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29,882
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|
32095
|
Discharge summary
|
report
|
Admission Date: [**2136-10-31**] Discharge Date: [**2136-11-10**]
Date of Birth: [**2094-2-19**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain and progressive lower extremity weakness
Major Surgical or Invasive Procedure:
ALIF T12-L2 & Thorocotomy
Posterior Fusion T9-L3
History of Present Illness:
Mr. [**Known lastname 26581**] fell 25ft from scafolding landing on his legs and
buttocks. He began experiencing lower extremity weakness and
dysesthesias thereafter and was taken to [**Hospital1 18**] for further
evaluation.
Past Medical History:
None
Social History:
Denies
Family History:
N/C
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; reflexes intact at biceps, triceps and
brachioradialis
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension; ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL [**4-2**] left, [**5-3**] on the
right; + dysesthesias lower extremities left greater than right
Pertinent Results:
[**2136-11-9**] 07:30AM BLOOD WBC-14.1* RBC-2.80* Hgb-8.9* Hct-25.3*
MCV-90 MCH-31.6 MCHC-35.0 RDW-13.6 Plt Ct-351
[**2136-11-8**] 07:15AM BLOOD WBC-19.4* RBC-3.06* Hgb-9.4* Hct-27.1*
MCV-89 MCH-30.9 MCHC-34.8 RDW-13.9 Plt Ct-325
[**2136-11-7**] 07:15AM BLOOD WBC-21.7*# RBC-3.61* Hgb-11.4* Hct-32.7*
MCV-91 MCH-31.5 MCHC-34.7 RDW-13.7 Plt Ct-377#
[**2136-11-4**] 07:05AM BLOOD WBC-8.9 RBC-3.14* Hgb-10.0* Hct-28.0*
MCV-89 MCH-31.7 MCHC-35.6* RDW-13.1 Plt Ct-217
[**2136-11-3**] 06:45AM BLOOD WBC-10.1 RBC-3.28* Hgb-10.2* Hct-29.0*
MCV-89 MCH-31.0 MCHC-35.1* RDW-12.8 Plt Ct-164
[**2136-11-7**] 07:15AM BLOOD Glucose-133* UreaN-14 Creat-0.9 Na-139
K-5.1 Cl-103 HCO3-29 AnGap-12
[**2136-11-4**] 07:05AM BLOOD Glucose-104 UreaN-8 Creat-0.9 Na-138
K-3.6 Cl-99 HCO3-34* AnGap-9
[**2136-11-2**] 01:16AM BLOOD Glucose-139* UreaN-15 Creat-1.0 Na-137
K-4.5 Cl-103 HCO3-30 AnGap-9
[**2136-11-7**] 07:15AM BLOOD Calcium-8.6 Phos-3.5# Mg-2.3
[**2136-11-3**] 06:45AM BLOOD Calcium-7.9* Phos-1.5* Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 26581**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for
an emergent anterior/posterior lumbar fusion with
instrumentation for his L1 burst fracture. He was informed and
consented for the procedure and elected to proceed. Please see
Operative Note for procedure in detail.
Post-operatively he was administered antibiotics and pain
medication. His chest tube was removed POD3 catheter and drain
were removed POD 4 and he was able to take PO's. His pain was
well controlled. He was febrile POD3 and incentive spirometer
was encouraged. He will return to clinic in ten days. He was
discharged in good condition.
Medications on Admission:
None
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for gi distress.
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
9. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal DAILY;
PRN ().
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
L1 burst fracture
Post-operative fever
Discharge Condition:
Good
Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.
|
[
"780.6",
"E881.1",
"806.4",
"998.89"
] |
icd9cm
|
[
[
[]
]
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"81.06",
"84.51",
"81.62",
"80.51",
"81.08",
"77.89",
"77.79"
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icd9pcs
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[]
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4218, 4426
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767, 1265
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282, 334
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451, 679
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701, 707
|
723, 731
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,556
| 125,659
|
39462
|
Discharge summary
|
report
|
Admission Date: [**2182-9-10**] Discharge Date: [**2182-9-11**]
Date of Birth: [**2104-9-14**] Sex: M
Service: MEDICINE
Allergies:
Streptokinase
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Unstable VT SBP 60s during ablation
Major Surgical or Invasive Procedure:
EP Study with ablation of ventricular scar for VT, complicated
by sustained unstable VT with SBP into the 60s
History of Present Illness:
77 yoM with ischemic cardiomyopathy, s/p BMS and ICD in [**2168**] for
inferior-MI followed by a BMS to LCX [**5-/2182**], s/p ablation for VT
in [**2179**] at [**Hospital1 112**], hyperlipidemia, HTN, s/p CVA in [**2167**] with
residual short-term memory deficitis, pulmonary fibrosis on 3L
home O2 at night, who now presents with an episode of unstable
VT, SBP in the 60s, requiring cardioversion during an EP study
to ablate ventricular scar.
On review of systems, he denies any prior deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. he denies recent fevers, chills or rigors. S/he denies
exertional buttock or calf pain. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
Upon arrival to the ICU, the patient, who had just been
extubated, had oxygen weaned easily. He complained of chronic
low back, worse than prior episodes, but of same quality.
Otherwise asymptomatic.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+) HTN
2. CARDIAC HISTORY:
-Ischemic dilated cardiomyopathy
-CABG: None
.
3. PERCUTANEOUS CORONARY INTERVENTIONS:
CARDIAC CATH: [**5-/2182**]
Left Ventricle: 141/12, 21
*LVEF Status: Estimate - 20%
LV Wall Motion: Global Hypokinesis - Severe
*Conc LV systolic function severely impaired - global
Right Dominant
*LMCA Minimal Disease
LAD Minimal Disease
CIRC (Mid), Patent Stent 0% Lesion
*RCA (Mid), Diffuse Complex 100% Lesion
INTERVENTION INFORMATION:
CIRC Distal to [**2168**] JJ stent [**66**] % Pre Stenosis 0 % Post
Stenosis
.
4. PACING/ICD:
-AICD [**2168**] with generator change [**10-15**] at [**Hospital3 **], ([**Company 2275**])
-Ventricular tachycardia ablation [**2179**]
.
5. PERTINENT CARDIAC STUDIES:
2D-ECHOCARDIOGRAM: [**9-/2179**]
Aortic valve: Mildly thickened/ca++. Trace AI.
Mitral valve: Mildly thickened. Mild MAC. Mild+ MR.
Pulmonic valve: Normal.
Tricuspid valve: Mild+ TR. PASP = 38 mmHg + CVP.
Aortic root: Normal.
Left atrium: Mildly enlarged. Right atrium: Mildly
enlarged.
Pulmonary artery: Normal.
Inferior vena cava: Normal.
*Left ventricle: Reduced systolic function. Severely
enlarged.
*Left ventricular ejection fraction (estimated): 15%
*Right ventricle: Normal.
Pericardial effusion: None.
Other: Pacer wire seen in right heart.
.
Persantine Stress: [**9-/2179**]
No evidence of ischemia based on EKG criteria. At peak infusion
the abnormalities seen on the baseline EKG persisted. There were
no additional ST segment depressions noted.
.
6. OTHER PAST MEDICAL HISTORY:
-pulmonary fibrosis r/t amiodarone-uses 3L o2 at night
-CVA [**2167**] with residual short term memory loss
-Arthritis/back pain
-Anxiety/depression
.
Social History:
SOCIAL HISTORY
-Tobacco history: 10 pack year hx, quit 15 years ago
-ETOH: none
-Illicit drugs: none
Family History:
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION:
GENERAL: WDWN M. in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated.
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. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Protuberant nontense, NT. No HSM or tenderness. Abd
aorta not enlarged by palpation. No abdominial bruits.
GROIN: R femoral sheaths in place; left femoral 2+ no bruit
EXTREMITIES: 1+ pitting edema bilaterally @ the ankles.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 2+
Pertinent Results:
LABS/STUDIES
EKG: intermittent a-v paced and a-paced, v-sensed, evidence of
old inferior infarct with Q waves in III, aVF
.
TELEMETRY:
Arrhythmias Recorded on Diagnostics during EP Study:
Comments: Two episodes of VT at 150bpm treated with ATP which
slowed VT but did not break it. Three episodes NSVT.
.
.
HEMODYNAMICS: No Swan
.
Labs on Admission:
[**2182-9-10**] 06:07PM GLUCOSE-101* SODIUM-140 POTASSIUM-3.7
CHLORIDE-107 TOTAL CO2-25 ANION GAP-12
[**2182-9-10**] 06:07PM CALCIUM-8.7 PHOSPHATE-2.8 MAGNESIUM-1.7
[**2182-9-10**] 06:07PM HCT-31.8*
[**2182-9-10**] 11:15AM GLUCOSE-124* UREA N-26* CREAT-1.1 SODIUM-141
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-29 ANION GAP-12
[**2182-9-10**] 11:15AM estGFR-Using this
[**2182-9-10**] 11:15AM WBC-7.8 RBC-4.40* HGB-11.2* HCT-34.1* MCV-78*
MCH-25.5* MCHC-32.9 RDW-15.3
[**2182-9-10**] 11:15AM NEUTS-85* BANDS-1 LYMPHS-10* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2182-9-10**] 11:15AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-1+
ELLIPTOCY-OCCASIONAL
[**2182-9-10**] 11:15AM PLT SMR-UNABLE TO
[**2182-9-10**] 11:15AM PT-18.0* INR(PT)-1.6*
[**2182-9-10**] 08:15AM WBC-8.1 RBC-4.52* HGB-11.2* HCT-35.2* MCV-78*
MCH-24.8* MCHC-31.9 RDW-15.3
[**2182-9-10**] 08:15AM PLT COUNT-150
[**2182-9-10**] 08:15AM PT-17.7* PTT-29.9 INR(PT)-1.6*
Labs on Discharge:
[**2182-9-11**] 05:05AM BLOOD WBC-7.1 RBC-3.85* Hgb-9.9* Hct-30.1*
MCV-78* MCH-25.7* MCHC-32.9 RDW-15.5
[**2182-9-11**] 05:05AM BLOOD PT-16.2* PTT-28.4 INR(PT)-1.4*
[**2182-9-11**] 05:05AM BLOOD Glucose-108* UreaN-24* Creat-1.2 Na-140
K-4.0 Cl-105 HCO3-28 AnGap-11
[**2182-9-11**] 05:05AM BLOOD Calcium-8.3* Phos-2.8 Mg-2.1
Brief Hospital Course:
77 yoM with ischemic cardiomyopathy, s/p BMS and ICD in [**2168**] for
inferior-MI followed by a BMS to LCX [**5-/2182**], s/p ablation for VT
in [**2179**] at [**Hospital1 112**], hyperlipidemia, HTN, s/p CVA in [**2167**] with
residual short-term memory deficitis, pulmonary fibrosis on 3L
home O2 at night, who now presents with an episode of unstable
VT, SBP in the 60s, requiring DC cardioversion during an EP
study to ablate ventricular scar. Admitted to CCU for close
monitoring for VT.
.
# Unstable VT s/p cardioversion with ATP and s/p ablation: The
patient was a-paced, v-paced with frequent ectopy throughout
admission. ICD was deactivated during EP study, reactivated
prior to transfer to the CCU and reset to 70 bpm prior to
discharge. Patient was continued on home doses of Metoprolol
succinate and sotalol per EP recommendations. He was instructed
to make a followup appointment with Dr.[**Last Name (STitle) 23682**] at [**Hospital3 29818**] within the next week.
.
# Right Femoral sheath: Removed by EP in the CCU without
complication. The patient had no bruit or hematoma on exam.
.
# Dilated ischemic cardiomyopathy: EF 15%. The patient remained
asymptomatic throughout admission and was able to lie supine
without evidence of orthopnea. Clinically he was mildly
hypervolemic. He was continue on home Toprol and Sotalol for
rate control. He was also continued on home Valsartan, HCTZ, and
Lasix. Warfarin, which had been held for his procedure, was
restarted. Patient was not bridged according to EP
recommendations.
.
# History of AF, s/p stroke: Patient has CHADS score of 5 and so
warfarin was restarted as above.
.
# CAD s/p stents x 2: Patient was continued on secondary
prevention medication: ASA 81 mg daily, Simvastatin 80 mg daily.
His ICD is in place.
.
# Anxiety, Psych history: Patient was continued on home
medications Effexor and Ativan.
.
# Pulmonary Fibrosis: [**1-8**] Amiodarone. Patient was continued on
home Prednisone, Albuterol and Oxygen (home O2 3 L NC QHS.)
.
# BPH: Patient was continued on finasteride.
Medications on Admission:
METOPROLOL SUCCINATE [TOPROL XL] - 100 mg [**Hospital1 **]
SOTALOL - 80 mg [**Hospital1 **]
VALSARTAN [DIOVAN] - 160 mg [**Hospital1 **]
FUROSEMIDE [LASIX] - 20 mg daily
HYDROCHLOROTHIAZIDE - 12.5 mg daily
WARFARIN - 4 mg daily
ASPIRIN - 81 mg daily
SIMVASTATIN - 80 mg daily
.
PREDNISONE 5 mg daily
ALBUTEROL SULFATE - Unknown dose
OXYGEN - 3 liters NC QHS
.
FINASTERIDE [PROSCAR] - 5 mg daily
OXYCODONE-ACETAMINOPHEN [PERCOCET] 1 tav [**Hospital1 **] prn pain
VENLAFAXINE [EFFEXOR XR] - 37.5 mg daily
LORAZEPAM [ATIVAN] - 1 mg TID
DOCUSATE SODIUM [COLACE] - 100 mg daily
Discharge Medications:
1. metoprolol succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a
day).
2. valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. warfarin 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. albuterol sulfate Inhalation
10. Oxygen
3 L NC QHS
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day) as needed for Back Pain.
13. venlafaxine 37.5 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO DAILY (Daily).
14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
16. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
EP Study with ablation of ventricular scar for VT, complicated
by unstable VT with hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 83939**],
It was a pleasure to take care of your at the [**Hospital1 18**]. You were
admitted to the hospital after you had an abnormal heart rhythm
with low blood pressure during a procedure here to ablate a scar
in your heart. Your blood pressures remained stable overnight
and we kept you on your home medications. We did not make any
changes to these medications. The ablation that you had should
prevent you from having abnormal heart rhythms at home.
Because you have congestive heart failure, please weigh yourself
every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs.
Followup Instructions:
Please followup with Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 23682**] at [**Hospital3 60734**]. His phone number is: ([**Telephone/Fax (1) 87183**]. You should see
Dr. [**Last Name (STitle) 23682**] within one week- this is very important. If you
cannot get an appointment, please call back the [**Hospital1 18**] at the
number provided so we can help facilitate this.
Please return to the ED for chest pain, dizziness, palpitations
or any other symptoms concerning to you.
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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|
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3342, 3495
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3511, 3616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,788
| 104,205
|
52456
|
Discharge summary
|
report
|
Admission Date: [**2137-2-16**] Discharge Date: [**2137-2-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Right AVF thrombosis
Major Surgical or Invasive Procedure:
AVF revision/thrombectomy
History of Present Illness:
86M with ESRD on HD admitted for fistula thrombectomy, which
occurred yesterday, now with systolic BP in 70s at dialysis,
chest pain, EKG changes with ST depressions in V3-V5. SBP rose
to 100s after IVF. At HD, 1L taken off, BP dropped to 70s,
fistula was used. CP started at noon, didn't resolve after 2
hours. Cards did a bedside echo which showed normal wall motion,
rec no need for CCU. Pt still having L arm numbness. Per renal,
ok to use HD catheter as fistula is now working for HD.
.
Pt states that chest pain is substernal, worse with deep
inspiration, feels like a hammer pounding into his chest. Does
have some numbness in his L arm which he says is intermittent.
Chest pain has stayed constant since its onset around noon. Pt's
BP dropped at HD last Saturday to 60s-70s [**Name8 (MD) **] RN (per records,
in 80s) but he did not have any chest pain. Feels that his chest
pain is similar to chest pain in past that resulted in CABG x4.
The most exertion pt performs at home is climbing a flight of
stairs, which results in no chest pressure but he has been
getting more short of breath.
.
Per cards, no evidence of CHF and no regional wall motion
abnormalities on echo - appears dry. Rec rate control and
heparin for a fib. Pt also has h/o NHL, s/p chemo and rituxan,
and per oncologist is not active.
.
Access includes 1 peripheral, R AV fistula, groin HD catheter.
Pt also has not had BM x3 days, concern for gastric dilatation.
.
Past Medical History:
CAD s/p CABG x4 [**2128**]
ESRD with R AVF
HTN
Hyperlipidemia
Non-Hodgkin's lymphoma
Prostate Ca
Seizure d/o
PVD
Lumbar stenosis and disk herniation
Social History:
Patient currently lives with his wife.
[**Name (NI) 1139**]: Previous, quit 20 years ago.
ETOH: None
Illicits: None
Family History:
Patient currently lives with his wife.
[**Name (NI) 1139**]: Previous, quit 20 years ago.
ETOH: None
Illicits: None
Physical Exam:
Vitals: T- 98.9, Tmx: 99.1
BP: 118/35 113-132/59-86
HR: 71
RR: 13-18 O2: 97-100% on 2L NC
I/O: 690/140 LOS: +5229
.
General: Patient is an elderly male, + chronic sun
exposure/hyperpigmented skin, pleasant, tired, in NAD
HEENT: NCAT, EOMI. OP: + upper dentures. MMM, no lesions
Neck: JVP visible, approximately 6cm
Chest: Mild course expiratory breath sounds, no focal rhonchi,
wheezes, crackles anterior or laterally. Posterior exam limited
secondary to lying flat on back s/p removal of groin line
Cor: RRR, normal S1/S2. II/VI systolic murmur, loudest at RUSB
Abdomen: Mildly distended, mildly tender diffusely but without
rebound or guarding. Notable abdominal "fullness", particularly
periumbilical
Extremity:
RUE: Dressing over fistula, C/D/I. Sutures intact, no erythema.
+Thrill
LE: Venodynes in place, [**1-29**]+ pedal edema
Pertinent Results:
Admission Labs:
[**2137-2-16**] 01:33PM BLOOD WBC-5.1 RBC-3.45* Hgb-11.3* Hct-33.7*
MCV-98 MCH-32.8* MCHC-33.6 RDW-15.6* Plt Ct-158
[**2137-2-17**] 02:05AM BLOOD PT-12.3 PTT-150* INR(PT)-1.1
[**2137-2-16**] 01:24PM BLOOD Glucose-75 UreaN-120* Creat-10.2*# Na-135
K-7.8* Cl-97 HCO3-20* AnGap-26*
[**2137-2-16**] 05:30PM BLOOD Calcium-8.4 Phos-8.2*# Mg-2.4
[**2137-2-16**] 05:30PM BLOOD CK(CPK)-55
Pertinent Labs/Studies:
[**2137-2-19**] CT Chest/Abdomen/Pelvis
1. Hyperenhancing left renal mass, which may represent lymphoma
or RCC.
2. Multiple new pulmonary nodules in the left lung as described.
A three- month followup CT is recommended for assessment of
stability.
3. Left adrenal mass.
4. Small bilateral pleural effusions
.
[**2137-2-19**] Echo: Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. The right ventricular cavity is dilated. Right
ventricular systolic function appears to be normal but views
were technically limited. The aortic root is mildly dilated at
the sinus level. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION:
Technically limited study due to poor acoustic windows.
Preserved
global/regional left ventricular systolic function. Right
ventricle may be dilated but function appears normal. No
structural valve disease. No
pericardial effusion.
.
[**2137-2-20**]: Chest Pa/Lat - FINDINGS: Compared to [**2137-2-19**], allowing
for differences in technique and rotation, no acute process or
significant interval change identified.
.
Troponin: 0.56 ([**2137-2-21**]) -> 0.38 ([**2137-2-23**])
Dilantin: ([**2137-2-25**]) 2.9 - dilantin increased to 200mg [**Hospital1 **] after
this level
Discharge Labs
.
[**2137-2-27**] 06:05AM BLOOD WBC-6.2 RBC-3.23* Hgb-10.3* Hct-30.8*
MCV-95 MCH-31.9 MCHC-33.6 RDW-16.5* Plt Ct-202
[**2137-2-27**] 06:05AM BLOOD Glucose-87 UreaN-29* Creat-6.5*# Na-141
K-3.8 Cl-102 HCO3-30 AnGap-13
Brief Hospital Course:
Prior to floor transfer: Patient is a 86M with ESRD on HD
admitted for fistula thrombectomy, which occurred [**2136-2-21**],
admitted to the MICU after devloping systolic BP in 70s at
dialysis, chest pain, EKG changes with ST depressions in V3-V5.
This was thought possibly to occur in the setting of blood loss
related to AV fistula thrombectoy. SBP rose to 100s after IVF.
At HD, 1L taken off, BP dropped to 70s, fistula was used. CP
started at noon, didn't resolve after 2 hours. Cards did a
bedside echo which showed normal wall motion, rec no need for
CCU and to medically manage. The patient was initially covered
with broad spectrum antibiotics including amp, cipro, flagyl
which were eventually D/C given no evidence for infectious
etiology of hypotension.
.
[**Hospital 38133**] hospital course also notable for abdominal pain. Given
Hct drop, CT C/A/P performed. No leaking AAA or similar seen,
but a left renal mass was observed, possible concerning for
recurrent lymphoma vs. RCC. Per MICU team, discussion with Onc
attending revealed that patient was likely not a candidate for
further treatment at this time.
.
On the floor:
1. Hypotension - As above, the likely etiology of the patient's
hypotension was bleed from surgery. He was covered with
antibiotics in the Micu, but did not exhibit infection. On the
floor the patient remained normotensive and eventally a low dose
beta-blocker was added given his recent NSTEMI which he
tolerated well. This was then changed to long acting Toprol.
Patient would likely ultimately benefit from addition of an ACE
inhibitor as pressures allow. This can be added as an outpatient
at the discretion of the patient's PCP.
.
2. NSTEMI - As above, the patient experienced an NSTEMI in the
setting of hypotension and Hct drop. Per cardiology, the patient
was medically managed with ASA, Plavix, and statin without plan
for acute intervention given the [**Hospital 228**] medical
comorbidities. Given his hypotension and bleed a beta-blocker
and heparin drip were held. His blood pressure improved on the
floor and he was started on a BB. He had no further events on
the floor. Consideration for follow-up with cardiology and
potential stress test can be made as on outpatient. However,
multiple co-morbidities may defer further evaluation or invasive
procedures regardless. As above, the patient may additionally
benefit from addition of an ACE if his BP remains WNL. This may
be started as an outpatient at the discretion of the patient's
PCP and other treaters.
.
2A. PAfib - patient with history of pafib. Patient is currently
on Toprol XL with normal heart rates. Patient was not initiated
on anti-coagulation given Hct drop, and hypotension earlier this
admission. Consideration towards initiation of anti-coagulation
should be performed as an outpatient after acute illness
resolved with consideration towards embolic risk as well as
malignancy and recent bleeding event, although this likely
occurred in the setting of surgical procedure.
.
3. Anemia - The patient received 3U PRBCs during the MICU
course, after his thrombectomy. On the floor his hematocrit
remained stable and was closely followed and his iron studies
revealed a component of anemia of chronic disease. His
stabilized by the time of discharge.
.
4. Renal Mass - The patient's renal mass is concerning for
recurrent lymphoma vs. RCC. Per conversation with MICU team, the
patient's treating Oncologist is aware of the renal mass and is
being followed. Pulmonary and Liver nodules, on CT are new
however since last imaging. Unfortunately, given multiple
medical comorbidities, patient not thought to be a likely
candidate for therapy regardless of etiology. He will have
ongoing follow-up with his oncologist as an outpatient.
.
5. ESRD on HD - The patient received dialysis with his new
fistula with no complications. He remained stable at dialysis
and had close care by the renal team. He will continue to
receive dialysis as scheduled on MWF.
.
6. Seizure disorder - The patient was continued on Phenytoin per
outpatient regimen. His levels were sub-therapuetic with
adjustment this admission. The patient should have levels
repeated during his rehab stay with goal [**11-11**]. If patient
remains sub-therapeutic, his Dilantin should be titrated as
appropriate. He remained seizure free during his course.
Continuation of this medication can be re-addressed as an
outpatient given notes which indicate thoughts towards
discontinuing this medication.
.
7. Dispo: the patient was discharged to nursing facility for
ongoing rehabilitation
.
8. Code status: patient is DNR/DNI, this was confirmed with the
patient and his wife [**Name (NI) 382**] this admission
Medications on Admission:
doxepin 25mg qHS
lisinopril 10mg [**Hospital1 **]
omeprazole 20mg [**Hospital1 **]
phenytoin 100mg [**Hospital1 **]
simvastatin 20mg daily
pentoxifylline 400mg daily
quinine 260mg daily
temazepam 15mg
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO BID (2 times a day).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q24H (every 24 hours).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for prn pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
Disp:*45 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
11. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for nausea.
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-29**]
Drops Ophthalmic PRN (as needed).
13. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
14. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
may repeat upto 3 times every 5 minutes.
15. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 38**] Rehab Hospital
Discharge Diagnosis:
Primary:
1. RUE AV fistula thrombosis.
2. NSTEMI
3. Hypotension NOS.
4. New 4.6 x 4.8 cm left renal mass.
5. New 3.5 x 3 cm left adrenal mass.
6. Multiple new left pulmonary nodules.
7. CKD Stage V on HD
8. Blood loss anemia.
Secondary:
1. Low grade NHL.
2. Seizure D/O NOS.
3. CAD s/p CABG.
4. HTN.
5. Prostate CA
Discharge Condition:
Stable. tolerating oral medications and nutrition
Discharge Instructions:
1. Call Transplant office [**Telephone/Fax (1) 673**] if fever, chills, nausea,
vomiting, decreased urine output, diarrhea, weight gain of 3
pounds in a day, edema or redness/bleeding/pain at incision.
Malfunction of AV fistula, bleeding/redness/increased drainage
at fistula or numbness/discoloration or increased swelling in
right arm
Continue HD M-W-F.
.
Please take all medications as directed.
.
Please make and attend the recommended follow-up appointments
Followup Instructions:
Scheduled Appointments :
.
Please call the office of your primary care physician to make an
[**Telephone/Fax (1) 648**] to be seen within one to two weeks.
.
You have an [**Telephone/Fax (1) 648**] with your Oncologist, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], MD. [**First Name (Titles) 2172**] [**Last Name (Titles) 648**] is on [**2137-3-12**] at 09:30, located
on [**Hospital Ward Name 23**] 9. Please call his office at [**0-0-**] at your
convenience if you have any scheduling needs or questions.
.
You have an [**Year (4 digits) 648**] with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] from the
division of Transplant Surgery. Your [**Last Name (NamePattern4) 648**] is on [**2137-3-7**]
at 3:00. Please call his office at [**Telephone/Fax (1) 673**] with any
questions or scheduling needs.
.
Please call the office of your Nephrologist, Dr. [**Last Name (STitle) 12596**] E. Reyad
to make an [**Last Name (STitle) 648**] for follow up.
|
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icd9pcs
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12125, 12184
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281, 308
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1804, 1955
|
1971, 2089
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,479
| 157,132
|
49727
|
Discharge summary
|
report
|
Admission Date: [**2176-9-1**] Discharge Date: [**2176-10-9**]
Date of Birth: [**2124-6-21**] Sex: F
Service: SURGERY
Allergies:
Tetracycline / Dilaudid
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy and lysis of adhesions for 2
hours.
2. Proctosigmoidectomy with end-colostomy.
3. Repair of ventral hernia and reconstruction of abdominal
wall
4. ex-lap, loa, jejunal resection
History of Present Illness:
Ms. [**Known lastname 1007**] is a 52 year-old female with past medical history
significant Crohn's Disease with multiple prior fistulas and
corrective surgeries (multiple bowel resections,
temporary/reversal colostomy, repair of enterocutaneous
fistulas, and ventral hernia repair with allograft complicated
by infection and hematoma), A-fib (not on anti-coagulation given
surgeries) presents the [**Hospital Unit Name 153**] after abdominoperineal resection,
end colostomy (decending) and ventral hernia repeair with mesh
for management of a-fib w/ RVR. She was previously admitted on
[**7-17**] for Crohn's flare and hypotension. Initally, treated
with cipro, zosyn, flagyl and narrowed to cipro/flagyl when
stable. He was continued on asacol, but her Humira was stopped.
The plan was for Dr. [**Last Name (STitle) 1120**] and [**Doctor First Name **] to perform proctocolectomy
with end ileostomy and ventral hernia
repair which was performed today. The patient was admitted on
[**2176-9-1**] to the surgery service for her planned surgery and with
chronic abdominal pain and chronic non-bloddy diarrhea that was
at her baseline. This has been attributed to her
proctosigmoiditis that manifested by as chronic diarrhea and
abdominal pain. She denied any fevers, chills, N/V.
.
The patient underwent abdominoperineal resection, end colostomy
(decending) and ventral hernia repeair with mesh with Dr. [**Last Name (STitle) 1120**]
and Dr. [**First Name (STitle) **] today. The patient received 5.8L of IVF. Her U/O
was 530ml, but towards the end of the procedure her urine output
was declining. The surgery was close to 12hrs long. They
estimated 200cc ESBL. Her ABG was 7.42/41/170/28. During the
procedure her rates increased to 130-160's . She was given a
total of 100mg Dilt IV and 30mg IV lopressor with labile HR.
The patient's BP ranged SBP 90-100's and she required
intermittent small amounts of neo (could not find documentation
in chart). The patient was transferred to the [**Hospital Unit Name 153**] for
management of continued a-fib w/ RVR.
.
On arrive the patient was in severe pain and given 1mg dilaudid
x2 and started on a PCA. Her HR ranged between 120-140's and
she was initially given 10mg IV Dilt and started in a Dilt gtt
(titrated to 15mg/hr). She was also given 5mg IV metoprolol x3.
Her blood pressures varied between SBP 80-100. She did require
intermittent boluses of neo to increase her BP and also helped
with her rate control. She was also given an additional 2L IVF.
Past Medical History:
Crohn's disease (diagnosed in [**2167**]): on Humira weekly therapy.
On prior Remicade. Prednisone caused enterocutaneous fistulas.
Did not tolerate prior azathioprine Rx.
Pre-diabetes
Hyperlipidemia
Benign multinodular goiter (followed by Dr. [**Last Name (STitle) **]
Cervical cancer
GERD
Paraspinal cyst (followed by Dr. [**Last Name (STitle) 575**]
Atrial fibrillation: developped 10 months ago. Per patient, her
cardiologist, Dr. [**Last Name (STitle) 5874**] ([**Hospital **] Medical Center), has
opted to defer cardioversion and coumadin therapy until a later
date after she has surgery for her hernia and Crohn's disease.
s/p L tib/fib fixation
Surgical History:
[**2167**] - Temporary colostomy
[**2168**] - reversal of colostomy
[**2169**] - reconstruction of fistulas
[**2172**] - bowel resection
[**2173**] - repair of ventral hernia with allograft
[**2174**] - patient reports 7 operations, to fix hernias, had a
abscess under her allograft
Social History:
On leave now but had been working as a physical therapist. She
smoked intermitently in college but no current or recent tobacco
use. No ETOH, no illicit drug use.
Family History:
Her father has ulcerative colitis. On her father's side, she has
an aunt who was diagnosed at 70 with Crohn's, and a cousin who
was diagnosed at 14 with IBD. There might be more; she says that
her family is very private and likely wouldn't share about their
condition. Her father had esophageal cancer, her maternal
grandfather liver cancer and her maternal grandmother lung
cancer. A paternal aunt had breast cancer and her mother had
basal and squamous cell carcinoma.
Physical Exam:
At Discharge:
Vitals: 98, 89, 101/71, 18, 96%RA
GEN: NAD, A/Ox3
CV: RRR, no m/r/g
RESP: CTAB, no w/r/r
ABD: large, ND, appropriately TTP, +BS, +flatus, +BM
Incision: midline abdominal incision OTA with Staples and
sutures distally. JP drain intact. Rectal sutures intact.
Ostomy: stoma Pink & viable with soft green-brown effluence
Extrem: no c/c/e
Pertinent Results:
[**2176-9-7**] 03:09AM BLOOD WBC-11.0 RBC-2.97* Hgb-8.0* Hct-25.7*
MCV-87 MCH-27.1 MCHC-31.3 RDW-20.7* Plt Ct-506*
[**2176-9-6**] 02:08AM BLOOD WBC-9.6 RBC-2.95* Hgb-8.1* Hct-25.4*
MCV-86 MCH-27.3 MCHC-31.8 RDW-21.1* Plt Ct-538*
[**2176-9-7**] 03:09AM BLOOD Neuts-75.7* Lymphs-14.9* Monos-5.6
Eos-3.6 Baso-0.1
[**2176-9-6**] 02:08AM BLOOD Neuts-72.2* Lymphs-17.9* Monos-5.4
Eos-4.4* Baso-0.2
[**2176-9-7**] 03:09AM BLOOD PT-17.9* PTT-27.9 INR(PT)-1.6*
[**2176-9-6**] 04:14PM BLOOD UreaN-5* Creat-0.5 Na-139 K-3.7 Cl-102
HCO3-29 AnGap-12
[**2176-9-7**] 03:09AM BLOOD Glucose-81 UreaN-5* Creat-0.5 Na-142
K-4.2 Cl-102 HCO3-32 AnGap-12
[**2176-9-7**] 03:09AM BLOOD ALT-10 AST-13 LD(LDH)-156 AlkPhos-70
TotBili-0.5
[**2176-9-7**] 03:09AM BLOOD Calcium-8.0* Phos-3.6 Mg-1.6
[**2176-9-6**] 04:14PM BLOOD Calcium-7.8* Phos-3.2 Mg-1.7
[**2176-9-4**] 05:15AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.021
[**2176-9-4**] 05:15AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2176-9-4**] 05:15AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2176-9-4**] 05:15AM URINE CastHy-75*
BCx, UCx (-)
.
Echo [**9-3**]: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated, RA moderately dilated; mild
symmetric LVH w/ nl cavity size; mild global LV hypokinesis
(LVEF = 45%), asc. aorta & arch mildly dilated; mitral valve
leaflets mildly thickened; trivial mitral regurg, trivial
pericardial effusion; findings similar to prior [**2176-8-14**] study w/
mild global LV hypokinesis
.
BAS/UGI AIR/SBFT [**9-17**]: Complete small-bowel obstruction
involving the proximal jejunum just past the ligament of Treitz.
There does appear to be some suture material at this site
raising concern for anastomotic stricture. However, correlation
with prior surgical history is recommended.
.
CT abd/pelvis [**9-19**]: Findings consistent with small bowel
obstruction with transition point likely at suture line from
prior anastomosis. Extensive fat stranding in the anterior
abdominal wall and adjacent to the end colostomy. No focal
organized fluid collection to suggest abscess at this time.
Mesenteric and retroperitoneal lymphadenopathy as well as lymph
nodes identified within the anterior abdominal wall.
.
[**2176-10-5**] 09:50AM BLOOD PT-13.3 PTT-49.3* INR(PT)-1.1
[**2176-10-6**] 08:23AM BLOOD PT-13.7* PTT-63.6* INR(PT)-1.2*
[**2176-10-7**] 05:03AM BLOOD PT-16.8* PTT-91.9* INR(PT)-1.5*
[**2176-10-8**] 05:05AM BLOOD PT-22.5* PTT-117.9* INR(PT)-2.1*
[**2176-10-9**] 06:24AM BLOOD PT-30.0* PTT-37.7* INR(PT)-3.0*
Brief Hospital Course:
#. A-fib w/ RVR: Pt with 10 month history of difficult to
control a-fib. She was not on anti-coagulation given her
scheduled surgeries. She was on 180mg dilt SR and 100mg
metoprolol TID po as her home regimen was controlled. However,
she was NPO for her procedure and did not receive po
medications. She required large amounts of IV meds intra-op and
post-op. She was placed on a dilt gtt on admission to the [**Hospital Unit Name 153**].
Pt tachycardia also affected by pain post-op and likely
hypovolemia after surgery. Pt is NPO including medications. Her
HR was difficult to control and she was persistently in A-fib w/
RVR up to the 130-150s. On [**9-6**] she was digoxin loaded w/
0.25mg then converted to 0.125mg daily, metoprolol IV was
increased to 20mg q4h, added to the diltiazem drip. She
responded well to this regimen and her diltiazem drip was dc'd
on [**9-7**] w/ HR in the 90s-100s. Patient was called out to the
surgical floors on q4 IV rate control medication which was
every 4 hours. Patient was readmitted to the [**Hospital Unit Name 153**] for
management until PO medications could be continued. On [**9-9**]
patient was cleared by surgery to receive oral medications via
NG tube. Patient was started switched over to PO diltiazem 90mg
QID, metoprolol 100mg TID, and digoxin 0.125mg daily. Patient
demonstrated ability to take pills by mouth. NGT was removed.
Patient was retransferred back to surgical floors for further
management.
.
#. Abdominal Surgery: abdominoperineal resection, end colostomy
(decending) and ventral hernia repeair with mesh. Pt being
followed by surgery. Pt with colostomy and 3 JP drains draining
serosang. Her NGT was taken out on [**9-3**]. She had persistent
nausea and vomiting of dark green fluid thought to be secondary
to post-op ileus and opioids, that was unresponsive to zofran,
reglan, ativan and compazine. NGT placement was attempted by
ICU team and surgery team on [**9-4**] but was unsuccesful due to
deviated septum. NGT was succesfully placed on [**9-5**] which, added
to zofran, reglan and ativan, greatly improved the patient's
nausea/vomiting. NGT was removed on [**9-10**] after patient
demonstrated ability to tolerate PO medications.
#. ST depression: On admission to the [**Name (NI) 153**] pt was noted to have
ST depressions on EKG. These that were thought to be due to
demand in the setting of rapid rate. Pt without prior MI or
documented CAD. Her risk factors for CAD include hyperlipidmia
and HTN. Her EF 40-50% was on last ECHO. Pt never complained of
chest pain or any other symptoms that would cause concern for
CAD. Spoke with cards fellow on call and faxed EKG at that time
their thought was that diffuse STD and TWI less likely coronary
and more likely rate related. CE??????s neg x4.
.
#Leukocytosis: Pt had an elevated WBC to 24.9 post-op. This was
thought to be reactive in the setting of recent surgery.
Differential on CBC showed no bands, blood and urine cultures
were negative, chest x-ray showed no signs of pneumonia. No
complications during surgery such as bowel perforation or other
complications were noted. She remained afebrile throughout
admission and her WBC trended down to 11.8 on [**9-10**].
.
#. Crohn's Disease: Pt has had multiple [**Doctor First Name **] and complications
as part of her disease process. No longer on Humira. Patient
says she had conversation with her gastroenterologist to stop
all the GI medications because of the surgery and will follow up
with gastroenterologist to see which ones need to be restarted.
.
General surgery:
The patient was transferred to general surgery from the [**Hospital Unit Name 153**].
However she was transferred back to the [**Hospital Unit Name 153**] secondary to A-Fib.
[**Hospital Unit Name 153**] course #2
#. A-fib w/ RVR: pt was transferred back to [**Hospital Unit Name 153**] for rate
control. Pt was found to have high residuals and PO diltiazem
was not being absorbed. Was restarted on IV diltiazem and
metoprolol, then transitioned back to PO diltiazem with good
tolerance. Heart rate is controlled to 90s-100s.
.
General surgery:
The patient returned to the general surgical floor once A-fib
was rate controlled with oral/iv meds. Her NGT remained in place
and the patient was unable to tolerate clamping trials.
Secondary to large amounts of NGT output, no flatus/ostomy
output and nausea a BAS/UGI AIR/SBFT was done on [**9-17**]. This
indicated complete small-bowel obstruction involving the
proximal jejunum just past the ligament of Treitz. There does
appear to be some suture material at this site raising concern
for anastomotic stricture. However, correlation with prior
surgical history is recommended.
.
The patient continued to have nausea, -flatus and - ostomy
output on [**9-19**] a CT of the abd/pelvis was done: Consistent with
small bowel obstruction with transition point likely at suture
line from prior anastomosis. Extensive fat stranding in the
anterior abdominal wall and adjacent to the end colostomy. No
focal organized fluid collection to suggest abscess at this
time. Mesenteric and retroperitoneal lymphadenopathy as well as
lymph nodes identified within the anterior abdominal wall.
.
The patient was than pre-op'd/consented and brought to the OR
for ex-lap, loa, jejunal resection.
.
[**Hospital Unit Name 153**]: Pt is POD 17 from proctosigmoidectomy and colostomy with
large abdominal wall reconstruction. After surgery, pt continued
to have large NGT outputs. UGI and CT demonstrated jejunal
obstruction w/ transition pt @ suture line of prior anastamosis
and pt underwent resection today . She received 1500cc fluid and
2 Units blood today intra-operatively with UOP 305cc. Hct 29-->
28--> 26 over last 3 days. Pt has gone into A-fib with RVR
during previous surgeries and is currently was in A-fib,
admitted to the [**Hospital Unit Name 153**] for IV diltiazem. On the floor, she was in
A-fib with HR 111. Pt c/o abdominal pain, no CP, no SOB.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
................................................................
General Surgery:
The patient returned to the floor and remained NPO with
IVF/NGT/PCA/Foley/Tele/TPN. Cards was consulted secondary to
several beats of V-Tach. Difficult to rate control AF and
frequent NSVT. With the return of bowel function/flatus the
patient's NGT was clamped intermittently. Reported nausea on and
off. Continued to re-trial clamping. Osotomy output gradually
increased with some flatus. Bowel function wax & waned. Patient
eventually tolerated clamping. NGT remained in place due to
failed progress during this admission. Right nare developed
pressure ulcer. Duoderm applied, and NGT repositioned to prevent
furhter breakdown. Started clear liquids around NGT.
Her foley was removed without issues. Abdominal incision
remained intact with staples from top to middle incision, distal
incision with sutures. Abdominal binder applied for comfort.
.
Started on sips to clears around NGT. Tolerated well. Continued
with TPN. Plastics service contact[**Name (NI) **] regarding management of JP
drains which were placed per Dr. [**First Name (STitle) **] [**Name (STitle) 25299**]. Two JP drains
removed. CT scan repeated to re-assess for obstruction prior to
removal of NGT. No evidence of obstruction noted. However, pt
found to have a portal vein thrombosis. Started on a Heparin
drip. NGT removed. Tolerated a regular diet. TPN discontinued.
Coumadin started a few days later. Physical Therapy consulted
during admission, cleared patient for discharge home.
.
PICC line removed prior to discharge. INR on [**2176-10-9**]-3. Patient
instructed to take 4mg of Coumadin daily until next INR check.
.
Medication changes reviewed with patient prior to discharge.
Coumadin was started in-patient for management of portal vein
thrombus. Patient's Diltiazem SR 180mg daily was switched to
Dilatiazem 60mg every 6 hours during her admission for better
heart rate control. She was discharged home on this regimen. In
addition, Reglan and Compazine PO were started and continued for
managment of chronic nausea. Lastly, patient advised to continue
with Nexium for reflux/indigestion.
.
Visiting Nurse arranged for home to assist with JP drain care,
ostomy care, and INR checks. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48642**] office will
follow patient's INR's. Goal INR [**3-12**].
Medications on Admission:
Mesalamine EC 400'', Ferrous Sulfate 325', Lorazepam 1'',
Cyanocobalamin 1000', Cholecalciferol (Vitamin D3) 400 unit
2Tab', Folic Acid 1', Pantoprazole 40', Acetaminophen 325
2Tabq6hrs PRN, Metoprolol Tartrate 100''', Diltiazem SR 180'
Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*240 Tablet(s)* Refills:*2*
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: Two (2)
Capsule PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours.
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for anxiety.
8. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical Q2H
(every 2 hours) as needed for pain for 2 weeks: apply to
perineal area
.
Disp:*qs * Refills:*0*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every four (4) hours as needed for pain for 2 weeks: Do not
exceed 4000mg of acetaminophen in 24hrs.
Disp:*45 Tablet(s)* Refills:*0*
10. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once
a day.
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed for heart
burn.
13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
1. Medically refractory proctosigmoiditis due to Crohn's
disease.
2. Multiple ventral herniae.
3. Post-op Jejunal stricture
4. Post-op Atrial fibrillation and VTACH
5. Post-op portal vein thrombosis
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples and sutures will be removed at your follow-up
appointment. Steri strips will be applied.
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
JP Drain Care:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Maintain the bulb deflated to provide adequate suction.
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Be sure to empty the drain frequently.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, Call Dr. [**Last Name (STitle) 1120**].
.
New Medications:
1. Coumadin: This medication is treat the blood clot in your
protal vein. Continue to take this medication as instructed. You
will have your blood checked (INR) 3 times per week. The
visiting Nurse will contact your [**Name (NI) 6435**] office for continued
management of your Coumadin doses.
2. Reglan and Compazine: These medications are to help manage
your nausea. Continue to take as prescribed.
**Continue your Nexium medication as prescribed to help manage
your heartburn.
3. Diltiazem: Please stop taking your previous dose of Diltiazem
SR (sustained release) 180mg once a day. Your dose was adjusted
during your admission. Continue taking Diltiazem 60mg every 6
hours. Follow-up with your PCP for management of your blood
pressure medications.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) 1120**] [**Telephone/Fax (1) 160**] in 2 weeks.
2. Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (Plastic Surgery) on Friday,
[**10-18**]. Please call [**Telephone/Fax (1) 9144**] to make the appointment.
3. Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2176-12-9**]
11:00
4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2177-1-13**] 10:00.
5. Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6925**] ([**Telephone/Fax (1) 451**] in 2
weeks.
Completed by:[**2176-10-9**]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,733
| 170,387
|
37178
|
Discharge summary
|
report
|
Admission Date: [**2101-12-22**] Discharge Date: [**2102-1-20**]
Date of Birth: [**2052-10-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Cefazolin / Sertraline Hcl
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
bronchopleural fistula with aspergillus superinfection
Major Surgical or Invasive Procedure:
Left modified [**Last Name (un) 72148**] window (Schede type thoracoplasty) and
debridement of empyema cavity, closure of bronchopleural
fistula, serratus anterior muscle flap, latissimus muscle flap,
and
bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
49 year-old gentleman with an extensive history of spontaneous
pneumothoraces, more commonly on the left than on the right, and
who is s/p multiple thoracotomies, resections, chest tubes, and
L pleurodesis. The patient presented to [**Hospital **] hospital in
[**Month (only) **] for fever/chills and was found during the workup to
have an infected bullus on the L side. He was discharged home
on oral antibiotics, and on [**2101-11-21**] underwent an elective
revision L thoracotomy with lysis of adhesions, wide wedge
resection of the LUL, nodal dissection, and resection of blebs
in the superior segment of the LLL. The patient was put on
unasyn postop and was later discharged home on oral antibiotics
with a chest tube connected to a Heimlich valve. However, he
was admitted again on [**2101-12-9**] with fever/chills,
nausea/vomiting, and L-sided chest pain. CT showed a large left
hydropneumothorax suspicious for a bronchopleural fistula and an
extensive consolidation in the LLL suspicious for PNA. His WBC
was 25.2, and his temperature was 102.6. The original chest
tube was left in place, but the
patient also underwent CT-guided drainage of the
hydropneumothorax, which returned aspergillus. The patient was
put on zosyn and voriconazole. The pigtail drain from the IR
procedure was left in place for several days and was connected
to suction. CXR after this period showed resolution of the
fluid
level in the L chest. A repeat chest CT on [**2101-12-21**], however,
showed a reaccumulation of the L hydropneumothorax, and the
patient was then transferred to [**Hospital1 18**] for management of his
likely bronchopleural fistula and aspergillus superinfection. On
the same admission to [**Hospital **] hospital, the patient also
complained of dysphagia with a sensation of food and liquid
"sticking." The patient underwent a barium swallow at the OSH
which showed decreased peristalsis of esophagus in mid and
distal portions but no aspiration. He also underwent
gastroscopy, which showed esophageal dysphagia characterized by
slow motility and little peristalsis. The patient says that his
dysphagia is
improving, however, and he is able to eat many foods. On ROS,
the patient endorses night sweats, fever/chills, weight loss of
25lb over 4 months, and SOB/DOE.
