderate (2+) AR, Mild [1+] TR. Mild PA systolic
hypertension. Mild thickening of mitral valve chordae. Mild to
moderate ([**1-3**]+) MR. LV inflow pattern c/w impaired relaxation on
echo [**2108**]
-Osteoporosis
-Carotid endarterectomy
-Cataract surgery bilaterally
-Hx of TIA
-Blind in one eye due to retinal emboli, left eye
-Macular degeneration
-Decreased appetite
-CAD hx
Social History:
She had quit smoking for a year and a half, but forgets this.
Had smoked 1.5 ppd for many years. Lives mainly with her son,
but travels during the week to other [**Hospital1 **] houses also
providing 24 hour care. She has been a housewife all her life.
She enjoys gambling and also dancing. She has 6 children. She
has no etoh use or drug hx. Unable to dress or bath herself. Has
to be observed eating due to poor PO intake. Uses a rolling
walker.
Family History:
Non contributory
Physical Exam:
Vitals- T: 96.6 BP: 159/47 P: 75 R: 22 O2: 100% on NRB
Gen- NAD, pleasantly confused
HEENT- dry MM, no SI
Neck- supple, no LAD
CV- RRR, no M
Pulm- crackles and rhonchi at left base with exp wheezes
Abd- soft NT, ND, +BS
Ext- no c/c/e, warm, thin
Neuro- A&O to person and "hospital", CN 2-12 intact, strength
[**5-6**]
Pertinent Results:
Lactate:2.0
Trop-T: 0.07 MB: 5
.
139 105 27
-------------< 93
4.6 22 1.8
.
Ca: 9.8 Mg: 2.6 P: 3.7
Alb: 4.3
.
WBC-10.2, plts- 332, hct 32.6
N:85.8 L:8.6 M:4.4 E:0.8 Bas:0.4
.
PT: 11.8 PTT: 22.2 INR: 1.0
.
Micro:
Blood cx x 2 pnd
Urine cx pnd
.
Images:
CTA chest
No PE. Interlobular septal thickening c/w interstitial edema.
Left lower lobe atelectasis/consolidation with small to moderate
left pleural effusion and tiny right pleural effusion. COPD with
multiple pulmonary nodules, including a 5 mm pulmonary nodule in
left upper lobe. F/u CT in 6 months to assess for change
.
EKG:
IN ER during SOB: rate of 104, depressions in I and II, V4-V6 ST
elevations in V1-V2, dynamic changes compared to initial EKG
On FLOOR:
NSR at 72, axis WNL, LVH, ST depressions in I, II,V4-V6 with
some degree of resolution since prior, less STE in V1 and V2
Brief Hospital Course:
MICU COURSE:
85 yo f with hx of COPD, Dementia, HTN, admitted from ER with
dyspnea and hemoptysis in setting of new PNA and with EKG
changes.
1. Dyspnea: Long history of COPD and now with worsening cough,
shortness of breath, and hemoptysis. CXR with new left pleural
effusion and CTA with LLL consolidation, likely representing
pneumonia. CTA negative for PE. The patient was originally
admitted to the MICU for tachypnea requiring bipap. In the
MICU, bipap was weaned and she was on 4 L NC. Pneumonia treated
with ceftriaxone and azithromycin. She was started on RTC
ipratropium and albuterol nebs. Given her hemoptysis, dyspnea,
unilateral pleural effusion, and signficiant smoking history,
there is some concern for lung cancer. The patient's HCP was
told of this concern, but would like to defer this work up. The
patient maintained oxygenation with NC and was felt ready to be
transferred to the floor on [**9-18**]. Goal O2 sat > 92%
2. EKG changes: Compared to a prior EKG from >5 years ago, the
patient was noted to have new ST depressions and elevations
concerning for ACS. She has a background of moderate aortic
stenosis and mild MR. She was noted to have dynamic changes in
the ED when she became tachypneic and was hypertensives with
changes in the lateral and precordial leads. Cardiology was
consulted and thought that these EKG changes were due to cardiac
strain. Pt was given 325 mg ASA, continued on her home statin,
[**Last Name (un) **] and CCB. Telemetry was monitored. EKGs were cycled. CEs
were also cycled and troponin was felt to be elevated due to
renal failure. CK and MBs remained flat. Echo was obtained
while in the ICU.
3. Hypertension: BP was elevated in ER during tachypnea.
Continued home amlodipine. Home [**Last Name (un) **] was changed to Valsartan.
4. Dementia: pt has chronic dementia, per family she is at
baseline A&O x 1. Continued Aricept.
5. Chronic renal failure: Cr is at baseline 1.8. [**Month (only) 116**] worsen in
setting of having a CTA. Monitor renal function.
6. Anemia: stable, chronic
7. Lung Nodules: Seen on chest CTA, long hx of smoking
concerning for cancer risk. Will need out pt follow up
8. Osteoporosis: chronic. Continue Ca and Vitamin D. Fosamax
weekly on Sundays
# FEN: replete electrolytes, will start diet once off BIPAP
# Prophylaxis: Subcutaneous heparin
# Access: peripherals
# Code: DNR/DNI, confirmed
# Communication: HCP is her daughter, copy of paperwork in chart
=====
The patient was then transferred to the floor. On the floor,
she was noted to be tachypneic, hypoxic, and tachycardic. ABG
was completed. EKG with new ST elevations. She was transferred
back to the MICU. In the MICU, she was maintained on
non-rebreather. Cardiology was consulted for STEMI. Patient
was accepted onto CCU service. She was then noted to go into
rapid AFib. Metoprolol IV x 1 and dilt IV x 1 were given. She
converted to NSR. However, before transfer could occur to CCU,
the patient was noted to become hypotensive and began to become
bradycardic. She PEA arrested, and because she was DNR/DNI, no
resuscitative measures were completed. Family was at bedside at
the time of death at 6:45 PM on [**2110-9-18**].
Medications on Admission:
-Alendronate-D3 Qweek
-Amlodipine 5mg [**Hospital1 **]
-Aricept 10mg qday
-Irbesartan 150mg qday
-Lidocaine 5% patch
-Penicillin 250mg [**Hospital1 **]
-Simvastatin 40mg qday
-Acetaminophen 325mg PRN pain
-Aspirin 325mg QMWF
-Tums
-Capsaicin
-Vitamin D2 400mg qday
-Flaxseed Oil 1g Qday
-MV Qday
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac Arrest
Severe Aortic Stenosis
Atrial Fibrillation
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2110-9-19**]
|
[
"518.89",
"585.9",
"786.3",
"403.90",
"410.91",
"414.01",
"276.52",
"272.0",
"427.31",
"733.00",
"285.21",
"511.9",
"486",
"491.21",
"294.8",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7781, 7790
|
4225, 7435
|
260, 267
|
7891, 7900
|
3353, 4202
|
7956, 7994
|
2982, 3000
|
7811, 7870
|
7461, 7758
|
7924, 7933
|
3015, 3334
|
201, 222
|
295, 1894
|
1916, 2501
|
2517, 2966
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,819
| 117,531
|
10860
|
Discharge summary
|
report
|
Admission Date: [**2177-8-19**] Discharge Date: [**2177-8-25**]
Date of Birth: [**2101-6-24**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 76-year-old patient
who was referred to [**Hospital6 256**] for
cardiac catheterization due to a history of worsening angina
and a history of positive exercise treadmill test. Cardiac
catheterization showed three-vessel coronary artery disease
and a normal left ventricular function. The patient was
admitted to [**Hospital6 256**] on [**8-19**]
for surgery with Dr. [**Last Name (STitle) **].
PAST MEDICAL HISTORY: 1. Hypertension. 2. Elevated
cholesterol. 3. Coronary artery disease. 4. History of
Parkinson's disease. 5. Status post tonsillectomy.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
PREOPERATIVE MEDICATIONS: Aspirin 325 mg p.o. q.d.,
Lopressor 50 mg p.o. b.i.d., Lipitor 10 mg p.o. q.d.,
Cogentin 1 mg p.o. q.i.d.
PREOPERATIVE PHYSICAL EXAMINATION: General: The patient is
a 76-year-old gentleman in no apparent distress. He was
alert and oriented times three. Neurological: Grossly
intact. Chest: Clear to auscultation bilaterally.
Cardiovascular: Regular, rate and rhythm. S1 and S2.
Within normal limits. Electrocardiogram normal sinus rhythm.
LABORATORY DATA: CBC with a white blood cell count of 6.8,
hematocrit 39.1, platelet count 185,000; sodium 141,
potassium 4.4, chloride 102, bicarb 30, BUN 27, creatinine
1.0.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2177-8-19**], by Dr. [**Last Name (STitle) **], for a coronary artery
bypass grafting times four, LIMA to diagonal, saphenous vein
graft to left anterior descending, saphenous vein graft to
OM1, saphenous vein graft to posterior descending artery;
please see operative note of that day for further details.