Past Medical History:
Numerous pneumothoraces since age 18 L>R, chest tube (last time
20 years prior to [**Hospital **] hospital), L apical posterior
segmentectomy in [**2077**], L pleurodesis, LUL wedge resection with
LLL bleb resection and LOA and nodal dissection [**2101-11-21**],
multiple pneumonias, infected LLL bullae, colonic abscesses,
depression, anxiety, appendectomy, hernia
Social History:
Ex-smoker, 30 pack-years. Quit on [**2100**].
Remarried 6 months ago. Has two children.
Family History:
Mother healthy, alive, had mild stroke at 73
Father died at 70 of brain aneurysm
Siblings has 5 brothers and 3 sisters all in good health
Physical Exam:
VS: T 97.7 HR: 88 SR BP: 101/72 RR 16 Sats: 98% RA
General: cachetic appearing gentleman in no apparent distress
HEENT: normocephalic
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur gallop or rub
Resp: clear breath sounds throughout
GI: bowel sounds positive abdomen soft non-tender/non-distended
Incision: Left [**Last Name (un) 72148**] window site clean, pink granulated
tissues, no odor
Skin: Sacral Stage II decubitus 0.2 cm yellow center. The ulcer
entirely measures approx 1.5 x 0.7 cm The surrounding tissue is
intact and not reddened.
Neuro: awake alert, oriented. Smiles when speaking with him.
Ambulates with no deficits.
Pertinent Results:
Chest CT scan Date: [**2101-12-9**] [x] outside film
Impression: Large L-sided hydropneumothorax with chest tube at L
apex, suspicious for bronchopleural fistula; extensive
consolidation of residual LLL suspicious for PNA; adjacent small
LLL pleural effusion
Chest CT scan Date: [**2101-12-21**] [x] outside film
Impression: L chest tube, large L hydropneumothorax, L lung loss
with L shift of mediastinum, extensive infiltrates involving the
remaining portion of the LUL and LLL, interstitial scarring at R
apex
PFTs Date: [**2101-11-15**] (prior to most recent resection)
[x] outside test
Actual % predicted
FVC 3.11 66
FEV1 2.93 83
DLCO 14.41 51
Barium swallow [**2101-12-12**]: vallecular pooling, no aspiration,
dereased peristalsis of esophagus in mid and distal portions,
retained puree and solid foods at these levels
Gastroscopy [**2101-12-14**]: no esophagitis but decreased motility of
esophagus
EKG [**2101-12-9**]: sinus tachy 111, incomplete RBBB, nonspecific at
ST
segment change
CXR
[**2102-1-8**] A pocket of pleural fluid persists posterior to the left
upper lung and much of the left lower lobe has been consistently
atelectatic. Packing material fills much of the chest wall
defect at the base of the left hemithorax above an elevated left
hemidiaphragm, all of which is unchanged since [**1-3**].
Aside from apical scarring the right lung is clear. The heart is
not enlarged. Marked leftward mediastinal shift is unchanged.
[**2101-12-22**]: Enlarged left hydropneumothorax is present with
elevation of the left hemidiaphragm consistent with
postoperative state. A left chest tube is present within the
region of the pneumothorax. Some mediastinal shift is also
present to the left.
The right lung appears clear. No infiltrates or pneumothorax is
present on
this side.
[**2102-1-12**] 06:00AM BLOOD WBC-10.2 RBC-3.88* Hgb-9.8* Hct-31.9*
MCV-82 MCH-25.3* MCHC-30.8* RDW-17.7* Plt Ct-500*
[**2102-1-8**] 03:40PM BLOOD WBC-11.7* RBC-3.57* Hgb-9.0* Hct-28.9*
MCV-81* MCH-25.2* MCHC-31.1 RDW-17.0* Plt Ct-537*
[**2102-1-3**] WBC-12.5* RBC-3.59* Hgb-9.3* Hct-30.6 Plt Ct-628*
[**2101-12-30**] WBC-15.1*# RBC-3.46* Hgb-8.7* Hct-27.6 Plt Ct-531*
[**2101-12-22**] WBC-18.8* RBC-3.01* Hgb-8.0* Hct-24.9* Plt Ct-558*
[**2101-12-30**] Neuts-83.2* Lymphs-12.3* Monos-3.4 Eos-0.7 Baso-0.3
[**2102-1-3**] Glucose-109* UreaN-8 Creat-0.6 Na-137 K-4.8 Cl-98
HCO3-30
[**2102-1-2**] Glucose-109* UreaN-8 Creat-0.5 Na-138 K-4.5 Cl-99
HCO3-33
[**2101-12-22**] Glucose-130* UreaN-15 Creat-0.7 Na-133 K-5.0 Cl-95*
HCO3-31
[**2102-1-15**] ALT-12 AST-11 AlkPhos-110 TotBili-0.2
[**2102-1-1**] ALT-13 AST-16 CK(CPK)-123 AlkPhos-90 TotBili-0.2
[**2102-1-15**] Albumin-3.0* Calcium-9.8 Iron-33*
[**2102-1-10**] Albumin-2.9* Iron-28*
[**2102-1-15**] calTIBC-238* Ferritn-476* TRF-183*
[**2102-1-10**] calTIBC-224* Ferritn-546* TRF-172*
[**2101-12-22**] calTIBC-182* Ferritn-1157* TRF-140*
[**2102-1-15**] TSH-4.9*
Pathology [**2101-12-29**] DIAGNOSIS:
I. "Left upper lobe bleb":Lung tissue with bleb formation.
Subpleural emphysema and acute and chronic inflammation.
II. Level 5 lymph node: No malignancy identified.
III. Wedge biopsy of lung, left upper lobe: Lung tissue with
scarring, pleural adhesions, abscess formation with necrosis,
bronchiectasis, bronchial epithelium with squamous metaplasia,
see note.
IV. Wedge biopsy of lung, left lower lobe: Lung tissue with
scarring, organizing pneumonitis and chronic inflammation. See
note.
Note: The findings are suggestive of a chronic infectious
process. No granulomatous inflammation seen. Clinical
correlation recommended.
[**2102-1-10**] VORICONAZOLE Antifungal Drug Level 0.33 ug/ml
[**2102-1-5**] VORICONAZOLE Antifungal Drug Level <0.2 ug/ml
Cultures:
[**2101-12-23**] pleural fluid: Aspergillus fumigatus
[**2101-12-29**] Tissue: Aspergillus fumigatus
[**2101-12-30**] BAL: Aspergillus Fumigatus
[**2101-12-30**] MRSA No growth
[**2101-12-23**] BC x 2 No growth
Brief Hospital Course:
Mr. [**Known lastname 3968**] was taken to the operating room on [**2101-12-30**] and
admitted to the TSICU following surgery. His postoperative
hospital course is summarized below (beginning [**12-30**]). He was
transferred to the floor on [**2102-1-2**].
Neuro: Postoperative pain control was initially managed with
PRN fentanyl/versed for dressing changes TID, as well as
intermittent fentanyl between dressing changes, Toradol,
Celebrex, gabapentin, OxyContin, and Wellbutrin. Acute pain
service was consulted and participated in the management of the
patient's pain control. Over the next several days the fentanyl
was decreased and a Dilaudid PCA was initiated with PRN Dilaudid
boluses for dressing changes. He received Ativan as needed for
anxiety.
CV: He remained hemodynamically stable postoperatively and was
restarted on his home simvastatin which was stopped secondary to
interference with Voriconazole.
Resp: He underwent dressing changes TID to the left chest.
This involved moist-to-dry dressings to the left chest cavity
using semi-sterile technique and 1.5 - 2 Kerlix gauze rolls
(tied together at the end) to pack the chest cavity. He
tolerated the painful dressing changes well with Dilaudid PCA
and IV bolus Dilaudid pre-medication. Good pulmonary toilet was
achieved through early ambulation, deep breathing, and incentive
spirometry. He received Guiafenesin for mucolytic therapy.
GI: He was started on a regular diet on postoperative day #1,
with protein shakes TID for supplementation. He was evaluated
by the nutrition team and his caloric intake was found to be
more than adequate for his needs. He received Zofran as needed
for nausea (thought due to high doses of narcotics) and his
bowel regimen included Colace, senna, and MiraLax.
GU: His Foley catheter was removed postoperatively and he
voided without difficulty.
Heme: Hematocrit remained stable postoperatively.
Skin: Stage II sacral debubitus. He reports having a pressure
ulcer on his coccyx for several weeks. He reports being bed
dependent for at least a month, perhaps longer. He was seen by
the Wound nurse for a Stage II debuitus sacral region has
improved The surrounding tissue is intact and not reddened.
They recommended continue Mepilex dressing.
ID: Cultures sent from the lung at the time of operation grew
aspergillus fumigatus. He was continued on voriconazole
postoperatively for his fungal lung infection, with plan to
continue this postoperatively indefinitely. His Voriconazole
level below goal level on [**2102-1-10**]. His dose was increased to
Voriconazole 300 mg [**Hospital1 **]. A repeat level was sent on [**2102-1-16**] was
0.57. His dose was changed to 200 mg tid take 1 hour before
meals. Please recheck trough in 1 week. Goal trough [**12-26**]. He
also needs to follow-up with ophthalmology in 1 month.
Psych: Psych was consulted for ongoing depression. There
impression was adjustment disorder with anxious and depressant
mood. They recommended lorazepam prn for anxiety. Bupropion SR
150 mg [**Hospital1 **], and Mirtazapine 15 mg HS. Follow free CA and
albumin. Social worker and mental health should follow-up at
rehab.
Disposition: He was discharged to [**Hospital3 **] on [**2102-1-20**].
Spoke with the wound care nurse [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 **]
[**Telephone/Fax (1) 58445**] or [**Telephone/Fax (1) 83741**] regarding [**Last Name (un) 72968**] Window
dressing changes. He will follow-up with Dr. [**Last Name (STitle) **], ID and
his ophthalmologist as an outpatient.
Medications on Admission:
zosyn 3.375gm IV q6h, voriconizole 200mg IV BID, buproprion
150mg PO BID, simvastatin 40mg PO qPM, omeprazole 40mg PO daily,
acetaminophen 650mg PO q4hprn, guaifenesin 200mg PO q6hprn, mag
hydroxide 30mL PO daily prn, melatonin 1mg PO HSMR1prn,
sennosides 1 tab PO faily prn, lorazepam 1mg PO q6hprn,
nitroglycerin 0.4mg SL Q5min x3 prn, metoclopramide 10mg IV
q8hprn, nasal spray sodium chloride, ketorolac 30mg IV q6hprn
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for no
bm. Tablet, Delayed Release (E.C.)(s)
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
6. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day) as needed for pain.
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
8. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for muscle pain.
10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
16. Lactulose 10 gram/15 mL Syrup Sig: Forty Five (45) ML PO
DAILY (Daily). ML(s)
17. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
19. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
20. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 10 days.
21. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) for 10 days.
22. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS): Goal Trough [**12-26**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Bronchopleural fistula with aspergillus invasive lung infection,
status post Left modified [**Last Name (un) 72148**] window (Schede type
thoracoplasty) and debridement of
empyema cavity, closure of bronchopleural fistula, serratus
anterior muscle flap, latissimus muscle flap, and bronchoscopy
with bronchoalveolar lavage.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
-Call with questions or concerns regarding [**Last Name (un) 72148**] Window
-Call with fevers > 101 or chills
-Do Not stop Antifungal Medication: Voriconazole
-Follow-up CBC w/diff, chem & & LFTs weekly while on
Voriconazole.
-Call with questions or concerns regarding [**Last Name (un) 72148**] Window
incision
-Call with fevers > 101 or chills
-Do Not stop Antifungal Medication: Voriconazole
-Follow-up CBC w/diff, chem & & LFTs weekly while on
Voriconazole. These results need to be sent to [**Hospital1 18**] infectious
disease.
Followup Instructions:
1. Follow up with Dr. [**First Name (STitle) 1532**] [**Last Name (NamePattern4) 8786**], MD
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2102-1-31**] 10:00am [**Hospital Ward Name 121**] Building
Chest Disease Center [**Hospital1 **] I
2. Follow up with AMI [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], (infectious disease) MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2102-3-6**] 11:30am [**Hospital1 18**] [**Hospital Unit Name 3269**] ground floor.
3. Please fax weekky CBC w/diff chem 7 and LFTs results to
Infectious disease nurse. [**Telephone/Fax (1) 1419**]
4. Dr. [**Last Name (STitle) **] to call with further instructions regarding
Voriconazole dose and trough level.
Completed by:[**2102-1-24**]
|
[
"484.6",
"707.22",
"309.0",
"707.03",
"510.0",
"338.18",
"117.3",
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icd9cm
|
[
[
[]
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[
"34.72",
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"34.73",
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] |
icd9pcs
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[
[
[]
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3429, 3569
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14616, 14941
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255, 312
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626, 2918
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14976, 15083
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2940, 3308
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3324, 3413
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,577
| 128,440
|
5704
|
Discharge summary
|
report
|
Admission Date: [**2188-4-6**] Discharge Date: [**2188-4-8**]
Date of Birth: [**2142-12-16**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] is a 48 year-old male with a history of CAD/CHF
(s/p pacer and AICD with EF 15%) and ESRD transferred here from
an OSH with chest pressure and wide complex tachycardia in 120s.
He awoke this morning (10:45am) and noticed [**5-1**] chest pressure
with walking. It would subside with rest, but return with any
exertion. He also noticed that his radial pulse was ~100, much
higher than his baseline of ~50. He also felt nauseated and
diapheretic and as though he was going to "pass out". Denies any
shortness of breath. Given his symptomas, he called EMS.
EMS arrived at 11:03pm. Vital showed SBPs in the 120s with HR in
the 80s-90s. Two aspirin were given. EKG showed a wide complex
tachycardia (? V-paced). He was brought to an OSH where his BP
was 120/70 with a rate of 80. CK was 21 with a troponin I of
0.04. An EKG showed an irregular tachcardia with IVCD. He was
bolussed with amiodarone and transferred to [**Hospital1 18**] for futher
management. CEs were normal.
In the ED, his initial VS were: BP 97/57, HR 96, RR 16, O2 sat
100% on room air. His SBPs remained in the 80-90s in the ED with
HR in the 110s (wide-complex). Before transfer to the floor, his
HR decreased to the 50s.
He received Plavix 75, ASA 325, morphine 2mg IV x2, Dilaudid 2mg
IV x1, and was placed on a heparin gtt. He was admitted to the
CCU for further monitoring and EP interrogation.
Past Medical History:
1. Heart disease:
- s/p Anterior MI ([**2178**]) with tPA and rescue PCI of LAD
--> P104 biliary stent placed in ostial LAD
--> 4.0x22mm in proximal LAD
--> 4.0x15mm in mid LAD
- s/p MI ([**9-23**])
- ICD placed in [**10-24**] with Pacemaker/ICD generator change on
[**2186-9-5**]
- PCI ([**2185-1-6**])
--> LMCA: free of disease
--> LAD: patent previously placed stents with 20% ISR in the
proximal segment
--> LCX: free of flow limitations
- s/p Cardiac arrest ([**8-27**])
- EF 20% and LV thrombus
2. Hypertension
3. Hyperlipidemia: [**9-23**]: TC 177; LDL 103; HDL 54
4. End-stage renal disease:
- s/p basilic vein brachial artery AV fistula
5. h/o line sepsis
Social History:
Social history is significant for the absence of current tobacco
use (10 pack-year history having quite ~[**2179**]). There is a
history of alcohol abuse prior to his MI, but no current use.
Family History:
There is no family history of premature coronary artery disease
(although fater did have CAD) or sudden death.
Physical Exam:
vitals - BP 119/81 mmHg while lying flat; HR 53beats/min and
regular; RR 13breaths/min with an O2 sat of 100% on room.
gen - well developed, well nourished and well groomed; oriented
to person, place and time; mood and affect were not
inappropriate.
heent - no xanthalesma and conjunctiva were pink with no pallor
or cyanosis of the oral mucosa. The neck was supple with IJ flat
at 30 degrees;
pulm - clear to ascultation bilaterally with normal breath
sounds and no adventitial sounds or rubs
cor - normal S1 and S2; II/VII holosystolic murmur best heard at
apex; no rubs, clicks or gallops
abd - abdominal aorta was not enlarged by palpation; no
hepatosplenomegaly or tenderness; abdomen was soft nontender and
nondistended; midline scar was noted
ext - no pallor, cyanosis, clubbing or edema.
vasc - no abdominal, femoral or carotid bruits. Inspection
and/or palpation of skin and subcutaneous tissue showed no
stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMIT LABS: [**2188-4-6**]
CBC:
WBC-6.9 RBC-3.72* Hgb-12.1* Hct-35.8* MCV-96# MCH-32.4*
MCHC-33.7 RDW-16.6* Plt Ct-130*#
Neuts-79.4* Lymphs-12.7* Monos-6.9 Eos-0.3 Baso-0.6
Hypochr-1+ Anisocy-1+ Macrocy-1+
COAGS:
PT-26.8* PTT-39.6* INR(PT)-2.7*
CHEMISTRIES:
Glucose-112* UreaN-60* Creat-9.4*# Na-134 K-5.1 Cl-95* HCO3-23
AnGap-21*
([**2188-4-7**]): Calcium-10.0 Phos-7.6* Mg-2.6
CARDIAC ENZYMES:
[**2188-4-6**] 03:00PM CK(CPK)-20* cTropnT-0.07*
[**2188-4-6**] 09:05PM CK(CPK)-19* CK-MB-NotDone cTropnT-0.07*
[**2188-4-7**] 06:12AM CK(CPK)-20* CK-MB-NotDone cTropnT-0.10*
CXR ([**2188-4-6**]):
No definite consolidations.
Brief Hospital Course:
1. CAD:
Prior anterior MI with stends to LAD. He presented with chest
pains that were worrisome for an ACS. Given that the pain was
associated with tachycardia and resolved with resolution of his
tachycardia, there was less worry for ACS. This might have
represented a demand process (angina) as opposed to an acute
coronary syndrome (unstable angina). Of note, the patient does
not appear to have anginal symptoms at other times as he is able
to walk and exert himself without chest discomfort or other
symptoms. Hiis beta-blocker was increased (see below) and he
was continued on statin and warfarin (given severely akinetic
LV). In addition, the patient did not present on aspirin (he
had been told he did not need to take it); this was started at
81mg daily.
2. Pump:
Has EF of <20% with multiple near akinetic areas (basal
inferoseptal, inferior, and inferolateral walls contract best
with the other areas akinetic). He appeared euvolemic on exam.
He did not present on an ACEI; the patient stated that some
"levels were high" on prior ACEI. This was not restarted,
although consideration for it's use could be re-addressed by his
outpatient cardiologist.
3. Rhythm:
His presenting rhythm appeared to be atrial tachycardia/atrial
fibrillation. EP interogated the pacer and felt that the atrial
lead was undersensing but pacing normally, causing inappropriate
atrial pacing. The sensitivity was increased from 0.6mV to 0.3mV
with better sensing seen after the change. His beta-blocker
(Toprol XL) was increased from 25mg to 75mg daily and amiodarone
was continued. Plan was for outpatient EP follow-up.
4. ESRD:
Etiology of this is unclear. [**Name2 (NI) **] the patient, this came about
after his first MI. His AV fistula had recently matured and was
used for a dialysis session the morning after admission.
Nephrocaps and Sevalemer were continued.
5. Hyperkalemia:
Morning after admission, had potassium of 6.4. Got
insulin/dextrose/calcium and, later, was dialyzed. Potassium
was normal thereafter.
6. Hypoglycemia:
Fingerstick 44 with syptoms after insulin given. This was
likely secondary to poor clearance of insulin in the setting of
renal failure.
7. Abdominal pain:
Patient had significant abdominal pain, which he attributed to
peritoneal fluid overload in the setting of IVF administration.
Had a history of these pains and reported great response to
dialysis. Before he was able to be dialyzed, he was given
morphine for symptom control. After dialysis, the pain resolved
and did not re-occur.
Medications on Admission:
1. Simvastatin 80mg daily
2. Amiodarone 200mg [**Hospital1 **]
3. Toprol XL 25mg daily
4. Warfarin 5mg daily
5. Protonix 40mg daily
6. Metoclopramide 5mg
7. Hydroxyl 25mg
8. Ambien 5mg QHS PRN
9. B Complex-Vitamin C-Folic Acid 1 mg daily
10. Sevalemer 800mg TID
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: Two (2) 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. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: Three
(3) Tablet Sustained Release 24 hr PO once a day.
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Atrial Tachycardia
2. Atrial Fibrillation
Secondary:
1. Coronary Artery Disease
2. Systolic Congestive Heart Failure
3. End-Stage Renal Disease
Discharge Condition:
Stable to be discharged to home.
Discharge Instructions:
Please continue all medications as previously prescribed. You
were found to have atrial tachycardia and atrial fibrillation.
Your Toprol XL was increased to 75 mg daily for better blood
pressure and heart rate control.
You were also restarted on a baby aspirin. It is important that
you take aspirin daily as you have a history of coronary artery
disease.
If you have chest pain, shortness of breath, palpitations,
lightheadedness, fevers, chills, or sweats, please come back to
the emergency department.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 11493**] in [**12-25**] weeks after discharge.
Call ([**Telephone/Fax (1) 22764**] to schedule that appointment.
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**12-25**] weeks.
Please continue your current outpatient hemodialysis regimen.
You were dialyzed through your AV fistula during this admission.
Previously scheduled appointments:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2188-8-29**] 11:20
|
[
"414.01",
"276.7",
"428.0",
"412",
"251.2",
"V45.82",
"427.89",
"585.6",
"428.20",
"427.31"
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icd9cm
|
[
[
[]
]
] |
[
"39.95",
"89.49"
] |
icd9pcs
|
[
[
[]
]
] |
8329, 8335
|
4505, 7035
|
278, 286
|
8536, 8571
|
3851, 4235
|
9127, 9768
|
2624, 2737
|
7347, 8306
|
8356, 8515
|
7061, 7324
|
8595, 9104
|
2752, 3832
|
4252, 4482
|
227, 240
|
314, 1711
|
1733, 2400
|
2416, 2608
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,934
| 128,413
|
18279
|
Discharge summary
|
report
|
Admission Date: [**2191-12-9**] Discharge Date: [**2191-12-12**]
Date of Birth: [**2132-2-26**] Sex: F
Service: SURGERY
Allergies:
Latex
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
Liver mass
Major Surgical or Invasive Procedure:
Segmental liver resection [**2191-12-9**]
History of Present Illness:
59-year-old female who is 2 years post segment 6 resection for
hepatocellular carcinoma. She has no underlying cirrhosis. She
now has 2 new lesions, a 5
cm lesion in segment 3 of the liver and 1.5 cm lesion in segment
8. Various treatment modalities were discussed with [**Known firstname 803**]
and her husband, and also discussed with the multidisciplinary
team. The decision was made to proceed with
resection, and then possibly consider her for a liver
transplantation, given her high risk of developing further
ecurrences. She is currently presenting for resection.
Past Medical History:
1. Partial right hepatic lobectomy.
2. Cholecystectomy.
3. Vaginal hysterectomy.
4. Laparoscopic retrieval of intrauterine device.
5. Basal cell carcinoma on temple.
6. Tonsillectomy.
7. Tubal ligation.
Social History:
She smokes tobacco and she has occasional alcohol. She is
married and she has two children
Family History:
Negative for liver disease. Her mother has breast cancer.
Physical Exam:
T 96.4 P 70 BP 96/60 RR 18 SaO2100% Ht 62, Wt 47.6kg
Patient was a well-developed female in no acute distress
CV:regular, rate, and rhythm with no bruits or murmurs
auscultated
Pulm: Lungs were clear to auscultation bilaterally
Abd: soft, nontender, nondistended, well-healing scar
Extremities: no edema
Pertinent Results:
[**2191-12-8**] 04:40PM PT-13.0 PTT-24.6 INR(PT)-1.1
[**2191-12-9**] 08:31AM freeCa-1.14
[**2191-12-9**] 08:31AM HGB-12.2 calcHCT-37
[**2191-12-9**] 08:31AM GLUCOSE-97 LACTATE-2.0 NA+-142 K+-3.8 CL--107
[**2191-12-9**] 08:31AM TYPE-ART PO2-340* PCO2-37 PH-7.45 TOTAL
CO2-27 BASE XS-2 INTUBATED-INTUBATED VENT-CONTROLLED
[**2191-12-9**] 10:53AM PT-12.9 PTT-21.4* INR(PT)-1.1
[**2191-12-9**] 10:53AM HCT-34.7*
[**2191-12-9**] 10:53AM CALCIUM-8.0* PHOSPHATE-3.8 MAGNESIUM-1.4*
[**2191-12-9**] 10:53AM GLUCOSE-124* UREA N-10 CREAT-0.7 SODIUM-143
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-26 ANION GAP-12
US INTR-OP 60 MINS [**2191-12-9**] 7:14 AM
CONCLUSION: Two hepatic masses compatible with HCC. No new
occult lesions demonstrated.
Also noted was the presence of a large inferior accessory right
hepatic vein.
Pathology Examination LAT SEGMENT LESION,SEGMENT LESION
DIAGNOSIS:
I. Liver, lateral segment, resection. (A-I):
Moderately-to-poorly differentiated hepatocellular carcinoma.
See synoptic report.
II. Liver, segment 8, resection. (J-N):
Moderately-to-poorly differentiated hepatocellular carcinoma.
See synoptic report.
Brief Hospital Course:
The patient was admitted on the day of surgery for a planned
segmental liver resection for recurrent HCC. She tolerated the
procedure well without complication. She had an epidural placed
for pain control. She had an episode of hypotension post-op to
a BP=70s/40s and her epidural was discontinued and she was given
a bolus of IV fluid. The patient was asymptomatic during this
episode and an EKG was unremarkable. Her hematocrit was stable.
She was transfered to the surgical ICU for close monitoring
following this episode. She had no further episodes and was
feeling well with stable vital signs and was transfered out of
the intensive care unit on POD2. Her foley was removed and she
voided without difficulty. She was tolerating a regular diet
and ambulating well. She was discharged to home on POD3 with
close follow-up with the transplant clinic.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Hepatocellular carcinoma
Discharge Condition:
Good
Discharge Instructions:
Please call [**Telephone/Fax (1) 673**] if you experience any significant
redness or drainage of your wound, if you have fevers >101.5 or
chills, if you have increasing abdominal pain, or have any other
concerns.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] this Monday. Call [**Telephone/Fax (1) 673**] for an
appointment.
|
[
"E934.2",
"305.1",
"790.92",
"285.9",
"V10.83",
"275.2",
"458.29",
"E879.8",
"155.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.22"
] |
icd9pcs
|
[
[
[]
]
] |
4085, 4136
|
2846, 3711
|
277, 321
|
4205, 4212
|
1677, 2823
|
4473, 4588
|
1273, 1333
|
3734, 4062
|
4157, 4184
|
4236, 4450
|
1348, 1658
|
227, 239
|
349, 923
|
945, 1149
|
1165, 1257
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,603
| 140,254
|
34220+57905
|
Discharge summary
|
report+addendum
|
Admission Date: [**2159-4-27**] Discharge Date: [**2159-5-18**]
Date of Birth: [**2108-8-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Sudden onset, worst headache of life
Major Surgical or Invasive Procedure:
[**4-27**]: Angiogram and coiling of p-comm aneurysm
[**4-27**]: Stereotactic placement of EVD
Placement of PICC Line
History of Present Illness:
Patient is a 50F who presented to OSH this afternoon after
experiencing worst HA of life while at home, and subsequent fall
to floor. She was taken to the local ED by EMS. She was CT
scanned at the OSH revealing a large left sided SAH, with IVH
and associated shift. There is also a SDH noted on transfer
likely caused by patient's fall to floor.
Past Medical History:
1.HTN
2. Obesity
Social History:
Married, residing at home with children
Family History:
Non-contributory
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: afebrile BP:170/80 HR: 80 RR: Intubated; rate per
ventilator CMV O2Sats: 99%
Gen: WD/obese female, intubated upon arrival to ED.
HEENT: normocephalic, atraumatic
Pupils: PERRL, sluggish
Neuro:
Mental status: Intubated, spontaneously moving all extremities,
left side greater than right. No spontaneous eye opening, does
not follow commands.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally, but sluggish.
III-XII: unable to assess
Motor: unable to asses, no posturing noted
Toes upgoing bilaterally
ON DISCHARGE:
Pertinent Results:
Head CT([**4-27**]):
IMPRESSION:
1. Diffuse left-sided subarachnoid hemorrhage with extension
into the basilar cisterns and ventricles bilaterally with no
evidence for hydrocephalus. The appearance may be slightly
exaggerated due to residual contrast material from prior
angiogram.
2. Small left subdural hematoma. No significant midline shift
with mild mass effect on the adjacent cortex.
Head CT([**4-28**], post-EVD):
IMPRESSION:
1. Interval placement of ventricular catheter from a right
frontal approach with tip terminating in the inferior frontal
[**Doctor Last Name 534**] of the right lateral ventricle.
2. Unchanged diffuse left-sided subarachnoid hemorrhage and
bilateral intraventricular hemorrhage without evidence of
hydrocephalus.
3. Unchanged left subdural hematoma without significant mass
effect or shift of normally midline structures.
CTA/P([**5-1**]):
IMPRESSION:
1. Status post coiling of posterior communicating artery
aneurysm. Compared to the study of one day prior, there is
diffuse mild narrowing of bilateral ACA and MCA which may
represent mild diffuse vasospasm. In addition, although the left
PCA demonstrates better flow compared to yesterday, a segment of
narrowing remains, consistent with persistent vasospasm.
2. CTA and CT perfusion demonstrate regions of increased blood
flow in the left operculum which may be due to reperfusion
phenomenon. No ischemic changes are seen.
3. Continued slight decrease in left frontoparietal subarachnoid
hemorrhage. Small left subdural hemorrhage and mild rightward
shift unchanged.
4. Right intraventricular catheter unchanged in position.
5. Hypodensities in the left centrum semiovale and extending
down to the level of the left lentiform nucleus unchanged and
likely due to prior intraventricular catheter placement.
6. Left inferomedial temporal lobe hypodensity consistent with
infarction, unchanged.
RADIOLOGY Final Report
CTA HEAD W&W/O C & RECONS [**2159-5-14**] 9:46 AM
CTA HEAD W&W/O C & RECONS
Reason: Please evaluate for vasospasm/perfusion. Please perform
CT a
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman s/p PComm coiling with significant vasospasm.
REASON FOR THIS EXAMINATION:
Please evaluate for vasospasm/perfusion. Please perform CT
angiogram with perfusion study [**2159-5-14**] to be performed with
Neurosurgery
CONTRAINDICATIONS for IV CONTRAST: None.
HISTORY: 50-year-old female status post posterior communicating
artery aneurysm coiling with significance vasospasm.
COMPARISON: CTA head and neck of [**2159-5-10**].
TECHNIQUE: Contiguous axial imaging was performed through the
brain without administration of IV contrast. Subsequent imaging
was performed during rapid infusion of 70 mL of IV Optiray.
Images were then processed on a separate workstation with
display of maximal intensity projection images. Apparently, no
CT perfusion study was performed. CIRCLE OF [**Location (un) **] VOLUME
RENDERED IMAGES ARE PENDING.
CT HEAD: There is no evidence of new intracranial hemorrhage.
The left subdural collection is unchanged, measuring up to 10 mm
in thickness. Associated sulcal effacement remains although
rightward shift is slightly less, from 7 mm to 5 mm. Left
frontoparietal subarachnoid hemorrhage is no longer apparent.
The patient is status post removal of a right intraventricular
catheter from a right frontal approach; small amount of air
remains within the right lateral ventricle.
Again streak artifact from coils within the left posterior
communicating artery aneurysm limits evaluation of the middle
cranial fossa, however hypodensity in the inferomedial portion
of the left temporal lobe and in the left basal ganglia are
unchanged, consistent with evolving infarcts. Hypodense tract
along the left centrum semiovale from prior catheter placement
is unchanged. Vascular calcifications are again noted in the
cavernous carotid arteries. There is complete opacification of
the right sphenoid sinus as well as mucosal thickening in the
left sphenoid sinus which may relate to the right-sided NG tube.
The mastoid air cells remain well aerated.
CTA HEAD: CIRCLE OF [**Location (un) **] VOLUME-RENDERED IMAGES ARE PENDING.
Again noted is diffuse narrowing of the intracranial arteries.
However, based on axial source images and MIP images alone,
there appears to be slight increased blood flow within the M1
and M2 segments of the left MCA compared to the prior CTA study
of [**2159-5-10**]. Otherwise, diffuse narrowing of the right MCA,
bilateral ACA, and the posterior circulation appears relatively
unchanged.
IMPRESSION:
1. CT head is little changed, with left subdural collection and
related sulcal effacement. Slight decrease in rightward shift
after removal of right intraventricular catheter. Small amount
of air remains in the right lateral ventricle. Evolving infarct
in the left medial temporal lobe and left basal ganglia
unchanged.
2. VOLUME-RENDERED IMAGES ARE PENDING. Based on source axial
images and MIP images, there appears to be slight increase in
blood flow in the M1 and M2 segments of the left MCA; otherwise,
diffuse vasospasm appears largely unchanged.
REPORT TO BE FINALIZED AFTER REVIEW OF VOLUME-RENDERED CIRCLE OF
[**Location (un) **] IMAGES.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 95**] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: TUE [**2159-5-15**] 9:53 PM
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2159-5-12**] 1:46 PM
CT HEAD W/O CONTRAST
Reason: evaluate for hydrocephalus following EVD removal
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with subarachnoid hemorrhage
REASON FOR THIS EXAMINATION:
evaluate for hydrocephalus following EVD removal
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 50-year-old female for followup of subarachnoid
hemorrhage, please evaluate for hydrocephalus following EVD
removal.
COMPARISON: [**2159-5-11**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: EVD has been removed, and ventricular size is slightly
increased, with expected pneumocephalus seen within the frontal
[**Doctor Last Name 534**] of the right lateral ventricle. Basal cisterns are normal.
4-mm rightward subfalcine herniation is unchanged, presumably
secondary to small left subdural hematoma, unchanged. Evolving
areas of hypodensity in the left basal ganglia and cerebral
hemisphere are again seen, consistent with evolving infarction.
Left internal carotid aneurysm coils are again noted, limiting
evaluation of structures in this region.
IMPRESSION: Slight ventricular enlargement, and small
pneumocephalus following EVD removal.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5718**]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: SAT [**2159-5-12**] 5:17 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2159-5-10**] 4:40 AM
CHEST (PORTABLE AP)
Reason: NGT placement
[**Hospital 93**] MEDICAL CONDITION:
50 year old woman with
REASON FOR THIS EXAMINATION:
NGT placement
INDICATION: 50-year-old woman with NG tube placement.
COMPARISON: [**2159-5-8**].
SINGLE AP SEMI-UPRIGHT BEDSIDE RADIOGRAPH OF THE CHEST: NG tube
is extending into the pyloric end of the stomach and out of the
field of view. The left subclavian catheter is terminating at
the brachiocephalic confluence, distal relative to [**5-8**]. The
lung volumes remained low however there are no focal
consolidations. There is no pulmonary edema. Cardiomediastinal
silhouette is unchanged. There is no pneumothorax.
IMPRESSION: NG tube extending into the pyloric end of the
stomach and out of the field of view. The left subclavian
catheter appears to be in the brachiocephalic confluence further
out relative to the prior study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: [**Doctor First Name **] [**2159-5-10**] 6:10 PM
Test Name Value Units Reference Range
[**2159-5-16**] 04:50AM
Report Comment:
Source: Line-R Subclavian
COMPLETE BLOOD COUNT
White Blood Cells 11.0 K/uL 4.0 - 11.0
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.42* m/uL 4.2 - 5.4
PERFORMED AT WEST STAT LAB
Hemoglobin 10.2* g/dL 12.0 - 16.0
PERFORMED AT WEST STAT LAB
Hematocrit 32.2* % 36 - 48
PERFORMED AT WEST STAT LAB
MCV 94 fL 82 - 98
PERFORMED AT WEST STAT LAB
MCH 29.9 pg 27 - 32
PERFORMED AT WEST STAT LAB
MCHC 31.8 % 31 - 35
PERFORMED AT WEST STAT LAB
RDW 15.1 % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 414 K/uL 150 - 440
PERFORMED AT WEST STAT LAB
Test Name Value Units Reference Range
[**2159-5-16**] 04:50AM
Report Comment:
Source: Line-R Subclavian
RENAL & GLUCOSE
Glucose 152* mg/dL 70 - 105
PERFORMED AT WEST STAT LAB
Urea Nitrogen 11 mg/dL 6 - 20
PERFORMED AT WEST STAT LAB
Creatinine 0.4 mg/dL 0.4 - 1.1
PERFORMED AT WEST STAT LAB
Sodium 140 mEq/L 133 - 145
PERFORMED AT WEST STAT LAB
Potassium 4.0 mEq/L 3.3 - 5.1
PERFORMED AT WEST STAT LAB
Chloride 102 mEq/L 96 - 108
PERFORMED AT WEST STAT LAB
Bicarbonate 32 mEq/L 22 - 32
PERFORMED AT WEST STAT LAB
Anion Gap 10 mEq/L 8 - 20
CHEMISTRY
Calcium, Total 9.7 mg/dL 8.4 - 10.2
PERFORMED AT WEST STAT LAB
Phosphate 4.6* mg/dL 2.7 - 4.5
PERFORMED AT WEST STAT LAB
Magnesium 2.1 mg/dL 1.6 - 2.6
PERFORMED AT WEST STAT LAB
CHEMISTRY
Calcium, Total 8.6 mg/dL 8.4 - 10.2
PERFORMED AT WEST STAT LAB
Phosphate 3.2 mg/dL 2.7 - 4.5
PERFORMED AT WEST STAT LAB
Magnesium 2.3 mg/dL 1.6 - 2.6
PERFORMED AT WEST STAT LAB
PITUITARY
Thyroid Stimulating Hormone 0.71 uIU/mL 0.27 - 4.2
Brief Hospital Course:
Pt was admitted to the [**Hospital1 18**] SICU after ER eval for SAH, IVH and
SDH after fall.
By report of EMS the pt experienced the worst HA of life while
at home, and had a subsequent fall to floor. She was taken to
the local ED by EMS. She was CT
scanned at the OSH revealing a large right sided SAH, IVH and
SDH.
She required EVD (external ventricular drain) placement in the
ED. The placement of the drain was difficult and required
stereotactic placement in the operating suite. She underwent a
cerebral angiogram based on the appearance of her CT scan. A
P-COMM aneurysm CT was identified and coiled during that same
angiogram. She was transferred back to SICU. She was started
on Nimodpine as well as AED. It was noted that her Left hand
was cool and discolored/blue. A vascular consult was obtained.
There was no formal treatment ie. embolization or thrombectomy.
She underwent multiple CTA/CTP's to assess for vasospasm. If
noted on imaging, it was followed up with a cerebral angiogram
with verapamil followed by HHH therapy.
During these imaging series it was noted that she had infarcts
to left medial temporal lobe as well as the left basal ganglia.
Clamping trials of the EVD were done. She did not tolerate
clamping early on during the hospitalization. A CSF sample was
sent off after pt had reported fever. The results showed
Klebsiella. AN ID consult was obtained and their
recommendations were followed. Ultimately her EVD was removed
on [**2159-5-11**] and she has tolerated this very well. She has no
active signs or symptoms of meningitis. She did have some right
sided weakness as well as aphasia. The weakness is improving
greatly as well as the aphasia.
Her HHH therapy was backed off on on [**5-14**] as this was day 18 post
bleed and the likelihood of continued vasospasm is very low. She
was transferred to the stepdown ICU on [**2159-5-15**] for continued
care.
Her tube feedings were held as she passed a speech swallow exam
on [**2159-5-16**]. The NGT will be removed as she assures us she can
take in enough po.
She is seen by PT OT as well. They reccomend acute
rehabilatation. On discharge her central line was removed and
midline catheter was placed. Neurologically she was awake, alert
and orientated X3. Though she has difficulty speech She answered
y/n questions appropriately, followed [**12-13**] step commands.
Expressively, she is
communicating via short phrases and sentences. While there is
no groping appreciated, sentences are often labored and slow
with several second pauses between words. Pt has frequent word
finding issues, of which she is aware and often frustrated.
Speech and voice are WNL. Her motor strength was full
throughout. She was tolerating a regular diet and voiding
without difficulty. She was discharged to rehab on [**2159-5-18**].
Medications on Admission:
Unknown
Discharge Medications:
1. Methimazole 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain. Tablet(s)
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Methimazole 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection four times a day: As directed during inpatient stay.
11. Ceftazidime 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Large left-sided Subarrachnoid hemorrhage
bilateral Intraventricular Hemorrhage
Small Left Subdural hemorrhage
Posterior Communicating Artery Aneurysm / coiled
Vascular compromise left hand, resolved
Cerebral Vasospasm
CNS infectin / Klebsiella
New diagnosis = Diabetes / Insulin dependent in hospital
Cerebral Infarct Left medial temporal lobe
Verebral Infarct left basal ganglia
Discharge Condition:
Neurologically greatly improved/ 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 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 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, or drainage.
?????? Fever greater than or equal to 101?????? F.
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 4 weeks.
??????You will need a CT scan of the brain without contrast.
- YOU NEED TO FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN TO
UPDATE HIM OR HER OF YOUR MEDICAL CONDITIONS / HOSPITALIZATION
AND FOR NEW DIAGNOSIS OF DIABETES.
Completed by:[**2159-5-18**] Name: [**Known lastname 12696**],[**Known firstname **] Unit No: [**Numeric Identifier 12697**]
Admission Date: [**2159-4-27**] Discharge Date: [**2159-5-18**]
Date of Birth: [**2108-8-26**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 40**]
Addendum:
ADDITIONAL D/C INSTRUCTIONS
IMPORTANT INFORMATION REGARDING MIDLINE PLACEMENT
-AN UNSUCCESSFUL MIDLINE PLACEMENT WAS ATTEMPTED AT [**Hospital1 8**]
-IT WAS AGREED THAT MEDICAL PERSONNEL AT [**Hospital **] REHAB WOULD
PLACE A MIDLINE ON MONDAY [**2159-5-21**]
CURRENT ANTIBIOTIC REGIMEN
1.CeftazIDIME 2 g IV Q8H
START DATE: [**2159-5-11**]
END DATE: **[**2159-5-24**]** per ID SPECIALISTS AT [**Hospital1 8**]
ADDITIONAL PERTINENT RESULTS:
[**2159-5-11**] CSF CULTURE: WBC RBC Polys Lymphs Monos Macroph
1501 650* 35 4 3 58
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**Name6 (MD) **] [**Last Name (NamePattern4) 43**] MD [**MD Number(2) 44**]
Completed by:[**2159-5-18**]
|
[
"401.9",
"443.9",
"996.63",
"790.7",
"430",
"250.00",
"E888.9",
"435.8",
"852.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"96.71",
"99.29",
"00.61",
"00.40",
"39.72",
"88.41",
"02.43",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18771, 18976
|
11450, 14278
|
354, 474
|
15821, 15863
|
18620, 18748
|
17378, 18601
|
966, 984
|
14336, 15303
|
8725, 8748
|
15417, 15800
|
14304, 14313
|
15887, 17355
|
1028, 1233
|
1611, 1611
|
278, 316
|
8777, 11427
|
502, 853
|
1398, 1595
|
4583, 7255
|
1013, 1013
|
1248, 1382
|
875, 893
|
909, 950
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,652
| 177,735
|
13491
|
Discharge summary
|
report
|
Admission Date: [**2106-11-24**] Discharge Date: [**2106-11-29**]
Date of Birth: [**2027-11-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet / Dilaudid
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2106-11-25**] Coronary Artery Bypass Graft x 5 (LIMA to LAD, SVG to
PDA w/ y-graft to PLB, SVG to Diag w. y-graft to Ramus)
History of Present Illness:
79 y/o male c/o chest pain and dyspnea on exertion with h/o
aortic stenosis who had an abnormal stress test. Refered for
cardiac cath which revealed severe threee vessel disease.
Past Medical History:
Hyperlipidemia, Hypertension, Chronic Obstructive Pulmonary
Disease, Arthritis, Prostate Cancer s/p Prostatectomy, Stroke
[**2099**], Carotid Artery Disease, s/p Appendectomy
Social History:
Denies tobacco. Social ETOH.
Family History:
non-contributory
Physical Exam:
VS: 71 18 161/82 5'6" 185#
Gen: Elderly WD/WN male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM, -JVD, left carotid bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused, trace edema, -varicosities
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
[**2106-11-28**] 06:55AM BLOOD WBC-10.2 RBC-2.96* Hgb-8.7* Hct-25.7*
MCV-87 MCH-29.4 MCHC-33.9 RDW-14.1 Plt Ct-197
[**2106-11-29**] 07:30AM BLOOD PT-21.9* INR(PT)-2.1*
[**2106-11-28**] 06:55AM BLOOD PT-16.1* INR(PT)-1.4*
[**2106-11-27**] 07:45AM BLOOD PT-15.8* INR(PT)-1.4*
[**2106-11-28**] 06:55AM BLOOD Glucose-114* UreaN-21* Creat-0.8 Na-134
K-4.7 Cl-103 HCO3-24 AnGap-12
[**11-25**] Echo: PRE-BYPASS: The left atrium is mildly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. No left
ventricular aneurysm is seen. There is moderate global left
ventricular hypokinesis (LVEF =30 %). Overall left ventricular
systolic function is moderately depressed (LVEF= 30 %). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are simple atheroma in
the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis(area
1.5 cm2). Mild to moderate ([**12-1**]+) aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen. There is no pericardial effusion.
Post_Bypass: Normal Right ventricular systolic function. Overall
LVEF 45%. Mild AS, Mild AI. Thoracic aortic contour is intact.
Brief Hospital Course:
Mr. [**Known lastname 25288**] was admitted one day prior to surgery secondary to
being on Coumadin and he required a pre-op Echo. On [**11-25**] he was
brought to the operating room where he underwent a coronary
artery bypass graft x 5. Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. Later on op
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 on this day he was transferred to the telemetry floor for
further care. On post-op day two his chest tubes were removed.
On post-op day three his epicardial pacing wires were removed.
He had atrial fibrillation for which he was started on
amiodarone. He was converted to sinus rhythm. He was restarted
on coumadin for history of CVA. He was ready for discharge to
rehab on POD #4.
Medications on Admission:
Coumadin 2.5mg except friday (last dose 12/21), Lipitor 20mg qd,
Prilosec 20mg [**Hospital1 **], Celebrex 200mg qd, MVI qd, Vit C and E qd,
Aspirin 81mg qd, Plavix 600mg on [**2106-11-19**]
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. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily ().
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400 mg daily x 1 week, then 200 mg daily ongoing until
dc'd by cardiologist.
9. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
check INR [**11-30**] and dose for CVA/Afib.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks: then reassess need for diuresis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
PMH: Hyperlipidemia, Hypertension, Chronic Obstructive Pulmonary
Disease, Arthritis, Prostate Cancer s/p Prostatectomy, Stroke
[**2099**], Carotid Artery Disease, s/p Appendectomy
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
[**Hospital 409**] clinic on [**Hospital Ward Name 121**] 6 in 2 weeks
Dr. [**Last Name (STitle) 4469**] in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks
Completed by:[**2106-11-29**]
|
[
"997.1",
"414.01",
"427.31",
"E878.2",
"V10.46",
"496",
"272.4",
"V12.54",
"433.10",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.14"
] |
icd9pcs
|
[
[
[]
]
] |
5057, 5123
|
2860, 3831
|
321, 449
|
5408, 5415
|
1261, 2837
|
5750, 5938
|
917, 935
|
4071, 5034
|
5144, 5387
|
3857, 4048
|
5439, 5727
|
950, 1242
|
250, 283
|
477, 657
|
679, 855
|
871, 901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,834
| 143,794
|
21850
|
Discharge summary
|
report
|
Admission Date: [**2111-10-30**] Discharge Date: [**2111-11-15**]
Service: CSU
HISTORY OF PRESENT ILLNESS: This 86-year-old female was
admitted from [**Hospital 2079**] Hospital after cardiac
catheterization on [**2111-10-30**]. Prior to the angiogram, the
patient reportedly had chest pain relieved by sublingual
nitroglycerin. She also reported shortness of breath after
one block and climbing any stairs. Cardiac catheterization
showed three-vessel disease. The patient was placed on
heparin drip and transferred to [**Hospital6 2018**]. The patient also had a history of transient ischemic
attack with no residual and was placed on Coumadin prior to
her admission.
PAST MEDICAL HISTORY: Hypertension.
Coronary artery disease.
Hypothyroidism.
Atrial fibrillation.
History of transient ischemic attack.
Status post cholecystectomy.
Status post pacemaker insertion.
Status post thyroidectomy.
Status post left total hip replacement, [**2109**].
MEDICATIONS ON ADMISSION: Aspirin, Coumadin, Lopressor 50 mg
p.o. b.i.d., Norvasc, Prilosec, Synthroid 125 mcg p.o. once
daily, Imdur 90 mg p.o. once daily, Zestril 3 mg once daily.
PHYSICAL EXAMINATION: She was in atrial fibrillation with a
heart rate of 85, saturation of 99 percent on three liters
nasal cannula, blood pressure 130/70 with a respiratory rate
of 16. She was alert and oriented times three but was a
fairly poor historian. Her lungs were clear bilaterally.
Heart was irregularly irregular. Abdomen was soft, nontender,
nondistended. She had two plus bilateral radial pulses, two
plus femoral pulse on the left. Her right femoral artery had
an A-line in place. Dorsalis pedis on the left was palpable
and on the right was biphasic.
LABORATORY DATA: Cardiac catheterization showed a left main
75 percent lesion, a mid left anterior descending coronary
artery lesion of 90 percent and totally occluded right
coronary artery and a ramus lesion of 50 percent.
Preoperative labs are as follows: Sodium 142, potassium 3.5,
chloride 105, bicarbonate 26, BUN 9, creatinine 0.7 with a
blood sugar of 110, hematocrit 39.1, PTT 26.9.
HOSPITAL COURSE: Cardiac echocardiogram and carotid
ultrasounds were also ordered. The patient did remain on the
Medical service for a number of issues prior to surgery,
which did not take place until [**2111-11-6**]. The first issue
that had to be addressed was the patient became febrile and
white blood cell count rose slightly. The patient was also
consulted by the Infectious Disease service as they looked
for a possible source of the fevers. The patient was also
followed by the Cardiology fellow. Her sheaths were pulled as
it was determined that she would not be going to surgery
right away. The patient was transferred into the Coronary
Care Unit after she was seen on admission. She was also
started on a nitroglycerin drip. This helped bring her blood
pressures down. On arrival, her blood pressure rose to
200/90. Nitroglycerin drip helped to improve her blood
pressure to the 130s systolic. The patient did not have any
chest pain or shortness of breath at the time. She continued
in atrial fibrillation and remained on an intravenous heparin
drip as well as receiving her beta blocker. She was seen by
Dr. [**Last Name (STitle) **] on [**2111-11-1**] who also quoted her significant
mortality of approximately 20 percent based on her age and
her other relative risk factors. She did remain afebrile on
[**2111-11-1**] with a normal white count. The plan was to wait
until she was afebrile, at least 24 hours. Additionally, the
patient had some postoperative bleeding from her right groin
site and required additional compression to avoid hematoma.
Heparin was held. The patient had a new bruit over the
femoral artery with decreasing blood pressures. Prior to the
groin bleeding, blood pressures systolic were 160/170 and
dropped to 104/51. CT scan was ordered to rule out also a
retroperitoneal bleed. The patient was given an intravenous
fluid bolus and was followed on the Cardiology service and
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], cardiologist, was also notified. Given her
fever and her groin bleed, the decision was made to postpone
her surgery. The following day, surgery was rescheduled but
the patient that night spiked a temperature to 101.2 and
surgery was again postponed.
The patient was also seen by the Oral and Maxillofacial
Surgery service preoperatively to rule out a dental
infection. Please refer to their consult note. White count
did rise on [**2111-11-2**] preoperatively to 11.1 and then
dropped to 7.4. Blood cultures were pending. At that time, we
renewed our request that cardiac surgery not be performed on
the patient until she remained afebrile for 24 hours with a
normal white count.
Carotid ultrasounds were performed on [**2111-10-31**], which
showed a 60-69 percent right internal carotid artery stenosis
and a 40-60 percent left internal carotid artery stenosis.
Please refer to the final report.
A dental consult also revealed the patient had a retained
root of a tooth which should probably be removed before
surgery but it was unlikely to be the source of her fever.
Their recommendations were followed in terms of specific
mouthwash for the patient to use. They recommended the
patient follow-up with her dentist or an OMFS as an
outpatient to have the root removed after surgery.
The patient was also seen by the Infectious Disease consult
team who recommended a full body scan for the patient's
chest, abdomen and pelvis to look for any sources of her
fever. The patient was also tested for tuberculosis.
The patient was also followed everyday by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
of Cardiology, her attending cardiologist. Fever workup
continued on [**2111-11-3**]. Dental and Infectious Disease
consults were noted and appreciated. H. pylori testing was
sent off also. On [**2111-11-4**], the patient's right groin
hematoma was approximately walnut sized with occasional
droplets of bright red blood oozing. Mini pressure dressing
continued to be applied with no further bleeding later in the
day. The patient was maintained on bedrest at the time and
did have pedal pulses.
The patient was cleared for surgery on [**2111-11-5**]. On
[**2111-11-6**], the patient underwent coronary artery bypass
grafting times four by Dr. [**Last Name (STitle) **] with the left internal
mammary artery to the left anterior descending coronary
artery, a vein graft to the posterior descending coronary
artery, a vein graft to the diagonal and vein graft to the
ramus. The patient was transferred to the Cardiothoracic
Intensive Care Unit AV paced in stable condition on a Neo-
Synephrine drip at 0.24 mcg/kg/min and propofol drip at 10
mcg/kg/min. Prior to surgery, urine cultures, blood cultures
and RPR were all negative on the patient. Abdominal scans did
not reveal anything other than an incidental infrarenal
abdominal aortic aneurysm. Please refer to the Vascular
Surgery consult. Chest CT showed some pulmonary nodules as
read by Radiology. Please refer to the final report.
Recommendation was made that the patient get outpatient
follow-up after discharge post bypass surgery to follow-up on
the nodules.
The patient was also seen by Electrophysiology service to
interrogate her pacemaker postoperatively. Their impression
was that the patient needed a new pacemaker generator before
discharge. Epicardial pacing wires remained in place.
On postoperative day one, the patient remained on an insulin
drip at two units per hour. Blood pressure 131/49.
Hemodynamically stable in sinus rhythm at 71. She remained on
the ventilator.
Postoperative labs were as follows: White blood cell count
10.2, hematocrit 28.2, platelet count 160,000, sodium 146,
chloride 112, bicarbonate 23, BUN 9, creatinine 0.7 with a
blood sugar of 75.
The patient continued on perioperative antibiotics. The
patient was also seen by the Case Management team. After
extubation on [**2111-11-8**], it was noted that the patient's
baseline speech was slightly garbled at times. The patient
was oriented though and following all commands and moving all
four extremities. The patient was in atrial flutter with the
pacer responding appropriately and periods of normal sinus
rhythm. Beta blockage was restarted with Lopressor. The
patient's saturation was 95-98 percent on three liters nasal
cannula. Her lungs were clear. Chest tubes remained in place.
On postoperative day two, the patient received two units of
packed red blood cells which brought her hematocrit up to 31.
Her heart was regular in rate and rhythm. Her chest tubes
remained in place. She had decreased breath sounds
bilaterally. She had one plus peripheral edema. Her incisions
were unremarkable. She was back in atrial fibrillation. The
patient was restarted on her Coumadin of 3 mg dose that
evening and started on Captopril. Chest tubes were pulled.
Lasix diuresis was begun and the patient was transferred out
to the floor.
On postoperative day three, pacing wires had also been
discontinued. The patient continued on Coumadin 3 mg dose
that evening. Hematocrit rose slightly to 33.2. Captopril was
increased to 6.25 twice a day. Creatinine remained stable at
0.8 with a potassium of 3.7. The patient remained V-paced
under her own pacemaker at 68. Incisions were clean, dry and
intact. She had a trace of pedal edema. She was seen again by
the Electrophysiology service on [**2111-11-9**] and recommended
keeping the patient NPO that day so that she could have her
generator changed the following morning as soon as she
received Infectious Disease clearance. She also continued to
work with the physical therapist. Occasionally, the patient
was slightly confused to time of day, asking some odd
questions. She was also noted to be very hard of hearing. She
continued in atrial flutter with underlying occasional runs
of supraventricular tachycardia. Electrolytes were all
repleted as needed.
On [**2111-11-9**], the patient was taken back to the
Catheterization Laboratory for a pacemaker generator change
by the Electrophysiology service and Dr. [**Last Name (STitle) **] [**Name (STitle) **].
The following day, the patient was transferred out of the
Cardiothoracic Intensive Care Unit. The patient was a little
bit confused and trying to get up. A sitter was requested for
the patient. Exam was unremarkable. Incisions were clean, dry
and intact. The patient had no complaints of pain at that
time.
On postoperative day six, the patient continued to have a
little bit of confusion and restlessness the evening prior
after her pacemaker change. This did require a sitter. She
was much clearer in the morning. She continued on vancomycin
perioperative antibiotics additionally to cover her pacemaker
change. She had decreased breath sounds bilaterally. She had
a nonfocal exam. Extremities were warm with one plus
peripheral edema. Incisions were clean, dry and intact. The
patient was encouraged to be more mobile with physical
therapy but was stable. Her Foley was removed and she
continued on her Coumadin dosing for atrial fibrillation. She
continued to work with the physical therapist. It was
determined the patient would probably require discharge to
rehabilitation as she was still requiring a sitter one to
one. The patient needed to be oriented appropriately p.r.n.
On [**2111-11-12**], the patient had a five-beat run of ventricular
tachycardia which resolved spontaneously. The following day,
the patient was much more alert and oriented. The one to one
sitter was discontinued. She had no confusion noted and was
responding appropriately. On postoperative day five,
discharge planning was begun and rehabilitation screens were
also accomplished to allow the patient to go to an outside
facility, to continue work with Physical Therapy and her
general overall strength given her age. The patient continued
to make rapid improvement and the plan was then changed to
allow her for the possibility of going home on [**2111-11-13**]
with the possibility of VNA services. The patient's sister
had agreed to stay with the patient during the day but was
unclear as to who was going to stay with the patient at night
but to make sure that the patient was safe in the evenings
this was all re-evaluated by the case manager.
On postoperative day six, the patient was back in sinus
rhythm with occasionally V-paced beats, blood pressure of
140/68, hemodynamically stable. She had some scattered
rhonchi bilaterally and her plan for discharge was again
delayed as her INR only rose to 1.9, well below therapeutic
range. On postoperative day eight, we continued to await the
rise in her INR. Her exam was unremarkable and she was
remaining hemodynamically stable with saturation of 97
percent on room air. She continued to progress and was using
her rolling walker without any difficulty. She was moving out
of bed and getting out of bed to bathroom by herself, also
without any difficulty. The patient was discharge to home on
[**2111-11-15**] with instructions for the VNA to draw blood for
INR levels and to call the results to the patient's primary
care physician. [**Name10 (NameIs) **] patient was also instructed to follow-up
with her local cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13175**], in
approximately 7-10 days after discharge; to follow-up with
her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57323**], for an
appointment in [**7-25**] days post discharge but Dr. [**Last Name (STitle) 57323**] is
also responsible for following the patient's Coumadin dosing
and INR, phone number [**Telephone/Fax (1) 33129**]. The patient was also
instructed to follow-up with Dr. [**Last Name (STitle) **], her surgeon, in the
office in approximately three weeks post discharge for her
postoperative surgical visit. In addition, an appointment had
been scheduled at the [**Hospital Ward Name 23**] Center Cardiac Services for
pacemaker device check at the clinic on [**2111-11-17**] and to
come to [**Hospital Ward Name 121**] 2 for her wound check on [**2111-11-23**].
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting times four.
Atrial fibrillation.
History of transient ischemic attack.
Hypertension.
Hypothyroidism.
Status post pacemaker generator change.
Status post cholecystectomy.
Status post thyroidectomy.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 81 mg p.o. once daily.
2. Colace 100 mg p.o. twice daily.
3. Lasix 20 mg p.o. once daily for five days.
4. Metoprolol 50 mg p.o. twice daily.
5. Captopril 12.5 mg p.o. three times daily.
6. Synthroid 112 mcg p.o. once daily.
7. Pravachol 10 mg p.o. once daily.
8. Potassium chloride 20 mEq p.o. once daily for five days.
9. This evening's dose of Coumadin, 1 mg for the evening of
discharge, 1 mg for post discharge day one on [**2111-11-14**]
and [**2111-11-15**], then INR check and call results to Dr.
[**Last Name (STitle) 57323**] for additional Coumadin dosing.
DISPOSITION: The patient was discharged to home with VNA
services in stable condition on [**2111-11-15**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2111-12-22**] 09:58:49
T: [**2111-12-22**] 11:08:44
Job#: [**Job Number 57324**]
|
[
"411.1",
"780.6",
"272.0",
"441.02",
"525.3",
"414.01",
"401.9",
"427.31",
"V53.31",
"244.9",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61",
"99.07",
"99.04",
"36.15",
"89.68",
"37.85"
] |
icd9pcs
|
[
[
[]
]
] |
14206, 14455
|
14478, 15430
|
997, 1154
|
2136, 14184
|
1177, 2118
|
120, 683
|
706, 970
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,100
| 150,204
|
34096
|
Discharge summary
|
report
|
Admission Date: [**2175-3-28**] Discharge Date: [**2175-4-8**]
Date of Birth: [**2106-2-14**] Sex: M
Service: SURGERY
Allergies:
Adhesive
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
[**2175-3-30**] - Bronchoscopy
History of Present Illness:
69M s/p OLT [**2-27**], recently discharged for dehydration and
hyperkalemia, now presents with dyspnea on exertion and SOB. He
was doing well at home until 3 days ago, when he developed
gradually worsening SOB. He states that this AM he was unable
to walk 10 feet because of severe SOB. Currently he feels ok,
but
notes that he has not done any physical activity since then.
Otherwise, he notes that he has done well. He is eating well,
has not had any recurrent diarrhea, and has not had any
fevers/chills, nausea/vomiting.
Past Medical History:
1. Cirrhosis. NASH vs autoimmune vs alcohol related per biopsy
at outside hospital. He also has heterozygote related to
hemachromatosis
gene mutation. His biopsy results demonstrate hemosiderin
deposits.
2. History of spontaneous bacterial peritonitis in [**2174-4-21**].
3. History of GI bleed in [**2174-7-22**] secondary to portal
gastropathy as well as esophageal varices.
4. Peripheral arterial disease status post stent to superficial
femoral artery approximately 10 years ago.
5. Hypertension.
6. Liver [**Year (4 digits) **] [**2175-2-24**]
Social History:
Former smoker, 20-pack-year history, quit [**2146**]. Prior social
EtOH drinker, none in 5 years. No h/o IVDU or other drugs. No
tatoos or piercings. Retired Home Care and Home Oxygen company
co-partner. Married x 42 years.
Family History:
Mother d. age 51 from leukemia. Father d. age 59 from
gastric cancer, and he had stomach ulcers and CAD. Brother d.
age
51 from alcohol, ? cirrhosis. Sister d. age 61 from cervical and
ovarian cancer.
Physical Exam:
On Admission
Tc 97.3, HR 105, BP 147/95, RR 18, O2sat 97RA
Genl: NAD
CV: RRR, no mrg
Resp: crackles at Right base, good excursion throughout, no
wheeze
Abd: s/nt/nd; well-healed Chevron incision
Extr: no c/c/e
LABS:
Na 139, K 4.9, Cl 115, CO2 pend, BUN 63, Creat 2.3, Glc 111
WBC 8.8, Hct 33.5, Plt 237
AST 10, ALT 9, Alkphos 1.3, Tbili 3.2
Pertinent Results:
Radiology Report CHEST (PA & LAT) Study Date of [**2175-3-28**] 12:05
PM IMPRESSION: Diffuse hazy opacity in bilateral lung bases.
While the findings may be due to a slightly atypical
distribution of pulmonary edema, focal infiltrates in particular
the right perihilar and left retrocardiac regions cannot be
entirely excluded.
Radiology Report LUNG SCAN Study Date of [**2175-3-28**] IMPRESSION:
Low likelihood ratio for acute pulmonary embolus.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2175-3-28**]
1:56 PM
IMPRESSION: No evidence for DVT in bilateral lower extremities.
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2175-3-29**]
10:31 AM IMPRESSION: 1. New widespread ground-glass attenuation,
septal thickening and peribronchiolar foci of consolidation. The
constellation of findings may all be due to an opportunistic
infection in this immune suppressed patient, such as viral or
PCP, [**Name10 (NameIs) **] hydrostatic edema coexisting with pneumonia is also
possible. 2. Widespread interstitial fibrosis, probably
unchanged compared to recent CT but difficult to assess in the
setting of acute lung disease. 3. Status post hepatic
transplantation with decrease amount of ascites, but incomplete
assessment of the liver on this dedicated chest CT study. If
evaluation of liver is desired clinically, dedicated ultrasound
could be considered. 4. New small pericardial and dependent
right pleural effusions and minimal increase in dependent left
pleural effusion.
Portable TTE (Complete) Done [**2175-3-30**] at 2:41:18 PM There is
severe global left ventricular hypokinesis (LVEF = 25-30 %).
Compared with the prior study (images reviewed) of [**2175-2-13**],
the left ventricular systolic function has significantly
worsened (LVEF >55%)
Radiology Report CHEST (PORTABLE AP) Study Date of [**2175-3-30**] 3:26
AM FINDINGS: Interval placement of endotracheal tube and
nasogastric tube in
standard position. Rapid progression of widespread bilateral
alveolar
opacities, superimposed upon underlying interstitial
abnormality. In an
immunosuppressed patient, this may reflect rapidly progressive
opportunistic infection, possibly complicated by ARDS. A
component of hydrostatic edema is also possible. Persistent
small right pleural effusion, but no evidence of pneumothorax.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2175-3-31**] 4:50
AM INDICATION: Bilateral infiltrates. Indwelling devices are in
standard position. Cardiomediastinal contours are unchanged.
Widespread combined alveolar and interstitial opacities show
mild to moderate improvement in the right perihilar region, but
slight worsening in the left retrocardiac area. Right pleural
effusion has slightly decreased in size and small left effusion
is unchanged.
Radiology Report DUPLEX DOP ABD/PEL LIMITED Study Date of
[**2175-3-31**] 2:49 PM IMPRESSION: 1. No hydronephrosis or stone. Mild
fullness in the left renal pelvis. Small simple cyst in the left
kidney. 2. Markedly thickened bladder wall, which may be due to
symmetric bladder wall hypertrophy from outflow obstruction or
spastic bladder neuropathy. 3. The Foley balloon tip is somewhat
low relative to the residual fluid in the bladder. DOPPLER
ULTRASOUND: Doppler exam was limited as the patient was on a
ventilator. There is good systolic upslope in the main renal
arteries bilaterally. RIs range from 0.71-0.73 on the right and
0.72-0.75 on the left.
Portable TTE (Complete) Done [**2175-4-4**] at 10:00:00 AM. There is
moderate global left ventricular hypokinesis (LVEF = 30-35 %).
Compared with the prior study (images reviewed) of [**2175-3-30**],
overall left ventricular function is slightly more vigorous. The
estimated pulmonary artery pressures are lower.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2175-4-4**] 3:40
AM Since [**2175-4-2**], multifocal alveolar opacity slightly
improved, likely
due to improved multifocal pneumonia. Atypical pulmonary edema
cannot be
ruled out, would be improved. Small bilateral pleural effusions
are
unchanged. Heart size is still top normal.
Brief Hospital Course:
Pt admitted to [**Hospital1 18**] on [**4-8**] for shortness of breath,
tachycardia and increased O2 requirement. Initial CXR on [**4-8**]
concerning for a RLL pneumonia, A V/Q scan was done as well as
lower extremity venous duplex studies which were low probability
for PE and did not demonstrate venous thrombosis in the lower
extremities. Empiric levofloxacin was begun for suspected
pneumonia. A chest CT done on [**3-29**] showed widespread global
ground glass opacities. Empiric ABX coverage was broadened to
Vancomycin, Zosyn, and levofloxacin. Pt continued to
decompensate from a respiratory perspective with arterial blood
gases showing markedly low CO2 in the 22-25 range. The pt was
transported to the ICU on [**2175-3-29**] due to increased work of
breathing and persistently low CO2 on ABG. The Infectious
disease service as well as pulmonology were consulted. The pt
was intubated on [**2175-3-30**]. An in-depth workup for possible
infectious agents was conducted. A bronchoscopy with lavage was
done on which did not grow any organisms. A trans thoracic echo
was performed on [**3-30**] which revealed global dysfunction and an EF
of 25-30% which has previously been >55%. The Cardiology service
was consulted at this time as well. Tube feeds via [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 43199**]
[**Last Name (un) **]-duodenal catheter were begun on [**2175-4-1**]. Vanc and Zosyn
were discontinued on [**4-2**] as cultures remained negative and an
empiric course of levofloxacin was continued. Clinically
Mr.[**Known lastname **] improved from a respiratory standpoint and was
extubated on [**4-1**]. The pt was transferred to the floor out of
the ICU on [**2175-4-5**]. He continuied to clinically improve as a
course of empiric levofloxacin was completed on [**2175-4-6**]. As PO
caloric intake improved the tube feeds were cycled at night.
Mr.[**Known lastname **] was discharged home on [**2175-4-8**] with VNA services for
tube feeds to be cycled at night.
Medications on Admission:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
6. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
follow taper.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Insulin Lispro 100 unit/mL Solution Sig: follow sliding scale
Subcutaneous four times a day.
9. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed.
Disp:*10 inhalers* Refills:*2*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q4H (every 4 hours) as needed.
Disp:*10 inhalers* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
8. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Prednisone 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
pneumonia, cardiomyopathy
Discharge Condition:
Good
Discharge Instructions:
Please call the [**Company **] clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, diarrhea, inability to take or
keep down food, fluids or medications or any problems with the
tube feedings.
If you develop chest pain or shortness of breath please proceed
via ambulance to the nearest emergency room.
Use oxygen at home as needed
Tube feeds will be cycled at night
Labs to be drawn every Monday and Thursday
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2175-4-13**] 1:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2175-5-17**] 9:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2175-5-17**] 9:30
|
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18,637
| 110,335
|
29446
|
Discharge summary
|
report
|
Admission Date: [**2131-12-2**] Discharge Date: [**2131-12-24**]
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Peripherally insterted central catheter
Nasogastric tube
History of Present Illness:
85 M with h/o CVA s/p recent CEA, DM2, CKD and HTN who presents
from [**Hospital1 1501**] with respiratory distress. Although it is not clear
from discharge summary, recent hospitalization complicated by
SICU stay for PNA vs CHF. Unclear if patient was reintubated but
was started on levofloxacin and diamox. Discharged ([**11-28**]) to
complete 2 week course of ciprofloxacin.
.
ROS: denies shortness of breath, fevers, chest pain. reports
only feeling worn and not well. + achy, tired, malaise. Denies
DOE (walks >1 block prior to previous admission with cane), PND.
Stable 2 pillow orthopnea. No ankle edema.
.
ED Course:
In ED, afebrile but briefly hypotension and responded to small
fluid bolus. CXR showed likely PNA and the patient was given a
dose of vanc/CTx. Requiring non-rebreather to maintain
oxygenation. Prior to coming up to the ICU, the patient went
into a fib with RVR (HR to 140s). Started on dilt drip.
.
MICU Course:
Treated for HAP with vanc/levo/flagyl. Respiratory status
improved with decreasing O2 requirement and afebrile. Weaned off
dilt gtt, AFib remained well-controlled on PO beta blocker and
spontaneously converted to sinus. One episode OB+ 'black' stool
but stable Hct and hemodynamics stable.
.
[**Hospital1 **] Course:
He was called out to the floor on [**12-4**]. On the floor he appeared
dyspneic and was diuresed for pulmonary edema, but dyspnea not
completely resolved. He had negative LENIs and V/Q scan with
intermediate probability PE. He also continued to tell the team
that "I want to die". SW was consulted and ritalin was started.
Pt was not taking in POs and creatinine also started trending up
again. [**2131-12-12**] pt was found to have BP 72/40 and decreased UOP.
He was given a 500 cc bouls and Bps initially trended up to
82/50 and then down to 70/40. He then received an additonal 1 L
fluid bolus and was transferred to the ICU.
.
MICU Course:
He received 7 liters of IVF with improvement of his blood
pressure and subsequent improvement in his mental status.
Psychiatry and neurology were consulted; his perseveration on "I
want to die. Hurry up." did not seem consistent with a diagnosis
of depression, but his behavior did raise concern of frontal
release . Neurology Celexa was stopped as it has been reported
to cause hypotension and is without immediate benefit to the
patient, and at the recommendation of psychiatry, ritalin was
stopped as well.
Past Medical History:
CVA with residual L hemiparesis (R MCA stroke [**2110**])
OA
Gout
Hypertension
Bilateral Carotid stenosis s/p left CEA [**11/2131**]
Type II DM, diet controlled
Gastritis
CKD (2-2.2)
Recent PNA on Cipro
Right parafalcine late subacute subdural hematoma
Social History:
Was living with wife and son but currently in rehab. Retired
salesman, air force pilot. No current or past tobacco use, no
EtOH abuse. No illicit drug use.
Family History:
No family hx of stroke, CAD, cancer, DM, or other neurologic
disease
Physical Exam:
T 97.8 HR 86 BP 120/58 RR 28 SaO2 93% on 1L
General: WDWN, NAD, jovial, very pleasant, breathing comfortably
on RA
HEENT: PERRL, EOMi, anicteric sclera, conjunctivae pink
Neck: supple, trachea midline, no thyromegaly or masses, no LAD,
left CEA surgery site with sutures but no erythema or drainage
Cardiac: RRR, s1s2 normal, no m/r/g, no JVD
Pulmonary: crackles at bases (L>R), occ wheeze
Abdomen: +BS, soft, nontender, nondistended, no HSM
Extremities: warm, 2+ DP pulses, no edema
Neuro: A&Ox3, speech slurred, CNII-XII intact, residual left arm
and leg weakness from prior CVA
Pertinent Results:
Hematology
[**2131-12-2**] 04:00AM WBC-37.4*# RBC-3.83* HGB-11.7* HCT-34.0*
MCV-89 MCH-30.5 MCHC-34.3 RDW-15.0
[**2131-12-2**] 04:00AM NEUTS-92* BANDS-1 LYMPHS-2* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2131-12-2**] 04:00AM PLT COUNT-316#
[**2131-12-2**] 04:00AM PT-15.6* PTT-29.6 INR(PT)-1.4*
.
Chemistry:
[**2131-12-2**] 04:00AM GLUCOSE-198* UREA N-120* CREAT-3.2*#
SODIUM-155* POTASSIUM-3.2* CHLORIDE-117* TOTAL CO2-20* ANION
GAP-21*
[**2131-12-2**] 04:00AM proBNP-2649*
[**2131-12-2**] 04:00AM CALCIUM-8.3* PHOSPHATE-5.9*# MAGNESIUM-2.3
.
EKG: sinus, 100bpm, LAD, freq PACs, IVCD similar to prior
.
CXR, portable ([**12-1**])- Large hiatal hernia. Increasing air space
opacities within the left lung and right lower lung zone. There
is no pneumothorax. There are no pleural effusions.
.
TTE ([**12-4**])- The left atrium is normal in size. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
.
CXR ([**12-6**])- The right PICC line tip terminates in the SVC. The
large hiatal hernia is again demonstrated. There is worsening
of bilateral infiltrates, suggesting increased degree of
pulmonary edema and also of the underlying pneumonia cannot be
excluded, especially in the right lower lobe and left upper
lobe. Bilateral pleural effusion is small-to-moderate.
.
Bilateral LE U/S ([**12-7**]): No evidence of deep venous thrombosis in
either lower extremity.
.
V/Q scan ([**12-7**]):
INTERPRETATION: Ventilation images obtained with Tc-[**Age over 90 **]m aerosol
in 8 views demonstrate central deposition of the
radiopharmaceutical, due to the turbulent flow. There are
widespread ventilatory abnormalities in RML, RLL, LUL, LLL,
predominantly at lung bases. Perfusion images in the same 8
views show similar pattern of perfusion abnormaliies, also most
pronounced at the bases. Chest x-ray shows diffuse bilateral
infiltrates with similar distribution pattern.
IMPRESSION: Matched perfusion and chest X-ray findings.
Intermediate likelihood ratio for pulmonary embolism.
.
Chest CT, non-contrast ([**12-10**]):
1. Intrathoracic stomach.
2. Multifocal pneumonia, most likely aspiration. Small
bilateral pleural
effusions and subcarinal mediastinal adenopathy, presumably
reactive.
3. Calcific cholelithiasis. No evidence of cholecystitis.
.
Head CT, non-contrast ([**12-12**]):
FINDINGS: The posterior fossa is not well seen on today's
examination
secondary to patient motion artifact. There is no evidence of
intracranial hemorrhage. Old areas of hypodensity seen within
the left external capsule are unchanged compared to [**2131-11-24**],
consistent with chronic lacunar infarction. A lacunar infarct
within the right caudate nucleus is also unchanged in
appearance. There is no evidence of intracranial mass lesion,
hydrocephalus or shift of normally midline structures. The
density values of the brain parenchyma are within normal limits.
The surrounding soft tissues and osseous structures are
unremarkable. The paranasal sinuses appear clear.
IMPRESSION: No new areas of acute infarction identified. The
previously reported tiny left parafalcine subdural hematoma seen
on MRI is not seen on today's examination, likely secondary to
interval resorption.
.
Brain, Head, Neck MRI/MRA ([**12-15**]):
FINDINGS: BRAIN MRI:
Comparison was made with the previous MRI examination of
[**2131-11-23**]. The
previously seen subtle increased signal in the right parafalcine
region in the frontal lobe on diffusion images is again
visualized and appears to be due to T2 shine through. Mild
periventricular changes of small vessel disease are seen. There
is no evidence of midline shift, mass effect or hydrocephalus
seen. There is moderate brain atrophy seen. On diffusion
images no evidence of acute infarct is noted. The previously
identified interhemispheric parafalcine subdural hematoma has
also resolved since the previous MRI examination with subtle
changes remaining in this region.
IMPRESSION: No evidence of acute infarct or new finding since
the previous MRI study. Resolution of previously noted subdural
hematoma. No mass effect or hydrocephalus.
MRA OF THE HEAD:
MRA demonstrates a normal flow signal in the anterior
circulation. The A1
segment of the left anterior cerebral artery is hypoplastic but
both A2
segments are well visualized. There is mild irregularity of the
flow signal seen in the basilar artery which could indicate mild
atherosclerotic disease. The distal right vertebral artery is
not visualized which appears to be secondary to the artery
ending in posterior inferior cerebellar artery, a normal
variation.
IMPRESSION: Mild atherosclerotic disease otherwise unremarkable
study.
MRA OF THE NECK:
The 3D time-of-flight MRA of the neck is limited by motion. No
evidence of vascular occlusion or stenosis seen.
IMPRESSION: Somewhat motion-limited normal MRA of the neck.
.
Right upper extremity U/S ([**12-16**]): Occlusive thrombus in the
right basilic vein surrounding indwelling PICC line. No deep
venous thrombus in the right upper extremity is identified.
.
EEG ([**12-18**]):
FINDINGS:
BACKGROUND: A 9 Hz disorganized posterior predominant rhythm was
noted
in the waking state, which attenuated with eye opening.
HYPERVENTILATION: Contraindicated due to mental status.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: The patient progressed from the waking to drowsy states,
but did
not attain stage II sleep.
CARDIAC MONITOR: A generally regular rhythm was noted, with an
average
rate of 90 beats per minute.
IMPRESSION: This is a normal EEG in the waking and drowsy
states. No
focal, lateralizing or epileptiform features were noted.
.
CXR ([**12-19**]): Multifocal opacities consistent with multifocal
pneumonia/aspiration are overall stable with slight clearing in
the left upper lobe and slight worsening in the right upper
lobe. Interval removal of the nasogastric tube. Left lower
lobe atelectasis is unchanged.
Brief Hospital Course:
85 M with h/o CVA s/p recent CEA, DM2, CKD and HTN who presented
with hypoxic respiratory distress [**1-4**] PNA and new-onset AFib
with RVR.
.
# Pneumonia: Multifocal PNA, treated for aspiration and HAP
given recent intubation / hospital stay with vanc/levo/flagyl x
11 days, vanc/zosyn/flagyl x 2 days, vanc/[**Last Name (un) 2830**]/flagyl x 4 days.
LENIs negative, V/Q scan intermediate probability PE. Pulm
consulted but rec no bronch as respiratory status improved. He
was taken off antibiotics x 2 days and spiked fever, tachypnic,
WBC increased from 10 -> 22 (C. diff negative), then decreased
11 after starting linezolid and levofloxacin (to complete 14 day
course on [**1-1**]). Respiratory status improved with diminished O2
requirement and resolution of tachypnea. Followup with PCP.
.
# Personality change: ?depression vs. frontal disinhibition.
Patient had been expressing wishes to die intermittently.
Occasional sundowning. Psych and neuro consulted. CT head shows
resorbed subdural hematoma, MR brain negative for acute CVA. EEG
was normal with no seizure activity. Intermittenly uncooperative
and somnolent, then spontaneously A&Ox3; likely [**1-4**] delerium
from toxic-metabolic cause in setting of significant frontal
atrophy noted on head CT. Tried on ritalin (d/c'd [**1-4**] concern
for MS change), celexa (d/c'd [**1-4**] concern for hypotension), and
remeron (d/c'd [**1-4**] concern for MS change, risk of serotonin
syndrome while on linezolid). Occasionally the patient developed
non-threatening hallucinations thought to be [**1-4**] toxic-metabolic
causes. If he develops agitation, psych recommends considering a
trial of haldol 0.5mg prn.
.
# Paroxysmal AFib: RVR to 140's at presentation, started on dilt
drip while in the ED, which was then weaned off in MICU.
Remained in sinus rhythm the rest of hospital course. No prior
h/o AFib per patient (confirmed with PCP). CHADS score 3, and
therefore would probably benefit from anticoagulation, but given
fall risk, recent SDH, comorbidites this was deferred (discussed
with PCP). Monitored on telemetry with no repeat events.
Continued metoprolol with good BP control; occasionally sinus
tachy likely [**1-4**] volume depleteion, stress, and infection.
.
# ARF on CRF: Resolved. Baseline Cre ~2.2; was 2.0 at discharge.
Most likely pre-renal azotemia in setting of hypovolemia (poor
intake, diarrhea) and responded to IVFs. Medications were
renally dosed.
.
# DM2: Diet-controlled. Hypoglycemic on transfer to MICU in
setting of starting NPH for persistant hyperglycemia; NPH was
then discontinued. Fingersticks were eventually discontinued as
serum glucose was well-controlled.
.
# CVA: s/p CEA, stable (followed by [**Doctor Last Name 1391**]). MR brain negative
for acute event. Vascular surgery made aware patient admitted,
no active issues. Cont ASA, Aggrenox.
.
# Cardiovascular: No documented h/o CAD or CHF but multiple risk
factors. Preserved EF on echo, although possible diastolic
dysfunction. CXR after MICU transfer with mild to moderate
volume overload and the patient was gently diuresed until
euvolemic. Cont ASA, statin, BB.
.
# Anemia: OB +ve stool noted while patient was in MICU, and then
intermittent positivity during rest of hospital stay.
?gastritis. Received 1 unit pRBC during admission with
appropriate increase in Hct, which remained stable. Started on
PPI [**Hospital1 **]. Recent c-scope (2 years ago per patient) negative;
denies ever having EGD or h/o GI bleeding. Would consider
pursuing outpatient GI followup.
.
# Coagulopathy: Elevated INR 1.4-1.5 at presentation likely
nutritional given poor PO intake. LFTs normal and
albumin/prealbumin low supporting nutritional deficiency.
Received vitamin K PO with slight improvement.
.
# Rash: Likely drug reaction [**1-4**] zosyn as this was only new
recent medication around the time the rash began. Serum eos
normal. The rash resolved after 1 week. Mild pruritis was
well-controlled with topical anti-itch cream.
.
# Hypernatremia: Resolved. Hypovolemic at presentation (~3.5L
H2O deficit), serum Na+ normalized with free water boluses but
recurred when stopped from poor PO intake and again improved
with free water (3L deficit). PO intake encouraged.
.
# Hypotension: Resolved after 8L of fluids in MICU. Likely [**1-4**]
hypovolemia from poor PO intake and diarrhea. Diarrhea also
resolved (C. diff neg x 3). Continued to supplement with IV
hydration and intermittent hypodermoclysis given poor POs.
.
# Hyperthyroidism: Mild with slighlty elevated free T4, slightly
depressed TSH. No thyroid nodules on exam. Difficult to
interpret in acute care setting, and therefore would suggest
rechecking as outpatient.
.
# Activity: PT worked with patient frequently. Goal OOB to chair
daily. Will likely need significant rehabilitation and will
benefit greatly from increased mobility and independence.
.
# FEN: Prethickened liquids / ground solids, PO intake
encouraged; Briefly with NG tube on tube feeds but d/c'd
according to family wishes due to somnolence and mental status
changes; Continue aspiration precautions; Repleted 'lytes prn
Medications on Admission:
1. Aspirin 81 mg QD
2. Folic Acid 1 mg QD
3. Simvastatin 20 mg QD
4. Metoprolol 25 TID
5. Ciprofloxacin 750mg Q48H for 2 weeks.
6. Dipyridamole-Aspirin 200-25 mg Cap, QD
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Insulin Regular QID PRN
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H (Every 3 to 4 Hours) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Artificial Saliva 0.15-0.15 % Solution Sig: 1-3 MLs Mucous
membrane PRN (as needed).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO BID (2 times a day).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day): apply to affected areas.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/wheeze.
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed: apply to affected areas.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Morphine Concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1-2H
() as needed.
12. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 8 days: Please have blood counts (CBC) checked on
[**2131-12-31**].
13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
14. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
18. CBC Sig: One (1) lab test once for 1 doses: Please have
blood counts (CBC) checked on [**2131-12-31**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital 21341**] Rehab
Discharge Diagnosis:
Primary:
[**Hospital 7502**] hospital-acquired
Acute renal failure
Altered mental status
Hypotension
Hypernatremia
Acute blood loss anemia
Atrial fibrillation
.
Secondary:
Cerebrovascular accident with residual left hemiparesis
Osteoarthritis
Gout
Hypertension
Bilateral carotid stenosis status post carotid endarterectomy
Type II diabetes mellitus
Gastritis
Chronic renal insufficiency
Right parafalcine subacute subdural hematoma
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed.
.
New medications: levofloxacin, linezolid
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
Please schedule a followup appointment with your PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 40075**], at [**Telephone/Fax (1) 40076**] in 2 weeks.
|
[
"693.0",
"451.82",
"585.3",
"707.03",
"E930.0",
"792.1",
"276.52",
"311",
"486",
"242.90",
"349.82",
"799.02",
"403.91",
"250.00",
"286.7",
"438.20",
"599.0",
"999.2",
"274.9",
"787.91",
"427.31",
"518.82",
"276.0",
"584.9",
"428.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.6",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
17725, 17778
|
10514, 15614
|
233, 292
|
18254, 18261
|
3883, 8658
|
18591, 18758
|
3196, 3266
|
15954, 17702
|
17799, 18233
|
15640, 15931
|
18285, 18568
|
3281, 3864
|
174, 195
|
320, 2731
|
8675, 10491
|
2753, 3007
|
3023, 3180
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,001
| 154,917
|
8981+8982+56000
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2143-11-5**] Discharge Date: [**2143-11-18**]
Service: GREEN SURGERY
ADMISSION DIAGNOSES:
1. Rectal mass admitted for low anterior resection.
2 . Emphysema.
3. Asthma.
4. Hypertension.
5. Congestive heart failure.
6. Colon cancer.
ADMISSION HISTORY AND PHYSICAL: This is a 81 year-old male
with a chief complaint of hematochezia. His past history
includes emphysema and asthma. Previous surgery includes
open cholecystectomy and a questionable pancreatic abscess.
MEDICATIONS AT HOME:
1. Dyazide.
2. Aspirin.
3. Albuterol.
4. Norvasc.
The patient had a colonoscopy, which showed a rectal mass at
approximately 12 to 17 cm and a rectal polyp approximately 2
cm.
ADMISSION PHYSICAL EXAMINATION: Afebrile, vital signs
stable. Thin elderly male in no acute distress. Clear to
auscultation bilaterally. Regular rate and rhythm. No
murmurs, rubs or gallops. Abdomen soft with a right
subcostal and midline well healed surgical scars. Rectal
examination shows a prolapsing 2.5 cm polyp. There is no
edema peripherally.
IMPRESSION: Rectal mass and rectal polyps.
PLAN: Low anterior resection, transanal excision of rectal
polyp.
HOSPITAL COURSE: The patient underwent low anterior
resection by Dr. [**Last Name (STitle) 1888**] on [**2143-11-5**]. Postoperatively, the
patient was extubated and sent to the PACU. At this point he
was noted to have low urine output. He got fluid boluses.
Postoperative electrocardiogram showed a questionable ST
depression in V3 and V4, less then 1 mm. Cardiac enzymes
were sent, which revealed only a slight bump in troponin
consistent with ischemia not infarction. The patient was
fluid bolused and eventually decreased his oxygen saturations
and thus was transferred to the unit. At that point it was
determined that the patient was slightly fluid overloaded and
slightly anemic. While in the Intensive Care Unit on
postoperative day two his hematocrit was shown to be 24.8
consistent with mild blood loss and hemodilution. He was
transfused 2 units and subsequent hematocrit was 30.8. His
hematocrit remained stable throughout the remainder of his
admission. Chest x-ray while in the unit was consistent with
left ventricular failure, which eventually resolved. After
being diuresed on postoperative day four the patient was
transferred back to the floor. While on the floor
significant events included the patient's inability to
tolerate solid po intake. A nutrition consult was obtained.
They suggested total parenteral nutrition. The patient was
placed on total parenteral nutrition on [**11-12**] using a PICC
line. This was continued until the day previous to
discharge. At that point the patient had received
approximately five days of total parenteral nutrition during
which time his chemistry levels remained within normal
limits.
Also while on the floor there was an event with the patient's
wife where she called Dr.[**Name (NI) 4999**] office claiming that the
patient was dead. This was done supposedly, because the
patient's wife thought that the patient was not getting
enough prompt medical attention. Social work was contact[**Name (NI) **]
and it was determined that the patient should be screened for
rehab as his presence at home is questionable, his wife's
ability to care for him at home. By the day of discharge the
patient was ambulating. He was tolerating a regular diet.
Physical therapy was involved and they cleared the patient
for discharge to a rehab facility. Foley catheter was
discontinued without event on postoperative day five. The
patient was continued on his home medication regimen while in
the hospital of Vasotec, Dyazide and Proscar. Heparin subq
was used for deep venous thrombosis prophylaxis. Mucomyst
was used as well. The patient was on Protonix for peptic
ulcer disease prophylaxis and pain postoperative was managed
effectively with morphine as needed.
DISCHARGE INSTRUCTIONS: The patient should follow up with
Dr. [**Last Name (STitle) 1888**] in two to three weeks. He will be discharged to
[**Hospital 100**] Rehab.
DISCHARGE CONDITION: Good. He is tolerating a regular diet.
[**Last Name (NamePattern4) 1889**], M.D. [**MD Number(1) 1890**]
Dictated By:[**Last Name (NamePattern1) 31154**]
MEDQUIST36
D: [**2143-11-18**] 08:21
T: [**2143-11-18**] 08:42
JOB#: [**Job Number 31155**]
Admission Date: [**2143-10-28**] Discharge Date:[**2143-12-3**]
Service: GREEN GENERAL SURGERY
ADDENDUM: The patient remained an inpatient as on [**2143-11-18**] he had been complaining of a moderate amount of
abdominal pain with some nausea and vomiting. A KUB was
performed on [**2143-11-19**] revealing persistently
distended bowel loops that was consistent with a prolonged
postoperative ileus versus an evolving partial small bowel
obstruction. He remained afebrile during this time and his
pain did improve. At this time, the team decided to make him
n.p.o. on IV fluids to maintain fluid hydration and a
Nutrition consult was made in order for TPN recommendations.
He was started on a day number two starter bag for TPN.
Additionally, a C. difficile specimen was sent since the
patient had also had several episodes of loose stool and this
came back negative.
On [**2143-11-20**], hospital day number 15, the patient's
abdominal distention had improved mildly but he did persist
with multiple episodes of loose stools. TPN was continued
for nutrition supplementation.
On hospital day number 16 through 19, the patient was
continued on TPN and he was restarted on a p.o. trial on
[**2143-11-21**] which he tolerated without any nausea or
vomiting, but continued to take only small amounts of p.o.
intake. Repeat C. difficile specimen was again negative and
the patient remained afebrile with normal laboratory values.
The patient's p.o. intake remained around 500 cc per day
despite active encouragement by the nursing and medical
staff.
A Nutrition consult came by on hospital day number 19 and
after discussion with the Surgical staff as well as the
attending, there was discussion whether or not the patient
may benefit from PEG tube placement to maintain enteral
feedings. This was brought up with the family which included
the patient's wife as well as the patient himself and they
adamantly refused any future attempts for feeding tube
placement, deciding to continue to encourage the patient
eating by mouth.
Marinol was started with small improvement of the patient's
occasional nausea, the patient was continued on Protonix 40
mg IV b.i.d. for his severe reflux disease.
On hospital day number 20, [**2143-11-25**], a repeat KUB was
performed revealing persistently distended bowel loops that
appeared slightly increased from the previous KUB on [**2143-11-19**]. However, there was evidence of gas and fecal
residue in the colon, making a diagnosis consistent with a
prolonged ileus.
On [**2143-11-26**], a nutrition consult determined that the
patient's p.o. estimated intake was 24% of caloric needs and
a small bowel follow through was done at this time revealing
a mild to moderate dilatation of the small bowel, again
likely consistent with an ileus, frank gastroesophageal
reflux disease as well as presbyesophagus and lastly a small
to moderate sized hiatal hernia.
The patient was preopped for PEG tube placement as an effort
to increase his nutritional needs. However, after a repeat
discussion with the patient and his wife, they decided that
they did not want to undergo PEG tube placement or NG tube
placement for enteral nutrition.
On hospital day number 23, a GI consult was obtained for
assistance with persistently poor p.o. intake and they
recommended considering a trial of tube feeding via a NG tube
and that a PEG tube was appropriate if the family was
willing. Tube feeds were not attempted via NG tube after the
family resisted measures for alternative enteral feeding.
The patient was continued on his regular diet which was then
changed to a pureed diet and he was supplemented with Boost
and actively encouraged by the nursing staff to take his p.o.
intake.
Meanwhile, the patient continued to do well in all other
respects, ambulating well with no pain. The patient was
prepared for discharge on hospital day number 27, [**2143-12-2**], and had shown over the past day that he had been
doing well with his p.o. intake, had been able to take all of
his p.o. medications. There was no evidence of any nausea or
vomiting and he was having his daily bowel movements.
Discharge planning was made through case management with a
rehabilitation facility to continue the patient's prolonged
postoperative care.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Rehabilitation center.
DISCHARGE MEDICATIONS:
1. Albuterol inhaler one to two puffs q. six hours p.r.n.
2. Atrovent nebulizer q. six hours p.r.n.
3. Albuterol nebulizer q. two hours p.r.n.
4. Theophylline 400 mg p.o. q.d.
5. Ambien 5 mg p.o. q.h.s.
6. Enalapril 10 mg p.o. q.d.
7. Percocet 5/325 one to two tablets p.o. q. four to six
hours p.r.n.
8. Fenasteride 5 mg p.o. q.d.
9. Colace 100 mg p.o. b.i.d.
10. Diltiazem 240 mg sustained release capsule p.o. q.d.
11. Protonix 40 mg tablet p.o. b.i.d.
12. Mucomyst nebulizer q. four to six hours p.r.n.
FOLLOW-UP PLANS:
1. The patient is to follow-up with Dr. [**Last Name (STitle) 1888**] in two to
three weeks. Please call his office at [**Telephone/Fax (1) 160**] to
schedule this follow-up appointment.
2. The patient should follow-up with his primary care
provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3357**], within one week after
discharge.
FINAL DIAGNOSIS:
1. Status post low anterior resection.
2. Prolonged postoperative ileus.
3. Chronic obstructive pulmonary disease.
4. Chronic renal insufficiency.
5. History of gallstone necrotizing pancreatitis.
6. History of cholecystectomy.
7. Hypertension.
These discharge plans were discussed with the team and with
the attending, Dr. [**Last Name (STitle) 1888**].
Dictated By:[**Last Name (NamePattern1) 31156**]
MEDQUIST36
D: [**2143-12-2**] 12:41
T: [**2143-12-2**] 12:54
JOB#: [**Job Number 31157**]
Name: [**Known lastname 5467**], [**Known firstname **] Unit No: [**Numeric Identifier 5468**]
Admission Date: [**2143-11-5**] Discharge Date: [**2143-11-18**]
Date of Birth: [**2062-1-8**] Sex: M
Service: GREEN SURGERY
DISCHARGE MEDICATIONS:
1. Albuterol sulfate one to two puffs q 6.
2. Ipratropium bromide nebulizer.
3. Albuterol inhaler.
4. Theophylline 200 mg q.d.
5. Ambien 5 mg at h.s.
6. Enalapril 10 mg once a day.
7. Percocet one to two tabs every four to six hours as
needed.
8. ______________ 5 mg once a day.
9. Docusate sodium 100 mg twice a day.
10. Diltiazem 240 mg once a day.
11. Protonix 40 mg once a day.
[**Last Name (NamePattern4) 5469**], M.D. [**MD Number(1) 5470**]
Dictated By:[**Last Name (NamePattern1) 5471**]
MEDQUIST36
D: [**2143-11-18**] 08:56
T: [**2143-11-18**] 09:54
JOB#: [**Job Number 5472**]
|
[
"493.20",
"211.4",
"997.4",
"154.0",
"428.0",
"E849.7",
"E878.2",
"560.1",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"48.63",
"49.39",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
4109, 8682
|
10524, 11164
|
1199, 3918
|
9725, 10501
|
3943, 4087
|
526, 718
|
121, 505
|
741, 1181
|
9316, 9708
|
8707, 8759
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,637
| 157,391
|
552+553+55221+55222
|
Discharge summary
|
report+report+addendum+addendum
|
Admission Date: [**2195-6-17**] Discharge Date: [**2195-7-7**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is an 84 year-old female
with a history of CREST, diverticular disease, irritable
bowel syndrome, and prior upper GI bleed in [**7-19**] secondary to
AVM and gastritis. Her previous UGIB required
hospitalization, which was notable for a hematocrit of 16 on
during stay, 2 units of fresh frozen platelets,
esophagogastroduodenoscopy showing gastritis and normal
duodenum, cauterization of a gastric AVM, and angiography
followed by embolization of left gastric artery.
She presented to the Emergency Room at this time with a chief
complaint of two days of dark stools, left lower abdominal
breath, lightheadedness, fevers or chills, and night sweats.
No bright red blood per rectum, no hematemesis. In the
Emergency Room she was found to be in no acute distress and
with a temperature of 99.5, blood pressure 143/53, pulse 86,
respirations 16, 98% on room air. Nasogastric suction
revealed 200 cc of coffee grounds and lavage with 250 cc H20
showed coffee grounds and a bright red tinge, but lavage was
stopped, because of patient discomfort. Central line in
femoral vein was placed and she was given one liter of normal
saline.
PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome
CREST with a history of dysphagia and dyspepsia (followed by
gastroenterologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]). 2. Hypertension.
3. Hypothyroidism. 4. Irritable bowel syndrome with
chronic diarrhea, constipation and abdominal pain. 5.
Diverticula seen on colonoscopy [**7-/2193**]. 6. Chronic
obstructive pulmonary disease with bronchiectasis, right
bronchial sclerosis. 7. History of bladder stretching.
PAST SURGICAL HISTORY: 1. Cholecystectomy. 2.
Pericholecystectomy hernia repair. 3. Hysterectomy.
SOCIAL HISTORY: Three pack years of smoking, quit twenty
years ago. Drinks no alcohol.
FAMILY HISTORY: Son has Crohn's disease times forty two
years.
ALLERGIES: Penicillin and sulfa.
MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2.
Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid
175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30
mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a
day.
PHYSICAL EXAMINATION: General, thin elderly woman in no
acute distress. Vital signs temperature 99.5. Blood
pressure 120/60. Pulse 86. Respiratory rate 18. Skin
normal capillary refill, plus telangiectasias on the back.
HEENT right ptosis. No scleral icterus. Pupils are equal,
round and reactive to light. Extraocular movements intact.
Mucous membranes are dry. No lower dentition. Neck supple.
No lymphadenopathy. Jugular veins flat. Chest clear to
auscultation bilaterally. Cardiovascular regular rate and
rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at
right upper sternal border. No gallops or rubs. Abdomen
flat. Scar along right abdomen. Positive bowel sounds,
nondistended. No tenderness to palpation. No
hepatosplenomegaly. Extremities no clubbing, cyanosis or
edema. Fingers and toes cool to touch. 2+ radial and
dorsalis pedis pulses. Rectal guaiac positive in the
Emergency Department. Neurological alert and oriented times
three. Pleasant affect. Cranial nerves II through XII are
intact. No asterixics.
LABORATORIES AND STUDIES: White blood cell count 11.1,
hemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH
29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0,
monocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128,
potassium 4.6, chloride 94, bicarbonate 27, BUN 47,
creatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8,
phosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis
negative. Electrocardiogram heart rate 84 beats per minute,
normal sinus rhythm, left axis deviation. No acute ischemic
changes.
HOSPITAL COURSE: 1. Gastrointestinal: The patient presented
with an upper gastrointestinal bleed with a hematocrit of
29.9, melena left lower quadrant pain and coffee grounds with
red tinge on nasogastric lavage. To look for a source of
bleed, several procedures were done. An
esophagogastroduodenoscopy was done on [**6-18**], which showed
diffuse gastritis and a normal duodenum consistent with what
was seen during admission a year before. On [**6-25**], enteroscopy
showed improved gastritis and a normal duodenum and jejunum.
Colonoscopy on [**6-29**] showed retained melena and multiple
nonbleeding diverticula, but no source of bleeding. A tagged
red cell scan on [**6-23**] did not identify a source of
gastrointestinal bleeding either. H-pylori antibody test was
negative. She was on supportive therapy with Protonix 40 mg
b.i.d. and Carafate, but she had continuous gastrointestinal
bleed as manifested by guaiac positive stools, both melena
and bloody stool and unstable hematocrit throughout most of
her stay.
On the evening of [**7-1**] (hospital day fifteen), the patient
had a dramatic gastric bleed with a hematocrit drop from 27.7
to 17.4. The patient became more tachycardic then baseline
to 130s, but maintained her blood pressure. Nasogastric
lavage at this point revealed bright red blood with clots
that did not clear with 420 cc of H20. She was transferred
to the MICU where she received 6 units of packed red blood
cells and 2 units of fresh frozen platelets. She was taken
to the IR the next morning where the left gastroduodenal
artery was embolized empirically. By hospital day seventeen,
the patient decided that she wanted no more blood product
transfusions and wanted CMO.
On the evening of hospital day seventeen, the patient was
transferred back to the Medicine Floor with stable hematocrit
of 36.7. However, one day after the transfer, her hematocrit
dropped to 24.1 with bloody diarrhea. The patient
reexpressed her wishes for CMO and did not want any more
laboratory tests or any blood product transfusions.
By hospital day twenty the patient appeared stable with
stable tachycardia and blood pressure. It appeared that
gastrointestinal bleeding either slowed or stopped, so after
discussion between the patient and the family and a
hematocrit check was done, which at the value of 26.4 showed
that she had stopped bleeding. Two more units of red blood
cells were transfused to increase her hematocrit to at least
greater then 30.
2. Hematology: At presentation the patient's hematocrit was
29.9 and was unstable throughout most of the admission. She
received a total of 20 units of packed red blood cells. Some
hematologic workup was done to look for other causes of
continued bleed, which was negative for GIC, hemolysis and
[**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease. Two of five studies (epinephrine
and arachidonic acid) for platelet aggregation were abnormal
so she was given Desmopressin intravenous times two doses
([**6-24**] and [**6-27**]) and one bag of platelets, which did not help
stabilize her hematocrit. A total of 5 units of fresh frozen
platelets were also given, because of multiple red blood
cells could have diluted the concentration of her clotting
factors and less likely, because of the possibility that she
had a coagulopathy given one PTT value. Hematology/oncology
consult did not feel that the patient had platelet
aggregation abnormalities or a coagulopathy.
3. Cardiovascular: The patient's antihypertensive
medications (Atenolol, Aldactone, Lasix) were held during her
hospital stay so that if she were to stop bleeding briskly,
her sympathetic system may respond appropriately to maintain
blood pressure. Her vital signs remained stable with a blood
pressure in the 140s/80s and heart rate in 80s until hospital
day five when she started having sinus tachycardic 100 to
130s. At this time she also developed a urinary tract
infection, so the tachycardia was thought to be secondary to
infection or dehydration. She was given normal saline
intravenous to lower the heart rate to the 110s. During the
remainder of th hospital course her heart rate remained
elevated in the 100s. When it rose again to 120 to 130s or
the patient was symptomatic with palpitations, administration
of normal saline intravenous helped control the tachycardia.
After the precipitous hematocrit drop on hospital day
fifteen, the patient's cardiac enzymes were checked and they
revealed a mild enzyme leak with CK 118 and 128, MB 8 and 9
and troponin 0.9. However, full enzyme cycling was not done,
because the patient decided on full CMO measures. The
patient was also found to have 3 out of 6 systolic murmur
loudest at right upper sternal border, radiating to
subclavian arteries. Consider outpatient workup with primary
care physician.
4. Pulmonary: During the MICU stay, where she was given 6
units of packed red blood cells and 2 units of fresh frozen
platelets she developed dyspnea and bilateral pleural
effusion. She was given 2 doses of Lasix 20 mg intravenous
after which her dyspnea improved.
5. Infectious disease: On hospital day five the patient
spiked a temperature to 101.5. Urinalysis showed 245 white
blood cells and blood culture was negative. She was treated
with Levofloxacin 500 mg once a day for eight days. During
the MICU stay her white blood cells spiked to 19.9, but she
was afebrile and there was no clear source of infection (no
pneumonia on chest x-ray, negative urine culture). The white
blood cells went down to 12.3 after transfer to the medicine
floor.
6. Lines: Access on this patient was difficult to obtain
and maintain. Access ranged as follows, femoral central
line, peripheral line and left IJ central line by IR.
7. FEN: Potassium, calcium, magnesium and phosphate were
repleted as needed.
8. Endocrine: Synthroid was continued for hypothyroidism.
9. CREST/Sjogren's: The patient uses Evoxac at home for
[**Last Name (un) **], but this was held during hospitalization. As it is a
cholinergic agonist it could have led to increased gastric
motility and dampen CVA response to hypotension.
DISCHARGE CONDITION: Stable. The patient will be discharged
to rehab with clear instructions on how she would like to be
cared for if she were to present with recurrent
gastrointestinal bleed.
DISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2.
Atenolol 20 mg once a day hold for systolic blood pressure
less then 110, heart rate less then 60. 3. Synthroid 175
micrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet
one tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg
po prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for
diarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5
mg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin
q.d.
FOLLOW UP: To arrange with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] of
gastroenterology and the patient's primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 4427**].
DISCHARGE DIAGNOSIS:
Upper gastrointestinal bleed secondary to gastritis.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4518**]
Dictated By:[**Doctor Last Name 4519**]
MEDQUIST36
D: [**2195-7-6**] 15:16
T: [**2195-7-7**] 08:18
JOB#: [**Job Number 4520**]
Admission Date: [**2195-6-17**] Discharge Date: [**2195-7-7**]
Service: [**Hospital1 **]
HISTORY OF PRESENT ILLNESS: This is an 84 year-old female
with a history of CREST, diverticular disease, irritable
bowel syndrome, and prior upper GI bleed in [**7-19**] secondary to
AVM and gastritis. Her previous UGIB required
hospitalization, which was notable for a hematocrit of 16 on
admission, 11 units of packed red blood cells transfusion
during stay, 2 units of fresh frozen platelets,
esophagogastroduodenoscopy showing gastritis and normal
duodenum, cauterization of a gastric AVM, and angiography
followed by embolization of left gastric artery.
She presented to the Emergency Room at this time with a chief
complaint of two days of dark stools, left lower abdominal
pain and weakness. She denied chest pain, shortness of
breath, lightheadedness, fevers or chills, and night sweats.
No bright red blood per rectum, no hematemesis. In the
Emergency Room she was found to be in no acute distress and
with a temperature of 99.5, blood pressure 143/53, pulse 86,
respirations 16, 98% on room air. Nasogastric suction
revealed 200 cc of coffee grounds and lavage with 250 cc H20
showed coffee grounds and a bright red tinge, but lavage was
stopped, because of patient discomfort. Central line in
femoral vein was placed and she was given one liter of normal
saline.
PAST MEDICAL HISTORY: 1. Sjogren's with Sicca syndrome
CREST with a history of dysphagia and dyspepsia (followed by
gastroenterologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**]). 2. Hypertension.
3. Hypothyroidism. 4. Irritable bowel syndrome with
chronic diarrhea, constipation and abdominal pain. 5.
Diverticula seen on colonoscopy [**7-/2193**]. 6. Chronic
obstructive pulmonary disease with bronchiectasis, right
bronchial sclerosis. 7. History of bladder stretching.
PAST SURGICAL HISTORY: 1. Cholecystectomy. 2.
Pericholecystectomy hernia repair. 3. Hysterectomy.
SOCIAL HISTORY: Three pack years of smoking, quit twenty
years ago. Drinks no alcohol.
FAMILY HISTORY: Son has Crohn's disease times forty two
years.
ALLERGIES: Penicillin and sulfa.
MEDICATIONS ON ADMISSION: 1. Atenolol 50 mg q.d. 2.
Aldactone 25 mg t.i.d. 3. Lasix 20 mg q.d. 4. Synthroid
175 micrograms q.d. 5. Prevacid 30 mg q.d. 6. Evoxac 30
mg t.i.d. 7. Serax 50 mg b.i.d. 8. Multivitamin once a
day.
PHYSICAL EXAMINATION: General, thin elderly woman in no
acute distress. Vital signs temperature 99.5. Blood
pressure 120/60. Pulse 86. Respiratory rate 18. Skin
normal capillary refill, plus telangiectasias on the back.
HEENT right ptosis. No scleral icterus. Pupils are equal,
round and reactive to light. Extraocular movements intact.
Mucous membranes are dry. No lower dentition. Neck supple.
No lymphadenopathy. Jugular veins flat. Chest clear to
auscultation bilaterally. Cardiovascular regular rate and
rhythm. S1 and S2. 3 out of 6 systolic murmur loudest at
right upper sternal border. No gallops or rubs. Abdomen
flat. Scar along right abdomen. Positive bowel sounds,
nondistended. No tenderness to palpation. No
hepatosplenomegaly. Extremities no clubbing, cyanosis or
edema. Fingers and toes cool to touch. 2+ radial and
dorsalis pedis pulses. Rectal guaiac positive in the
Emergency Department. Neurological alert and oriented times
three. Pleasant affect. Cranial nerves II through XII are
intact. No asterixics.
LABORATORIES AND STUDIES: White blood cell count 11.1,
hemoglobin 10.3, hematocrit 27.9, platelets 235, MCV 85, MCH
29.3, MCHC 34.4, neutrophils 87.9%, lymphocytes 8%, bands 0,
monocytes 2.6%, eosinophils 1.1%, basophils 0.1%, sodium 128,
potassium 4.6, chloride 94, bicarbonate 27, BUN 47,
creatinine 1.1, glucose 122, calcium 8.5, magnesium 1.8,
phosphate 2.8. PT 13.4, PTT 30.1, INR 1.3. Urinalysis
negative. Electrocardiogram heart rate 84 beats per minute,
normal sinus rhythm, left axis deviation. No acute ischemic
changes.
HOSPITAL COURSE: 1. Gastrointestinal: The patient presented
with an upper gastrointestinal bleed with a hematocrit of
29.9, melena left lower quadrant pain and coffee grounds with
red tinge on nasogastric lavage. To look for a source of
bleed, several procedures were done. An
esophagogastroduodenoscopy was done on [**6-18**], which showed
diffuse gastritis and a normal duodenum consistent with what
was seen during admission a year before. On [**6-25**], enteroscopy
showed improved gastritis and a normal duodenum and jejunum.
Colonoscopy on [**6-29**] showed retained melena and multiple
nonbleeding diverticula, but no source of bleeding. A tagged
red cell scan on [**6-23**] did not identify a source of
gastrointestinal bleeding either. H-pylori antibody test was
negative. She was on supportive therapy with Protonix 40 mg
b.i.d. and Carafate, but she had continuous gastrointestinal
bleed as manifested by guaiac positive stools, both melena
and bloody stool and unstable hematocrit throughout most of
her stay.
On the evening of [**7-1**] (hospital day fifteen), the patient
had a dramatic gastric bleed with a hematocrit drop from 27.7
to 17.4. The patient became more tachycardic then baseline
to 130s, but maintained her blood pressure. Nasogastric
lavage at this point revealed bright red blood with clots
that did not clear with 420 cc of H20. She was transferred
to the MICU where she received 6 units of packed red blood
cells and 2 units of fresh frozen platelets. She was taken
to the IR the next morning where the left gastroduodenal
artery was embolized empirically. By hospital day seventeen,
the patient decided that she wanted no more blood product
transfusions and wanted CMO.
On the evening of hospital day seventeen, the patient was
transferred back to the Medicine Floor with stable hematocrit
of 36.7. However, one day after the transfer, her hematocrit
dropped to 24.1 with bloody diarrhea. The patient
reexpressed her wishes for CMO and did not want any more
laboratory tests or any blood product transfusions.
By hospital day twenty the patient appeared stable with
stable tachycardia and blood pressure. It appeared that
gastrointestinal bleeding either slowed or stopped, so after
discussion between the patient and the family and a
hematocrit check was done, which at the value of 26.4 showed
that she had stopped bleeding. Two more units of red blood
cells were transfused to increase her hematocrit to at least
greater then 30.
2. Hematology: At presentation the patient's hematocrit was
29.9 and was unstable throughout most of the admission. She
received a total of 20 units of packed red blood cells. Some
hematologic workup was done to look for other causes of
continued bleed, which was negative for GIC, hemolysis and
[**First Name5 (NamePattern1) **] [**Last Name (Prefixes) 4516**] disease. Two of five studies (epinephrine
and arachidonic acid) for platelet aggregation were abnormal
so she was given Desmopressin intravenous times two doses
([**6-24**] and [**6-27**]) and one bag of platelets, which did not help
stabilize her hematocrit. A total of 5 units of fresh frozen
platelets were also given, because of multiple red blood
cells could have diluted the concentration of her clotting
factors and less likely, because of the possibility that she
had a coagulopathy given one PTT value. Hematology/oncology
consult did not feel that the patient had platelet
aggregation abnormalities or a coagulopathy.
3. Cardiovascular: The patient's antihypertensive
medications (Atenolol, Aldactone, Lasix) were held during her
hospital stay so that if she were to stop bleeding briskly,
her sympathetic system may respond appropriately to maintain
blood pressure. Her vital signs remained stable with a blood
pressure in the 140s/80s and heart rate in 80s until hospital
day five when she started having sinus tachycardic 100 to
130s. At this time she also developed a urinary tract
infection, so the tachycardia was thought to be secondary to
infection or dehydration. She was given normal saline
intravenous to lower the heart rate to the 110s. During the
remainder of th hospital course her heart rate remained
elevated in the 100s. When it rose again to 120 to 130s or
the patient was symptomatic with palpitations, administration
of normal saline intravenous helped control the tachycardia.
After the precipitous hematocrit drop on hospital day
fifteen, the patient's cardiac enzymes were checked and they
revealed a mild enzyme leak with CK 118 and 128, MB 8 and 9
and troponin 0.9. However, full enzyme cycling was not done,
because the patient decided on full CMO measures. The
patient was also found to have 3 out of 6 systolic murmur
loudest at right upper sternal border, radiating to
subclavian arteries. Consider outpatient workup with primary
care physician.
4. Pulmonary: During the MICU stay, where she was given 6
units of packed red blood cells and 2 units of fresh frozen
platelets she developed dyspnea and bilateral pleural
effusion. She was given 2 doses of Lasix 20 mg intravenous
after which her dyspnea improved.
5. Infectious disease: On hospital day five the patient
spiked a temperature to 101.5. Urinalysis showed 245 white
blood cells and blood culture was negative. She was treated
with Levofloxacin 500 mg once a day for eight days. During
the MICU stay her white blood cells spiked to 19.9, but she
was afebrile and there was no clear source of infection (no
pneumonia on chest x-ray, negative urine culture). The white
blood cells went down to 12.3 after transfer to the medicine
floor.
6. Lines: Access on this patient was difficult to obtain
and maintain. Access ranged as follows, femoral central
line, peripheral line and left IJ central line by IR.
7. FEN: Potassium, calcium, magnesium and phosphate were
repleted as needed.
8. Endocrine: Synthroid was continued for hypothyroidism.
9. CREST/Sjogren's: The patient uses Evoxac at home for
[**Last Name (un) **], but this was held during hospitalization. As it is a
cholinergic agonist it could have led to increased gastric
motility and dampen CVA response to hypotension.
DISCHARGE CONDITION: Stable. The patient will be discharged
to rehab with clear instructions on how she would like to be
cared for if she were to present with recurrent
gastrointestinal bleed.
DISCHARGE MEDICATIONS: 1. Protonix 40 mg b.i.d. 2.
Atenolol 20 mg once a day hold for systolic blood pressure
less then 110, heart rate less then 60. 3. Synthroid 175
micrograms q.d. 4. Ativan 0.5 mg po b.i.d. 5. Darvocet
one tab prn q 6 hours. 6. MSIR (oral solution) 10 to 30 mg
po prn q 4 hours. 7. Colace 100 mg po b.i.d. hold for
diarrhea. 8. Imodium 2 mg po prn q 6 hours. 9. Zolpidem 5
mg po prn h.s. 10. Evoxac 30 mg t.i.d. 11. Multivitamin
q.d.
FOLLOW UP: To arrange with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] of
gastroenterology and the patient's primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 4427**].
DISCHARGE DIAGNOSIS:
Upper gastrointestinal bleed secondary to gastritis.
[**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**]
Dictated By:[**Doctor Last Name 4519**]
MEDQUIST36
D: [**2195-7-6**] 15:16
T: [**2195-7-7**] 08:18
JOB#: [**Job Number 4520**]
Name: [**Known lastname **], [**Known firstname 516**] Unit No: [**Numeric Identifier 517**]
Admission Date: [**2195-6-17**] Discharge Date: [**2195-7-9**]
Date of Birth: [**2110-2-17**] Sex: F
Service:
Addendum:
She had three other medications added to her list.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg po qd
2. Albuterol inhaler 2 puffs prn q 4 to 6 hours
3. Atrovent inhalers 2 puffs prn q 4 to 6 hours
FOLLOW UP: She is to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 518**] who is her
primary care physician, [**Name10 (NameIs) 519**] Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**]
Dictated By:[**Doctor Last Name 523**]
MEDQUIST36
D: [**2195-7-9**] 14:22
T: [**2195-7-13**] 14:34
JOB#: [**Job Number 524**]
Name: [**Known lastname **], [**Known firstname 516**] Unit No: [**Numeric Identifier 517**]
Admission Date: [**2195-6-17**] Discharge Date: [**2195-7-9**]
Date of Birth: [**2110-2-17**] Sex: F
Service:
Addendum:
She had three other medications added to her list.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg po qd
2. Albuterol inhaler 2 puffs prn q 4 to 6 hours
3. Atrovent inhalers 2 puffs prn q 4 to 6 hours
FOLLOW UP: She is to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 518**] who is her
primary care physician, [**Name10 (NameIs) 519**] Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**]
Dictated By:[**Last Name (NamePattern4) 525**]
MEDQUIST36
D: [**2195-7-9**] 14:22
T: [**2195-7-13**] 14:34
JOB#: [**Job Number 524**]
|
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icd9cm
|
[
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[]
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13789, 15360
|
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|
12738, 13232
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13353, 13426
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,039
| 125,689
|
43566
|
Discharge summary
|
report
|
Admission Date: [**2194-7-21**] Discharge Date: [**2194-8-7**]
Date of Birth: [**2111-10-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2194-7-23**] Cardiac Catheterization with Placement of IABP
[**2194-7-24**] Coronary artery bypass grafting x4 with left internal
mammary artery to left anterior descending coronary artery;
reverse saphenous vein graft from the aorta to the first obtuse
marginal coronary artery; reverse saphenous vein graft from the
aorta to the distal right coronary artery; as well as a reverse
saphenous vein graft from the obtuse marginal vein graft to the
ramus intermedius coronary artery.
[**2194-8-5**] - Pacemaker Implant ([**Company 1543**] Sensia #NWL254604H)
History of Present Illness:
This is an 83 year old female with known CAD s/p DES to LAD
([**2185**]), who was otherwise well until about 2 months ago when she
began to complain of chest pain. During past 2 weeks prior to
admission, her chest pain progressed, often [**11-3**] with minimal
exertion, and radiating to left arm, jaw, associated with
shortness of breath. On the day prior to admisstion, she awoke
complaining of [**11-3**] chest pain at 2AM and reported to [**Hospital1 18**]
for evaluation and treatment.
Past Medical History:
Coronary Artery Disease, s/p DES to LAD
Diabetes Mellitus
Hypertension
Hyperlipidemia
Arthritis
s/p Hernia repair x2
s/p Hysterectomy
Social History:
Patient lives with husband in [**Name (NI) 583**]. Able to maintain most
ADLs. Son, [**Name (NI) **] is PCP at [**Name9 (PRE) 882**] and is quite involved with
care.
-No smoking
-No EtOH
-No recreational drugs
Family History:
Parents both died during war at young age. Unknown.
Physical Exam:
VS: T=97.9 BP=156/54 HR=55 (wenkebach) RR=16 O2 = 100 on
2L NC
GENERAL: lying in bed , in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: supple, no LAD, mandible, bruits.
CARDIAC: wenkebach, soft S1, S2. 3/6 SEM over R and L upper
sternal border. No r/g appreciable. No thrills, lifts. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB
ABDOMEN: Soft, NT, with large hernia and palpable mesh. No HSM
or tenderness.
EXTREMITIES: +2 pitting edema to shins bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
[**2194-7-21**] ECG: Sinus rhythm with variable Wenckebach periodicity
and P-R interval prolongation. Anterior ST segment depression.
Since the previous tracing of [**2181-3-6**] type I second degree A-V
block is new. Precordial ST segment depression is new.
.
Echo ([**7-23**])
VERY Suboptimal image quality. Preserved global left ventricular
function. Moderate functional mitral stenosis from severe mitral
annular calcification. At least mild mitral regurgitation. At
least mild pulmonary hypertension. Mild aortic stenosis.
.
CXR ([**7-23**])
AP VIEW OF THE CHEST: Intra-aortic balloon pump terminates 5.3
cm below the roof of the aortic arch. There is moderate
cardiomegaly. Bibasilar
atelectasis is noted in the setting of low lung volumes. There
is no effusion or pneumothorax. There is minimal vascular
engorgement without overt pulmonary edema.
.
CT Chest ([**7-23**])
IMPRESSION:
1. Normal caliber ascending thoracic aorta heavily calcified at
the annulus, with a gap in the calcification of the anterior
aortic wall.
2. Possible pulmonary arterial hypertension.
3. Hemodynamic significance of the aortic valvular calcification
is indeterminate.
4. Two lung lesions could be post-inflammatory or lung
carcinomas, particularly bronchioloalveolar cell. Suggest repeat
study in 6 months.
5. 2.5-cm right adrenal nodule, not fully evaluated by this
examination.
6. Small central calcifications in both kidneys could be
vascular or
papillary stones.
7. Inflated intra-aortic balloon pump extends below the level of
heavily
calcified superior mesenteric artery.
.
[**2194-7-24**] Intra-op TEE:
Overall left ventricular systolic function is normal (LVEF>55%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the aortic root. There are simple atheroma in the ascending
aorta. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. There is mild aortic valve stenosis (valve area
1.2-1.9cm2). Mild to moderate ([**1-26**]+) aortic regurgitation is
seen. There is mild valvular mitral stenosis (area 1.5-2.0cm2).
Mild (1+) mitral regurgitation is seen. Intraop TEE Post Bypass:
The patient is now s/p CABG. The patient is on a neosynephrine
drip @0.6 mcg/kg/min. LV function is preserved at>55% Mitral and
Aortic regurgitation are similar to prebypass. Proximal
ascending Aorta is intact post decannulation.
.
[**2194-8-6**] CXR: Compared with prior chest x-ray, there is
improvement of upper redistribution and lung vascular
congestion. Bilateral pleural effusions also seem to be
improved. No evidence of pneumothorax. The sternotomy wires are
intact and pacer leads are in the same position as they were
yesterday. Mediastinal silhouette and hilar contours are
unremarkable.
.
[**2194-7-21**] 07:30PM BLOOD WBC-7.8 RBC-3.81*# Hgb-10.8*# Hct-33.0*
MCV-87 MCH-28.4 MCHC-32.8 RDW-14.7 Plt Ct-222
[**2194-8-6**] 04:35AM BLOOD WBC-8.0 RBC-3.02* Hgb-9.1* Hct-26.4*
MCV-88 MCH-30.2 MCHC-34.5 RDW-14.8 Plt Ct-508*
[**2194-8-7**] 04:35AM BLOOD WBC-8.2 RBC-3.23* Hgb-9.6* Hct-29.3*
MCV-91 MCH-29.8 MCHC-32.8 RDW-14.8 Plt Ct-547*
[**2194-7-21**] 07:30PM BLOOD PT-12.4 PTT-26.8 INR(PT)-1.0
[**2194-8-4**] 04:25AM BLOOD PT-12.9 PTT-27.3 INR(PT)-1.1
[**2194-7-21**] 07:30PM BLOOD Glucose-131* UreaN-36* Creat-1.3* Na-142
K-4.8 Cl-106 HCO3-27 AnGap-14
[**2194-8-6**] 04:35AM BLOOD Glucose-150* UreaN-34* Creat-1.5* Na-140
K-4.7 Cl-103 HCO3-29 AnGap-13
[**2194-8-7**] 04:35AM BLOOD Glucose-118* UreaN-31* Creat-1.5* Na-139
K-4.6 Cl-100 HCO3-29 AnGap-15
[**2194-7-21**] 07:30PM BLOOD Calcium-9.3 Phos-3.7 Mg-2.3
[**2194-8-6**] 04:35AM BLOOD Calcium-8.2* Phos-4.6* Mg-3.0*
Brief Hospital Course:
Presented with episodes of chest pain and underwent cardiac
catheterization. She was found to have severe coronary artery
disease and intra aortic balloon pump was placed due to disease.
Additionally she was started on heparin and nitroglycerin
intravenous infusions and underwent preoperative workup. Her
preoperative workup included Chest CT to evaluate aortic
calcification and echocardiogram. On [**7-24**] she was brought to the
Operating Room for coronary artery bypass graft surgery. See
operative report for further details. Post operatively she was
transferred to the intensive care unit for post operative
management. Her intra aortic balloon pump was discontinued
within hours of surgery as hemodynamics were stable. She
remained intubated that evening and required vasoactive
medications for blood pressure management. She did have some
acute perioperative respiratory insufficiency with bibasilar
effusions and RLL collapse which resolved following
bronchoscopy. She was extubated on POD 3. Sedation was weaned
and the patient was confused initially. Narcotics were
minimized and confusion improved. EP was consulted for second
degree AV block and beta blockade was gently titrated as
tolerated. Subcutaneous heparin was administered for VTE
prophylaxis. Chest tubes were discontinued without complication.
She was found to be MRSA positive on routine screen and was
placed on appropriate precautions. Mid-line was placed for
access on [**2194-7-28**]. The patient discontinued her atrial pacing
wires on [**2194-7-30**] without incident. She continued to have second
degree heartblock (Wenckebach) as well as junctional rhythm with
pauses. The electrophysiology service recommended placement of a
pacemaker which was performed [**2194-8-4**]. Please see operative note
for details. The pacemaker was interrogated on [**2194-8-6**] and was
found to be functioning normally. Vancomycin was initially given
post-procedure but was switched to Augmentin upon discharge.
Antibiotics should continue for 10 days after discharge for
multiple erythematous incisions. Sternum was stable with mild
erythema at upper pole. In addition, there was mild erythema at
left ankle. As her creatinine had increased to 1.9, Lasix was
held and her renal function was followed. Creatinine trended
down and at discharge was 1.5. She worked with physical therapy
post-op for strength and mobility. On post-op day 14 she was
discharged to rehab with the appropriate medications and
follow-up appointments.
Medications on Admission:
Atenolol 25mg [**Hospital1 **]
Avapro 75mg daily
ASA 81mg daily
Plavix 75mg daily
Metformin 500mg daily
Lipitor 40mg daily
Fe 325mg daily
Cymbalta 60mg daily
Lasix 40mg daily
Amitiza 24mg [**Hospital1 **]
Nitro patch every other day
Tramadol 50mg qhs
norvasc 2.5mg daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
8. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
10. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days. Tablet(s)
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every four
(4) hours as needed for pain.
16. insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-119 mg/dL 0 Units 0 Units 0 Units 0 Units
120-159 mg/dL 2 Units 2 Units 2 Units 0 Units
160-199 mg/dL 4 Units 4 Units 4 Units 2 Units
200-239 mg/dL 6 Units 6 Units 6 Units 4 Units
240-280 mg/dL 8 Units 8 Units 8 Units 6 Units
17. Outpatient Lab Work
BUN and Creatinine [**8-12**]
18. diabetic medication
continue to hold on metformin due to creatinine
please continue with insulin sliding scale for blood glucose
management, goal BG < 120
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Coronary Artery Disease - s/p CABG
Second Degree Heart Block - Mobitz I/Wenkebach s/p PPM
Atrial fibrillation
Postop Lower Extremity Cellulitis
Postop Acute kidney injury
Methicillin resistant staph aueus - nasal screen
Diabetes Mellitus type 2
Hypertension
Hyperlipidemia
Obesity
Discharge Condition:
Alert and oriented x3 nonfocal - primary language Russian but
understands and speaks simple english
Ambulating with assistance
Sternal pain managed with tylenol as needed
Sternal Incision - mild erythema mid incision no drainage
Left leg EVH - mild erythema ankle area no drainage
Left subclavian pacer incision - remove dressing [**8-8**] no
erythema no drainage, steristrips intact
Edema: 1+ pitting edema bilaterally
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound check cardiac surgery office - [**Telephone/Fax (1) 170**]
[**Hospital **] medical building [**8-13**] at 10:45 am
Surgeon Dr. [**Last Name (STitle) 914**] Phone:[**Telephone/Fax (1) 170**] on [**2194-8-26**] 1:15
Cardiologist Dr. [**Last Name (STitle) 171**] Phone:[**Telephone/Fax (1) 62**] on [**2194-8-18**] 11:00
You will need device check next week - office will contact you
with appointment
Please call to schedule the following
Primary Care Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 93726**] in [**4-29**] 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:[**2194-8-7**]
|
[
"V85.38",
"426.13",
"584.9",
"311",
"934.1",
"997.5",
"518.5",
"278.01",
"250.00",
"427.31",
"682.6",
"998.59",
"V02.54",
"411.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61",
"33.24",
"37.72",
"37.61",
"37.83",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11356, 11516
|
6411, 8907
|
319, 879
|
11840, 12261
|
2552, 6388
|
13132, 13916
|
1800, 1853
|
9228, 11333
|
11537, 11819
|
8933, 9205
|
12285, 13109
|
1868, 2533
|
269, 281
|
907, 1400
|
1422, 1557
|
1573, 1784
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,861
| 172,888
|
22369
|
Discharge summary
|
report
|
Admission Date: [**2125-9-9**] Discharge Date: [**2125-9-11**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
DKA
Chest pain
Major Surgical or Invasive Procedure:
done
History of Present Illness:
Ms. [**Known lastname **] is 20 year old female with a past medical history
signifcant for type I DM, diagnosed 4 years ago, who has had
multiple admissions for DKA in the recent past. She was admitted
to [**Hospital3 1810**] from [**Date range (3) 58214**] with DKA and here
for DKA from [**Date range (1) 14790**]. In addition, she was complaining of RUQ
pain secondary to an enlarged liver although RUQ U/S was
negative.
Ms. [**Known lastname **] states that the day prior to admission she went out
to eat with cousins. Following the meal, she had 3 loose bowel
movements. At least 2 of her cousins reported abdominal pain as
well. The morning of admission, the patient awoke with stabbing
substernal chest pain and acute shortness of breath. She denies
pedal edema, palpitations, syncope, or presyncope.
Of note, Ms. [**Known lastname **] reports mild dysuria but denies increased
vaginal discharge. It seems possible that the DKA may have been
precipitated by a UTI or a gastroenteritis.
Past Medical History:
1. Diabetes Type I diagnosed in [**2120**] after her first pregnancy.
Most recent Hgb A1C 10.4 % ([**7-/2125**])
2. Hyperlipidemia
3. S/P MVA [**5-4**] - lower back pain since then. + back muscle
spasm treated with tylenol.
4. Goiter
5. Depression
6. DKA admissions
7. G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p
C-section in [**2122**], not menstruating secondary to being on
Depo-Provera shots
Social History:
Completed high school in [**2122**]. She has a two-year-old son with
her current partner. [**Name (NI) 1139**]: [**12-1**] ppd x 3 years. No EtOH. No
marijuana, cocaine, heroin or other recreational drugs.
Unemployed. Sexually active. 4 life partners. Currently
monogamous over 1 year.
Family History:
GM with Type I diabetes. Otherwise non-contributory. Relatives
with "acid in blood" not related to diabetes.
Physical Exam:
98.6, 110/58, 96, 18, 100% on RA
Gen: cooperative, in NAD
HEENT: MMM, OP clear, CN II- XII grossly intact
CV: RRR, no murmurs
Pulm: CTAB no wheezes or crackles
Abd: soft, NT ND + BS
Ext: WWP, DP 2+ bilaterally
Psych: flat affect, A+O x 3
Pertinent Results:
[**2125-9-9**] 06:32PM GLUCOSE-93 UREA N-12 CREAT-1.0 SODIUM-136
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-13* ANION GAP-18
[**2125-9-9**] 06:32PM CK(CPK)-69
[**2125-9-9**] 06:32PM CK-MB-1 cTropnT-<0.01
[**2125-9-9**] 06:32PM CALCIUM-8.8 PHOSPHATE-2.5*# MAGNESIUM-1.9
[**2125-9-9**] 11:15AM ALT(SGPT)-15 AST(SGOT)-17 CK(CPK)-82 ALK
PHOS-129* AMYLASE-44 TOT BILI-0.3
[**2125-9-9**] 11:15AM LIPASE-25
[**2125-9-9**] 11:15AM WBC-10.3# RBC-5.10# HGB-15.1# HCT-48.3*#
MCV-95 MCH-29.6 MCHC-31.3 RDW-13.4
RIGHT UPPER QUADRANT ULTRASOUND: Limited views of the liver are
unremarkable. The gallbladder is unremarkable without evidence
of stones, wall thickening, or pericholecystic fluid. The common
bile duct is not dilated and measures 2 mm.
IMPRESSION: No evidence of cholelithiasis or acute
cholecystitis.
Brief Hospital Course:
Ms. [**Known lastname **] is a 20 year old who presented with DKA and new
onset of atypical chest pain.
Endocrine: Ms. [**Known lastname **] presented with DKA. She was admitted to
the [**Hospital Unit Name 153**] where she was made NPO, aggressively fluid resucitated,
and started on an insulin drip with repletion of her potassium.
Her gap closed and her insulin drip was replaced with her home
glargine 28u qam and SSI humalog. She had a few other high
glucose readings arrival to the floor. She was given another
liter of NS and POs were encouraged. The patient carbohydrate
counts and managed her own insulin when she was back on the
floor. Her urine was sent for analysis and culture since she
complained of dysuria. The culture was pending at time of
discharge. [**Last Name (un) **] was involved in her care and their
recommendations were followed.
Cardiology: The patient has a history of hyperlipidemia and
atypical chest pain, so she was ruled out for MI. Aspirin and
atorvastatin were continued.
FEN: It appears that in the [**Hospital Unit Name 153**] she complained of right upper
quadrant pain. Labs were within normal limits and a RUQ U/S
showed no cholestasis or stones. The etiology of this pain is
not entirely clear. Ms. [**Known lastname **] has a history of GERD so her
protonix continued. It was thought that her atypical chest pain
may be due to dyspepsia. A trial of maalox resulted in relief of
symptoms.
Psych: The patient has baseline depression and anxiety so she
received ativan prn.
She was discharged home in good condition with followup at
[**Last Name (un) **] for both her diabetes and for her eye care.
Medications on Admission:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Insulin Glargine 100 unit/mL Solution Sig: One (1) 28
Subcutaneous once a day.
4. Insulin NPH Human Recomb 100 unit/mL Suspension, sliding
scale.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
3. Insulin Glargine 100 unit/mL Solution Sig: One (1) 28
Subcutaneous once a day.
4. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
[**1-9**] Subcutaneous four times a day: please see attached sliding
scale.
Discharge Disposition:
Home
Discharge Diagnosis:
DKA
hyperlipidemia
depression
dyspepsia
Discharge Condition:
good
Discharge Instructions:
Continue to take your home meds. Call your doctor if you feel
weak, nausea, vomitting, or abdominal pain. You had a urine
culture sent. Please ask your PCP to review the findings with
you.
Followup Instructions:
Please see Dr. [**First Name (STitle) 4375**] [**Name (STitle) 3617**] on [**9-17**] at 3:30 pm and you have an
eye appointment with Dr. [**First Name (STitle) **] on [**2125-10-2**] at 3pm. You had a urine
culture sent. Please ask your PCP to review the findings with
you. Please schedule follow up. UPHAMS CORNER HEALTH CTR
[**Telephone/Fax (1) 7538**]
|
[
"311",
"786.59",
"536.8",
"305.1",
"272.4",
"240.9",
"276.5",
"250.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5699, 5705
|
3320, 4966
|
322, 329
|
5789, 5795
|
2485, 3297
|
6032, 6390
|
2102, 2212
|
5309, 5676
|
5726, 5768
|
4992, 5286
|
5819, 6009
|
2227, 2466
|
268, 284
|
357, 1354
|
1376, 1783
|
1799, 2086
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,584
| 106,259
|
52191
|
Discharge summary
|
report
|
Admission Date: [**2102-3-7**] Discharge Date: [**2102-3-10**]
Service: [**Hospital1 **]
CHIEF COMPLAINT: This is a [**Age over 90 **]-year-old female admitted with
atrial fibrillation with a rapid ventricular response,
hypertension and electrocardiogram changes at Dialysis.
HISTORY OF PRESENT ILLNESS: On the day of admission, the
patient was at Dialysis and received two hours of treatment
when she became hypertensive and confused. She has a history
of similar complaints on an admission on [**2101-1-24**]. She
was brought to the Emergency Department. Heart rate was in
the 140s. Systolic blood pressure was 40. She was found to
be in irregular narrow complex rhythm and was given two
liters of normal saline. Attempts at cardioversion at 100,
200 and 360 joules failed to convert her to sinus rhythm.
Her blood pressure slowly rose to 95/50s with fluids and the
patient became increasingly response and interactive. An
attempt at a left subclavian line failed in the Emergency
Department. She was given 5 mg Lopressor intravenous for
persistent tachycardia without any change. Her blood
pressure became 70s/50s. She was given another liter of
normal saline for a total of 3 and transferred to the Medical
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. End stage renal disease from nephrolithiasis with
obstruction. She is receiving hemodialysis at [**Location (un) 4265**] and has
a right AV fistula. She is dialyzed Tuesday, Thursday and
Saturday.
2. Ulcerative colitis status post colectomy with ileostomy,
remote.
3. Paget's disease.
4. Peptic ulcer disease, status post hemigastrectomy.
5. History of cholecystectomy.
6. Osteoporosis.
7. Admitted [**2101-1-24**] for atrial fibrillation with rapid
response and lateral ST depressions with troponin leak
attributed to demand ischemia and renal failure.
Echocardiogram was done and was normal except for delayed
relaxation. She had no stress test or cardiac
catheterization because patient and family did not desire
revascularization. She was started on aspirin at that time.
8. Severe memory deficit and dementia.
9. Recent fall, [**2102-3-3**] with staples to forehead
laceration.