The patient was transferred to the Intensive Care Unit in
stable condition. In the Intensive Care Unit, the patient
required FFP, Protamine, and blood transfusions for elevated
chest tube drainage which subsequently resolved. The patient
was weaned from mechanical ventilation that evening and
extubated without problem. The patient remained
hemodynamically stable. The patient was transferred out of
the Intensive Care Unit on postoperative day #1 in stable
condition.
The patient's chest tubes and pacing wires were removed on
postoperative day #3. The patient remained tachycardiac on
increasing doses of Lopressor. The patient was noted to have
a hematocrit of 23.9 which had been stable. The patient was
given a blood transfusion for tachycardia and orthostasis.
Repeat hematocrit after transfusion was 25.3. The patient
experienced some confusion on postoperative day #4 which
resolved spontaneously. The patient's Foley catheter was
removed on the evening of postoperative day #4. The patient
had a postvoid residual checked which was greater than 300
cc. The Foley catheter was inserted at that time. The Foley
catheter was subsequently removed several hours later, and
the patient once again was unable to void, and a Foley was
reinserted. Urinalysis on that day was negative for signs of
infection.
On postoperative day #5, the patient was also noted to have
left upper extremity IV site that was erythematous and
indurated. The patient was placed on intravenous Kefzol.
Ultrasound was obtained to rule out deep venous thrombosis.
Ultrasound was positive for basilic vein thrombosis, negative
for deep venous thrombosis. The patient was continued on
antibiotics, and it was determined that there was no need for
anticoagulation at that time.
The patient is ambulating with Physical Therapy 340 feet on
postoperative day #6 with several rest periods. The patient
was screened for [**Hospital 3058**] rehabilitation placement and was
accepted and was cleared for discharge on [**2177-8-25**].
CONDITION ON DISCHARGE: Vital signs: T-max 100.7??????, pulse 98
in sinus rhythm, blood pressure 125/84, respirations 20, room
air oxygen saturation 94%. General: The patient was alert
and oriented times three with a right upper extremity tremor,
worsening with activity, which the patient reported was the
same as preoperatively secondary to Parkinson's disease.
Cardiovascular: Regular, rate and rhythm. Without rub or
murmur. Respiratory: Lungs clear to auscultation
bilaterally. No wheezes, rhonchi, or rales. GI: Positive
bowel sounds. Soft, nontender, nondistended. The patient is
tolerating a regular diet without nausea or vomiting. GU:
The patient had a Foley catheter in place, draining clear,
yellow urine. Chest: Sternal incision with staples intact
without erythema or drainage. Sternum is stable.
Extremities: Right lower extremity saphenectomy site clean
and dry without erythema or drainage. Left upper extremity
basilic vein with a palpable cord. No erythema. No purulent
drainage.
DISCHARGE LABORATORY VALUES: Urinalysis from [**8-24**] was
negative. Electrolytes from [**8-21**] revealed a sodium of
137, potassium 4.2, chloride 101, bicarbonate 24, BUN 24,
creatinine 1.1, glucose 106. CBC from [**8-23**] with a white
blood cell count of 11.2, hematocrit 25.3, platelet count
111,000.
DISPOSITION: The patient is to be discharged to
rehabilitation in stable condition.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting.
2. Hypertension.
3. Elevated cholesterol.
4. Benign prostatic hypertrophy with urinary retention.
5. History of Parkinson's disease.
6. Left basilic vein thrombosis.
7. Status post tonsillectomy.
DISCHARGE MEDICATIONS: Lopressor 100 mg p.o. b.i.d.,
Cogentin 2 mg p.o. b.i.d., Lasix 20 mg p.o. b.i.d. x 7 days,
KCl 20 mEq p.o. b.i.d. x 7 days, Colace 100 mg p.o. b.i.d.,
Aspirin 81 mg p.o. q.d., Lipitor 10 mg p.o. q.h.s., Keflex
500 mg p.o. q.i.d. x 7 days, Ibuprofen 600 mg p.o. q.4-6
hours p.r.n.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to
rehabilitation with Foley catheter in place. The patient is
to make an appointment with his urologist, Dr. [**Last Name (STitle) 35380**], in
[**Location (un) 620**], phone [**Telephone/Fax (1) 35381**], upon discharge from
rehabilitation for monitoring and management of benign
prostatic hypertrophy and Foley catheter.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 35382**]
MEDQUIST36
D: [**2177-8-25**] 12:27
T: [**2177-8-25**] 13:20
JOB#: [**Job Number 35383**]
|
[
"414.01",
"785.0",
"293.0",
"453.8",
"332.0",
"272.0",
"788.20",
"413.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
5559, 5840
|
5283, 5535
|
1464, 3844
|
5865, 6504
|
817, 937
|
960, 1446
|
177, 584
|
607, 790
|
3869, 5262
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,982
| 184,919
|
7367
|
Discharge summary
|
report
|
Admission Date: [**2124-8-21**] Discharge Date: [**2124-8-25**]
Service: OTOLARYNGOLOGY
Allergies:
Unasyn
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
metastatic melanoma
Major Surgical or Invasive Procedure:
[**2124-8-21**]
Radical resection of recurrent metastatic melanoma left neck.