MEDICATIONS: Epogen 10,000 units subcutaneously q.
hemodialysis, Tums 500 mg po t.i.d. with meals. She was
discharged on aspirin [**2101-1-24**] but apparently not taking,
Ferrlecit at hemodialysis.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at home and has full time
[**Last Name (LF) 13222**], [**First Name3 (LF) **], who provides 24 hour care. She has a
distant tobacco history. She drinks one vodka tonic every
afternoon. Her cardiologist is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient had a son
nearby but he died within the last several years. Patient's
proxy is her [**Last Name (LF) 802**], [**Name (NI) 5627**] [**Name (NI) **], and she is closely
involved in her aunts care and transport.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 98.6. Heart rate 130.
Blood pressure 99/70. Respiratory rate 24. 100% on
nonrebreather. In general, patient is lying in bed in no
acute distress, staples to forehead, laceration clean, dry
and intact. Oropharynx is clear. Mucous membranes were dry.
Sclerae were anicteric. Neck was supple. Jugular venous
distention was 7-8 cm. Lungs were clear to auscultation
bilaterally. Cardiovascular: Irregular rhythm, tachycardic,
3/6 systolic ejection murmur blowing loudest at the apex.
Abdomen was soft with normal active bowel sounds, was
nondistended. There was a colostomy in place draining brown
stool, no edema. Extremities are warm. There was a fistula
in the right upper extremity. Neurologically, she was alert
and oriented times one and grossly nonfocal.
LABORATORIES ON [**3-3**]: White blood cell count 4.3,
hematocrit 35.3. Chem-7 notable for BUN of 28 and creatinine
of 5.7. Admission CK 45 with troponin of 1.1. Arterial
blood gases 7.39/35/87, lactate 3.1. CT of the head showed
no bleed or acute process. Chest x-ray showed no effusion
and no infiltrate. Electrocardiogram showed atrial
fibrillation at 150 with 1-[**Street Address(2) 1766**] depression in V4 to V6
which was new compared to [**2102-3-3**] except for the ST
depression in V4 which is old. After spontaneous conversion,
she was in normal sinus rhythm without ST depressions.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit with a diagnosis of hypertension and
atrial fibrillation resulting from the stress of
hemodialysis. She was given a 250 cc normal saline bolus, 20
mg of intravenous diltiazem and then placed on a drip at 8 mg
per hour, spontaneously converted to normal sinus rhythm at a
rate of 78 on the evening of the 12th. A right femoral line
was attempted but returned arterial blood and was removed
without complications. She was transferred to the [**Hospital1 139**]
Medicine Floor Team on [**3-8**]. She was seen by her
Cardiologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], that evening, who started her on an
amiodarone load hopefully to prevent recurrence of atrial
fibrillation at her next hemodialysis. Electrocardiogram
showed resolution of her ST depression after her atrial
fibrillation broke. CKs were elevated because of her
cardioversion with negative MB fractions and troponin.
She was stable throughout [**3-8**] and on [**3-9**] at
hemodialysis, she went back in atrial fibrillation with rapid
response, however, this time she held her blood pressure and
did not have mental status changes. She actually finished
the entire dialysis treatment. Back on the floor, systolic
blood pressure then dropped to 70s to 90s with a heart rate
in the 120s to 160s. After a long discussion with the
patient and her proxy, [**Name (NI) 5627**] [**Name (NI) **], the patient and proxy
desired the patient to be made "Do Not Resuscitate, Do Not
Intubate" with no CPR. This is in keeping with a decision
that she made previously when she was less demented. She is,
however, to be full care including shocks if she is not in
cardiac arrest. The patient at this point was then treated
with a total of 25 mg diltiazem in 5 mg intravenous boluses
and then placed back on diltiazem drip and again converted
back to normal sinus rhythm overnight.
The following morning she was at her baseline and was
receiving po diltiazem. She underwent echocardiogram
cardiography that morning which revealed new left ventricular
hypertrophy and 2+ mitral regurgitation plus ejection
fraction of greater than 60% and 2+ tricuspid regurgitation.
Prophylaxis throughout her stay was with Zantac and normal
diet and subcutaneous heparin, although, patient sometimes
refused the heparin despite explanation of its importance.
Because of her paroxysmal atrial fibrillation,
anticoagulation was considered but heparin was not initiated
and full dose aspirin is used instead because she is a frail
elderly patient with a history of recent fall with head
injury and because according to her proxy, comfort is her
primary goal. She is going home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Heart's
monitor to assess for recurrent atrial fibrillation and
monitor her q.d. amiodarone. Her home health aid and proxy
were advised that her nightly vodka tonic does place her at
risk for recurrent falls as the history is that she may have
fallen shortly after the vodka tonic.
DISCHARGE STATUS: "Do Not Resuscitate, Do Not Intubate" but
full care if not in cardiac arrest.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS:
1. Amiodarone 400 mg po b.i.d. times two days, 400 mg q.d.
times two weeks and then 200 mg po q.d.
2. Nephrocaps 1 po q.d.
3. Aspirin 325 po q.d.
4. Epogen 10,000 units subcutaneous at hemodialysis.
5. Tums 500 mg po t.i.d. with meals.
6. Diltiazem 30 mg q.i.d. converting to 120 mg extended
release on [**3-11**] a.m.
DISCHARGE FOLLOW-UP:
1. VNA to do home safety evaluation. Assess for need for PC
and hopefully remove the staples from her head laceration in
about one week.
2. With [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] regarding Cardiology issues and the results
of her [**Doctor Last Name **] of Heart's monitor.
3. Hemodialysis on Tuesday, Thursday and Saturday. At her
next dialysis on [**2102-3-11**], she should be monitored
closely for recurrence as she has now had atrial fibrillation
with two consecutive dialyses.
DISCHARGE DIAGNOSES:
1. Paroxysmal atrial fibrillation with rapid response
triggered by hemodialysis.
2. Dementia.
3. End stage renal disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2102-3-14**] 14:34
T: [**2102-3-14**] 14:34
JOB#: [**Job Number **]
|
[
"276.5",
"427.31",
"733.00",
"458.2",
"731.0",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7595, 7604
|
2966, 2984
|
8516, 8911
|
7627, 8495
|
4411, 7573
|
3007, 4393
|
117, 288
|
317, 1256
|
1278, 2418
|
2435, 2949
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,704
| 101,311
|
35929
|
Discharge summary
|
report
|
Admission Date: [**2144-1-12**] Discharge Date: [**2144-1-15**]
Date of Birth: [**2120-12-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
nasogastric tube placement
History of Present Illness:
Briefly, this is a ~30 yo unidentified male admitted to the ICU
after he became unrepsonsive in a police cruiser. He had been
picked up for breaking & entering a school.
.
His ED course was significant for myoclonic jerking. Neurology
was consulted and recommended EEG, which showed diffuse slowing
w/o focal abnormalities. Tox screen was positive for cocaine and
opiates. Toxicology saw the patient and advised conservative
care. ABG showed 7.37/42/126 on 20% FiO2.
.
He was admitted to the MICU where he was hemodynamically stable,
but continued to be unresponsive x 24 hours. On day of
admission, he had 1 episode of a.flutter which broke with
diltiazem and he did not have further episodes. He awoke on HD2
during NGT placement. He refuses to identify himself and reports
schizophrenia and not knowing his own identity. He was following
verbal commands. He was started on continuous EEG and MRI of his
head was without acute abnormalities.
.
Currently, he is awake and conversational. He endorses mild
chest pain with deep breath and mild SOB. He endorses breaking
into buildings - usually abandoned- and living in halls for the
past few years. He had used crack earlier day of admission, [**Male First Name (un) 239**]
denies breaking and entering the school. He will not identify
himself and denies recollection of events surrounding his
presentation. He is able to give some medical history as below.
C- spine cleared.
.
Review of sytems:
(+) Per HPI, also endorses occassionally hearing "voices".
(-) Denies chest pain or tightness, palpitations at baseline.
Denies fever, chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. No nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
h/o psychiatric illness - unknown but notes that he's seen
outpatient psychiatrist in the past as well as been in inpatient
psych.
- endorses having been raped at an inpatient psych facility
current crack use- will not disclose amount- endorses use day of
admission
current etoh use- will not disclose amount - says last drink was
"1 week prior" though he had +etoh level
h/o multiple stabbings- scar from abdomen is from when he was
little
G6PD +
Social History:
Has been breaking into buildings - usually abandoned-and living
in halls for the past few years. Has stayed at [**Location (un) 5131**]
shelter before. Denies having accessed primary care within the
past several years. Denies tobacco use.
Family History:
sister w/diabetes; mother passed away with complications of
sickle cell
Physical Exam:
Vitals: T 98, HR 72, BP 150/80, RR 20, 98% RA
General: in neck brace, police cuffs on hands/leg
HEENT: PERRL, sclera anicteric, oropharynx clear dry MM, + mild
conjunctival injection
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Large midabdominal scar noted, 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: oriented to situation, month, not aware of place, will
not disclose person
Psych: appropriate though he does endorse "voices"
Skin: No rash, multiple scars
Pertinent Results:
MICROBIOLOGY:
[**2144-1-12**], [**2144-1-13**] Blood Cx - no growth
Urine Cx - no growth
.
Imaging:
[**2144-1-12**] HEAD CT:
1. No intracranial hemorrhage or fracture.
2. Sinus disease, most significantly involving the right
maxillary sinus.
3. Punctate hyperdensity within the soft tissues overlying the
frontal
sinuses. Please correlate with physical exam for evidence of
foreign body
.
[**2144-1-12**] C-SPINE CT:
1. No fracture, malalignment or prevertebral soft tissue
swelling.
2. Degenerative changes at C5-6, with severe narrowing of the
right neural foramen and moderate narrowing of the left neural
foramen.
3. Osteophytes at C3-4 and [**3-29**] also narrow the spinal canal.
4. There is an old fracture of the C7 spinous process.
Brief Hospital Course:
This is an unfortunate young man who was admitted for
unresponsiveness that was likely feigned in the setting of being
arrested for breaking and entering. He was admitted to the ICU
in police custody for unresponsiveness. EEG was negative for
seizure activity, CT and MRI were negative for acute pathology
including stroke, hemorrhage, or evidence of trauma though MRI
revealed possible foreign body in his sinus.
He has a severe crack cocaine addiction and also abuses Etoh. He
had no evidence of withdrawal during his admission. He was seen
by our neurology service as well as psychiatric service. He
endorses "hearing voices" but the pscychiatric service did not
feel that he had pscychosis, likely again feigned in the setting
of his arrest. Social work consulted for his substance abuse
issues as well as his homelessness.
Upon admission, his CK levels were elevated but trended down
with diuresis. His cardiac enzymes were negative and EKGs were
with out ischemic changes.
He should be further assessed by the court clinical
psychiatrist.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
substance abuse
Homelessness
Discharge Condition:
stable
Discharge Instructions:
You were admitted for unresponsiveness which resolved on the
second day of your hospitaliztion. You were not found to have
any acute neurologic issues. You were evaluated by our
psychiatry service who felt that you should have further
evaluation by the court psychiatrist.
Please have further evaluation by the court psychiatrist.
Followup Instructions:
Further evaluation by court psychiatrist needed. Also, need for
assessment regarding medication regimen for psychiatric
disorder.
|
[
"333.2",
"305.00",
"728.88",
"305.50",
"304.20",
"V60.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5756, 5762
|
4626, 5672
|
330, 359
|
5835, 5844
|
3859, 3975
|
6224, 6357
|
3012, 3085
|
5727, 5733
|
5783, 5814
|
5698, 5704
|
5868, 6201
|
3100, 3840
|
277, 292
|
1833, 2267
|
387, 1815
|
3984, 4603
|
2289, 2739
|
2755, 2996
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,939
| 118,594
|
38435
|
Discharge summary
|
report
|
Admission Date: [**2182-6-26**] Discharge Date: [**2182-7-10**]
Date of Birth: [**2116-2-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2182-6-28**] cardiac catheterization
[**2182-7-1**] Pericardiectomy for constrictive pericarditis and
Mediastinal lymph node biopsy
History of Present Illness:
66 year old female from [**Country 11150**], who was admitted to outside
hospital complaining of shortness of breath along with severe
upper back and neck pain with a leukocytosis and an ECG showing
diffuse low voltage and tachycardia consistent with pericardial
effusion. Chest CT scan done ruled out dissection and pulmonary
embolism, but a moderate pericardial effusion was noted as well
as pathologic mediastinal adenopathy. Echocardiagram confirmed
pericardial effusion. No obvious tamponade was evident on
echocardiogram. She was transferred to [**Hospital1 18**] for further
evaluation and likely surgical intervention.
Past Medical History:
s/p hysterectomy
Social History:
Race: Asian
Lives with: visiting son from [**Name (NI) 11150**]
[**Last Name (NamePattern1) 1139**]:denies
ETOH:denies
Family History:
non contributory
Physical Exam:
Pulse: 110 Resp: 30 O2 sat: 98%
B/P Right: 169/77 Left:
Height: Weight:
General:A&Ox3, tachypneic at rest
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [](R) diminished/(L)greater
aeration
Heart: RRR [] Irregular [] Murmur -Muffled heart sounds
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left:2+
Pertinent Results:
[**2182-6-28**] Chest CT: . Bulky mediastinal lymphadenopathy.
Differential diagnosis is broad and includes lymphoma,
metastatic disease, small cell lung cancer, and granulomatous
processes such as sarcoid and granulomatous infection. 2.
Widened pericardial stripe with Hounsfield units greater than
simple fluid concerning for pericardial thickening and/or
complex pericardial effusion. Consider cardiac echo or cardiac
MRI for more complete assessment. Again, differential diagnosis
is broad and has been described above for the mediastinal lymph
nodes. 3. Bilateral pleural effusions. 4. Incompletely
characterized thickening of right adrenal gland. 5. Small right
breast lesion, possibly a cyst, but correlation with mammography
recommended if the patient has not undergone this examination
recently. 6. Nonspecific lung parenchymal findings, which could
relate to hydrostatic edema or a more chronic infiltrative
process.
[**2182-6-28**] Cardiac cath: 1. Selective coronary angiography of this
right dominant system demonstrated no angiographically apparent
flow limiting stenoses. The LMCA was without stenosis. The LAD
was without angiographically apparent stenosis. The Cx was
without stenosis. The RCA was without angiographically apparent
flow limiting stenosis. 2. Hemodynamic measurements revealed
equalization of end diastolic pressures and evidence of
ventricular interdependence consistent with a constrictive
pericarditis. There was elevated right and left sided filling
pressures with RVEDP of 25 mm Hg and mean PCWP of 24 mm Hg.
There was mild pulmonary hypertension of 43/24 mm Hg. The
cardiac index was preserved at 2.5 L/min/m2 (using an assumed
oxygen consumption). FINAL DIAGNOSIS: 1. Coronary arteries had
no angiographically apparent flow limiting disease. 2.
Constrictive pericarditis. 3. Biventricular diastolic
dysfunction. 4. Mild pulmonary arterial hypertension.
[**2182-7-1**] Echo: No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is a
trivial/physiologic pericardial effusion. The pericardium
appears thickened. There are no echocardiographic signs of
tamponade. The echo findings are suggestive of pericardial
constriction.
[**2182-7-9**] 03:27AM BLOOD WBC-10.7 RBC-3.76* Hgb-10.1* Hct-30.7*
MCV-82 MCH-26.8* MCHC-32.8 RDW-15.4 Plt Ct-617*
[**2182-6-26**] 05:34PM BLOOD WBC-15.7* RBC-4.77 Hgb-12.7 Hct-38.5
MCV-81* MCH-26.6* MCHC-32.9 RDW-15.1 Plt Ct-583*
[**2182-7-4**] 02:46AM BLOOD Neuts-78.9* Lymphs-11.6* Monos-4.6
Eos-4.5* Baso-0.4
[**2182-7-9**] 03:27AM BLOOD Plt Ct-617*
[**2182-6-26**] 05:34PM BLOOD Plt Ct-583*
[**2182-6-26**] 05:34PM BLOOD PT-13.7* PTT-28.7 INR(PT)-1.2*
[**2182-7-10**] 04:39AM BLOOD Glucose-104* UreaN-19 Creat-2.5* Na-135
K-4.6 Cl-98 HCO3-27 AnGap-15
[**2182-7-9**] 03:27AM BLOOD Glucose-126* UreaN-23* Creat-2.7* Na-137
K-5.0 Cl-99 HCO3-29 AnGap-14
[**2182-7-5**] 04:30AM BLOOD Glucose-106* UreaN-24* Creat-3.2* Na-133
K-5.5* Cl-97 HCO3-29 AnGap-13
[**2182-7-4**] 02:46AM BLOOD Glucose-132* UreaN-18 Creat-2.9* Na-132*
K-4.7 Cl-95* HCO3-29 AnGap-13
[**2182-7-2**] 01:45PM BLOOD UreaN-13 Creat-2.0* Na-134 K-5.2* Cl-97
[**2182-6-26**] 05:34PM BLOOD Glucose-120* UreaN-17 Creat-0.8 Na-135
K-4.9 Cl-97 HCO3-26 AnGap-17
[**2182-7-8**] 05:25AM BLOOD ALT-10 AST-19 LD(LDH)-230 AlkPhos-74
Amylase-61 TotBili-0.4
[**2182-7-8**] 05:25AM BLOOD Lipase-43
[**2182-7-10**] 04:39AM BLOOD Calcium-8.5 Phos-4.6* Mg-2.1
[**2182-6-26**] 05:34PM BLOOD Albumin-3.8 Calcium-9.1 Phos-3.1 Mg-2.1
[**2182-6-29**] 04:50AM BLOOD HIV Ab-NEGATIVE
[**2182-7-1**] 04:20AM BLOOD QUANTIFERON-TB GOLD-Test
[**2182-7-1**] 9:20 am TISSUE PERIAORITIC LYMPH NODE.
GRAM STAIN (Final [**2182-7-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2182-7-4**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2182-7-7**]): NO GROWTH.
ACID FAST SMEAR (Final [**2182-7-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
LEGIONELLA CULTURE (Final [**2182-7-9**]): NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2182-7-1**]):
INAPPROPRIATE SITE FOR PCP [**Name Initial (PRE) **].
TEST CANCELLED, PATIENT CREDITED.
Time Taken Not Noted Log-In Date/Time: [**2182-7-1**] 11:53 am
TISSUE Site: PERICARDIUM
GRAM STAIN (Final [**2182-7-1**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2182-7-4**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2182-7-7**]): NO GROWTH.
ACID FAST SMEAR (Final [**2182-7-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2182-7-1**]):
NO FUNGAL ELEMENTS SEEN.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
Time Taken Not Noted Log-In Date/Time: [**2182-7-1**] 11:53 am
TISSUE Site: PERICARDIUM
GRAM STAIN (Final [**2182-7-1**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2182-7-4**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2182-7-7**]): NO GROWTH.
ACID FAST SMEAR (Final [**2182-7-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2182-7-1**]):
NO FUNGAL ELEMENTS SEEN.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
[**2182-7-1**] 9:02 am PLEURAL FLUID RIGHT PLEURAL FLUID.
GRAM STAIN (Final [**2182-7-1**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2182-7-4**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2182-7-7**]): NO GROWTH.
ACID FAST SMEAR (Final [**2182-7-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2182-7-2**]):
NO FUNGAL ELEMENTS SEEN.
VIRAL CULTURE (Final [**2182-7-1**]):
QUANTITY NOT SUFFICIENT.
PATIENT CREDITED.
Brief Hospital Course:
She was transferred in for surgical evaluation and underwent
preoperative workup. Her workup revealed constrictive
pericarditis, pericardial effusion without tamponade physiology
and mediastinal adenopathy. Due to shortness of breath she was
aggressively diuresed preoperatively. She was placed in
isolation room for possible tuberculosis which was changed after
negative sputum cultures were obtained and infectious disease
was consulted. On [**2182-7-1**] she was brought to the operating room
where she underwent a pericardiectomy and mediastinal lymph node
biopsy. Please see operative report for surgical details.
Following surgery she was transferred to the intensive care unit
for invasive monitoring in stable condition. Within 24 hours she
was weaned from sedation, awoke neurologically intact and was
extubated without complications. Initially postoperatively her
urine output was decreased and she received fluid boluses with
response, however her creatinine progressively increased that
day and over the next few days with peak creatinine 3.2 and now
down to 2.5 on day of discharge with plan for follow up labs
tuesday [**2182-7-16**]. Renal service followed her for the acute renal
failure in hospital and plan for follow up with primary care
physician at [**Name9 (PRE) **] health for continued management, and refer
back to outpatient renal service if renal function worsens. She
started increasing her activity level and was transferred to the
floor on POD #3. Physical therapy worked with her on strength
and mobility. She continued to progress, was treated with
antibiotics for urinary tract infection. Infectious disease
continued to follow her for appropriate treatment course based
on culture data from operating room. Due to acute renal failure
and risk with medications to worsen renal function, plan to
recheck renal function as outpatient and follow up in infectious
disease clinic for treatment. She was ready for discharge home
on post operative day nine with follow up wound check, labs and
new primary care appointment for [**2182-7-16**] which she and her
family are aware and agree with plan.
As there is no coronary artery disease and no record of elevated
cholesterol preoperatively, no indication for statin at this
time. She will need regular medical care follow up including
cholesterol screening
Lymph node biopsy was negative, so no further follow with Dr
[**First Name (STitle) **] from Thoracic surgery
Medications on Admission:
none
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
every eight (8) hours as needed for pain.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Constrictive pericarditis
s/p Pericardiectomy and mediastinal lymph node biopsy
Acute renal failure
Urinary tract infection
osteoarthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with walker
Incisional pain managed with tylenol prn
Incisions:
Sternal - healing well, no erythema or drainage
Edema trace bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**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
Lab work: Chem 7 - please have drawn in outpatient lab tuesday
[**7-16**]
outpatient lab is in the [**Hospital **] medical building [**Location (un) 448**]
prior to wound check
Wound check - [**7-16**] at 11am - please come to [**Hospital Ward Name **] 6 nurses
station
[**Telephone/Fax (1) 3071**]
[**Hospital 778**] health center -
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 780**] tuesday [**7-16**] at 12:30 pm
Dr [**First Name (STitle) **] [**Name (STitle) **] tuesday [**7-16**] at 1:40 pm
Surgeon: Dr. [**Last Name (STitle) **]( for Dr. [**First Name (STitle) **]at [**Hospital1 **] on Thursday
[**7-25**]
@ 9:00 AM [**Telephone/Fax (1) 6256**]
Dr [**Last Name (STitle) 85577**] [**Name (STitle) **] Infectious Disease [**Telephone/Fax (1) 457**] - [**Hospital **]
medical building - Date/Time:[**2182-7-26**] 11:30
Please call to schedule appointments :
Cardiologist Dr. [**Last Name (STitle) 20683**] in [**12-22**] weeks [**Telephone/Fax (1) 6256**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2182-7-10**]
|
[
"423.2",
"584.9",
"428.31",
"511.9",
"785.6",
"599.0",
"416.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"38.93",
"37.23",
"39.61",
"88.56",
"37.31",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
12042, 12061
|
8912, 11368
|
294, 431
|
12244, 12442
|
1961, 3650
|
13280, 14599
|
1280, 1298
|
11423, 12019
|
12082, 12223
|
11394, 11400
|
3667, 6367
|
12466, 13257
|
1313, 1942
|
8615, 8646
|
8679, 8889
|
235, 256
|
459, 1088
|
1110, 1128
|
1144, 1264
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,460
| 168,270
|
48245
|
Discharge summary
|
report
|
Admission Date: [**2174-12-22**] Discharge Date: [**2175-1-11**]
Date of Birth: [**2125-6-25**] Sex: F
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Colocutaneous fistula
Major Surgical or Invasive Procedure:
1. Takedown of Colocutaneous fistula with closure of colonic
defect
2. Ventral Hernia repair
History of Present Illness:
Pt is a 49 yo female with multiple medical problems, who
presented to [**Hospital1 18**] on [**12-22**] for elective repair of both a
colocutaneous fistula and a ventral hernia.
Past Medical History:
1. Colocutaneous Fistula
2. Right total knee replacement in [**2173-2-16**], complicated by
infection, s/p 6 surgeries, most recently [**7-22**].
3. Pulmonary embolus with anticoagulation, complicated by large
retroperitoneal bleed.
4. Chronic abdominal pain.
5. Depression, anxiety.
6. Polysubstance abuse.
7. Morbid obesity.
8. Hep C Cirrhosis with undetectable viral load
9. Multiple abdominal hernias which have been repaired.
10. Iron deficiency anemia.
11.Nephrolithiasis.
12.Cardiomyopathy with EF 35%.
13.Degenerative Joint Disease.
14.S/p CCY
15.Chronic narcotic use.
16. Hypertension.
17. Nl C-scope and EGD in [**8-21**]
Social History:
Pt reports that she lives alone. She has a 50-60 pack-year
smoking history. She denies etoh use. She reports a history of
heroin use from age 36 to 45. She also reports a past history
of opiate and barbituate abuse.
Family History:
F: MI, died at 54 brain and lung cancer
M: MI in 89 from brain aneurysm
Sister: died breast cancer in 50s
Brother: lymphoma
Brother: colon cancer
Brother: Prostate cancer
Sister: MI at 52
No DM in family.
2 healthy children
Physical Exam:
General: alert, oriented, obese, comfortable, with some SOB at
baseline
HEENT: PERRLA, normocephalic; no JVD, LAD, or hyromegaly noted.
Chest: clear to auscultation bilaterally
CV: RRR without murmur noted
Abdomen: obese, prominent ventral hernia, soft, nontender
Brief Hospital Course:
Ms. [**Known lastname 101537**] presented to [**Hospital1 18**] for elective repair of both a
colocutaneous fistula and ventral hernia on [**2174-12-22**]. Pt
underwent surgery repair of her colocutaneous fistula and
ventral hernia on the same day, by a combined effort between the
general surgery service led by Dr. [**Last Name (STitle) 519**], and the plastic surgery
service led by Dr. [**First Name (STitle) **]. The pt tolerated the procedure well.
After recovery in the [**Name (NI) 13042**], pt was transferred to the floor in
stable condition. Postoperatively, Ms. [**Known lastname 101537**] was noted to
have worsening SOB. CXR revealed worsening opacity of RLL
consistent w/ pneumonia with some component of fluid overload.
She was started on levaquin. Diuresis was initiated with lasix.
However, she continued to be dyspneic, and on POD 3, it was
noted that she was increasingly somnolent. ABG obtained
revealed a pCO2 of 72. She was transferred to the ICU, and she
intubated for respiratory failure. Ms. [**Known lastname 101537**] would remain
intubated in the unit for several more days on antibiotics for
pneumonia. Sputum cultures from [**12-30**] grew out MRSA, and she was
started on Vancomycin. She also was aggressively diuresed for
volume overload. However, throughout her ICU stay, she remained
clinically stable. On POD 16, she was weaned from the
ventilator and extubated, which she tolerated well. She
remained clinically stable following extubation. She continued
working with physical therapy. Her wound area continued to
remain well-healing, with the exception of a small area of
necrosis along the inferior portion of her wound, which should
slough and heal well. She was discharged to rehab for further
care on [**1-10**], in stable condition.
Discharge Medications:
1. Hydromorphone HCl 2 mg/mL Syringe Sig: One (1) Injection
Q4-6H (every 4 to 6 hours) as needed.
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Venlafaxine HCl 75 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
4. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
9. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours).
10. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
11. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
12. Methadone HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous [**Hospital1 **] (2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Colocutaneous fistula
Ventral Hernia
Respiratory failure
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
Please take medications as prescribed. Continue low sodium
diet. Seek medical atttention immediately if you experience
fever, chills, nausea, vomiting, increased abdominal pain, or
shortness of breath. Leave your JP drains in place until you
follow-up with Dr. [**First Name (STitle) **] from plastic surgery. Keep abdominal
binder in place.
Followup Instructions:
Please call Dr.[**Name (NI) 1745**] office at [**Telephone/Fax (1) 6554**] within the next
week after discharge to rehab to schedule a follow-up
appointment. Also, please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 1416**] within the next week after discharge to rehab to
schedule a follow-up appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"427.1",
"E878.4",
"300.4",
"V09.0",
"568.0",
"304.01",
"425.4",
"278.01",
"569.81",
"041.04",
"518.5",
"V16.3",
"V43.65",
"997.3",
"553.21",
"401.9",
"V12.51",
"305.1",
"250.00",
"482.41",
"728.84",
"070.70",
"428.0",
"V17.3",
"518.0",
"280.9",
"V09.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"99.77",
"99.62",
"38.93",
"86.83",
"94.49",
"96.04",
"46.76",
"54.59",
"83.65",
"53.61",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5045, 5051
|
2029, 3821
|
289, 385
|
5165, 5173
|
5567, 6059
|
1499, 1725
|
3844, 5022
|
5072, 5144
|
5197, 5544
|
1740, 2006
|
228, 251
|
413, 592
|
614, 1247
|
1263, 1483
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,588
| 105,759
|
52995
|
Discharge summary
|
report
|
Admission Date: [**2109-12-15**] Discharge Date: [**2109-12-20**]
Date of Birth: [**2028-4-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Abdominal pain and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81M with history of CAD s/p MI x 4 per patient (no PCI or
interventions), CVA, presenting with two days of abdominal pain
and nausea without chest pain or dyspnea. Pain started 2 days
PTA, felt he had to go to BR. Took maalox for pain. Did not
take any of his medications that day and poor PO intake. Pain
returned on day prior to admission (?unclear if resolved in
interim); went into OSH. He went to OSH where had CXR showing ?
free air. Cardiac enzymes found to be high; also with renal
failure and hyperkalemia. Given ASA 325 mg PO and zosyn for
?infiltrate on CXR.
.
In the ED, initial vs were: T98.1 70 130/84 18 98%. CT
concerning for SBO. NGT placed. Cardiac enzymes positive.
Cards and surgery consulted. Patient was given plavix 300 mg,
and heparin gtt started.
.
On the floor, patient quite lethargic. Does arouse to loud
voice and tactile stimulation, but easily falling asleep.
Unclear if he is currently having pain.
Past Medical History:
- CAD s/p MI x 4 prior per patient/wife.
- CVA [**2109-10-6**] - residual deficits affects speech as well
as weakness; initially involved more one side than other.
Speech - when excited tends to slur speech together.
- HTN
- CHF (details unknown)
- CKD (creatinine 1.7 from [**2098**]-[**2101**] - last records)
- History of prostate surgery 8 years ago
Social History:
Lives with wife; had been at rehab after hospital stay for
stroke. She often has to push him to move around the house a
lot, take meds, eat. Balance poor since stroke (supposed to use
walker or cane).
- Tobacco: ? remote history
- Alcohol: none recent
- Illicits: none
Family History:
Non-contributory
Physical Exam:
General: Lethargic but arousable, seems to become more lethargic
with repeated stimulation; more awake and interactive when first
being awoken.
HEENT: Sclera anicteric, PERRL but somewhat resists opening of L
eye, MM slightly dry, oropharynx clear. NGT in place.
Neck: supple, JVD appears 2 cm ASA, no LAD, supple.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, S4 present, no
murmurs.
Abdomen: distended, slightly firm, minimal bowel sounds,
tympanic throughout. Mild to moderate diffuse tenderness to
palpation, no guarding ro rebound.
Ext: cool feet and hands, 2+ pitting edema of bilateral LEs,
some chronic venous stasis changes.
Neuro: Oriented to [**Hospital3 4107**], not able to specify date.
Very lethargic but arousable, though falling asleep easily.
Moves all extremities to command but unable to participate in
formal strength testing.
Pertinent Results:
Admission labs: [**2109-12-15**]
WBC-9.4 RBC-4.81 Hgb-14.2 Hct-43.4 MCV-90 MCH-29.5 MCHC-32.7
RDW-16.2* Plt Ct-221
PT-14.5* PTT-24.9 INR(PT)-1.3*
Glucose-108* UreaN-49* Creat-1.9* Na-145 K-5.4* Cl-107 HCO3-23
AnGap-20
ALT-38 AST-56* CK(CPK)-491* AlkPhos-77 TotBili-1.4
.
Other Pertinent labs:
[**2109-12-15**] 09:10PM BLOOD CK-MB-35* MB Indx-7.1*
[**2109-12-15**] 09:10PM BLOOD cTropnT-0.38*
[**2109-12-16**] 04:52AM BLOOD CK-MB-21* MB Indx-6.6* cTropnT-0.36*
[**2109-12-16**] 03:45PM BLOOD CK-MB-15* MB Indx-4.5 cTropnT-0.46*
.
Discharge Labs: [**2109-12-20**]
OD Glucose-67* UreaN-24* Creat-1.2 Na-144 K-3.7 Cl-105 HCO3-32
AnGap-11
WBC-5.1 RBC-4.42* Hgb-12.2* Hct-38.6* MCV-87 MCH-27.7 MCHC-31.7
RDW-16.3* Plt Ct-230
Phos-2.0* Mg-1.9
.
CT abd/pelvis: moderate R pleural effusion, small L effusion
with atelectasis. RLL ?aspirated barium. stomach dilated and
dilated small bowel loops, more distal loops decompressed -
concerning for SBO. no clear transition point. no free air
.
CT head: no hemorrhage, edema, mass effect. chronic small
vessel ischemic disease, old infarcts seen (R parietal lobe)
.
CXR: no lines/tubes. cardiomegaly. bilateral atelectasis.
dilated stomach and colon.
.
EKG: NSR at 84, LBBB with associated ST segment and T wave
changes. No significant change compared to priors from ED and
OSH ED. \
.
Echo: [**2109-12-16**]
Left ventricular cavity dilation with severe global dysfunction
c/w multivessel CAD or diffuse process (toxin, metabolic, etc.).
LVEF <20 %. The prominent trabeculations raises the possibility
of Non-compaction Syndrome. Right ventricular dilation with free
wall hypokinesis. Pulmonary artery systolic hypertension.
Dilated ascending aorta.
Brief Hospital Course:
81 yo M with history of CAD, CVA, admitted with NSTEMI, SBO, and
lethargy.
.
# NSTEMI/CAD. The patient was found to have elevaated troponins
prior to transfer. On arrival to [**Hospital1 18**] CD 419, MB index 7,
Troponin 0.36. ECG with LBBB, but did get documentation that
this is old (past ECG in chart). Cardiology was consulted while
patient was in the MICU and recommended to continue medical
management of CAD with ASA, plavix, ace-inhibitor, high dose
statin, b-blocker and also continuing heparing gtt for 48 hours.
They felt the elevated troponin leak was less likely to be from
ACS and more likely from demand. Heparin drip was stopped after
48 hours and he continued to be chest pain free on medical
management. TTE demonstrated an EF of 20%. His tropol XL was
increased to 75mg daily, he was started on lisinopril 10mg
daily, continued on atorvastatin 80mg. His aspirin was increased
to 325mg and plavix 75mg daily was started. The patient should
undergo cardiac rehabilitation upon discharge from [**Hospital1 1501**] as well
as continued physical therapy. During rehabilitation please
watch for symptoms of chest pain, shortness of breath, syncope,
palpitations. His work effort should be advanced slowly with
monitoring for the development of symptoms. He was restarted on
lasix and is being discharged on lasix 80mg twice daily (prior
home dose 40mg twice daily). His weight should be monitored
daily and consider dose increase with weight increase of 3lb.
Please check his chemistry on [**12-23**] and replete K if needed.
Please also monitor BUN/Cr on increased dose of lasix and
lisinopril.
.
# Abdominal pain/SBO. Unclear precipitant. No known surgical
history other than prostatectomy. No identified transition
point from CT, but does have distal decompressed bowel. Patient
with benign exam and CT only suggestive of SBO without other
process. General surgery followed patient during hospitalization
and recommended no acute surgical intervention along with serial
abdominal exams. Patient's abdominal pain resolved after having
a bowel movement. A NGT was also placed and put on intermittent
low suction. After low residuals were observed, the NG tube was
clamped and later removed. His diet was advanced to low
sodium/cardiac heart healthy. He tolerated solid foods well with
no abdominal pain prior to discharge. The patient was also
having normal bowel movements.
.
# Lethargy. Baseline per wife as above. Generally is able to
get up and ambulate; speech deficits and generalized weakness at
baseline. Also noted by wife to be intermittently lethargic and
falls asleep easily. Head CT negative for acute process.
.
# Renal failure. Possible mild acute component on chronic, but
unclear what actual baseline is. Was 1.7 in [**2101**]. The patient
was given IVF fluids and his Cr improved to 1.2 prior to
discharge.
.
# Acute systolic CHF: Echo done and shows EF of 20%. Patient
on appropriate CHF medications (see NSTEMI/CAD above). Due to
being fluid overload on exam, his lasix dose was increased once
his kidney function improved. He responded well to diuresis with
no increase in his Cr. His lasix dose has been increased to 80mg
po BID for continued lower extremity edema. Please check chem 7
on [**12-23**]
.
# O2 requirement: Initially required 2-3L NC. This is likely [**1-7**]
CHF. The patient was diuresed as indicated above. He was
discharged on room air.
.
# Communication: Patient and wife [**Telephone/Fax (1) 109246**]
Medications on Admission:
- ASA 81 mg daily
- Toprol XL 25 mg daily
- Lasix 40 mg [**Hospital1 **]
- NTG 0.2 mg/hr patch q24
- atorvastatin 80 mg daily.
- cozaar 50 mg daily
Discharge Medications:
1. Cardiac rehabilitation
Please refer to cardiac rehabilitation
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal once a day.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 40 mg Tablet Sig: Two (2) Tablet PO twice a day.
9. Outpatient Lab Work
Please check chemistry 7 on [**2108-12-23**].
Discharge Disposition:
Extended Care
Facility:
[**Known lastname 13990**] Health Care
Discharge Diagnosis:
Primary Diagnosis:
Small bowel obstruction
NSTEMI
.
Secondary Diagnosis:
CAD
CVA
HTN
Chronic systolic CHF : EF < 20%
CKD
History of prostate surgery 8 years ago
Discharge Condition:
Stable. cooperative, needs assistance of ambulations.
Discharge Instructions:
You were admitted to the hospital with abdominal pain and a
heart attack. Your abdominal pain was due to a small bowel
obstruction which was treated with supportive care and resolved.
Cardiologists evaluated you while in the hospital. We treated
your heart attack with a blood thinner, heparin. Your cardiac
function has worsened and we have increased your cardiac
medications to help improve your heart's function. Please see
below. You should follow up with Dr. [**Last Name (STitle) **] after your
discharge. An appointment has been made for you.
Physical therapists worked with you and recommended that you go
to a rehabilitation facility.
We made the following changes to your medications:
1) Stop Cozaar
2) Start lisinopril 10mg by mouth once a day
3) Increase Aspirin to 325mg by mouth once a day
4) Start Plavix 75mg by mouth once a day
5) Increase Toprol XL to 75mg by mouth once a day
6) Increase lasix to 80mg twice daily - Your lasix has been
increased. You should be weighed daily and your dose of lasix
should be changed if your weight changes by more than 3 lbs.
Followup Instructions:
MD: [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Specialty: Internal Medicine/ Cardiovascular Disease
Date/ Time: [**Last Name (LF) 2974**], [**1-3**], 3:45pm
Location: [**Street Address(2) **], [**Hospital1 **] - [**Location (un) 470**]
Phone number: [**Telephone/Fax (1) 4475**]
Completed by:[**2109-12-20**]
|
[
"438.89",
"560.9",
"403.90",
"428.0",
"584.9",
"414.01",
"410.71",
"276.7",
"438.19",
"585.3",
"428.23",
"728.89",
"416.8",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9211, 9276
|
4696, 8169
|
346, 353
|
9481, 9537
|
2977, 2977
|
10665, 10995
|
2006, 2024
|
8368, 9188
|
9297, 9297
|
8195, 8345
|
9561, 10229
|
3522, 3962
|
2039, 2958
|
10258, 10642
|
277, 308
|
381, 1325
|
3971, 4673
|
9370, 9460
|
2993, 3248
|
9316, 9349
|
3270, 3506
|
1347, 1702
|
1718, 1990
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,619
| 156,730
|
50227
|
Discharge summary
|
report
|
Admission Date: [**2156-8-18**] Discharge Date: [**2156-8-24**]
Date of Birth: [**2073-6-26**] Sex: F
Service: MEDICINE
Allergies:
Zithromax
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
Hypotension and Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is an 83-year-old Russian-speaking woman with a past
medical history of CAD s/p CABG, atrial fibrillation on warfarin
and amiodarone, 2:1 AV block s/p pacer, systolic CHF (EF 40%),
hypertension, and hypothyroidism, who presented to the ED today
for evaluation of chest pain and elevated blood pressure. The
patient c/o left-sided chest pain, described as a gnawing pain,
worse with deep inspiration, and associated with shortness of
breath today. She took her blood pressure at the time and noted
it to be 170/90 (up from her baseline SBPs of 140), so she took
her double her usual dose of Norvasc. Her blood pressure
improved, but her chest pain continued, so she took 1 sublingual
nitroglycerin, which also did not help her chest pain. She
denied any radiation of the pain, any cough or fevers.
.
She does acknowledge nighttime "spasms" that have been occurring
nightly x2-3weeks. She denies any pain, and notes that the
spasms have been worse in her legs than in her arms. She has
found relief for these spasms with Ambien, which has helped her
relax and then allowed her to sleep. Review of systems is
otherwise completely negative.
.
In the ED: VS - Temp 100.5 F, BP 85/60, HR 100, R 18, O2-sat 99%
RA. Exam was unremarkable, but labs showed a WBC of 12.2 with
neutrophilic predominance, INR 2.4, Cr 1.7 (baseline). UA was +
LE and nitrite with 21-50 WBC and many bacteria. CXR showed a
probable pneumonia in the RML and ? LLL. Trop was elevated to
0.31. [**Hospital Unit Name 196**] was consulted, who felt that the pt did not need a
heparin gtt and that the troponin leak was in the setting of her
renal failure and ongoing infections. She is being admitted to
the ICU for further care given her low blood pressures,
infections, and troponin leak.
Past Medical History:
1. CAD - s/p 2V CABG [**4-/2145**] to OM/CX and to RCA. Recath [**8-/2145**] -
occluded RCA [**Last Name (LF) **], [**First Name3 (LF) **] OM [**First Name3 (LF) **] disease, previously diseased
LCx and LAD free of disease (followed by Vainov/[**Doctor Last Name **])
2. Atrial fibrillation on warfarin and amio
3. s/p DDD pacer for 2:1 AV block
4. Hypertension
5. Hyperlipidemia
6. Peptid Ulcer Disease
7. Glaucoma
8. Hypercalcemia [**2-7**] hyperparathyroidism - s/p parathyroid
resection in '[**28**]'s now with recurrence; noted to have new large
complex left-sided thyroid nodule (inconclusive biopsies) -
followed by Endocrine
9. s/p TAH/BSO
10. Osteoporosis
11. h/o neurogenic bladder, urethral stricture
12. Hyperplastic colonic polyps
13. h/o mod MR, mild PAH, LAE (TTE [**2144**])
14. Congestive heart failure, systolic, EF 40%
15. Hypothyroidism
Social History:
She lives alone in an apartment in [**Location (un) 86**] and cares for herself.
Son and daughter live nearby. Husband died last year. She denies
any tobacco or EtOH use. Retired ENT physician from [**Country 532**].
Family History:
Non-contributory
.
Physical Exam:
VS - afebrile, BP 95/46, HR 83, R 20, O2-sat 97% 2L NC
GENERAL - well-appearing elderly woman in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, mildly dry MM,
OP clear
NECK - supple, no thyromegaly or JVD
LUNGS - decreased BS on left, otherwise CTA bilat, no r/rh/wh,
good air movement, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 1+ DPs, 2+ radials
NEURO - awake, A&Ox3, non-focal and grossly intact throughout
Pertinent Results:
Admission Labs:
[**2156-8-18**] 05:10PM WBC-12.2*# RBC-3.41* HGB-8.7* HCT-27.0*
MCV-79* MCH-25.5* MCHC-32.2 RDW-15.9*
[**2156-8-18**] 05:10PM NEUTS-86.2* LYMPHS-7.0* MONOS-6.6 EOS-0.1
BASOS-0
[**2156-8-18**] 05:10PM PLT COUNT-294
[**2156-8-18**] 05:10PM PT-24.5* PTT-30.2 INR(PT)-2.4*
[**2156-8-18**] 05:10PM DIGOXIN-0.8*
[**2156-8-18**] 05:10PM CALCIUM-9.2 PHOSPHATE-2.4* MAGNESIUM-2.2
[**2156-8-18**] 05:10PM CK-MB-NotDone
[**2156-8-18**] 05:10PM cTropnT-0.31*
[**2156-8-18**] 05:10PM CK(CPK)-43
[**2156-8-18**] 05:10PM estGFR-Using this
[**2156-8-18**] 05:10PM GLUCOSE-109* UREA N-33* CREAT-1.7* SODIUM-134
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-14
[**2156-8-18**] 05:40PM URINE RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0
[**2156-8-18**] 05:40PM URINE BLOOD-SM NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2156-8-18**] 05:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2156-8-18**] 05:43PM LACTATE-1.0
.
Pertinent Labs:
[**2156-8-20**] 04:40AM BLOOD WBC-7.2 RBC-3.25* Hgb-8.7* Hct-26.7*
MCV-82 MCH-26.7* MCHC-32.4 RDW-16.0* Plt Ct-204
[**2156-8-24**] 05:13AM BLOOD WBC-7.1 RBC-3.45* Hgb-8.9* Hct-28.5*
MCV-83 MCH-25.9* MCHC-31.4 RDW-15.3 Plt Ct-218
[**2156-8-23**] 07:26AM BLOOD Neuts-72.5* Lymphs-17.7* Monos-7.1
Eos-2.5 Baso-0.2
[**2156-8-20**] 04:40AM BLOOD Glucose-95 UreaN-26* Creat-1.4* Na-139
K-4.0 Cl-109* HCO3-20* AnGap-14
[**2156-8-24**] 05:13AM BLOOD Glucose-86 UreaN-28* Creat-1.5* Na-144
K-3.9 Cl-112* HCO3-24 AnGap-12
[**2156-8-18**] 05:10PM BLOOD cTropnT-0.31*
[**2156-8-19**] 01:32AM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2156-8-19**] 04:10AM BLOOD CK-MB-NotDone cTropnT-0.17* proBNP-[**Numeric Identifier 7577**]*
[**2156-8-20**] 04:40AM BLOOD Calcium-9.4 Phos-2.8 Mg-2.1
[**2156-8-24**] 05:13AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.4
.
CXR [**8-18**]:Right basilar opacity concerning for pneumonia
.
ECG 8/13Sinus rhythm with regular ventricular demand pacing.
[**Month/Year (2) **] rhythm - no further analysis
.
TTE: [**2156-8-19**]
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with severe hypokinesis of the distal [**1-8**]
of the left ventricle (LVEF 40-45%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade II (moderate)
LV diastolic dysfunction. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size is normal. with
focal hypokinesis of the apical free wall. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. Significant pulmonic
regurgitation is seen. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension.
Compared with the prior study (images reviewed) of [**2155-11-18**],
the left ventricular systolic function is similar (diastolic
function is worsened). The severity of mitral regurgitation and
tricuspid regurgitation may have increased. The estimated
pulmonary artery systolic pressure also increased.
Brief Hospital Course:
83-yo Russian-speaking woman w/ h/o CAD s/p CABG, A-fib,
AV-block s/p pacer, sCHF, HTN, and hypothyroidism, who p/w chest
pain that has since resolved, but also w/ hypotension, UTI,
pneumonia, and a troponin leak.
.
#. Hypotension - The patient originally presented to [**Hospital1 18**] with
hypotension to SBP 90s, down from her baseline in the 140s. Per
report of the patient, she had noted elevated SBPs to 170s-180s
in the setting of her chest pain and took double her prescribed
dose of Norvasc. Upon presentation to the ED, the patient given
2L of NS and which alleviated her hypotension and maintained her
urine output. The patient was originally sent to the MICU to r/o
septic etiologies for her hypotension, but was subsequently
transferred to the floor once her BP normalized. The patient's
BP was stable for the rest of her hospital course. She was
restarted on her home beta blocker. Her Aldactone was restarted
at half her home dose the night before discharge/
.
#. Pneumonia - The patient presented with symptoms of pleuritic
chest pain, shortness of breath, and cough. X-ray shows hazy
right heart border and linear atelectasis at left lung base. The
patient was dx with CAP and started on a seven day course of
Levofloxacin , renally dosed in the setting of an Azithromycin
allergy. During her hospital course the patient had an oxygen
requirement up to 2-3L with bibasilar crackles in the setting of
aggressive fluid strategy following the patients original
hypotensive presentation. Blood cultures were all negative for
growth.
.
#. UTI - The patient presented with a UA + for LE and nitrite,
with 21-50 WBCs and many bacteria. Started on Levofloxacin in
the ED, which should provide adequate coverage. Final cultures
revealed pan-sensitive E. Coli. The patient was continued on
Levofloxacin for a seven day course while con-currently treating
her PNA.
.
#. Elevated troponin - The patient had elevated troponins to
0.31 with chest pain in setting of hypotension and multiple
infections on admission. Pt has h/o CAD s/p CABG. This was
discussed with [**Hospital Unit Name 196**] in ED, and diagnosed as a likely troponin
leak in setting of demand ischemia and renal failure. ECG shows
LBBB paced at 95-100bpm, uninterpretable for signs of ischemia.
The patients enzymes slowly trended downward in the setting of
CRI. She had no other episodes of CP once transferred to the
floor. Her HR was well controlled throughout the duration of her
hospital course. She was continued on an ASA, Statin, and
restarted on her BB and spironolactone. A TTE on [**8-19**] revealed
the left ventricular systolic function that was similar to an
[**Month/Year (2) 113**] in [**11-12**] (diastolic function is worsened). The severity of
mitral regurgitation and tricuspid regurgitation may have
increased. The estimated pulmonary artery systolic pressure also
increased.
.
#. Renal failure - The patients presented with a Cr 1.7 on
admission, this improved to 1.5 over the course of her
admission.
.
# Anemia - The patient was admitted with a hct of 27.0, this
drifted to down to 24.8 in the setting of IVF. The patient
received one unit of pRBCs and had an adequate response. Iron
studies were sent and are attached. Recommended outpatient
evaluation of anemia work-up.
.
#. CHF - Pt w/ h/o sCHF (EF 40%). Appears approx euvolemic
currently. The patient received fluid in the setting of
hypotension, which were later diuresed with IV Lasix in addition
to her home Lasix dose of 40mg PO daily. At the time of
discharge the patient was instructed to continue on her home
regimen and have her nurse check her weights daily.
.
#. Atrial fibrillation. The patient was paced and continued on
warfarin, digoxin and amiodarone. The patients Dig level was low
on admission.
.
#. Hypothyroidism - The patient was continued on her home
Levothyroxine
Medications on Admission:
- Albuterol 90mcg 2sprays PO QID PRN cough
- Amiodarone 200mg PO daily
- Amlodipine 2.5mg PO daily
- Atorvastatin 20mg PO QHS
- Calcitriol 0.25mcg PO TID
- Carvedilol 6.25mg PO BID
- Digoxin 62.5mg PO every other day
- Furosemide 40mg PO daily
- ISMN 30mg PO daily
- Levothyroxine 50mcg PO daily
- Lorazepam 0.5mg PO daily PRN anxiety
- Losartan 25mg PO daily
- Meclizine 12.5mg PO BID
- NTG SL PRN
- Pantoprazole 40mg PO daily
- Spironolactone 25mg PO daily
- Warfarin 1mg PO daily
- Zolpidem 5mg PO QHS PRN
- Acetaminophen 1000mg PO TID PRN
- ASA 325mg PO daily
- Senna 2tabs PO BID
- NaCl Nasal spray daily-[**Hospital1 **]
- Triclosan 1% lotion TID PRN
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
12. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
16. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
17. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
18. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
19. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
20. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q48H
(every 48 hours) for 1 doses.
Disp:*3 Tablet(s)* Refills:*0*
21. Losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagonsis
-Pneumonia
-Urinary tract infection
Secondary Diagnosis
-Acute Systolic Heart Failure
Discharge Condition:
Stable. Patient ambulating with assistance. Saturationg in the
mid-90's on ambulation.
Discharge Instructions:
You were admitted with pneumonia and a urinary tract infection.
We started you on an antibiotic called levofloxacin, which you
will need to complete seven days of.
.
Please take all of your medications as directed, we have made a
changes to two of your medications as listed below.
.
1)Aldactone 12.5mg PO Daily (Half your normal dose)
2)Levofloxacin please take 1 pill, 750mg on Thursday morning.
.
Please follow up as indicated below.
.
Please make an appointment to see your PCP [**Name Initial (PRE) 151**] 1-2 weeks of
discharge.
.
If you develop any new symptoms of shortness of breath, fevers,
bloody stools or dizziness, please return to the emergency
department to be evaluated.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2156-12-21**]
11:00
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge.
Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2156-12-1**] 2:30
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2156-11-18**]
2:30
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55,545
| 131,840
|
41443
|
Discharge summary
|
report
|
Admission Date: [**2169-4-8**] Discharge Date: [**2169-4-21**]
Date of Birth: [**2106-11-21**] Sex: M
Service: SURGERY
Allergies:
seasonal allergies / lisinopril
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Pancreatic pseudocyst
Shortness of breath
Major Surgical or Invasive Procedure:
[**2169-4-9**]: Successful replacement of existing catheter with
larger 10 French [**Last Name (un) 2823**] catheter, followed by drainage of 500
ml of hemorrhagic material.
.
[**2169-4-11**]: Drainage of pancreatic pseudocyst with pancreatic
debridement and placement of transgastric feeding jejunostomy
tube.
History of Present Illness:
The patient is a 62M with recent admission ([**Date range (1) 90156**]) for
peri-pancreatic
fluid drainage and drain placement after ERCP induced
pancreatitis for CBD stricture presenting now with 1 week of
worsening nausea, dry heaves, decreased PO intake, fatigue, and
2 days of foul-smelling drain output. Patient denies fevers, and
his drain volume/appearance unchanged. Since his recent
admission
he has had to sleep on 3 pillows, though his SOB has much
improved since his peri-pancreatic fluid drainage. Denies
vomiting, changes in bowel habits, bloody or [**Doctor Last Name 352**] stools,
abdominal pain, shortness of breath, dizziness. He also notes a
dry cough that he has had since being placed on lisinopril in
the
hospital; his PCP changed this medication to amlodipine 3 days
ago.
Past Medical History:
PMH:
1. Hypertension
2. Hyperlipidemia
3. ERCP induced pancreatitis
3. Pancreatic pseudocyst
PSH:
1. Tonsillectomy ([**2128**])
2. R achilles repair x 2 ([**2138**])
Social History:
Lives with wife in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1475**], MA. Retired, former
furniture warehouse employee. Now volunteers as sports referee.
Denies tobacco use past/present. Social EtOH.
Family History:
Mother: deceased at age 86 w hx emphysema (heavy smoker), MI x 3
in her 60s
Father: deceased at age 58 [**2-15**] COPD/emphysema (heavy smoker)
Physical Exam:
On Admission:
Vitals: 99.6 120 123/69 18 97%
GEN: A&O, NAD, fatigued looking
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Bibasilar crackles
ABD: soft, obese abdomen, distended, nontender, no rebound or
guarding, normoactive bowel sounds. Drain in place draining dark
bilious fluid. No erythema or edema around drain site.
DRE: normal tone, enlarged prostate, no gross or occult blood
Ext: No LE edema, LE warm and well perfused, PICC line intact,
no
erythema
On Discharge:
VS: 98.8, 97, 138/74, 20, 96% RA
GEN: NAD, AAO x 3
CV: RRR, no m/r/g
Lungs: Diminished bilaterally L > R
Abd: Midline incision with steri strips, proximal part open with
wet-to-dry dressing. JP # 1 (chest tube) and JP # 2 in LUQ with
dry dressing and c/d/i, GJ tube LUQ capped insertion site c/d/i.
Extr: Warm ,no c/c/e
Pertinent Results:
[**2169-4-8**] 03:00PM BLOOD WBC-24.3*# RBC-3.02* Hgb-8.6* Hct-25.4*
MCV-84 MCH-28.4 MCHC-33.8 RDW-14.7 Plt Ct-386
[**2169-4-8**] 03:00PM BLOOD Glucose-129* UreaN-38* Creat-1.4* Na-132*
K-4.4 Cl-93* HCO3-24 AnGap-19
[**2169-4-8**] 03:00PM BLOOD ALT-35 AST-25 CK(CPK)-18* AlkPhos-177*
TotBili-0.6
[**2169-4-9**] 12:26AM BLOOD Albumin-2.5* Calcium-8.3* Phos-4.2
Mg-1.5*
[**2169-4-20**] 07:45AM BLOOD WBC-13.4* RBC-3.53* Hgb-10.1* Hct-30.2*
MCV-86 MCH-28.6 MCHC-33.4 RDW-15.0 Plt Ct-539*
[**2169-4-20**] 07:45AM BLOOD Glucose-110* UreaN-20 Creat-0.8 Na-137
K-4.0 Cl-102 HCO3-30 AnGap-9
[**2169-4-14**] 05:23AM BLOOD ALT-36 AST-28 AlkPhos-130 Amylase-89
TotBili-0.7
[**2169-4-20**] 07:45AM BLOOD Calcium-8.5 Phos-4.3 Mg-2.1
[**2169-4-8**] ECG:
Sinus tachycardia. Possible prior inferior myocardial
infarction. Compared to the previous tracing of [**2169-3-14**] the
findings are similar.
[**2169-4-8**] PA/LAT:
IMPRESSION: Interval decrease in left pleural effusion with left
basilar
opacity likely representing compressive atelectasis, though
cannot exclude
pneumonia. PICC line in unchanged position.
[**2169-4-8**] ABD CT:
IMPRESSION:
1. Complex fluid collections, likely pancreatic pseudocysts, in
the upper
abdomen as detailed, with drainage catheter in the dominant
collection.
Hyperdense material in the dominant collection may represent
blood products. Gas within the collections likely secondary to
indwelling catheter though infection cannot be excluded.
Consider additional drainage catheter placement if clinically
indicated.
2. Indeterminate 14 mm right renal and 9 mm left renal lesion
for which MRI is recommended for further evaluation.
3. Stable left pleural effusion and lower lobe compressive
atelectasis.
Interval improvement of right pleural effusion.
[**2169-4-10**] CARDIAC ECHO:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
[**2169-4-10**] CXR:
Moderate left pleural effusion is larger today than on [**4-8**].
There is
also greater opacification in the left lower lobe which could be
worsening
atelectasis. Right lung and right pleural space are normal. Mild
cardiomegaly is longstanding.
[**2169-4-11**] KUB:
1. No evidence of bowel obstruction.
2. NG tube and GJ tube project over stomach.
[**2169-4-14**] PA/LAT:
IMPRESSION:
1. Probable stable moderate left pleural effusion.
2. Resolution of mild pulmonary edema.
3. Right internal jugular catheter at the low SVC, unchanged.
4. Stable left lower lobe atelectasis.
[**2169-4-15**] KUB:
IMPRESSION: Unchanged position of gastrojejunostomy tube. If
localization is required, a small amount of contrast can be
injection through the tube.
Brief Hospital Course:
The patient with history of pancreatic pseudocyst was admitted
to the General Surgical Service with foul-smelling pancreatic
cyst drain output, increased abdominal pain and shortness of
breath. The abdominal CT scan on admission revealed infected
pancreatic pseudocyst, multiple renal lesions and left pleural
effusion. The patient was started on broad spectrum antibiotics,
and he underwent replacement of his existing pancreatic cyst
drain in IR. On [**2169-4-11**], the patient underwent drainage of
pancreatic pseudocyst with pancreatic debridement and placement
of transgastric feeding jejunostomy tube, which went well
without complication (reader referred to the Operative Note for
details). Post operatively, the patient was transferred to the
ICU intubated secondary to severe shortness of breath prior
operations. The patient was NPO, on IV fluids and antibiotics,
with a foley catheter, and IV Propofol for pain control. The
patient was hemodynamically stable.
On POD # 1, the patient was extubated without difficulty and
transferred on the floor on POD # 2.
Neuro: The patient received IV Dilaudid when on the floor with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Cardiac Echo
on HD # 3 was grossly normal with LVEF >55%.
Pulmonary: The patient was hypoxic on admission with high
supplemental O2 requirements. Postoperatively was kept intubated
in ICU until POD # 1. On POD # 2, the patient was transferred on
the floor on 4L n/c. The patient was diuresed with Lasix IV [**2-15**]
pulmonary edema and LE edema. The pulmonary edema resolved on
POD # 2, the left pleural effusion remained stable with stable
left lower lobe atelectasis. Lower extremities edema resolved
prior discharge. The patient's pulmonary status greatly
improved, he was weaned off the O2. Good pulmonary toilet, early
ambulation and incentive spirrometry were encouraged throughout
hospitalization.
GI: The patient was made NPO after admission and his PICC line
was discontinued. On POD # 1, the patient was restarted on full
TPN. The diet was advanced to clears on POD # 4 and advanced to
regular with supplements on POD # 6. The patient was able to
take adequate amount of nutrition PO prior discharge, daily
calories intake was counted. The TPN was discontinued on POD #
9.
ID: On admission the patient's blood, urine and PICC line tip
were sent for microbiology. The blood was positive for E-coli
and Staphylococcus. The pseudocyst fluid was also positive for
E-coli. The patient was covered with broad spectrum ABX until
final sensitivity. The cultures came back sensitive for
Levaquin, the patient was given Levaquin IV during
hospitalization. The patient will continue on Levaquin PO x 7
days after discharge. The patient's WBC was 24.3 on admission
and continued tranding down during hospitalization, fever curve
were closely watched. The patient had 3 JP drains in place, on
POD # 7 right JP was discontinued. Two remaining JPs will be
continued to bulb suction after discharge. Wound was monitored
daily for s/s of infection. Staples were d/cd on POD # 9, small
amount of serosanguinous fluid was noticed from proximal part of
the incision. Wet-to-dry dressing was applied with order to
change daily. The patient was discharged home with [**Month/Day (2) 269**] services
to monitor his JPs output and wound care.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's HCT was 25.4 on admission and dropped
to 21.3 on HD # 2, the patient was transfused with one unit of
RBC and HCT improved to 24.6. Preoperatively, the patient was
transfused with 2 units of RBC, his HCT remained stable low
during hospitalization. No more transfusions were indicated, HCT
prior discharge was 28.8.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with cane, and pain was well controlled. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
ASA 81', hydrochlorothiazide 12.5', calcium carbonate 200(500)
QHS PRN, pantoprazole SR 40', amlodopine 5 mg QD
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO once a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] [**Hospital1 269**]
Discharge Diagnosis:
1. Infected pancreatic pseudocyst
2. Shortness of breath [**2-15**] large pancreatic pseudocyst
3. Left pleural effusion
4. Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-23**] 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:
*[**Month/Year (2) 269**] nurses will change the dressing on the upper part of your
incision daily.
*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.
JP Drain Care:
*You have two JP drains
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or [**Month/Year (2) 269**] nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
GJ-tube:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
Follow up with PCP to discuss the lesions identified by CT scan
on your kidneys for which you should have more imaging studies.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 2998**] Date/Time:[**2169-5-3**]
12:00 [**Hospital1 **] [**Location (un) 620**], [**Street Address(2) 3001**], [**Location (un) 620**], [**Numeric Identifier 3002**]
.
Provider: [**Name Initial (NameIs) 2963**] (ST-4) GI ROOMS Date/Time:[**2169-5-5**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2169-5-5**] 2:00
Please arrive for the procedure at 12:30 PM
Completed by:[**2169-4-21**]
|
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icd9cm
|
[
[
[]
]
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[
"52.22",
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"52.01",
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icd9pcs
|
[
[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,373
| 185,321
|
8699
|
Discharge summary
|
report
|
Admission Date: [**2203-8-24**] Discharge Date: [**2203-9-16**]
Date of Birth: [**2148-10-18**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Fever, altered mental status
Major Surgical or Invasive Procedure:
ERCP
IR guided drainage of abcess
History of Present Illness:
54 yo m s/p liver transplant [**2197**], with chronic rejected from
recurrent hep C now admitted to MICU with AMS, fever and apnea
requiring intubation. Pt unable to relay his hx, but per ER, pt
had been having increased AMS and fevers at home after his
recent hospitalization from [**8-18**] to [**8-20**]. Pt was treated at that
hospitalization for an elevated INR and worsening
encephalopathy.
.
Per sister by phone, pt was more congested for last week over
the phone. Tuesday stopped Coumadin due to elevated INR. Sister
is concerned about his lungs. Was given z pack as out pt before
hospitalization, but never filled Rx from pharmacy.
.
In the ED, initial vs were: T 102.1 P 88 BP 117/56 R 20 O2 sat.
99% 10L on NRB. Had rectal temp of 103. Patient was given vanco
1 g, ceftriaxone 2g, Decadron 10mg IV, Flagyl 500mg IV,
etomidate 20mg, Succ 120mg, Propofol gtt, Lactulose 40gm, and 1
liter IVF. Had an LP, not consistent with menigitis. Lowest BP
was 93/46. Pt was intubated due to apena with RR of 6, vent set
on CMV, TV of 500, RR of 14, PEEP of 5, FIO2 of 100%. Had a
negative head CT. Blood, urine, and CSF cx sent. CXR without
acute changes. Also had a Foley placed with 475ml UO. EKG
unremarkable.
.
Review of sytems:
pt unable to answer questions
Past Medical History:
-ITP
-SVT last episode approximately [**1-30**], medically managed at this
time
-Hepatitis C
-ESLD s/p liver Tx [**2198-5-20**], s/p revision [**12-27**]; complicated with
rejection and steroid use since [**2199-4-20**] to present; also
complicated with Hepatitis C recurrence and restarted peg
interferon [**2199-6-17**]. Hep C possibly contracted from tatoo [**2171**].
-Thoracic compression fractures: [**5-27**]
-Cognitive disorders: h/o post hypoxic encephalopathy [**2190**].
-Depression /anxiety
-Neutropenia and infections including c. diff x3, streptococcal
septicemia, anal fistula
-History of fistula in anus s/p Fistulectomy [**11/2198**]
-Chronic pain especially rectal pain
-Diabetes : steroid induced, managed at [**Hospital **] Clinic, recent
HBA1C 5.1 % ( had received blood transfusions with splenectomy
),
insulin requirements decreased
-S/p Appy
-S/p tonsillectomy
-Bilateral inguinal hernia
-S/p hernia repair which has failed
-S/p umbilical hernia repair and right inguinal hernia repair
[**11-23**]
-S/p ccy
-Left sided hydronephrosis due to obstruction from splenomegaly,
s/p left ureteral stent placement [**5-29**].
-Secondary hyperparathyroidism due to CKD managed by Dr. [**Last Name (STitle) 4090**]
at [**Last Name (un) **].
-Splenectomy, distal pancreatectomy, c/w fistula, s/p spent and
then removal [**2201**]
Social History:
Lives with mother in [**Name (NI) 583**] and they both help with ther
health issues. He has a sister that lives in [**State **] that is
very involved in his care. Patient sates he smoked in highschool
socially (only in parties), but quit since then. He denies any
current or past alcohol intake. He also denies at thit time any
illegal substance use, however, he also is denying any past
illegal substance use.
Family History:
Mother has DM2 and HTN. Uncle with cancer in his 80s (unknown
site). Denies any family history of MI, sudden cardiac death,
stroke and lung diseases has DM2
Physical Exam:
Vitals: T: 97.6 BP: 97/64 P: 58 R: 13 18 O2: 100% on FIO2 100%
CMV
General: intubated, sedated
HEENT: dry MM, clear OP
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
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**8-20**] Head CT: There is no evidence for acute hemorrhage, edema,
mass effect, or recent infarction. The [**Doctor Last Name 352**]-white matter
differentiation is preserved. There is prominence of the
ventricles and sulci, unchanged from prior examinationand
consistent with diffuse parenchymal atrophy. This is slightly
more prominent than would be expected for the patient's age,
however, is unchanged from [**2198**]. The visualized paranasal
sinuses and mastoid air cells are unremarkable. No osseous
abnormality is identified.
[**8-23**] CXR:
1. Mild fluid overload.
2. Bibasilar opacities may be due to a atelectasis, but
infectious
consolidation is not excluded.
[**9-8**] ERCP:
ERCP: Images demonstrate cannulation of the pancreatic duct with
no obvious filling abnormalities or contrast extravasation. An
abrupt cutoff is present, reflecting prior distal
pancreatectomy. A plastic pancreatic duct stent was placed.
Subsequent injection of the common bile duct demonstrates distal
filling
defects consistent with stones. Contrast is seen entering the
jejunum,
consistent with prior choledochojejunostomy.
.
[**9-12**] CT abdomen: 1. Interval placement of a left flank pigtail
catheter with apparent drainage of abscess/fluid, but persisting
phlegmon, albeit decreased in size.
2. Apparent resolution of right lower lobe pneumonia. Resolution
of right
pleural effusion and persisting small left pleural effusion.
3. Unchanged appearance of extensive portal/mesenteric/splenic
venous clot.
4. Persistent omental varices.
5. Stable renal cysts.
.
[**2203-8-23**] 09:10PM WBC-21.1*# RBC-3.16* HGB-10.5* HCT-33.1*
MCV-105* MCH-33.1* MCHC-31.6 RDW-16.1*
[**2203-8-23**] 09:10PM ALBUMIN-2.8* CALCIUM-9.7 PHOSPHATE-3.2
MAGNESIUM-1.6
[**2203-8-23**] 09:10PM LIPASE-49
[**2203-8-23**] 09:10PM ALT(SGPT)-33 AST(SGOT)-99* ALK PHOS-335* TOT
BILI-3.6*
[**2203-8-23**] 09:10PM GLUCOSE-63* UREA N-36* CREAT-1.5* SODIUM-137
POTASSIUM-5.5* CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2203-8-23**] 09:15PM AMMONIA-79*
[**2203-8-23**] 09:16PM LACTATE-1.4
[**2203-8-23**] 09:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-NEG
[**2203-8-24**] 12:30AM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-276*
POLYS-20 LYMPHS-70 MONOS-8 MACROPHAG-2
[**2203-8-24**] 12:30AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-21*
POLYS-0 LYMPHS-84 MONOS-16
[**2203-8-24**] 12:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-32
GLUCOSE-50
[**2203-8-24**] 04:36AM WBC-28.0* RBC-3.17* HGB-10.5* HCT-33.4*
MCV-105* MCH-33.0* MCHC-31.4 RDW-16.5*
[**2203-8-24**] 04:36AM tacroFK-9.1
[**2203-8-24**] 05:19AM TYPE-ART O2-50 PO2-143* PCO2-46* PH-7.38
TOTAL CO2-28 BASE XS-1 -ASSIST/CON INTUBATED-INTUBATED
Brief Hospital Course:
54 yo m with hx of liver transplant with recurrent cirrhosis,
admitted with AMS, fever, and apnea.
.
AMS/Encephalopathy: Presentation to ICU with altered mental
status was initially secondary to hepatic encephalopathy and
delerium from multiple infections: pneumonia and abdominal
abcess. Initial work up involved: a lumbar puncture with normal
CSF, CT of the head sig for no acute process, and negative blood
and urine cultures. An ultrasound of the abdomen showed chronic
portal vein thrombosis. Patient was continued on lactulose and
started on rifaximin for hepatic encephalopathy. Mental status
decompensated [**8-27**] during hospitalization secondary to
iatrogenic narcotic overdose (see below for full details) in the
ICU, but improved with narcan x1 and holding of all sedating
medications (oxycodone, methadone, and trazadone). Mental
status improved to baseline with treatment of multiple infection
and rifaimin and lactulose.
.
Apnea: Patient was found to be apneic and intubated in the ED.
Respiratory depression was felt to be related to hepatic
encephalopathy and delirium secondary to PNA and abdominal
abscess infections. Patient was extubated on [**8-26**] without any
complications. On [**8-27**] patient was agitated, placed on wrist
restraints, and given haldol, trazadone and oxycodone in the
ICU. Upon transfer to the floor the subsequent day the patient
was apneic with constricted pupils secondary to iatrogenic
oversedation. He was given narcan x1 and respiratory status
improved. All sedating medications, oxycodone, methadone, and
trazadone were held. Patient remained stable on room air
without any respiratory problems and was restarted on his home
dose of trazadone at a later date. Patient had self tapered
from methadone (see below) and this was not restarted as he no
longer complained of pain.
.
Pneumonia: On presentation, patient was febrile with
leukocytosis and was started on broad spectrum antibiotics. A
CT [**8-24**] showed a RLL pneumonia with parapneumonic effusions.
Patient completed a course of antibiotic therapy for community
acquired vs aspiration pneumonia with cefepime ([**8-27**]->[**8-30**]) and
leukocytosis improved. Interval CXR improvement of
consolidation and repeat CT showed resolution of pneumonia.
.
LUQ abcess: This abcess is a recurrent process after distal
pancreatectomy and splenectomy and has required multiple courses
of IV antibiotics and drainage in the past. Patient initially
was started on Vanc ([**Date range (1) 30466**]), Flagyl ([**Date range (1) 30467**]), and
Cipro ([**8-24**]). CT of abdomen showed abdominal abcess (4 x 10cm)
and patient went for IR guided drainage. Initial set of abcess
cultures demonstrated proteus resistant to cipro. He antibiotic
regimen were changed to Flagyl (day 1: [**Date range (1) 30468**]) and Cefepime
(day 1: [**8-27**]-> [**8-30**] and restarted [**9-1**]). A picc line was
placed [**8-27**]. Patient was put on trial of PO bactrim DS
monotherapy, which he failed and cefepime iv was reinitiated
([**9-1**]). A second set of abcess cultures were sent which showed
ESBL organism (pan-resistant klebsiella). Infectious disease
was consulted and the patient was maintained on iv cefepime
throughout the rest of his hospitalization and the JP drain
continued to drain 20-30cc of serosangounous fluid. Patient
underwent ERCP with stent placement in the CBD for prevention of
future reaccumulation. A repeat CT of the abdomen [**9-13**] showed
improvement of the fluid collection. JP drain accidentally fell
out when patient getting up out of bed [**9-14**] and was unable to
be replaced under IR because fluid collection not observable on
CT. Patient was discharged with iv meropenem [**9-16**] to rehab
with follow up with infectious disease to determine when
antibiotic would be transitioned to PO prophylactic regimen.
.
Nutrition: An NGT was placed in the ICU and discontinued upon
transfer to the floor. The patient passed speech and swallow,
but continued to have very poor PO intake while on the floors.
Nutrition was consulted and calorie counts were done. Patient
was encouraged to increase PO intake but reported little
appetite, and abdominal discomfort with eating. A decision was
made to replace feeding tube on [**9-12**] and tube feeds were
started.
.
Hypercalcemia: Patient had hypercalcemia, and was maintained on
IVFs. TSH and cortisol were normal, and a PTH was abnormally
within normal limits. His endocronologist was [**Name (NI) 653**], who
reported secondary hyperparathyroid disease from vitamin D
deficiency. His calcitriol was discontinued, with some
improvement in his calcium levels. A PTHrP was pending.
Patient was discharged on his home dose of oral bisphosphonate.
.
S/p liver transplant with recurrent liver failure: Tacro level
elevated and on [**8-27**] was changed from home dose of 0.5 mg [**Hospital1 **]
to 0.5 ever other day. Elevation in trough thought to be in the
setting of multiple antibiotics and being off coumadin. Patient
was continued lamivudine for ppx and home ursodiol. He was
treated with lactulose and rifaximin was started. Bactrim was
changed to dapsone for PCP prophylaxis as patient was
persistantly hyperkalemic.
.
Chronic Pain: Patient has chronic rectal pain s/p fissures and
multiple complications. A rectal tube was put in place for skin
protection given multiple bowel movements while uptitrating
lactulose. Rectal tube was d/c'd on [**8-28**]. While in the ICU,
patient receiving home dose of gabapentin. He was also given
5mg Methadone tid, as regular dose could not be confirmed, and
10mg of oxycodone. On transfer to the floor patient was apneic
secondary to overdose of sedating medications and narcan was
given x1 with improvement in respiratory status. Methadone and
oxycodone were discontinued. Pain was not an issue on this
admission and methadone was not restarted as he was
self-tapered.
.
PVT: Patient has chronic PVT and was on coumadin as outpatient.
Coumadin was d/c since last hospitalization in the setting of
elevated INR. Decision made to keep patient permanently off
coumadin.
.
Anemia: Patient has chronic anemia secondary to liver disease.
Hematocrit remained stable throughout hospitalization.
.
Diabetes: BS only mildly elevated patient was initially
maintained on ISS. This was discontinued as his fingersticks
were within normal limits.
.
Hypertension: Initially atenolol and Cartia were held given an
episode of bradycardia in the MICU. HR improved and patient was
started on metoprolol while inpatient. BP remained stable and
he had no further episode of bradycardia.
.
SVT: Patient has a history of SVT, with a normal ECG in the
emergency room. Patient had an episode of bradycardia in the
MICU (as above) and so diltiazam and atenolol were initially
held. Patient was subsequently started on metoprolol while
inpatient and diltiazam was held. Heart rate remained in 60-70s
throughout remainder of hospitalization.
.
Coagulopathy: Patient had a recent supratheraputic INR, and
coumadin was not restarted. Coags were monitored and INR
decreased and remained stable at 1.3.
.
HyperKalemia: Patient had episodes of hyperkalemia, with normal
ECGs and treated with kayexelate. A hemolysis work up was done
and was negative. His bactrim ppx was d/c'd and switched to
dapsone. Patient was started on florinef with improvement in K.
Florinef was discontinued and K remained within normal limits
throughout rest of his hospitalization.
.
Depression: Patient was continued on home dose of sertraline. A
family meeting was arranged to discuss goals of care. Patient
expressed that he wanted to live and have optimal medical
manegement.
Medications on Admission:
Medications: (from prior d/c summary)
1. Atenolol 50 mg PO once a day.
2. Cartia XT 180 mg PO once a day.
3. Lamivudine 100 mg PO DAILY
4. Lasix 40 mg Tablet once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Methadone 10 mg PO DAILY
6. Calcitriol 0.25 mcg PO DAILY
7. Pancrease 20,000-4,500- 25,000 unit Capsule, Delayed Two (2)
PO 4 times a day with meals.
8. Gabapentin 100 mg PO twice a day.
9. Latanoprost 0.005 % 1 Drop HS right eye.
10. Omeprazole 40 mg Capsule PO twice a day.
11. Risedronate 35 mg PO once a week.
12. Lactulose 10 gram/15 mL PO three times a day.
13. Ursodiol 300 mg PO BID
14. Trazodone 50 mg PO HS as needed for insomnia.
15. Percocet 5-325 mg PO once a day as needed for pain.
16. Tacrolimus 0.5 mg PO Q12H
17. Drisdol 50,000 unit PO twice a week.
18. Sertraline 100 mg PO once a day.
19. AndroGel 1 %(50 mg/5 gram) Gel in One (1) packet Transdermal
once a day.
20. Peridex 0.12 % Mouthwash (15) mL Mucous membrane twice a day
as needed.
21. Arithromycin Z pac, not started
Discharge Medications:
1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day): No script needed, going to rehab.
Disp:*0 Capsule(s)* Refills:*2*
4. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
No script needed, going to rehab.
Disp:*0 Tablet(s)* Refills:*0*
5. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day): No script needed, going to rehab.
Disp:*0 Tablet(s)* Refills:*0*
6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): No script needed, going to rehab.
Disp:*0 Capsule(s)* Refills:*0*
7. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): No script needed, going to rehab.
Disp:*0 Tablet(s)* Refills:*0*
8. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day): No script needed, going to rehab.
Disp:*0 ML(s)* Refills:*0*
9. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO QOD (): No
script needed, going to rehab.
Disp:*0 Capsule(s)* Refills:*0*
10. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
No script needed, going to rehab.
Disp:*0 Tablet(s)* Refills:*0*
11. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day: No
script needed, going to rehab.
Disp:*0 Tablet(s)* Refills:*0*
13. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: No script needed,
going to rehab.
Disp:*0 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
14. Risedronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
15. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours): No script needed, going to
rehab.
Disp:*0 Recon Soln(s)* Refills:*0*
16. Peridex 0.12 % Mouthwash Sig: One (1) 15ml Mucous membrane
twice a day as needed for dental plaque.
17. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1)
Transdermal once a day.
18. Outpatient Lab Work
Please perform weekly CBC with diff, BUN, Cr, LFTs had fax these
results to [**Telephone/Fax (1) 22248**]
19. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily).
20. Lidocaine-Prilocaine 2.5-2.5 % Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for pain: anal fissure.
21. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for heartburn.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary: hepatic encephalopathy, pneumonia, abdominal abcess
Secondary: Portal vein thrombosis, ESLD s/p liver Tx,
Depression, Secondary hyperparathyroidism, Chronic pain
Discharge Condition:
Stable
Discharge Instructions:
You were seen in the hospital for altered mental status, lung
infection and abdominal infection. You were intubated because
you were not breathing well. Your breathing and mental status
improved as we treated your liver disease with lactulose and
rifaximin and as we treated your pneumonia and abdominal
infection with antibiotics.
We put a drain to help resolve your abdominal infection, when
the drain was discontinued we were not able to put it back in
because there was no longer any fluid collection. You underwent
an ERCP and had a stent placed to prevent further reaccumulation
of infection. You were not eating well and so a feeding tube
was placed.
The following changes were made to your medications:
1. You no longer need to take Cartia XT, methadone, lasix,
Calcitriol, Drisdol, or Percocet.
2. We have switched your tacrolimus from 0.5mg [**Hospital1 **] to 0.5 every
other day.
3. We have added rifaximin to your medications, please take this
daily.
4. Please continue with the rest of your home medications.
Please return to the emergency room if you have fevers greater
than 101, lightheadedness, abdominal pain, sleepiness, or any
other concerning symptoms.
Followup Instructions:
You will need to follow up with Infectious Diseases on [**2203-9-20**]
10:00am with Dr. [**Known firstname **] [**Last Name (NamePattern1) 724**]. His number is [**Telephone/Fax (1) 673**]. They
will decide when you should have a CT of your abdomen, and when
you can stop the iv meropenem.
You will need to follow up with [**Hospital 1326**] Clinic on [**2203-9-21**] at
3:20pm. Their number is [**Telephone/Fax (1) 673**]
You will need to follow up with ERCP on [**2203-11-10**] at 10:00am
Completed by:[**2203-9-16**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,557
| 183,341
|
27353
|
Discharge summary
|
report
|
Admission Date: [**2130-5-30**] Discharge Date: [**2130-6-14**]
Date of Birth: [**2058-11-17**] Sex: F
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
A 70yoF with recent influenza A infection complicated by ARDS,
now transferred from [**Hospital6 1597**] with pneumomediastinum
likely [**3-9**] tracheal perforation, and MRSA PNA and pseudomonas
UTI.
Major Surgical or Invasive Procedure:
bronchoscopy
EGD
tracheosteomy
PEG
History of Present Illness:
A 70yoF who presented to [**Hospital6 **] in [**4-10**] with
lethargy and fevers, and was found to have influenza A. Her
hospital course was complicated by ARDS. She was treated with
ceftriaxone, azithromycin, and then levofloxacin and vancomycin,
as well as a long course of steroids. She was intubated, and
later trached for on-going respiratory support at pulmonary
rehab in [**Hospital1 **]. She went to rehab with a tracheostomy tube
and off ventilatory support, but returned after a short period
of time with lethargy, hypercarbic respiratory distress
requiring mechanical ventilation (trach was decannulated and
replaced with button, and ET tube was replaced), a new LLL PNA,
paroxysmal rapid AFib (hr 180s), diarrhea, and upon workup was
found to have a pneumomediastinum, upper esophageal dilatation,
and an LLL PNA and UTI. She underwent bronchoscopy which was
apparently unremarkable, and was treated empirically with
vancomycin and ceftazidime for pneumonia, and flagyl (for
diarrhea). Her course has been complicated by hypotension
requiring levophed and rapid AFib for which conversion was
attempted unsuccessfully with ibutilide. Cultures revealed MRSA
PNA/bacteremia, and pseudomonas UTI, and treatment was initiated
with vancomycin and zosyn.
Past Medical History:
1. Influenza A in [**4-10**] complicated by ARDS eventually leading to
intubation, ventilatory support, and tracheostomy.
2. Remote history of pneumonia.
3. Status post left eye cataract surgery.
Social History:
no significant tobacco or alcohol use.
Family History:
non-contributory.
Physical Exam:
VS: 96.6 | 110/65 | 74 | 30 | 100% O2 sat; wt=59kg.
vent settings: PS 100% FiO2, peak pressure 31 +5 PEEP, Vt
400-450
gen: intubated, sedated.
HEENT: pupils 2mm->1mm, accomodation intact, midline, EOM could
not be assessed, OP clear, MMM, no JVD, no carotid bruit.
neck: no masses, no LAD, mild subcutaneous crepitus/emphysema
noted on left neck.
CV: RRR, nl s1s2, no murmurs.
chest: crackles and rales, halfway up on left, dullness on left
base, no wheezes, right lung clear.
abd: soft, nt/nd, +bs, no organomegaly.
extr: warm well perfused, 2+ dp pulses, no cyanosis, pitting
edema up to thighs b/l.
neuro: sedated, nl tone; CN's, strength, sensation,
coordination, language not assessed.
Pertinent Results:
[**2130-5-30**] 08:29PM BLOOD WBC-12.3* RBC-3.09* Hgb-9.1* Hct-29.4*
MCV-95 MCH-29.5 MCHC-30.9* RDW-17.8* Plt Ct-115*
[**2130-5-30**] 08:29PM BLOOD Neuts-87.9* Lymphs-8.6* Monos-3.4 Eos-0.1
Baso-0.1
[**2130-5-30**] 08:29PM BLOOD PT-15.4* PTT-25.2 INR(PT)-1.4*
[**2130-5-30**] 08:29PM BLOOD Plt Ct-115*
[**2130-5-30**] 08:29PM BLOOD FDP-0-10
[**2130-5-30**] 08:29PM BLOOD Fibrino-586* D-Dimer-1891*
[**2130-5-30**] 08:29PM BLOOD Glucose-76 UreaN-31* Creat-0.3* Na-150*
K-3.4 Cl-119* HCO3-28 AnGap-6*
[**2130-5-30**] 08:29PM BLOOD ALT-8 AST-11 LD(LDH)-197 AlkPhos-72
Amylase-27 TotBili-0.4
[**2130-5-30**] 08:29PM BLOOD Albumin-1.8* Calcium-7.2* Phos-1.4*
Mg-2.2
[**2130-5-30**] 09:02PM BLOOD Type-ART Temp-35.9 Rates-18/12 PEEP-5
FiO2-100 pO2-157* pCO2-59* pH-7.31* calHCO3-31* Base XS-1
AADO2-507 REQ O2-84 Intubat-INTUBATED Vent-CONTROLLED
[**2130-5-30**] 09:02PM BLOOD freeCa-1.14
[**2130-5-30**] 09:02PM BLOOD Lactate-0.6
.
CT neck [**5-31**]: pending.
.
CXR: [**5-29**]: 1. Interval worsening of the consolidation in the
right lower lobe superimposed on bilateral chronic lung changes.
2. Slight interval improved appearance of the subcutaneous
emphysema and no clear visualization of the previously noted
pneumomediastinum.
.
TTE [**5-29**]: All cardiac [**Doctor Last Name 1754**] normal in size. The ascending
aorta is mildly dilated. LV systolic function is preserved with
an estimated EF of 60%. RV systolic function is preserved.
Mitral leaflets are minimally thickened with mild MR. There is
mild TR with moderate pulmonary hypertension. Estimated PASP is
40 mmHg + CVP. Minimal pericardial effusion as well as
significant pleural effusion is noted. Compared to a prior
study dated [**2130-4-22**], the PA pressure is
now elevated.
.
CT chest [**5-30**]: 1. Interval decrease in the pneumomediastinum and
subcutaneous gas. 2. Overdistention of the endotracheal tube
balloon, which increases risk of tracheal injury. 3. Slight
increased air space consolidation in the superior segment of the
left lower lobe. 4. Nasogastric tube terminating in the distal
esophagus well above
the level of the diaphragm.
.
CT chest [**5-28**]: 1. Extensive pneumomediastinum and subcutaneous
emphysema on the left axillary and supraclavicular regions
without evidence of pneumothorax. 2. Extensive bilateral
alveolar opacities with small pleural effusions.
.
Blood cx [**5-27**]: MRSA.
Blood cx [**5-29**]: NGTD.
Urine cx [**5-27**]: Pseudomonas.
Sputum cx [**5-28**]: MRSA.
------------------
CT abdomen with contrast [**2130-6-5**]:
IMPRESSION:
1) Moderate abdominal and pelvic ascites without evidence of
acute intra- or retroperitoneal hematoma.
2) Bibasilar fibrosis and bronchiectasis with a small anterior
right basilar pneumothorax and small bilateral pleural
effusions.
3) Anasarca.
4) Dilated gallbladder with layering sludge/gallstones.
5) Scoliosis.
------------------
Brief Hospital Course:
70yoF with recent influenza A infection complicated by ARDS, now
with pneumomediastinum likely [**3-9**] tracheocutaneous fistula.
.
# pneumomediastinum: evidence for pneumomediastinum is that
respiratory symptoms (hypercarbic failure) and AF with RVR
became worse when ET tube was in higher position, and resolved
when ET tube was repositioned lower, presumably below the site
of a fistula. A bronch at OSH revealed no defects in the
tracheal wall, and an esophageal gastrograffin study was
negative as well. Patient was trach'd for respiratory distress.
Multiple imaging studies did not reveal any pneumomediastinum.
Repeat EGD/Rigid bronchoscopy did not show any TE fistula. The
tracheostomy site was revised and a new #8 Portex Per-fit tube
was placed. Patient was continued on supportive ventilation.
.
#respiratory failure: Pt. recovering from ARDS, which occurred
in the setting of influenza A infection in [**4-10**], and also with
LLL MRSA PNA on arrival -finished full course of vanco. Likely
will take some time to resolve full lung function. Pt. has been
on a chronic vent previously. Now pt. w/ new trach. Pt's
respiratory status has not been improving much - difficult to
wean pt. Pt. has failed multiple attempts at weaning--tires out
quickly on pressure support, and had to be placed back on assist
control and be fully supported. Sedation was weaned off, and
the patient was placed on PRN sedation/pain meds. Patient's
ABGs remained great, inhalers were continued. A PEG tube was
placed for enteral feeds. Patient was maintained on full
respiratory support, breathing on AC, failed PSV multiple times.
Patient is to be weaned off the vent at pulmonary rehab.
.
#Hct drop. Crit is stable at this point. No source has been
found- no hemolysis noted on lab work, CXR neg for bleeding into
mediastinum and no evidence of RP bleed on CT. Stool guaiac was
negative.
.
# Afib: has been refractive to both medical and chemical
treatments. likely occurring secondary to respiratory
decompensation, rapid AFib resolved when ET tube was advanced,
decreasing the tension pneumomediastinum. Has not been a
problem ever since the pneumomediastinum/TE fistula issue has
been resolved. Patient remained very well rate-controlled.
Responds to lopressor. Heart rate to be re-assessed at rehab.
.
# ID: Pt. w/ icnreased WBC a few days ago, but was found to have
C. diff and is receiving flagyl for this. Pt. continue to be
afebrile. Pt. completed course of vancomycin for MRSA LLL
PNA/bacteremia and s/p 1 week cipro treatment of cipro-sensitive
pseudomonas UTI. Was transiently on stress dose steroids while
exhibiting septic physiology, but once BP stabilized, steroids
were tapered off. The patient should complete 14 day course of
flagyl while at rehab, day 6 out of 14 today.
.
# FEN: Pt became hyponatremic during her hospital course with
~2L free water deficit, so she was corrected slowly with D5W.
Other electrolytes were repleted as well.
.
# Psych - during the last few days of the hospital course, pt
was very depressed, expressing wishes of dying. Psychiatry
consult was consulted, but due to the patient's respiratory
status, conmmunications with a psychiatrist Unlikely that pt.
will be able to communicate w/ a psychiatrist. Low dose of
Celexa was started
.
# FEN: Pt. had PEG placed (has trach, aspiration risk).
Continue TFs at goal, lytes PRN.
.
# Ppx: bowel regimen, PPI, SC heparin (HIT negative), insulin
gtt (sepsis protocol), pneumoboots, nystatin.
.
# Access: PIV, A-line.
.
# Code: full, corroborated with family.
.
# Dispo: to rehab tomorrow pending family's approval.
.
# Ppx: bowel regimen, PPI, RISS, pneumoboots, nystatin.
.
# Access: pt has a PICC, will need PICC care at rehab.
.
Medications on Admission:
(meds on transfer)
1. Nystatin Swish/Swallow 5 mg p.o. q.i.d.
2. Fosamax 5 mg p.o. daily.
3. Ferrous sulfate 325 mg p.o. daily.
4. Multivitamin 1 tab p.o. daily.
5. Vitamin D 800 units p.o. daily.
6. Insulin gtt.
7. Combivent 2 puffs q.6h.
8. Vancomycin 1 gm IV q.12h.
9. Hydrocortisone 60 mg IV q.8h.
10. Nexium 40 mg IV daily.
11. Zosyn 4.5 gm IV q.6h.
12. Levophed gtt.
Discharge Medications:
1. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**7-13**]
Puffs Inhalation Q4H (every 4 hours) as needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day) as needed for constipation.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 weeks: Last day = [**2130-6-21**].
9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
11. Diazepam 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
14. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO once a day: please check phosphate frequently, pt
is often low and needs repletion.
15. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day: pt frequently
requires potassium repletion, please check levels daily.
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
18. Morphine 2 mg/mL Syringe Sig: One (1) mg Injection Q4H
(every 4 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
ARDS
Discharge Condition:
stable
Discharge Instructions:
Call your doctor or come to the ER if you develop fevers,
chills, chest pain, difficulty breathing, trouble with your
tracheostomy tube, abdominal pain, diarrhea, problems with the
PEG tube or any other concerns.
Followup Instructions:
Follow up with your primary care doctor and with the doctors [**First Name (Titles) **] [**Name5 (PTitle) 32080**].
|
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17,891
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24626+57409
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Discharge summary
|
report+addendum
|
Admission Date: [**2122-4-15**] Discharge Date: [**2122-6-2**]
Date of Birth: [**2075-12-28**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Pancytopenia status post liver transplant.
HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male
status post liver transplant in [**2121-11-16**] whose course
has been complicated by hepatic artery thrombosis status post
PTC catheter placement, high-grade VRE bacteremia on long-
term linezolid currently, PTC placement for biliary sepsis.
He has been followed closely by Dr. [**Last Name (STitle) 816**] and Dr. [**Last Name (STitle) 724**] from ID
as a outpatient. Recently Valcyte was stopped on [**3-26**] after
3 months of treatment. Patient has been having labs drawn
every 2-3 days, which revealed hematocrit, white blood cell,
and platelet count being low that had been steadily trending
down reaching critical levels today with a white count of 1,
hematocrit of 17, and a platelet count of 45.