Pectoralis myofascial transpositional flap.
Placement of meshed skin graft (1.5:1) measuring 10 cm x 20 cm
in area.
Closure of pharyngeal defect
Nasogastric tube placement
History of Present Illness:
Mr. [**Known lastname 27137**] is a 83 year old gentleman who underwent excisional
biopsy of a nasal lesion in [**7-/2120**] with pathology revealing a
lentigo maligna melanoma. He underwent wide local excision with
reconstruction of the nasal dorsum with a transposition flap and
sentinel lymph node biopsy on [**2120-9-3**]. Reexcision pathology
revealed a lentigo maligna melanoma, [**Doctor Last Name 10834**] level IV, 1.75 mm
thick nonulcerated without perineural invasion. One sentinel
lymph node was negative for metastases. In [**1-/2122**], a nasal
recurrence was noted. He underwent surgical resection with
reconstruction of the nasal defect with transposition nasolabial
fold flap and sentinel lymph node biopsy with melanoma in one of
two lymph nodes. He underwent right radical neck dissection on
[**2122-4-21**] with 33 lymph nodes removed, all negative for
melanoma. In [**8-/2122**], left submandibular mass was noted with
FNA confirming melanoma. He underwent left radical neck
dissection on [**2122-9-28**] by Dr. [**Last Name (STitle) 1837**] with 1 of 12 lymph
nodes positive with extracapsular extension. He completed
radiation therapy in mid [**Month (only) 404**]. In the interim, he
established oncology follow up in [**Location (un) 27138**] and at his visit
in [**2124-4-21**] he was found to have a nodule in the left
submandibular region. FNA of this lesion confirmed melanoma.
He has also undergone staging CTs with the head CT negative for
any intracranial involvement. He had resection of the
submandibular mass on [**2124-7-31**] and which was found to have
inadequate margins on pathology and returns for a more extensive
resection.
Past Medical History:
metastatic melanoma (see HPI)
Brachytherapy for prostate ca ([**2115**])
HTN
chronic renal insufficiency
vitiligo
h/o colonic polyps
Social History:
Does not smoke, does not drink.
NKDA
Family History:
Non contributory
Physical Exam:
Tmax 99.4 Tcurrent 98.2 93 128/68 18 95%RA
NAD
RRR
CTAB
soft NT/ND, NGT in place
Neck: flat, skin graft in place, clean dry and intact
L skin flap: mild edema, warm, + capillary refill <2sed,
JP drains intact to bulb suction, serosanguinous output
L thigh donor site-xeroform in place, c/d/i
Pertinent Results:
[**2124-8-24**] 07:15AM BLOOD WBC-7.1 RBC-4.07* Hgb-12.6* Hct-35.5*
MCV-87 MCH-31.0 MCHC-35.5* RDW-13.3 Plt Ct-151
[**2124-8-25**] 07:00AM BLOOD Glucose-118* UreaN-25* Creat-1.0 Na-142
K-3.8 Cl-102 HCO3-32 AnGap-12
[**2124-8-25**] 07:00AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.3
[**2124-8-24**] 07:15AM BLOOD Glucose-125* UreaN-21* Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-30 AnGap-11
[**2124-8-24**] 07:15AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.3
[**2124-8-23**] 07:30AM BLOOD Glucose-125* UreaN-21* Creat-1.0 Na-137
K-4.2 Cl-103 HCO3-29 AnGap-9
[**2124-8-23**] 07:30AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.2
[**2124-8-22**] 04:45AM BLOOD Glucose-172* UreaN-24* Creat-1.2 Na-141
K-4.0 Cl-104 HCO3-28 AnGap-13
[**2124-8-22**] 04:45AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
[**2124-8-21**] 04:53PM BLOOD Glucose-144* UreaN-23* Creat-1.4* Na-143
K-4.0 Cl-105 HCO3-29 AnGap-13
[**2124-8-21**] 04:53PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 27137**] is an 83 year old gentleman who presented for left
radical neck dissection and excision of submandibular connective
tissue for metastatic melanoma. He was taken to the operating
room on [**2124-8-21**] with Dr. [**Last Name (STitle) 1837**] for the left neck
procedure with excision of melanoma connective tissue from left
neck and Dr. [**First Name (STitle) **] then reconstructed the left neck with a left
pectoralis myofascial transpositional flap, with placement of
meshed skin graft (1.5:1) measuring 10 cm x 20 cm in area,
closure of pharyngeal defect and nasogastric tube placement.