The patient was called at home and asked to come in. His ALT
and AST were also elevated. ALT was 124, AST 146 for which
this is the 1st time since his transplant that his liver
function tests had been abnormal. He denied any fevers,
chills, nausea, vomiting, diarrhea, constipation, shortness
of breath. He says he has had sweats x2 days and some
increased fatigue over the past few weeks, but otherwise
feels well. Appetite was unchanged.
ALLERGIES: Penicillin, benzocaine.
PAST MEDICAL HISTORY: Liver transplant on [**2121-11-16**], then
Roux-en-Y hepaticojejunostomy, hepatitis C, cryptogenic
cirrhosis complicated by hepatic artery thrombosis, very high-
grade VRE bacteremia on [**2122-2-14**], source was the biliary
tree treated with linezolid, status post PTC drain in [**2122-2-14**] for stricture, now capped, methemoglobinemia in [**2122-2-14**] from Hurricaine spray during TEE, history of
Cryptococcal pneumonia on fluconazole long-term. He should be
on 200 mg p.o. daily for 1 year, nutcracker esophagus,
chronic renal insufficiency, creatinine baseline is 1.2,
right inguinal hernia, diverticulitis, esophageal varices,
history of hyperkalemia treated with Kayexalate p.r.n. and
increased prolactin.
MEDICATIONS AT HOME: Oxycodone 5 mg p.r.n., multivitamin 1
daily, regular insulin sliding scale, Protonix 40 daily, NPH
28 units q.a.m., Epogen 20,000 units every week, Colace,
nifedipine 10 mg p.o. b.i.d., Bactrim single strength 1
daily, fluconazole 200 mg daily, Kayexalate 15 grams p.r.n.,
linezolid 600 mg p.o. b.i.d., Valcyte 450 mg daily, Rapamune
3 mg daily, ferrous sulfate daily.
PHYSICAL EXAM: Temperature was 101. He was in no acute
distress. Lungs are clear. Heart was regular rate and rhythm.
Abdomen: Soft, nondistended. PTC catheter was in place and
capped. Reducible left inguinal hernia on the left and right.
Extremities: No clubbing, cyanosis, or edema.
LABS ON ADMISSION: White count was 2.1, hematocrit 17.2. He
was transfused with a total of 3 units of packed red blood
cells. His hematocrit increased to 24. He was given an
additional 2 units of packed red blood cells for a repeat
hematocrit of 30. He was started on IV fluid. He spiked a
temperature up to 102 in the evening of hospital day 1. Blood
cultures were sent off. He had 4/4 bottles positive for
Enterococcus faecium resistant to ampicillin, penicillin, and
vancomycin, sensitive to daptomycin and linezolid. He
remained on daptomycin as he had been previously on this for
long-term.
He was sent for an abdominal CT. This revealed markedly
increased ascites seen throughout the abdomen and pelvis
without fat stranding diffusely in the abdomen, especially
surrounding the liver. There was a 7-cm fluid collection
filled with contrast at the tip of the tube in the subhepatic
area which likely represented a leak, abscess, or loop of
bowel. It was noted that this was a limited study for
evaluation of a major abdominal organs due to the lack of
intravenous contrast [**Doctor Last Name 360**]. It was noted that he had a
cirrhotic-appearing liver and splenomegaly, bilateral
hydrocele greater on the right, bibasilar atelectasis, and
tubular opacity in the left lower lobe measuring 1.2 cm
unchanged since prior study, and gynecomastia.
HOSPITAL COURSE: On [**4-17**], a Roux tube cholangiogram was
done. This revealed a large contrast collection in the region
of the left hepatic lobe consistent with a large bile leak.
There was associated dilatation of the intrahepatic ducts
with numerous filling defects consistent with sloughed mucosa
and debris. These findings were concerning for biliary
ischemia.
On [**4-18**], he went to CT for successful aspiration and a
drainage catheter placement in the large hepatic fluid
collection. He also underwent a TTE which was negative for
vegetations on the heart valves. Ejection fraction was
approximately 55%. The fluid from the above tap of abdominal
fluid grew 3 organisms: Enterococcus gallinarum, Strep
viridans heavy growth, and enterococcus. The enterococcus was
pansensitive and indeterminate for vancomycin. The
enterococcus 2nd species was resistant to ampicillin,
levofloxacin, penicillin, and tetracycline.
He remained on daptomycin. He continued on his Rapamune
throughout this hospital course with dose adjustments based
on level. His appetite was poor. He received calorie counts.
He was taking in anywhere from 845 kilocalories per day to
1,100 kilocalories per day. His liver function tests on
admission demonstrated an AST of 126, ALT of 79, alkaline
phosphatase of 134 with a total bilirubin of 0.4. These
remained relatively stable. There was slight increase in the
alkaline phosphatase noted.
He went for repositioning of the CT-guided drain on [**4-23**].
On [**4-26**], he spiked a temperature up to 101 again while on
the daptomycin. Repeat blood cultures were drawn daily on
[**4-20**] through [**4-24**]. These were all negative.
On [**4-27**], he underwent another CT-guided drainage. His
pigtail catheter was in place. There was interval decrease in
the size of the intrahepatic abscess with persistent ascites.
He continued to drain small amounts of fluid from this
pigtail catheter.
Infectious disease was consulted and followed the patient
closely throughout this hospital course making
recommendations with respect to antibiotic coverage. A CMV
viral load was sent off on [**2122-4-15**]. This was
subsequently found to be negative. Bile was sent from the PTC
drain. This demonstrated E. coli and Enterococcus gallinarum.
The E. coli was resistant to ampicillin, ciprofloxacin,
levofloxacin, and Bactrim. Otherwise, pansensitive. The
enterococcus was pansensitive.
He was started on levofloxacin on hospital day 16, and he
remained on levofloxacin for a total of 7 days. He continued
to complain of upper abdominal discomfort for several days.
White blood cell count improved from admission. White count
of 2.1; it rose to 9.9 on hospital day 13. Given poor
appetite and low calorie counts, he was started on total
parenteral nutrition via PICC line. A right arm PICC line was
placed on [**2122-4-21**]. [**Last Name (un) **] followed the patient for
hyperglycemia helping to titrate his insulin. Nutrition also
followed this patient throughout this hospital course making
recommendations.
On [**4-30**], hospital day 16, he underwent successful
ultrasound-guided therapeutic and diagnostic paracentesis.
Three-point 2 liters of dark-yellow fluid was withdrawn. This
fluid demonstrated no growth and 4+ polymorphonuclear
leukocytes.
Around hospital day 13, he started to complain of abdominal
distention and tenderness in the upper abdominal area. He had
a reducible hernia. He did experience some nausea and had
some emesis. He was medicated with Anzemet. He continued to
complain of persistent burning upper abdominal pain that
waxed and waned. The patient refused an upper endoscopy to
evaluate nausea. It was noted that on his paracentesis, he
had elevated white blood cells consistent with peritonitis
for which he remained on Levaquin for approximately 1 week. A
NG tube was placed on hospital day 18 for nausea and
vomiting.
NG tube put out approximately 4 liters per day consistent
with outlet obstruction. Hepatology followed the patient
closely throughout this hospital course. It is felt the
patient had an ileus related to opioids for abdominal pain
for which he was receiving p.r.n. Dilaudid with good effect.
He was taken to the OR on [**2122-5-3**] for complete small
bowel obstruction secondary to an internal hernia. He
underwent a reduction of internal hernia, closure of
mesocolon defect, Tru-Cut biopsy of the liver, and feeding
jejunostomy. Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] did the surgery, assisted
by resident, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 955**] under general anesthesia.
Patient tolerated the procedure well. Please see operative
report. He did receive 2 units of packed red blood cells.
Blood loss was minimal.
His abdominal pain was much better postsurgery. He remained
on IV daptomycin and Levaquin. He spiked a temperature on
[**5-11**] to 104, which he had a chest x-ray that demonstrated
no pneumonia with improving right apical hydropneumothorax.
He underwent an abdominal CT with successful replacement and
drainage of the left hepatic lobe collection with a small 3.2
cm residual collection along its anteromedial aspect. Of
note, a new hypodense collection in the lateral subcapsular
segment 5 yielded only a small amount of [**11-17**] cc of purulent
material. A small hemoperitoneum was noted postaspiration.
He was transferred to the SICU for further management. Blood
cultures demonstrated E. coli. Bile also grew E. coli
resistant to ampicillin, levofloxacin, Cipro, and Bactrim.
Enterococcus was indeterminate to vancomycin, otherwise
pansensitive. A urine culture was negative. He remained on
daptomycin. In addition to the temperature spike of 104, his
white blood cell count increased to 20.4. He also complained
of some lightheadedness and dizziness. He was transferred to
the surgical intensive care unit for IV resuscitation and
monitoring.
He was started on vasopressin. He remained on Levaquin,
Flagyl, ceftazidime, and daptomycin as well as linezolid.
Repeat abdominal CT was done on [**5-12**] with successful
replacement and drainage of the left hepatic lobe collection
as previously stated. He underwent a renal ultrasound at that
time. This demonstrated patent main renal arteries
bilaterally. Renal artery stenosis could not be excluded on
this technically limited exam. This was done for elevated
creatinine of 1.4. Creatinine trended back down with IV
hydration.
He experienced postop ileus as well. He had been started on
J. tube feedings, and his TPN had been weaned off. While in
the surgical intensive care unit, he was intubated. He was
started on meropenem. The ceftazidime was discontinued. The
left liver abscess collection had gram-positive cocci. The
right abscess had also gram-positive cocci. Blood cultures
were positive for E. coli and gram-negative rods.
Gradually he improved. He was extubated on [**5-16**]. His white
blood cell count trended down. A repeat abdominal CT was done
on [**5-15**]. This demonstrated improving 5-cm segment 4 liver
abscess with pigtail catheter. Two other dominant fluid
collections were unchanged. Ascites was worse. There was
resolution of the small bowel obstruction.
On [**5-15**], he was relisted for liver transplant with
resolution of small bowel obstruction. His J. tube feeding
was resumed. He tolerated this without event. He continued to
do well. He received a total of 6 days of meropenem.
He was transferred out of the surgical intensive care unit on
[**5-19**]. He did experience some diarrhea for which stools were
sent for C. difficile. These were subsequently negative. He
remained on p.o. fluconazole for cryptococcal treatment. He
had a history of cryptococcal pneumonia and was to remain on
fluconazole for 1 year. He received empiric Flagyl for
diarrhea.
On [**5-19**], he underwent an abdominal CT with contrast. This
demonstrated slight increase in size of the previously seen
segment 4 hepatic abscess/bile collection. Previously placed
pigtail catheter appeared to have been removed. There was
slight increase also in segment 2 abscess with a new drainage
catheter in place. The 3rd collection in the right lobe was
unchanged. There was abundant ascites tracking into the
pelvis and scrotum via the inguinal canals. This was
unchanged. There were also bilateral small pleural effusions
with associated atelectasis.
A repeat abdominal CT was done on [**5-21**]. A right-sided liver
pigtail drain was inserted as well as the left side liver
pigtail drain was placed. Paracentesis was done, and the
drain was inserted. Three liters of straw-color fluid was
sent off for culture and cell count. This demonstrated 2+
polymorphonuclear leukocytes and enterococcus resistant to
ampicillin, penicillin, and vancomycin, but sensitive to
linezolid. No anaerobes were isolated.
On [**2122-5-22**], the ascites fluid was increased. He still
had a pigtail drain in place. Two liters of fluid were
drained off utilizing low wall suction, then 5 additional
liters were removed via the standard paracentesis tube with
suction bottle. Patient tolerated this without incident, and
the pigtail catheter was removed. This ascites fluid
demonstrated Enterococcus faecium resistant to vancomycin and
sensitive to linezolid. He continued on daptomycin. He was
started on caspofungin IV for yeast that was detected in the
abscess drainage drawn on [**5-21**].
He received 2 units of blood on [**5-23**] for a hematocrit of
26. He was started on Epogen. He received another unit of
blood on [**5-24**] for hematocrit of 29.5. His temperature
spiked to 101 again on [**5-24**]. PICC was removed. No growth
was demonstrated. Urine culture was negative. Blood cultures
were sent daily for surveillance. These were all negative.
His white blood cell count started to trend down into the 2.3
range.
Repeat abdominal CT was done on [**5-24**] for this temperature
spike of 101. No evidence of contrast extravasation or large
hematoma within the abdomen or pelvis was noted to explain
the patient's drop in hematocrit from 34.9 down to 26.2.
There was persistent pleural effusions with bibasilar
atelectasis. He had a stable appearing hepatic abscesses and
bile collections within segments 4 and 2 of the liver. There
was slight decrease in the size of the right lobe collection
with a new drainage catheter in place. There was also slight
interval decrease in abundant ascites tracking into the
pelvis and scrotum.
He was given IV Lasix for edema. This was stopped when his
blood pressure dropped down to 90/70. He had been on IV
Lopressor as well as p.o. Lopressor for some tachycardia;
though, the Lopressor was stopped. He received some IV
hydration.
A podiatry consult was obtained for long toenails. These were
debrided. An ophthalmology consult was also obtained for
patient's complaint of progressive decrease vision in both
eyes. Findings demonstrated left greater than right
subcapsular cataracts, presbyopia, and refractive error.
[**Location (un) **] glasses were suggested, and cataract evaluation as an
outpatient.
Given drop in white blood cell count, meropenem was stopped.
He had received a total of 14 days of this. Caspofungin was
also stopped after a total of 6 days, and ceftriaxone 1 gram
was started daily as well as AmBisome 675 mg daily. His white
blood cell count still continued to stay in the 2.1-2.8
range. His hematocrit trended downward to 23.7. Epogen was
increased. His creatinine remains stable. His LFTs were
stable. Rapamune was continued. His levels trended downward
to 3.8. He was tolerating his tube feeding. Foley catheter
remained in place given large scrotal edema. Physical therapy
worked with him and recommended rehab.
He was started on AmBisome on [**5-27**] for concern for mold in
the abscess that could be consistent with Zygomycetes. He
continued to have low grade temperatures of 100.9. He
remained on ceftriaxone for Strep viridans replacing the
meropenem. A repeat CT was done on [**5-28**]. Several fluid
collections were again noted within the left and right lobes
of the liver which were unchanged in size. There were 3
external percutaneous drainage catheters in place and 1
internal/external biliary catheter was unchanged in position.
Bilateral pleural effusions were noted and large amount of
ascites was noted.
Wound care consult was obtained for sacral decubitus. He has
a full-thickness ulcer coccyx site unable to stage due to
yellow fibrinous wound bed. The ulcer is approximately 2 x 1
cm. Wound bed is 100% yellow and fibrinous. Wound edges were
defined. There was minimal drainage from the site. No
cellulitis was noted. Wound gel, DuoDerm gel was applied to
the ulcer. He remained on a ________low air loss pressure
release mattress.
In summary, the patient had a prolonged hospital course and
became debilitated. He was relisted for a liver transplant
pending clearance of multiple liver abscesses, infections.
His p.o. intake was poor. He remained on cycled J. tube
feedings at night. Foley remained in place for large amount
of scrotal edema. His right JP abscess drain continued to
drain murky discharge with bilious drainage from his liver
abscesses. His PTC catheter remained capped. He was assisted
out of bed to the chair by PT.
Plan is to send him to rehab on daptomycin, caspofungin, and
ceftriaxone. He will follow up with infectious disease.
DISCHARGE DIAGNOSES: Status post liver transplant, status
post hepatic artery thrombosis, liver abscesses growing
yeast, enterococcus, vancomycin-resistant enterococci,
malnutrition, status post small bowel obstruction with
hernia, ascites, depression, sacral decubitus, history of
cryptococcal pneumonia.
DISCHARGE MEDICATIONS: Albuterol nebulizers p.r.n. q.6.,
AmBisome 675 mg IV q.24h. with prehydration, ceftriaxone 1
gram IV q.24h., daptomycin 450 mg IV daily, Epogen 10,000
units subcutaneously every Monday, Wednesday, and Friday,
heparin 5,000 units subcutaneous twice a day, Dilaudid 1 mg
IV p.r.n. q.3-4h. for pain, insulin sliding scale and fixed
dose of Lantus, loperamide 2 mg p.o. b.i.d. for loose stools
to be held if no bowel movements, nifedipine 10 mg p.o.
b.i.d., oxycodone 5-10 mg p.o. p.r.n. q.4-6h., Protonix 40 mg
p.o. daily, Rapamune 2 mg p.o. daily, Bactrim single strength
1 tablet p.o. daily, Tylenol p.r.n.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**], M.D. [**MD Number(2) 6727**]
Dictated By:[**Name8 (MD) 4664**]
MEDQUIST36
D: [**2122-6-1**] 21:53:57
T: [**2122-6-2**] 05:45:26
Job#: [**Job Number 62179**]
Name: [**Known lastname **],[**Known firstname **] V. Unit No: [**Numeric Identifier 11193**]
Admission Date: [**2122-4-15**] Discharge Date: [**2122-8-19**]
Date of Birth: [**2075-12-28**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Benzocaine
Attending:[**First Name3 (LF) 2648**]
Addendum:
He remained in hospital after discovering that liver abscesses
grew sparse mucor. ID recommended posoconazole in addition to
ambisone. This was started and he continued on this for the
remainder of hospital course. The decision was made to keep him
hospitalized until re-transplanted.
Psychiatry was consulted for depression. Dextroamphetamine
was recommended as first choice with zoloft being an alternative
[**Doctor Last Name 932**]. Zoloft was started and dose increase during remainder of
hospital stay with some improvement in mood.
2 units of PRBC were given for a hct of 22 on [**6-4**]. Epogen
was continued. On [**6-5**] an abd ct revealed mod ascites for which
hepatology was consulted. A paracentesis was performed. He was
cultured for a temp of 101.7 on [**6-7**] for which the c-line was
changed. The tip was neg for growth as well as urine and blood.
On [**6-9**] he grew gram +cocci (VRE-enterococcus faecium)only
sensitive to linezolid. Given past h/o myelosuppression, he was
started on Tigecycline. Tigecycline continued for 16 days. He
spiked a temp on [**6-12**] and again the c-line was changed over a
wire. A rpt ABD CT revealed two fluid collections within the
left and right lobes of the liver. The collection within the
right lobe of the liver appeared to have increased in size,
measuring 5.6 x 4.1 cm. The left liver lobe collection was
essentially unchanged. Bilateral pleural effusions, greater on
the left, were decreased slightly and a large amount of ascites,
which was decreased slightly. There was evidence of peritoneal
enhancement. The fluid extended into the inguinal canals, and
was loculated on the right side. Ceftriaxone which was used for
E.coli was stopped after 18 days and Meropenum was started for
E.coli & Strep veridins to broaden coverage. Dapto was stopped.
He remained on meromenum for 38 days. He continued to spike
temps.
Repeat paracentesis was done on [**6-15**]. Cultures were
negative. On [**6-18**], he was removed from the Transplant list given
multidrug resistant multifocal liver abscesses, poor nutritional
status despite J tube feedings, debilitation and poor prior
outcomes in other patients with similar setting. On [**6-16**] blood
cultures grew yeast. Ambisone was started [**6-19**]. Repeat blood and
drain cultures were sent. A TTE was done to r/o vegetations.
This was negative. An Ophthalmology exam was negative as well.
On [**6-23**] a repeat abd CT revealed two large fluid collections
within the left and right lobes of the liver. The left lobe
fluid collection had decreased in size, whereas the right lobe
fluid collection had increased in size. A large well
circumscribed fluid collection extending down the right inguinal
canal into the right scrotum was seen. A head CT was done to r/o
infection. This was negative.
On [**6-24**] an 8 Fr catheter was repostitioned in RLQ. Culure of
the fluid grew ENTEROCOCCUS SP,CITROBACTER FREUNDII COMPLEX.
SPARSE GROWTH, NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA.
[**Female First Name (un) **] (TORULOPSIS) GLABRATA.MODERATE GROWTH and CITROBACTER
FREUNDII COMPLEX. Blood cultures from [**6-23**] continued to grow
yeast and VRE. Blood cultures were done q 3 days. On [**7-1**] CT
findings showed new area of decreased enhancement in segment [**Doctor First Name **]
of the liver, worrisome for a new area of ischemia/infarction.
Internal air bubbles were present, and superinfection of this
area could not be excluded. The area did not appear to have
adequate liquification for percutaneous catheter drainage. Two
collections in left lobe of the liver had appropriately
positioned drainage catheters appeared slightly smaller and a
collection in right lobe of the liver, which contained an
appropriately positioned catheter was unchanged in size. On [**6-30**]
Dapto was restarted as well as gentamycin for synergy to attempt
to clear VRE.
Ambisone was changed to Caspo on [**7-3**]. On [**7-7**],the catheter in
right lobe of liver was advanced several centimeters with
aspiration of approximately 20 cc of purulent material. This
appeared in continuity with multiple bilomas/dilated ducts,
which were slightly more prominent than on the previous study.
ID recommended a TTE to r/o vegetation, but the patient refused
TTE.
Synercid was started perioperatively for VRE coverage. On
[**7-17**] he was taken to the OR for irrigation and debridement of
hepatic abscess, right lobe by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 40-50cc of
purulent, bile stained drainage was removed. A large drain was
left in place and placed to suction. He tolerated this procedure
well. Blood cultures and cline tip on [**7-7**] were negative.
Cultures were negative until [**7-14**]. He was relisted for liver
transplantation. Subsequent cultures grew enterococcus faeceum.
Repeat cultures were negative, but then reculture grew
enterococcus faeceum and presumed torulopsis glabrata (per
ID).Levaquin was added for additional gram negative coverage.
Repeat Abd CT showed interval placement of JP drain into
the right lobe of the liver with associated focal subcutaneous
air/surgical emphysema. Air containing abscess in the right lobe
superior to this appeared to have increased in size.
Splenomegaly and ascites were again noted. On [**7-21**], he underwent
successful CT-guided pigtail cath placement in enlarging fluid
collection at the junction of segments 8 and 4A.
On [**7-29**] abd CT revealed 1) S/p multiple drains. Confluent
biloma/abscess involving segment [**Doctor First Name **] and VIII of the liver, the
component in the right lobe is smaller compared to the CT of
[**2122-7-21**].
2) Small bilateral pleural effusions.
3) Persisting ascites, predominantly left-sided and partially
loculated.
4) Nonvisualized proper hepatic artery, likely occluded. Partial
SMV occlusion.
5) Prominent right-sided hydrocele.
6) Splenomegaly.
Abscess cultures persistently grew VRE and [**Female First Name (un) **]
(TORULOPSIS) GLABRATA. P.
On [**7-31**] Caspofungin and meropenum was stopped. The 2
drains in the left lobe were removed. A repeat CT on [**8-3**]
revealed collection in left lobe and a drain was placed into
this site and 10cc was sent for culture. Results are pending.
On [**8-6**] the capped PTC drain fell out with no adverse
effects. Developed diarrhea after tube feed formula changed.
Stool was sent for c.diff. Stool neg on [**8-5**] and pending for
[**8-6**]
On [**8-14**] the right liver abscess catheter fell out. This
area was then loosely packed with normal saline moist gauze [**Hospital1 **].
Potassium was consistently running high. A renal consult was
obtained. Bactrim and synercid were felt to be contributing to
hyperkalemia. Bactrim SS was decreased to 3x/week and the tube
feeding was changed back to 1/2 strength Nepro. Potassium
decreased within the normal range.
In summary, this hospital course was extremely long and
complicated. He has remained afebrile for last few weeks.
Posoconazole, Levaquin, Synercid will continue. Rifaximin is to
prevent encephalopathy. Bactrim is for pcp [**Name Initial (PRE) 2515**]. The plan
is to send [**Doctor First Name **] to [**Hospital **] Rehab Hospital with the hope of
building him up nutritionally and increasing his physical
strength and independence with the hope of keeping him afebrile
while awaiting re-transplantation of a second liver. He will be
followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Transplant Surgeon) and Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 25**] (ID).
Major Surgical or Invasive Procedure:
polymicrobial liver abscesses-ecoli, mucor, yeast, vre [**12-18**]
ischemic biliary ducts
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2122-8-17**] 05:15AM 2.4* 3.14* 9.0* 26.4* 84 28.7 34.2 20.7*
68*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2122-5-2**] 06:36PM 87* 3 3* 4 1 0 1* 1* 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr Ovalocy Schisto
[**2122-5-2**] 06:36PM 1+1 1+ OCCASIONAL NORMAL 2+ OCCASIONAL
1 1+
MANUAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2122-8-17**] 05:15AM 68*
BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2122-5-17**] 04:17AM 523*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2122-8-17**] 05:15AM 162* 34* 0.7 133 4.4 99 29 9
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2122-8-18**] 06:00AM 18*1
1 VERIFIED BY REPLICATE ANALYSIS
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
5. Posaconazole Sig: Two Hundred (200) mg QID (4 times a day).
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Nifedipine 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
10. Psyllium Packet Sig: One (1) Packet PO DAILY (Daily).
11. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two
(2) ML Intravenous DAILY (Daily) as needed: picc line care.
14. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours).
15. Quinupristin-Dalfopristin 500 mg Recon Soln Sig: One (1)
Recon Soln Intravenous Q12H (every 12 hours).
16. Hydromorphone 2 mg/mL Syringe Sig: One (1) mg Injection prn:
q4-6.
17. Insulin Glargine 100 unit/mL Solution Sig: Twenty One (21)
units Subcutaneous once a day.
18. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**]
Completed by:[**2122-8-19**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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"50.29",
"46.39",
"50.91",
"88.72",
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"54.91",
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icd9pcs
|
[
[
[]
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29480, 29718
|
26841, 26932
|
26951, 27857
|
17644, 17930
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27880, 29457
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4250, 17622
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2224, 2594
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2610, 2885
|
172, 216
|
245, 1460
|
2900, 4232
|
1483, 2202
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,735
| 121,357
|
36383
|
Discharge summary
|
report
|
Admission Date: [**2154-5-4**] Discharge Date: [**2154-5-15**]
Date of Birth: [**2107-4-30**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
CC:[**CC Contact Info 82431**]
Major Surgical or Invasive Procedure:
[**5-10**] craniotomy for tumor resection
History of Present Illness:
HPI: This is a 47yF who had witnessed seizures after being found
down in her bed by her fiance. Allegedly, according to her
fiance, she has been in good health until yesterday when she
complained of a headache. Today on arrival back home he notes
that she was unresponsive, blue, and choking on her emesis in
the
apartment. EMS found the patient flaccid on her L side and
noticed a generalized tonic-clonic seizure in the field. She had
been given Valium in the field and then brought to [**Hospital **]
hospital where she was intubated. There she received 1500mg of
dilantin as well as 10mg Decadron. Repeat seizures cleared with
up to 6mg IV ativan. Urine/serum toxicology negative.
Past Medical History:
PMHx: none known
Social History:
Social Hx: was about to be married to American fiance in 3 days,
he denies any EtOH or drug abuse or any suicidal behavior
Family Hx: unknown
Family History:
Family Hx: unknown
Physical Exam:
PHYSICAL EXAM:
O: T: 99.1 BP: 154/83 HR: 93 R 20 O2Sats 100 on CMV
Gen: intubated, agitated off propofol, uncooperative
HEENT: Pupils: reactive
Neck: Supple.
Lungs: wet ronchi b/l.
Cardiac: sinus tachy. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated and agitated off propofol
Recall: unable to assess
Language: unable to assess
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
2 mm bilaterally.
III, IV, VI: unable to assess
V, VII: unable to assess
VIII: unable to assess
IX, X: unable to assess
[**Doctor First Name 81**]: unable to assess
XII: unable to assess
does not open eyes to commands / pain
Motor: Normal bulk and tone bilaterally. With purposeful
withdrawal to painful stimuli in all extremities. Right side
grossly 5/5 strength. L side with 4+/5 strength though will
again
move spontaneously and withdraw from noxious stimuli
Sensation: grossly intact to painful stimuli in all extremitites
Toes upgoing on right, difficulty with assessing left due to
agitation
ON DISCHARGE
O: T:98.3 BP: 113/71 HR: 82 R 18 O2Sats 98% on R/A
Gen: Comfortable, In no acute distress
HEENT: Pupils: 4.0mm to 3.0mm RRLA
Neck: Supple. No JVD or upstrokes
Lungs: CTA bilat.
Cardiac: sinus tachy. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro: CN II-XII Grossly intact
Mental status: Awake, Alert and Oriented x3 through her fiance
interpreting daily.
Language: Russian speaking only. Speech is fluent via fiance.
Motor: Normal bulk and tone bilaterally. Motor strength 5/5
throughout as tested in all muscle groups. She is ambulating in
halls with min contact.
Sensation: grossly intact to light touch in all extremities
Toes upgoing bilaterally
Pertinent Results:
Radiology Report CHEST (PORTABLE AP) Study Date of [**2154-5-3**]
10:11 PM
Reason: ett placement
SINGLE AP CHEST RADIOGRAPH: There is an endotracheal tube
located
approximately 1.5 cm above the carina. This should be withdrawn
for optimal
positioning. Nasogastric tube courses into the stomach. The lung
volumes are
low, but there is no focal consolidation. Minimal density at the
left
costophrenic angle may suggest a small effusion, consolidation,
or
atelectasis. The hilar and cardiomediastinal contours are
normal. The osseous
structures and surrounding soft tissues demonstrate no
abnormality.
IMPRESSION:
1. Endotracheal tube 1.5 cm from the carina. This should be
retracted [**12-21**]-cm for optimal positioning.
2. Increased density at the left costophrenic angle may reflect
a small
effusion, atelectasis, or an early consolidation.
Neurophysiology Report EEG Study Date of [**2154-5-4**]
OBJECT: EVALUATE FOR SEIZURES.
FINDINGS:
ABNORMALITY #1: Throughout the recording, there were long
periods of
generalized slowing of the background in the delta and low theta
ranges.
These periods alternated with brief periods of attenuation of
the
background lasting up to two seconds and with other periods of
faster
activity resembling spindle activity.
BACKGROUND: As above. There was no predominant posterior rhythm
evident in this recording.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: Although some of the above-mentioned patterns were
suggestive in
themselves of certain sleep patterns, the abrupt changes from
one
pattern to the other made it unlikely to be sleep and more
likely to
represent encephalopathy.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 102 bpm.
IMPRESSION: This is an abnormal portable EEG recording due to
the
alternating patterns of mild slowing of the background,
attenuation of
the background, and spindle pattern suggestive of a moderate to
severe
encephalopathy. There were no clear lateralized features in this
recording and no epileptiform features. This pattern is not
suggestive
of a non-convulsive status epilepticus pattern.
CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY [**5-3**] Clip #
[**Clip Number (Radiology) 82432**]
Reason: please second read
Final Report
FINDINGS: There is a calcified lesion within the right frontal
region,
measuring approximately 2 cm, the exact margins are difficult to
determine, as well as its exact location whether intra-axial or
extra-axial. There is a small amount of surrounding vasogenic
edema. If this lesion is extra-axial,may represent a meningioma.
If this is intra-axial, oligodendroglioma would be a
consideration, further characterization with MR is suggested.
There is no evidence of intracranial hemorrhage, shift of normal
midline structures, or acute major vascular territorial
infarction. Ventricles and sulci are normal in caliber and
configuration. Visualized paranasal sinuses and mastoid air
cells reveal mucosal thickening of the left maxillary sinus, as
well as patchy opacification of the ethmoid sinuses. Secretions
are seen within the nasopharynx. No osseous erosion or
irregularity is seen in the region of the lesion in the right
frontal region.
IMPRESSION: Calcified lesion in the right frontal region,
difficult to
determine whether intra-axial or extra-axial, with mild
surrounding vasogenic
edema. If extra-axial, this could represent a meningioma. If
intra-axial,
consideration could be oligodendroglioma. An MRI is suggested
for further
characterization.
Radiology Report MR FUNCTIONAL BRAIN BY PHYS/PSYCH Study Date of
[**2154-5-6**] 1:55 PM
Provisional Findings Impression: RXRa WED [**2154-5-8**] 10:17 AM
PFI: There is evidence of a left frontal intra-axial lesion with
small areas of heterogeneous signal as demonstrated previously
on the MRI dated [**2154-5-4**]. This lesion is worrisome for
neoplastic infiltration, the pre-surgical functional MRI
demonstrates normal activation areas during the movement of the
left hand in the primary motor cortex on the right cerebral
hemisphere at more than 1 cm of distance from this lesion. A
possible supplementary area is identified in the medial
convexity (401:6). During the movement of the left hand there is
evidence of some areas of activation adjacent to the lesion,
likely representing venous contamination, the activation area
during the movement of the right hand appears within normal
limits. During the movement of the right foot, some small areas
of activation appears adjacent to the lesion (500:3). During the
movement of the left foot no areas of activation are adjacent to
the lesion. The dominance of the language apparently is
located on the left cerebral hemisphere.
Preliminary Report !! PFI !!
PFI: There is evidence of a left frontal intra-axial lesion with
small areas of heterogeneous signal as demonstrated previously
on the MRI dated [**2154-5-4**]. This lesion is worrisome for
neoplastic infiltration, the pre-surgical functional MRI
demonstrates normal activation areas during the movement of the
left hand in the primary motor cortex on the right cerebral
hemisphere at more than 1 cm of distance from this lesion. A
possible supplementary area is identified in the medial
convexity (401:6). During the movement of the left hand there is
evidence of some areas of activation adjacent to the lesion,
likely representing venous contamination, the activation area
during the movement of the right hand appears within normal
limits. During the movement of the right foot, some small areas
of activation appears adjacent to the lesion (500:3). During the
movement of the left foot no areas of activation are adjacent to
the lesion. The dominance of the language apparently is located
on the left cerebral hemisphere.
Brief Hospital Course:
Pt was admitted through the emergency department after her
significant other found her unconscious with possible seizure.
She was intubated at an OSH and came to [**Hospital1 18**] on propofol after
CT revealed new Right Frontal Brain mass.
On initial exam she moved her lower extremeties spontaneously.
Her Left upper extremity was without motor function. She was
loaded with dilantin and decadron and transferred to the ICU.
Her exam did not readily improve and there was concern for
sub-clinical seizure. Neurology was consulted and an EEG
obtained. Through the next 24 hours she started to improve and
was able to be extubated. Her EEG showed global slowing without
spikes. Decadron was discontiued and Keppra continued.
She was transfered to floor status and evaluated by speech for
dysphagia. After video swallow she was advanced on her diet
with chin tuck.
She had a wand study (MRI) on [**2154-5-9**] in the evening for prep
for OR the am of [**2154-5-10**]. She was ambulating with minimal
assistance from her fiancee. Her mental status was at baseline
except she was described as a little slower than usual per her
fiancee. She went to the OR for craniotomy for tumor resection
[**5-10**] and post-operatively she was sent the the ICU. Post
operative course was unremarkable. The patient subsequently
tolerated good POs and was cleared by PT for discharge. The
patient was discharged home.
Medications on Admission:
none
Discharge Medications:
1. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**12-21**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*90 Tablet(s)* Refills:*2*
2. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for headache.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Right Frontal Mass
Discharge Condition:
Neurologically Stable
Discharge Instructions:
??????Have a friend/family member check your incision daily for signs
of infection.
??????Take your pain medicine as prescribed.
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
??????You may shower before this time using a shower cap to cover
your head.
??????Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
??????You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
??????Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????Make sure to continue to use your incentive spirometer while at
home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
??????New onset of tremors or seizures.
??????Any confusion or change in mental status.
??????Any numbness, tingling, weakness in your extremities.
??????Pain or headache that is continually increasing, or not
relieved by pain medication.
??????Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
??????Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please return to the office in [**6-28**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**5-27**],[**2153**] at 11:30 AM. The Brain [**Hospital 341**] Clinic is located on the
[**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain, as this was done during
your acute hospitalization
Completed by:[**2154-5-15**]
|
[
"787.23",
"780.1",
"348.5",
"191.1",
"780.39",
"342.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"89.14",
"96.71",
"88.96",
"88.91"
] |
icd9pcs
|
[
[
[]
]
] |
11034, 11040
|
8970, 10384
|
349, 393
|
11103, 11127
|
3141, 8947
|
13039, 13829
|
1332, 1353
|
10439, 11011
|
11061, 11082
|
10410, 10416
|
11151, 13016
|
1383, 1640
|
279, 311
|
421, 1111
|
1760, 2736
|
2751, 3122
|
1133, 1154
|
1170, 1316
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,899
| 193,309
|
37067
|
Discharge summary
|
report
|
Admission Date: [**2173-3-14**] Discharge Date: [**2173-3-24**]
Date of Birth: [**2112-2-5**] Sex: M
Service: MEDICINE
Allergies:
Lorazepam
Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
hemothorax
Major Surgical or Invasive Procedure:
VATS
Chest tube
History of Present Illness:
Pt is 61 yo M w/ recent dx of HCC ([**11-25**]) s/p RFA procedure for
SVT on [**2173-2-26**], s/p RFA of HCC on [**2173-3-11**] as part of clinical
trial,IVC clot on lovenox, who presented to the [**Hospital1 18**] ED w/
fever, dyspnea. Pt stated that although he initially felt well
after the procedure he began to note R sided chest pain that was
worse with deep inspiration, which radiated to the R shoulder
and R upper back. He also noted dyspnea on exertion, with
activities including climbing the stairs. He presented to the ED
where a CT scan was obtained which demonstrated a large R
hemothorax. Thoracic surgery was consulted and a chest tube was
placed. The Pt was then admitted to the MICU.
.
In the ED, initial vs were: 96.0 100 111/70 16 100% on unknown
oxygen level. Patient had a CXR that showed large R pleural
effusion, CT scan showed a large right hemothorax. Thoracics
placed a chest tube. and did not think that protamine was
indicated. 2 18g and 1 20g PIV were placed for access. While in
the ED, the pt developed O2 requirement and vitals at the time
of transfer were 98% 4L, P 119, RR 18, BP 108/66.
.
Upon arrival to the floor, T 99.7, HR 112, BP 112/73, rr 17, O2
sat 98% on 2L. Pt is complaining of pain at the site of chest
tube insertion.
Past Medical History:
1. h/o SVT since age 39
2. HCV cirrhosis, HCC:
- HCV dx [**2150**], genotype 3, presumably [**1-19**] IVDU
- [**11/2169**] liver biopsy showed cirrhosis, s/p Pegylated
Interferon-Ribavirin x48 weeks, became aviremic but lost to f/u
x1 year, no documented SVR
- abnl LFTs noted [**9-/2172**] when hospitalized for unrelated
illness
- AFP [**2172-11-6**]: 14.8
- CT [**2172-11-20**]: ill-defined 5.6cm mass in superior right lobe of
liver
- Bx [**2172-12-4**]: moderately-differentiated HCC, with broad bands
of fibrosis
- Not transplant candidate (lesion outside [**Location (un) 6624**] criteria), not
resection or chemoembolization candidate (tumor thrombus)
- s/p CyberKnife [**1-/2173**] to tumor thrombus
- Cirrhosis well-compensated, with evidence of portal
hypertension (varices) and ascites seen on last CT scan
3. Biliary colic since [**11/2172**] (on ursodiol)
4. peripheral neuropathy - he has numbness of the soles of his
feet and the tip of his second toe bilaterally, appears to be
[**1-19**] interferon treatment
5. Hypertension
6. history of alcohol use
7. history of IV drug use
8. Seasonal allergies
9. s/p knee surgery age 16
Social History:
He is married and has one daughter, age 24. [**Name2 (NI) **] has a distant
history of moderate alcohol use but quit 20 years ago. He smoked
cigarettes but quit in [**2163**]. He currently lives in the [**Location (un) 83563**].
Family History:
Denies any family history of hepatitis or
hepatocellular carcinoma. Grandfather died from heart disease
and his grandmother had an unknown cancer.
Physical Exam:
Vitals: T 99.7, HR 112, BP 112/73, rr 17, O2 sat 98% on 2L
General: Alert, oriented, no acute distress, somewhat cachetic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated 8cm, no LAD, trachea midline
Lungs: Breath sounds absent on R lower and middle lung base, no
wheezes, rales, ronchi
CV: tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops. Chest tube in place draining
Abdomen: soft, distended,bowel sounds present, no rebound
tenderness or guarding.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
[**2173-3-14**] 02:43PM LACTATE-2.6*
[**2173-3-14**] 02:40PM GLUCOSE-130* UREA N-24* CREAT-1.0 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-96 TOTAL CO2-26 ANION GAP-13
[**2173-3-14**] 02:40PM ALT(SGPT)-60* AST(SGOT)-74* CK(CPK)-60 ALK
PHOS-95 TOT BILI-1.7*
[**3-14**]
IMPRESSION:
1. Large right-sided hemothorax with two areas of active
extravasation, one
of which may be arising from intercostal artery.
2. Expected hematoma within the RFA site in the liver dome
without
enhancement.
3. Thrombus within the main portal vein and SMV, slightly
decreased when
compared to prior exam. Previously identified thrombus in the
middle hepatic
vein is not well seen. Cavernous transformation of the portal
vein is also
identified.
4. Heterogeneous appearance of the liver concerning for
multifocal tumor,
incompletely characterized.
5. Large amount of ascites.
The study and the report were reviewed by the staff radiologist
.
CXR
Small loculated areas of air seen in the right base at the site
of one of the
chest tubes which has now been removed. No apical pneumothorax
is present.
Atelectasis at the right base persists, little changed from the
prior chest
x-ray. The left lung field remains clear. There is no failure.
IMPRESSION: No significant change.
Brief Hospital Course:
# Hemothorax: The patient was initially admitted for Hemothorax
which was felt to be secondary to intercostal vessel injury in
the setting of his RFA. This required VATS with 2 Liters of old
blood removed, and the placement of three chest tubes.
Eventually all three chest tubes were pulled, the patients CXRs
showed healing, and he began to ambulate easily with physical
therapy. The patient was initially recomended for subacute
rehab placement, however an amenable facility could not be
found. He worked more intensely with PT who cleared him to go
home with home PT. Follow-up was scheduled with thoracic
surgery.
.
# Increasing abdominal distension: On the second day out of
the unit the patient began experiencing abdominal distension,
gastric discomfort. NG tube was placed, KUB was checked and an
illeus was discovered. Eventually with NG suction, ambulation,
and PR suppositories, the illeus resolved and the patient felt
relief. He continued to complain of abdominal distension and
discomfort. Repaeat imaging showed resolution of his bowel gas
pattern, and persistent ascites. Paracentesis was discussed
among the team, the patient, and the patient's HCP and it was
determined that the preference would be to spare the patient
another procedure. He was initially started on 50 of
spironolactone and 20 of lasix, with a small improvement in his
distension.
.
# SVT: Patient is s/p ablation for SVT, however the night
before he was transferred out of the ICU he was found to be in
SVT, which he came out of with IV dilt. With oral metoprolol he
never returned into a rapid rhythym. He was in sinus the entire
time he was on the floor.
.
#Anemia: Pt w/ Hct on admission of 29 from 39.5, 4 days ago. Up
to 33.4 with 8 units transfed in unit, though no transfusions
since the 29th. His HCT was stable the entire time he was on
the floor.
.
#Hyponatremia: Pt w/ Na of 131 upon arrival to the floor.
Suspect hypovolemic hyponatremia in setting of recent blood loss
into hemothorax. Has increased to 134 with IVF and xfusions.
Eventually normalized with IV hydration (albumin).
.
#HCC: Pt currently on clinical trial for HCC, Dr. [**Last Name (STitle) **]
followed the whole time the patient was in house, which was
greatly appreciated.
.
#IVC clot vs SMV/Portal Vein clot
There was extensive imaging of this lesion, which was documented
to have resolved and the patient was discharged without need for
anticoagulation.
.
#Hypertension
- We held home antihypertensive medications in setting of the
bleed, and the patient never had issues with hypertension so he
was sent out off of them.
.
Medications on Admission:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ursodiol 500 mg Tablet Sig: One (1) Tablet PO once a day.
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day then once a day: Take one tablet twice a day for three
days, then take one tablet once a day (in the morning) for three
more days, then stop.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain for 14 days.
Disp:*84 Tablet(s)* Refills:*0*
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on then remove for 12 hours.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Simethicone 80 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables
PO QID (4 times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day).
Disp:*60 Suppository(s)* Refills:*2*
9. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Personal Touch VNA
Discharge Diagnosis:
Hemothorax
Illeus
Ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after being found to have bleeding following
your RFA for your hepatocellular cancer. You underwent surgical
drainage of this blood and briefly required chest tubes. You
did well after these chest tubes came out and eventually were
safe to walk around the floor. Your stay was complicated by
constipation known as illeus, and accumulated fluid in your
abdomen. We started you on diuretic medications for the fluid
and laxatives for the illeus.
.
The following changes were made to your home medications:
The following medications were stopped and must be discussed
with your PCP at [**Name9 (PRE) 83565**]
Lisinopril, Amlodipine, ursodiol
The following medications were started:
Dilaudid 2mg .5-1tab every four hours as needed for pain
Lidocaine patch 12 hours on 12 hours off once per day for pain
Metoprolol 25mg three times per day to control your heart rate
Omeprazole 40mg Daily to protect your stomach
Docusate 100mg twice per day for constipation
Senna 8.6mg 1 tab twice per day for constipation
Simethicone 80mg up to four times per day as needed for gas
Bisacodyl 10mg per rectum up to twice per day as needed for
constipation
Spironolactone 50mg daily
Lasix 20mg Daily
albuterol inhalers every 6 hours as needed for SOB/wheezing
atrovent inhalers every 6 hours as needed for SOB/wheezing
Followup Instructions:
Department: TRANSPLANT
When: FRIDAY [**2173-4-2**] at 10:00 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: THORACIC SURGERY
When: TUESDAY [**2173-4-6**] at 9:30 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: EAST Best Parking: [**Street Address(1) 592**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2173-4-14**] at 2:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], 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
Completed by:[**2173-3-25**]
|
[
"511.89",
"V15.82",
"998.11",
"560.1",
"273.8",
"572.3",
"584.9",
"456.21",
"427.89",
"799.02",
"276.6",
"998.2",
"477.8",
"E879.2",
"571.5",
"155.0",
"070.70",
"401.1",
"285.1",
"V12.51",
"285.29",
"276.1",
"789.59",
"E870.8",
"238.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"34.21",
"34.09"
] |
icd9pcs
|
[
[
[]
]
] |
9600, 9649
|
5055, 7667
|
280, 298
|
9719, 9719
|
3782, 5032
|
11217, 12175
|
3024, 3172
|
8403, 9577
|
9670, 9698
|
7693, 8380
|
9870, 10379
|
3187, 3763
|
10397, 11194
|
230, 242
|
326, 1594
|
9734, 9846
|
1616, 2761
|
2777, 3008
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,907
| 109,951
|
42032
|
Discharge summary
|
report
|
Admission Date: [**2144-12-3**] Discharge Date: [**2144-12-5**]
Date of Birth: [**2069-8-30**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hematemesis and melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
75 year old female presenting to OSH with about 24 hours of
hemetemesis and melena. Patient was found by daughter this
morning to be lethargic and less responsive. Patient has hx of
significant NSAID use for her chronic back pain. Upon
presentation to the ED she was oriented and alert. She had 2 IVs
started and given 1L crystalloid bolus. She was noted to have
large amount of melena in the ED. She was given a protonix bolus
and started on IV infusion. At the OSH the patient denied any
chest pain, shortness of breath with mild abdominal discomfort.
The mild abd pain has been present for a couple of weeks.