The patient tolerated the procedure well, was extubated and
transferred to the PACU in stable condition. He remained in the
PACU overnight for close graft monitoring. He was started on
Unasyn for post operative antibiotic prophylaxis and was made
NPO for 2 weeks secondary to the pharyngeal defect repair. He
was transferred to the floor on post operative day 1 and
continued to do well, with his vital signs remaining stable, his
pain well controlled and the flap/graft continued to be stable.
He developed a hive-like rash on his arms, which was thought to
be secondary to the Unasyn. The Unasyn was discontinued, the
patient was started on Clindamycin and the rash resolved within
24 hours. He was started on tube feeds on post op day 2 and
tolerated advancing to goal of 75cc/hr.
He continued to do well through his hospitalization, he was
afebrile, vital signs stable, flap/graft intact and stable,
tolerating tube feeds and pain well controlled on oral
medications (Tylenol). He is being discharged to rehab on post
operative day 4 in stable condition and will continue to be NPO,
all meds per NGT, continue tube feeds, continue drains to bulb
suction and antibiotics until futher instructed at plastic
surgery follow up appointment in 1 week. He will follow up with
Dr. [**Last Name (STitle) 1837**] in [**11-23**] weeks as well. He was instructed to
keep his head/neck neutral or facing to the right at all times.
Medications on Admission:
Diovan/HCTZ 160/12.5mg daily
ASA 81mg (stopped [**2124-7-25**])
MVI
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily): please administer per NGT only.
2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please administer per NGT only.
3. Acetaminophen 160 mg/5 mL Solution Sig: [**11-23**] PO Q6H (every 6
hours) as needed for pain/fever: please administer per NGT only.
4. Ascorbic Acid 90 mg/mL Drops Sig: Five Hundred (500) mg PO
BID (2 times a day) for 2 weeks: please administer per NGT only.
5. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
DAILY (Daily) for 2 weeks: please administer per NGT only.
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID
(2 times a day): please apply to tongue with swab and have
patient spit out, do not have patient swish and swallow
.
7. Clindamycin Palmitate 75 mg/5 mL Recon Soln Sig: Twenty (20)
ML PO every eight (8) hours: (300mg) Please administer through
NGT only.
continue while drains are in.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
metastatic melanoma
Discharge Condition:
stable
Discharge Instructions:
Seek immediate medical attention for fever >101.5, chills,
increased redness, swelling or discharge from incision, chest
pain, shortness of breath, or anything else that is troubling
you.
Please keep xeroform dressing on left thigh and left neck at all
times, left neck xeroform may be changed prn. JP drains to bulb
suction.
ambulate as tolerated with assistance
Please keep head in a neutral position or facing to the right at
all times.
No pressure or strain on left neck.
Followup Instructions:
please follow up with plastic surgery, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], in 1
week, call ([**Telephone/Fax (1) 10820**] to schedule that appointment
Follow up with otolaryngology, Dr. [**Last Name (STitle) 1837**] in [**11-23**] weeks,
call [**Telephone/Fax (1) 7732**] to schedule that appointment.
|
[
"585.9",
"V58.66",
"709.01",
"198.89",
"V10.82",
"V10.46",
"693.0",
"V12.72",
"403.90",
"518.89",
"E930.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"83.82",
"83.32",
"86.69"
] |
icd9pcs
|
[
[
[]
]
] |
6834, 6900
|
3704, 5760
|
240, 492
|
6964, 6973
|
2774, 3681
|
7502, 7843
|
2428, 2446
|
5878, 6811
|
6921, 6943
|
5786, 5855
|
6997, 7479
|
2461, 2755
|
181, 202
|
520, 2201
|
2223, 2357
|
2373, 2412
|
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