Patient was initially tachycardic and hypotensive to 90
systolic.
At OSH pt underwent EGD after elective endotracheal intubation
for airway protection. The EGD showed large clot in the stomach
with gastric varices. No esophageal varices were identified. no
evidence of ulcer in duodenum. No intervention was performed.
She was transferred here for tertiary care. At OSH she received
a total of 7 units pRBC, 6 FFP, and 4L of crystalloid. She was
started on an octretide drip. Patient's blood pressure remained
relatively stable and required a short time of peripheral
pressor support.
.
On arrival to the MICU, patient was intubated but arousable. She
was hemodynamically stable with normal blood pressure. She was
on sedation as well as an octreotide drip.
.
Review of systems:
(+) Per HPI
Past Medical History:
Right Breast cancer [**2139**] with lumpectomy, Type 2 DM, HTN,
hyperlipidemia, hyperthyroidism, depression, anxiety, COPD
Tubal ligation, appendetomy, hysterectomy, tonsillectomy
Social History:
- Tobacco: Significant hx of previous tobacco use, quit about 3
yrs ago
- Alcohol: Denies
- Illicits:
Family History:
Not able to obtain currently
Physical Exam:
Vitals: T:99.5 BP:134/58 P:92 R: 18 O2:
General: Intubated, arousable to verbal stimuli, does not appear
to be in distress
HEENT: Sclera anicteric, PERRL
Neck: supple, JVP not elevated,
CV: A. fib; no M,R,G
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly; active melena
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: intubated and sedated. Patient is moving extremities.
Pertinent Results:
[**2144-12-3**] 09:39PM PT-14.7* PTT-27.1 INR(PT)-1.3*
[**2144-12-3**] 09:39PM PLT COUNT-190
[**2144-12-3**] 09:39PM NEUTS-79.0* LYMPHS-16.9* MONOS-3.8 EOS-0.2
BASOS-0.2
[**2144-12-3**] 09:39PM WBC-10.0 RBC-2.60* HGB-7.8* HCT-22.8* MCV-88
MCH-29.9 MCHC-34.1 RDW-15.8*
[**2144-12-3**] 09:39PM ALBUMIN-2.7* CALCIUM-6.7* PHOSPHATE-2.8
MAGNESIUM-1.4*
[**2144-12-3**] 09:39PM cTropnT-<0.01
[**2144-12-3**] 09:39PM LIPASE-20
[**2144-12-3**] 09:39PM ALT(SGPT)-11 AST(SGOT)-25 LD(LDH)-174 ALK
PHOS-39 TOT BILI-0.3
[**2144-12-3**] 09:39PM estGFR-Using this
[**2144-12-3**] 09:39PM GLUCOSE-167* UREA N-24* CREAT-0.7 SODIUM-146*
POTASSIUM-3.4 CHLORIDE-114* TOTAL CO2-22 ANION GAP-13
AP chest reviewed in the absence of prior chest imaging:
ET tube ends no less than 4 cm above the carina in standard
placement. Right internal jugular introducer ends in the upper
SVC. No pneumothorax, pleural effusion, or mediastinal widening.
Heart size top normal. Diminished pulmonary vasculature
suggests emphysema. No pneumonia or pulmonary edema.
CT abdomen/pelvis:
IMPRESSION:
1. Bilateral pleural effusions, bibasilar atelectasis and mild
interstitial edema.
2. Splenic vein thrombosis. Multiple varices noted in the region
of the spleen and anterior to the stomach.
3. Thrombosed aneurysm at the origin of the SMA, with
reconstitution of the distal SMA from adjacent vessels.
EGD:
Esophagus:
Contents: Old blood was seen along the mucosa of the lower third
of the esophagus.
Mucosa: Normal mucosa was noted in the whole esophagus. There
was no evidence of esophageal varices or esophagitis.
Stomach:
Contents: A large amount of clotted blood was seen in the
fundus. Thirty minutes were spent trying to suction and remove
the clot to visualize the fundus, however the fundus could not
be fully visualized. The GE junction was carefully examined and
there was no evidence of gastro-esophageal varices. Isolated
fundal varices could not be ruled out.
Duodenum:
Mucosa: Old blood was noted in the whole duodenum, however the
mucosa was normal without ulcers
Brief Hospital Course:
75 year old female with history of HTN, hyperlipidemia, breast
cancer s/p lumpectomy in remission transferred from OSH with
significant active upper GI bleed. Patient required multiple
packed red cell transfusions with continued instability upon
admission. Emergent EGD showed extensive hemorrhage in the
stomach; a lesion could not be localized. Patient underwent a
massive transfusion protocol, and received 14 units of packed
red cells at the outside hospital and [**Hospital1 18**]. Octreotide and
pantoprazole gtts were continued. CT abdomen suggested gastric
varix due to splenic vein thrombosis was possible source of
bleeding.
.
#Diabetes- monitored finger sticks
.
#COPD- Continued home meds (ventolin and adviar)
.
#Hyperlipidemia- Held Crestor
.
#Hypertension- held lisinopril until hemodynamically stable
.
# FEN: IVF, NPO
# Prophylaxis: Pneumaboots
# Access: peripherals x 3, right IJ trauma line was placed
# Communication: HCP [**Name (NI) **] [**Name (NI) 732**] [**Telephone/Fax (1) 91259**]; discussed case
# Code: DNR
.
Following initial stabilization, patient had another episode of
significant hematemesis and melena on the afternoon of [**2144-12-4**],
and was hemodynamically unstable, requiring additional packed
red cell transfusions. An emergent conference was held
involving attending physicians from the hepatology,
interventional radiology, ICU and surgical services to discuss
possible therapeutic interventions. It was felt that no
endoscopic options were possible and that, due to multiple
varices and very difficult/calcified/aneurysmal anatomy, IR
options were not optimal. Surgery was felt possible but
extremely high risk and with a low likelihood of long-term
control. [**Hospital **] health care proxy, [**Name (NI) **] [**Name (NI) 732**] (daughter),
was involved in the process. She expressed that patient would
not wish to undergo major surgery. After an informed
discussion, the decision was made to transition the patient to
comfort care. No further interventions were pursued. With
family at her bedside, the patient expired peacefully on
[**2144-12-5**] at 2:07 a.m.
Medications on Admission:
Ventolin 2puffs Q4H, crestor 40mg qd, lisinopril 20mg qd,
arimidex 1mg qd, vicodin 5-500 q6h prn pain, naproxyn 375 mg
[**Hospital1 **], methimazole 5mg TID, metformin 1000mg [**Hospital1 **], advair q12h,
aspirin 81mg QD
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"242.90",
"V15.82",
"578.1",
"785.50",
"442.83",
"V66.7",
"447.4",
"272.4",
"578.0",
"300.4",
"V49.86",
"401.9",
"724.5",
"338.29",
"289.59",
"456.8",
"285.1",
"V10.3",
"250.00",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
7183, 7192
|
4757, 6878
|
310, 315
|
7243, 7252
|
2665, 4734
|
7308, 7447
|
2092, 2123
|
7151, 7160
|
7213, 7222
|
6904, 7128
|
7276, 7285
|
2138, 2646
|
1736, 1750
|
247, 272
|
343, 1717
|
1772, 1955
|
1971, 2076
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,071
| 178,482
|
50763
|
Discharge summary
|
report
|
Admission Date: [**2117-1-27**] Discharge Date: [**2117-2-2**]
Date of Birth: [**2052-3-25**] Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
64M h/o COPD and empyema, tobacco abuse with 40+ pack year
smoking history, HLD, HTN, prostate ca s/p cyberknife and
radiation p/w gradual onset dyspnea, productive cough and
conjunctivitis. Patient started having more difficulty
breathing and cough on Friday. Initially got better through
saturday, but worsened over the last few days and acutely felt
that he was unable to catch his breath last night. Tried using
albuterol inhaler at home, does't think it helped. Cough is new
and prodcutive of green sputum. Denies myalgias, but does have
some nasal congestion and conjunctival discharge (bilateral, not
itching) since Friday as well. He had a flu shot this year.
Recently visited friends, one of whom had a cold or pneumonia.
At home he checked his temperature several times, ranging
99-100.7 since Saturday. Has been admitted in the past for COPD
exacerbation, last in [**2113**], at which time he had PNA and empyema
which was drained. Has not been intubated in the past.
.
In the ED initial VS were 99.9 103 162/58 36 91% RA, temp later
checked increased to 100.4. Pt was noted to have increased work
of breathing. CXR showed increased vascular markings bibasilar
with no obvious consolidation. ABG drawn prior to startig NIPPV
showed 7.36/42/71. Becasue of his work of breathing and RR of
30s was put on NIPPV with improvement in O2 sat to high 90s and
appeared more comfortable. After 30 minutes, attempted to
remove NIPPV and was replaced because appeared very
uncomfortable. Given ceftriaxone and azithromycin IV for CAP
coverage, solumedrol 125 mg IV and magnesium 2 gm for possible
asthma component although has no hx and albuterol and
ipratroprium nebs. Blood and sputum cx sent. Labs notable for
Na 131, WBC of 13.1 Transferred to ICU for need for NIPPV.
.
On arrival to the ICU, pt appears comfortable on BiPAP, denies
any complaints.
Past Medical History:
Past Medical History:
COPD (empyema s/p drainage in [**2113**])
HLD
HTN
Prostate cancer s/p cyberknife and radiation
gout
L VATS decortication on [**2114-4-23**] for a strep
milleri empyema
Social History:
Lives wtih wife, has 45+ year packing history and last smoked 6
weeks ago. No EtOH or drugs.
Family History:
Mother with [**Name2 (NI) **], Father deceased with MI
Physical Exam:
ADISSION EXAM:
General: Alert, oriented, no acute distress, comfortable on
BiPAP
HEENT: Sclera anicteric, yellow-white conjunctival discharge,
dry MM, no oropharyngeal lesions, occasional production of
yellow-green sputum
Neck: supple, JVP difficult to assess due to body habitus, no
LAD
Lungs: expiratory wheezes throughout, moving air well, no rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE EXAM:
Lungs clear to auscultation, breathing comfortably, >95% on room
air with ambulation
Pertinent Results:
ADMISSION LABS:
.
[**2117-1-27**] 07:56AM BLOOD WBC-13.4* RBC-4.46* Hgb-14.6 Hct-41.7
MCV-94 MCH-32.8* MCHC-35.1* RDW-13.3 Plt Ct-246
[**2117-1-27**] 07:56AM BLOOD Neuts-89.6* Lymphs-5.4* Monos-4.3 Eos-0.2
Baso-0.5
[**2117-1-27**] 11:59AM BLOOD PT-13.4* PTT-28.8 INR(PT)-1.2*
[**2117-1-27**] 07:56AM BLOOD Glucose-134* UreaN-27* Creat-1.1 Na-131*
K-4.3 Cl-94* HCO3-21* AnGap-20
[**2117-1-27**] 07:56AM BLOOD proBNP-300*
[**2117-1-27**] 07:56AM BLOOD cTropnT-<0.01
[**2117-1-27**] 11:59AM BLOOD Calcium-8.4 Phos-3.5 Mg-3.0*
[**2117-1-27**] 08:47AM BLOOD Type-ART O2 Flow-4 pO2-71* pCO2-42
pH-7.36 calTCO2-25 Base XS--1 Intubat-NOT INTUBA Comment-NASAL
[**Last Name (un) 154**]
[**2117-1-27**] 08:05AM BLOOD Lactate-1.6
DISCHARGE LABS:
[**2117-2-1**] 09:00AM WBC-14.8* RBC-4.52* Hgb-14.6 Hct-42.8 MCV-95
Plt Ct-332
[**2117-1-31**] 07:08AM Glc-111* BUN-12 Creat-0.8 Na-139 K-3.8 Cl-103
HCO3-28
MICROBIOLOGIC DATA:
[**2117-1-27**] Blood culture (x 2) - pending
[**2117-1-27**] Urine culture - pending
[**2117-1-27**] Legionella urine antigen - negative
[**2117-1-27**] MRSA screen - positive
[**2117-1-27**] Sputum culture - contaminated sample
IMAGING STUDIES:
[**2117-1-27**] CHEST (PORTABLE AP) - Single AP erect portable view of
the chest was obtained. There is perihilar and bibasilar
opacities which could relate to fluid overload, although
underlying infectious process could also be present in the
appropriate clinical setting. No pleural effusion or
pneumothorax is seen. Cardiac and mediastinal silhouettes are
stable and unremarkable.
PA/LATERAL:
Mildly improved, but persistent pulmonary edema or, in the
correct clinical context, bibasilar pneumonia (including
atypical, viral or PCP [**Name Initial (PRE) 105601**]).
Brief Hospital Course:
64M h/o COPD and empyema, tobacco abuse with 40+ pack year
smoking history, HLD, HTN, prostate ca s/p cyberknife and
radiation p/w gradual onset dyspnea and productive cough and
conjunctivitis, thought to be secondary to a COPD exacerbation
and pneumonia.
# COPD exacerbation, Pneumonia: Patient was weaned from BiPAP to
supplemental oxygen for nasal cannula. Blood, urine and sputum
cultures were obtained and are no growth at the time of
discharge. Fluticasone and tiotropium treatments were continued.
Oral steroids as well as Ceftriaxone and Azithromycin coverage
for COPD exacerbation were continued and the patient was
transitioned to Levofloxacin at discharge to complete a total of
eight days of antibiotics as well as a steroid taper. Overall
his clinical exam improved, he was weaned from oxygen, and he
had good oxygen saturations on room air with ambulation prior to
discharge.
# Tobacco abuse: counseled on quitting smoking, currently trying
to quit.
# Depression: continued buproprion
# HTN: continued home dosing of losartan, nifedipine.
# Gout: continued allopurinol.
# Transitional Issues:
-follow up CXR in [**5-7**] weeks
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) by mouth q 4 hours as needed for cough/wheezing 3
month supply
ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth Once a day
COLCHICINE [COLCRYS] - 0.6 mg Tablet - 1 Tablet(s) by mouth
twice
a day as needed for gout
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2
Puffs(s) Inhaled Once a day Rinse after use
LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth Once a day
NIFEDIPINE [NIFEDICAL XL] - 60 mg Tablet Extended Rel 24 hr - 1
Tablet(s) by mouth once a day
SILDENAFIL [VIAGRA] - 50 mg Tablet - 1 Tablet(s) by mouth 1 hour
pre-sexual activity
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - 1 Puff inhaled Once a day
TRIAMTERENE-HYDROCHLOROTHIAZID - - 37.5 mg-25 mg Tablet - 1
Tablet(s) by mouth daily (Just started takign again [**1-24**])
Buproprion 100 mg [**Hospital1 **]
ASPIRIN 81 mg Tablet, Delayed Release (E.C.)
- 1 Tablet(s) by mouth Once a day
Discharge Medications:
1. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
5. triamterene 50 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. prednisone 10 mg Tablet Sig: As directed Tablet PO once a day
for 6 days: Take 3 Tablets (30mg) [**2117-2-3**] and [**2117-2-4**]; take 2
tablets (20mg) [**2117-2-5**] and [**2117-2-6**]; take 1 tablet (10mg)
[**2117-2-7**] and [**2117-2-8**].
Disp:*12 Tablet(s)* Refills:*0*
10. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Community Acquired Pnuemonia
- Acute COPD Excacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with cough and shortness of breath.
You have been treated for pneumonia and an exacerbation of COPD.
You are being sent home to complete a course of antibiotics and
a taper of your steroids. It is important that you follow-up
with your primary care doctor to ensure that your breathing
continues to improve.
Please keep all of your appointments as listed below
Followup Instructions:
Department: BIDHC [**Location (un) **]
When: THURSDAY [**2117-2-11**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5080**], MD [**Telephone/Fax (1) 3329**]
Building: [**Location (un) 3966**] ([**Location (un) 55**], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
***The office is working on a sooner appt for you and will call
you at home with the appt. If you dont hear from them by
Wednesday afternoon, please call them directly to book.
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2117-2-15**] at 10:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: MONDAY [**2117-2-15**] at 11:00 AM
With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
****This appointment is with a specialist who will focus
directly on managing your COPD as you transition from the
hospital to home. After this visit you will be scheduled in the
department as needed with either your regular pulmonologist or
with a new one.
|
[
"401.1",
"274.9",
"491.21",
"276.1",
"311",
"486",
"V10.46",
"272.4",
"372.30"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8378, 8384
|
5133, 6220
|
291, 318
|
8503, 8503
|
3376, 3376
|
9079, 10431
|
2553, 2609
|
7307, 8355
|
8405, 8482
|
6305, 7284
|
8653, 9056
|
4111, 4520
|
2624, 3254
|
3270, 3357
|
231, 253
|
346, 2213
|
3392, 4095
|
8518, 8629
|
6243, 6279
|
2257, 2426
|
2442, 2537
|
4537, 5110
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,221
| 199,877
|
15672
|
Discharge summary
|
report
|
Admission Date: [**2195-10-8**] Discharge Date: [**2195-11-17**]
Date of Birth: [**2118-4-21**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 77 year old
woman who had complaints of back pain and leg pain for two to
three days prior to admission. She fell at home with
increasing confusion. She was brought to the [**Hospital6 45215**] where a head computerized tomography scan showed
subarachnoid hemorrhage and she was transferred to [**Hospital6 1760**] for further management. She
had a repeat head computerized tomography scan at [**Hospital6 1760**] which was positive for a
subarachnoid hemorrhage. She went directly to angio where
she had an A1 aneurysm coiling. She also has a left internal
carotid artery occlusion. She tolerated the procedure well
and was monitored in the Surgical Intensive Care Unit post
procedure. On [**10-9**], she was weaned and extubated. She
was moving all extremities. She was restless while intubated
but sleeping comfortably post extubation. She nodded her
head appropriately to questions. She had a vent drain placed
at the time of the coiling. Her intracranial pressure was 10
and her blood pressure was being controlled with Nipride. On
[**10-11**], the patient was conversing but not totally
oriented, she does not know the year and month but knows the
family and answered questions appropriately. The patient had
a repeat head computerized tomography scan on [**10-11**],
which is essentially unchanged, continues to show the
bifrontal hemorrhages with no extension and coiling of the
aneurysm. The patient continued to do well neurologically
until [**2195-10-16**] when she was found to have right upper
extremity weakness. She had a poor cough, was agitated and
fatigued and required reintubation at that point and was
brought back to angio where it was positive for vasospasm.
She was treated with Papaverine with effect. She had a head
computerized tomography scan which showed no new bleed and
she was brought back to the neurological Intensive Care Unit
with improved neurological status post treatment of
vasospasm. She remained unchanged with her blood pressure
160 to 180, right side still slightly weaker but moving all
extremities on the bed, very alert. The patient was
extubated on [**2195-10-18**]. Chest PT was done. She was
very congested and rhoncerous. On [**10-19**], she developed
right-sided weakness again and she was less alert. She went
back to Angio where she was also given Papaverine again. She
was reintubated for Angio and remained intubated post
procedure. Her blood pressure was labile, controlled on and
off Nipride. She was moving all extremities to noxious
stimulation. Her hematocrit was 26. She was given 1 unit of
packed cells and her repeat hematocrit was 30. We attempted
to extubate on [**2195-10-25**] but it was unsuccessful. The
patient remained on a pressure support of 15. She continued
to have vent draining at 20 cm above the tragus. She was
alert but following commands, lethargic at times.
Computerized tomography scan on [**10-22**], showed no change.
She was on Labetalol to control her blood pressure. On
[**2195-10-27**], the patient had an episode of congestive
heart failure, her central venous pressure went up to 29 and
SVP went up to 200. She had crackles on the right lung
fields and left-sided exploratory wheezes. She was given
Lasix. Her positive end-expiratory pressure was increased to
7.5 with good effect, increasing her pO2. On [**10-29**], the
patient was increasingly lethargic. Neo drip was increased.
She had a stat head computerized tomography scan which was
unchanged. Neo was off. The patient sustained blood
pressure parameters without pressors. She was given 1 unit
of packed cells for a low hematocrit. [**2195-11-1**] the
patient had a brown guaiac positive stool, serial hematocrits
were done. The patient remained on CPAP with 5 of pressure
support, 5 of positive end-expiratory pressure. She
continued with a moderate amount of thick secretions and the
patient continued to be diuresed, given 20 of Lasix
intravenously on [**11-1**]. Head dressing was intact.
Pupils were equal, round and reactive to light. She was
following commands. On [**11-2**], the patient had an upper
gastrointestinal series which was consistent with coffee
ground aspirate, guaiac positive stool and epigastric pain.
Upper gastrointestinal series showed two gastric ulcers, not
actively bleeding at the gastric junction and a nonbleeding
longitudinal ulcer. On [**2195-11-3**], the patient had her
tracheostomy and percutaneous endoscopic gastrostomy
procedure without complications. She continued to have
coffee ground aspirate. She also had an abdominal ultrasound
which showed one stone in the neck of her gallbladder but no
cholecystitis. Neurologically she continued to be alert,
nodding and mouthing words appropriately, moving all
extremities strongly. Speech and swallow consult was ordered
to attempt p.o. intake. On [**11-5**], the patient was
awake, alert and oriented to self, opens eyes to voice, able
to follow directions. Pupils were 3 mm and brisk, able to
hold and lift all extremities off the bed. Denies pain. She
has a strong gag and cough reflex. The patient was tested
for Helicobacter pylori which was negative. On [**11-5**]
she had coagulase positive Staphylococcus in her sputum and
gram positive cocci. The patient was treated with Oxacillin
for 14 days. The patient had a repeat head computerized
tomography scan on [**2195-11-10**] which showed mild
ventricular dilation with no clinical hydrocephalus.
Continue to wean from the ventilator and will continue to
screen for rehabilitation. The patient was awake and
attempted smiling, squeezing to command, moving all
extremities spontaneously but still vented. The patient was
weaned from the ventilator on [**2195-11-10**]. She
tolerated it for 72 hours. She was transferred to the
regular floor and then on [**2195-11-13**] she was
transferred back to the Intensive Care Unit for respiratory
distress, continued on Oxacillin for her Staphylococcus
pneumonia and was placed back on a ventilator. She was day
#10 of 14 of Oxacillin on [**2195-11-13**]. The patient had
percutaneous endoscopic gastrostomy placed on [**2195-11-14**]. Tube feedings were started. She tolerated the
procedure well with no complications. The patient remains on
a ventilator. She continues to be awake, alert and oriented
times three, following commands, moving all extremities. She
was continued on Oxacillin for her Staphylococcus pneumonia.
She had a bronchoscopy on [**2195-11-15**]. Bronchoscopy
showed copious secretions at the main carina and the right
and left main stem bronchi. It also showed evidence of
pulmonary edema. The patient was followed by physical
therapy and occupational therapy. She remained on pressure
support of 10 with positive end-expiratory pressure of 5.
DISCHARGE MEDICATIONS:
1. Colace liquid 100 mg p.o. b.i.d.
2. Labetalol 150 mg p.o. b.i.d., hold for systolic blood
pressure of less than 150
3. Albuterol 2 puffs q. 6 hours
4. Salmeterol 2 puffs b.i.d.
5. Heparin 5000 units subcutaneously q. 12 hours
6. Oxacillin 1 gm intravenously q. 6 hours, to be
discontinued on [**2195-11-18**]
7. Insulin sliding scale
8. Atrovent 2 puffs q. 6 hours
9. Flovent 2 puffs q. 12 hours
10. Dicloxacillin 500 mg p.o. q.i.d. times four days
11. Oxacillin was discontinued
12. The patient has tube feeding ProMod with fiber at 70
cc/hr.
13. Tylenol 650 p.o. q. 4 hours prn
14. Percocet 1 to 2 tablets p.o. 4 hours prn
15. Hydralazine 10 mg intravenously q. 6 hours prn for
systolic blood pressure greater than 160
DISCHARGE CONDITION/INSTRUCTIONS: Stable. Protonix was
changed to 40 mg per percutaneous endoscopic gastrostomy q.
day. Vital signs remained stable. She was neurologically
awake, alert and oriented times two to three, moving all
extremities, following commands. She will be discharged to
vented rehabilitation and follow up with Dr. [**Last Name (STitle) 1132**] in three
to four weeks with a repeat head computerized tomography
scan. She as stable at the time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2195-11-17**] 08:46
T: [**2195-11-17**] 08:57
JOB#: [**Job Number 45216**]
|
[
"E888.9",
"428.0",
"433.10",
"482.41",
"852.00",
"518.81",
"285.9",
"531.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"33.22",
"39.72",
"96.6",
"44.32",
"96.72",
"02.2",
"88.41",
"96.04",
"31.1",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6990, 8465
|
175, 6967
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,903
| 108,403
|
50568
|
Discharge summary
|
report
|
Admission Date: [**2200-4-18**] Discharge Date: [**2200-4-28**]
Date of Birth: [**2127-1-27**] Sex: M
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old
male with the sudden onset of dysarthria and left-sided
hemiparesis and numbness. The symptoms began an hour before
Emergency Room admission.
The patient has a history of basal artery stenosis and a
history of intermittent left-sided hemiplegia and was begun
on Coumadin in the past for these symptoms.
PAST MEDICAL HISTORY: (Past Medical History includes)
1. Coronary artery disease.
2. Atrial fibrillation; status post a coronary artery bypass
graft one year ago.
3. History of gastrointestinal bleed.
4. Prostate cancer.
5. Status post appendectomy.
6. Status post diagnosis of severe basal artery
insufficiency.
7. History of transient ischemic attacks.
MEDICATIONS ON ADMISSION: The patient's medications on
admission included aspirin, Lipitor, metoprolol, lisinopril,
digoxin, Prilosec, and Detrol.
ALLERGIES:
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, the patient's temperature was 98.2, heart rate
was 64, blood pressure was 162/64, respiratory rate was 18,
and oxygen saturation was 95% on room air. His pupils were
equal, round, and reactive to light. Extraocular movements
were full. He had decreased strength in the left side, leg
and arm. Cranial nerves were intact. Cardiovascular
examination revealed a respiratory rate. The chest was clear
to auscultation.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 7.2, hematocrit
was 39.6, and platelets were 222. INR was 2.5, prothrombin
time was 19.5, and partial thromboplastin time was 28.3.
Sodium was 141, potassium was 4.6, chloride was 105,
bicarbonate was 23, blood urea nitrogen was 18, creatinine
was 0.7, and blood glucose was 91.
PERTINENT RADIOLOGY/IMAGING: A magnetic resonance imaging
showed multiple small strokes.
HOSPITAL COURSE: The patient was admitted to the Neurology
Surgical Intensive Care Unit and was seen by the Stroke
Service.
The patient was taken to the angio suite by Dr. [**Last Name (STitle) 1132**]. On
[**2200-4-22**], the patient underwent a basilar artery stent
procedure without complications.
Postoperatively, he was awake, alert and oriented times
three. Extraocular movements were full. Visual fields were
full. Pupils were symmetric and reactive. No pronator
drift. No hematoma in the groin. Positive pedal pulses.
His condition remained stable. He remained on heparin for
his history of atrial fibrillation, and Plavix and aspirin
for his stent procedure.
He remained in the Intensive Care Unit until [**2200-4-24**]
when he was discharged to the floor. He remained
neurologically stable. Awaiting Coumadin to be therapeutic
before discharged to home.
DISCHARGE DISPOSITION: He was discharged on [**2200-4-28**]
with an INR of 1.9. Heparin was discontinued. He was also
discharged on aspirin 325 mg p.o. once per day and Plavix 75
mg p.o. once per day along with all his prior medications.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 100 mg p.o. twice per day.
2. Tolterodine 1 mg p.o. twice per day.
3. Aspirin 325 mg p.o. once per day.
4. Plavix 75 mg p.o. once per day.
5. Digoxin 0.25 mg p.o. once per day.
6. Atorvastatin 20 mg p.o. once per day.
7. Tocopheryl 400 units p.o. once per day.
CONDITION AT DISCHARGE: The patient's condition on discharge
was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP: He was to follow up with
Dr. [**Last Name (STitle) 1132**] in two weeks' time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2200-4-28**] 11:17
T: [**2200-5-2**] 08:17
JOB#: [**Job Number **]
|
[
"414.01",
"435.0",
"V45.81",
"272.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.50",
"39.90"
] |
icd9pcs
|
[
[
[]
]
] |
2898, 3116
|
3142, 3435
|
895, 1994
|
2013, 2874
|
3535, 3865
|
3450, 3500
|
169, 504
|
527, 868
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,992
| 182,579
|
4621+4695+55592
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2200-4-28**] Discharge Date: [**2200-5-9**]
Date of Birth: [**2133-2-12**] Sex: M
Service: OTOLARYNGOLOGY
HISTORY OF THE PRESENT ILLNESS: The patient is a 66-year-old
with a complicated past medical history of sinonasal
carcinoma complicated by osteomyelitis of the right mandible
and recurrent squamous cell carcinoma at the skull base and a
right facial orocutaneous fistula. He had been discharged
recently from the [**Hospital1 **] with a PICC line, IV antibiotics, and a
PEG with the plan to start tube feeds.
He presented on [**2200-4-28**] for his planned procedure,
resection and reconstruction, by Plastic Surgery.
PAST MEDICAL HISTORY:
1. Maxillary sinonasal carcinoma.
2. Right mandible osteomyelitis.
3. Prostate cancer.
PAST SURGICAL HISTORY:
1. Status post PICC, left arm.
2. Status post PEG.
3. Status post total maxillectomy.
4. Status post radiation therapy with ostial radial necrosis
of the right mandible.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS FROM HOME:
1. Colace.
2. Duragesic patch 75 micrograms per hour.
3. Neurontin 800 mg b.i.d.
4. Multivitamin.
5. Prozac 20 q.d.
6. Erythromycin ointment to the right eye t.i.d.
7. Ibuprofen p.r.n.
8. Vancomycin 1.25 grams every day.
9. Ceftriaxone 2 grams every day.
10. Reglan 10 mg per PEG.
11. Roxicet p.r.n.
12. Neomycin to the right ear.
13. Iron.
14. Oxycodone 40 mg p.o. b.i.d.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: The patient
was afebrile with vital signs stable. Cranial nerves II
through XII were intact with exceptions including the right
second nerve, right seventh nerve zygomatic buccal arch, the
right maxillary sinus is gone, right mandible is exposed,
right eyelid was swollen with erythema. Lungs: Clear on
auscultation. Heart: Regular rate and rhythm. Abdomen:
Nontender, nondistended, soft with positive bowel sounds.
Extremities: Warm and well perfused with full motor and
strength.
ADMISSION LABORATORY DATA: White count 10.0, hematocrit 29,
platelets 325,000. Coagulations: INR 1.2, BUN 24,
creatinine 0.7.
His chest x-ray showed no acute disease but bilateral apical
thickening and emphysematous changes.
EKG revealed sinus rhythm at 54, no change compared to
[**2199-10-4**].
HOSPITAL COURSE: The patient was evaluated by Plastic
Surgery, Dr. [**Last Name (STitle) 13797**], and was taken to the Operating Room on
[**2200-4-29**].
By ENT he had (1) Tracheostomy. (2) Right modified radical
neck dissection including levels [**2-2**]. (3) Orbital excision.
(4) Overlying facial defect removed. (5) Mandibulectomy.
Findings were that the tumor did involve the orbit and there
is a pathological fracture in the mandible.
Plastic Surgery on [**2200-4-29**] did a right rectus abdominis
myocutaneous transfer to the right hemifacial defect. Total
ID was 6,200. Urine output was 2,500. EBL 500 cc. He was
taken to the ICU with frequent flap checks.
Prior to this, he received 2 units of packed red blood cells
for a crit of 29 prior to going for the operation. He
tolerated the procedure well. He stayed in the ICU for two
days. He was taken off the ventilator without problems. [**Name (NI) **]
was transferred to the floor.
ID was consulted regarding his antibiotics and they
recommended for his history of osteomyelitis and
radionecrosis, especially in the setting of a new
myocutaneous flap, to continue his antibiotics, vancomycin,
ceftriaxone, and Flagyl, for a total of six weeks. He has a
left PICC line for this.
His electrolytes were checked and repleted. Potassium one
day was found to be 2.9 and repleted to goal.
GASTROINTESTINAL: He has had some difficulty with tube
feeds. At first he had nausea and high residuals. He
received two days of Reglan. He now has continuing diarrhea.
His C. difficile is negative. We have changed the tube
feeds. We are starting Lomotil today and had some
improvement, but he is otherwise tolerating his tube feeds at
goal. Pain is well controlled. He does complain of a
headache. A new finding is also of a left foot drop with
some numbness on the dorsum of his foot anteriorly. This is
new in the hospital, presumed to be due to operating room
positioning during this long case and should resolve.
Physical Therapy has seen him and will be following him at
home. He has a foot brace that has been helping. He is
independently ambulating and deemed safe for discharge with
VNA on [**2200-5-9**].
FOLLOW-UP: The patient is to follow-up in ENT with Dr.
[**First Name (STitle) **], [**Telephone/Fax (1) 41**]. He is to call for an appointment in one
to two weeks. He is to follow-up with Plastic Surgery, Dr.
[**Last Name (STitle) 13797**], [**Telephone/Fax (1) 19606**]. He is to call for an appointment in
one to two weeks. He is also to follow-up with Infectious
Disease, Dr. [**Last Name (STitle) 13901**]. He has an appointment set up for [**2200-5-30**] at 11:00 a.m. in 11 Riseman at the [**Hospital3 **] [**Hospital Ward Name 8559**]. He is also to follow-up with his primary care
provider this week.
DISCHARGE MEDICATIONS:
1. Ceftriaxone 2 grams q. 12 hours IV for five more weeks.
2. Fluoxetine 20 mg q.d.
3. Gabapentin 800 mg b.i.d.
4. Aspirin 81 mg q.d.
5. Lorazepam [**3-4**] milliliters every six hours as needed.
6. Vancomycin 750 mg IV q. 12 for five more weeks.
7. Metronidazole 500 mg t.i.d. for three weeks.
8. Famotidine 20 mg per G tube twice a day.
9. Tylenol elixir p.r.n.
10. Oxycodone solution p.r.n. pain.
11. Chlorhexidine gluconate solution 15 ml four times a day.
DISCHARGE INSTRUCTIONS:
1. Concerning his diarrhea: C. difficile is negative. He
is to continue his home tube feeds, seven cans a day of
ProMod with fiber or Nestle equivalent. In two days, if he
has continued diarrhea, the VNA is to check CBC and
chemistries and sent results to his PCP or Dr. [**First Name (STitle) **]. He was
also started on Lomotil in the hospital and can titrate this
to effect at home.
2. Physical therapy: For the left foot drop, he will be
followed and evaluated.
3. He is to continue antibiotics for a total of five weeks.
4. JP drain management per Plastics. They are to keep this
JP drain in with recording of daily output and bring to the
Plastic Surgery appointment.
5. Wound check: There is a small orocutaneous fistula at
the anterior side of the mouth. Please check on this daily.
His old tracheostomy site has been closed with Steri-Strips
and covered with a dry sterile dressing. Only change the dry
sterile dressing.
6. He has a PICC line in the left arm which should be
flushed and kept patent.
7. PEG tube for which he will have tube feeds and should be
flushed to keep patency.
[**Name6 (MD) **] [**Last Name (NamePattern4) 13798**], M.D. [**MD Number(1) 13799**]
Dictated By:[**Last Name (NamePattern4) 19607**]
MEDQUIST36
D: [**2200-5-9**] 11:45
T: [**2200-5-9**] 23:26
JOB#: [**Job Number 19608**]
Admission Date: [**2200-4-28**] Discharge Date: [**2200-5-9**]
Date of Birth: [**2133-2-12**] Sex: M
Service: OTOLARYNGOLOGY
HISTORY OF THE PRESENT ILLNESS: The patient is a 66-year-old
man with a complicated medical history of sinonasal carcinoma
complicated by osteomyelitis of the right mandible with
recurrent squamous cell carcinoma at the skull base. Also, a
right facial orocutaneous fistula. He had been discharged
with a PICC line, IV antibiotics, and a PEG recently.
He presented to the [**Hospital6 256**] on
[**2200-4-28**] for an operation to include a
hemimandibulectomy, skin excision, question of a facial nerve
resection and dissection, tracheostomy, and free flap.
ALLERGIES: The patient has no known drug allergies.
[**Name6 (MD) **] [**Last Name (NamePattern4) 13798**], M.D. [**MD Number(1) 13799**]
Dictated By:[**Last Name (NamePattern4) 19607**]
MEDQUIST36
D: [**2200-5-9**] 11:24
T: [**2200-5-9**] 23:05
JOB#: [**Job Number 19812**]/[**Numeric Identifier 19813**]
Name: [**Known lastname **], [**Known firstname 2892**] Unit No: [**Numeric Identifier 3226**]
Admission Date: [**2200-4-28**] Discharge Date: [**2200-5-9**]
Date of Birth: Sex:
Service:
ADDENDUM: In regards to his new left foot drop, Neurology
was consulted and confirmed it was a peroneal nerve
compression probably during the operation, probably will
resolve over time. She is to follow-up with the
Neuromuscular Group at [**Telephone/Fax (1) 190**]. He is to have a
follow-up appointment in three to four weeks. He is to call
[**Last Name (LF) 228**], [**5-12**] to schedule an EMG and nerve conduction
study to occur within the next one to two weeks. No further
imaging will be needed.
Plastic Surgery follow-up with Dr. [**Last Name (STitle) 2023**] to occur as soon
as possible within the next week after discharge.
DR.[**First Name (STitle) 3227**],[**First Name3 (LF) 3228**] 04-134
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2200-5-9**] 05:55
T: [**2200-5-10**] 12:48
JOB#: [**Job Number 3229**]
|
[
"160.2",
"733.19",
"198.89",
"526.4",
"198.5",
"496",
"E879.2",
"733.49",
"355.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"04.07",
"86.74",
"76.31",
"31.1",
"16.59",
"38.93",
"40.41",
"96.71",
"76.39",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5117, 5588
|
2296, 5094
|
5612, 6007
|
800, 1456
|
6025, 9133
|
1471, 2278
|
686, 777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,655
| 169,458
|
30018
|
Discharge summary
|
report
|
Admission Date: [**2115-3-28**] Discharge Date: [**2115-4-10**]
Date of Birth: [**2038-1-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
Transfer from ICU, admission for COPD flare/CHF/bronchitis
Major Surgical or Invasive Procedure:
catheterization
History of Present Illness:
Briefly, 77 M w/ CHF, COPD on 3L oxygen at home, Afib p/w
dyspnea. For the past week, pt has been waking up SOB. He has 2
pillow orthopnea at baseline that has been unchanged. He has
also had a recent cough productive of yellow sputum, with no
hemoptysis, that has been worsening. Wife with recent URI.
.
In MICU pt's respiratory status has improved. Pt initially
requiring NRB, now on home 3L. Has remained afebrile and vitals
o/w stable. Echo checked today that revealed EF 15-20%, severe
global right ventricular free wall hypokinesis, and severe
overall LV depression. Pt subjectively feeling better, though he
did wake mildly dyspneic last night. Pt to be transferred to
medical floor for further management.
.
Past Medical History:
--COPD (home O2 3L NC)
--CHF (unknown EF)
--Afib (on coumadin)
--Adrenal insufficiency?
--abdominal hernias
Social History:
retired. lives with wife. [**Name (NI) **] current tob use. No etoh. No drugs
Family History:
NC
Physical Exam:
Temp 97 BP 101/50 Pulse 96 Resp 20 O2 sat 100% 3 l NC
Gen - Alert, no acute distress
HEENT - extraocular motions intact, anicteric, mucous membranes
slightly dry
Neck - no JVD, no cervical lymphadenopathy
Chest - crackles at bases bilaterally
CV - Normal S1/S2, irred irreg, no murmurs appreciated
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Skin - No rash
rectal: good tone, brown stool, guaiac negative
Pertinent Results:
admission labs:
[**2115-3-27**] 08:45PM WBC-13.5* RBC-4.14* HGB-11.9* HCT-33.7*
MCV-82 MCH-28.7 MCHC-35.2* RDW-16.4*
[**2115-3-27**] 08:45PM CALCIUM-8.5 PHOSPHATE-4.0 MAGNESIUM-2.2
[**2115-3-27**] 08:45PM GLUCOSE-108* UREA N-28* CREAT-1.2 SODIUM-131*
POTASSIUM-6.3* CHLORIDE-99 TOTAL CO2-23 ANION GAP-15
[**2115-3-28**] 05:00AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2115-3-28**] 05:00AM CK-MB-NotDone cTropnT-0.03* proBNP-[**Numeric Identifier 71631**]*
.
studies:
[**3-27**] cxr: IMPRESSION: CHF superimposed on emphysema. Bilateral
lower lobe atelectasis.
.
[**3-27**] ekg: Multifocal atrial tachycardia and ventricular ectopy.
Left anterior fascicular block. Prior anteroseptal myocardial
infarction. No previous tracing available for comparison
.
echo [**3-29**]:
Conclusions: ef 15-20%
The left atrium is elongated. The estimated right atrial
pressure is
11-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is severely
depressed. The right ventricular cavity is dilated. There is
severe global right ventricular free wall hypokinesis. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly to moderately thickened. Cannot exclude mild aortic
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**2-12**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The pulmonary artery systolic pressure could
not be determined. There is no pericardial effusion.
.
[**2115-4-1**] ct chest:
IMPRESSION:
1. Severe emphysema. Residual bibasilar edema or pneumonia,
right lower lobe, relatively mild.
2. Two right lung lesions concerning for malignancy,
particularly one at the right base with adjacent pleural
thickening.
3. Bilateral pleural effusions, layering and nonhemorrhagic,
right greater than left.
.
[**4-3**] LE US: IMPRESSION: No evidence of DVT in the right lower
extremity
.
abdomen US: IMPRESSION:
1) Patent hepatic vasculature with hepatopetal portal flow.
2) Gallbladder stones and sludge without evidence of acute
cholecystitis.
3) Severely atrophic right kidney.
4) Pleural effusions and prominent IVC/hepatic veins consistent
with known CHF.
5) Small simple left renal parapelvic cyst.
6) Enlarged prostate gland with large postvoid residual.
.
CATH:
Brief Hospital Course:
1. CHF: The patient has a history of CHF and had Echo here with
LVEF of 15-20%. The patient was diuresed in the Unit, but once
on floor had dyspnea on [**3-31**] and given symptoms and CXR was
thought to have flashed. He improved slightly with diuretics,
morphine and nebs, but was not tolerating diuresis based on
hypotension. His verapamil was stopped to allow more room for
diuresis and he was aggressively diuresed while trying to
balance his low blood pressure. He was followed closely by the
CHF service, and he did well with diuresis, aldactone, ace, bb
and digoxin. Given his severe heart failure he should be
reavaluted in [**4-16**] months with maintained euvolemia to see if he
needs an ICD.
.
2. Transaminitis: During the patient's course he developed very
elevated LFT's. His work-up revealed a normal RUQ US, negative
hepatitis panel and as he improved with aggressive diuresis,
this was thought to be related to CHF hepatopathy. With
diuresis, his LFT's continued to normalize.
.
3. CAD - Given the patient's severe hypokinesis on ECHO a
concern for CAD was raised and he had a cath that was completely
normal.
.
4. COPD/pneumonia - In the unit it was thought the patient had a
COPD exacerbation so he was treated with steroids that were
slowly tapered. He had a sputum sample showing staph aureus and
given his tenous respiratory state he was treated initially with
ceftriaxone and azithromycin and later, based on sensitivities
was treated with levaquin. He did well with the above and
inhalers.
.
5. Atrial fibrillation: The patient has a history of atrial
fibrillation and required a diltiazem drip on admission for rate
control, he was then on verapamil and well controlled. Given the
need for diuresis and hypotension, the patient was switched from
verapamil to a low dose beta-blocker. He improved and was
thought to initially be in rapid afib because of his pulmonary
status. He was kept on heparin and coumadin, but during his
course he had elevated INR. His coumadin was held and with
vitamin K it improved. After cardiac cath his coumadin was
restarted and should continue to be closely followed as an
outpatient.
.
6. Acute renal failure- The patient has a baseline creatinine of
1.1 and this increased to 2 during his course. This was
attributed to poor forward cardiac flow as with diuresis his
creatinine normalized. Additionally, the patient was restarted
on his flomax which helped his urine output significantly.
.
7. Right Lower Extremity swelling: The patient's right leg was
more swollen than the left. The patient was ruled out for DVT
with a negative LE US. A vascular surgery consult was obtained
who felt that the patient has significant arterial insufficiency
which explains the asymmetry of his edema. The swelling improved
with diuresis and the patient should follow up with his vascular
surgeon in [**2-12**] months from discharge to discuss re-intervention.
.
8. Possibly pulmonary malignancy: On Chest CT the patient was
noted to have two right lung lesions concerning for malignancy,
particularly one at the right base with adjacent pleural
thickening. The patient was notified and this should be further
followed as an outpatient and may need a more extensive work-up.
Medications on Admission:
meds (home):
--furosemide 40 mg daily
--prednisone 5 mg daily
--coumadin 2 mg daily
--flomax 10 mg daily
--rabeprazole 20 mg daily
--folic acid 2 mg daily
--quinine 200 mg daily
--cilostazol 200 mg daily
--lisinopril 10 mg daily
--albuterol
--atrovent
.
meds (in ICU):
Azithromycin 250 mg PO Q24H
CeftriaXONE 1 gm IV Q24H
folate
lasix 40 daily
hep sc
ISS
atrovent
lisinopril
mucinex
pantoprazole
prednisone taper
verapamil
warfarin
xopenex
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML
Inhalation Q6h ().
Disp:*120 ML(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
Disp:*qs qs* Refills:*0*
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Tablet(s)
12. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
13. Outpatient Lab Work
Please have your PT/INR checked in 2 days for a goal INR of [**3-16**]
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
1. Congestive heart failure
2. Transaminitis secondary to heart failure
3. COPD
4. pneumonia
5. Atrial fibrillation
6. Arterial Insufficiency
Discharge Condition:
stable, tolerating medications
Discharge Instructions:
1. You were admitted for shortness of breath and found to have
heart failure, pneumonia, arterial insufficiency to your lower
legs, and a rapid irregular heart rate. You were diuresed with
lasix and given antibiotics for your infection, and your
symptoms improved. Vascular surgery was consulted to evaluate
your legs, and the feeling was you likely will need surgical
intervention, but that you can follow up with your vascular
surgeon in the next few months as an outpatient.
.
2. Please take all medications on your new list.
.
3. Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 5162**], chills, shortness of
breath, chest pain, vomiting, and inability to take medications.
.
4. Please make all follow-up appointments.
.
5. You will need your INR closely monitored as an outpatient.
Please have this checked in 2 days.
Followup Instructions:
1. Please call Dr. [**Last Name (STitle) 24016**],[**First Name3 (LF) **] K at [**Telephone/Fax (1) 55082**] for an
appointment in 1 week.
2. Please have your right lung/pleura mass followed up as an
outpatient.
3. Please follow up with your vascular surgeon in [**2-12**] months
from discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
|
[
"414.01",
"794.8",
"427.31",
"443.9",
"574.20",
"482.41",
"584.9",
"491.21",
"511.9",
"428.0",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
9696, 9770
|
4423, 7658
|
373, 391
|
9956, 9989
|
1919, 1919
|
10884, 11304
|
1380, 1384
|
8149, 9673
|
9791, 9935
|
7684, 8126
|
10013, 10861
|
1399, 1900
|
275, 335
|
419, 1137
|
1935, 4400
|
1159, 1269
|
1285, 1364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,216
| 198,299
|
44403+58715
|
Discharge summary
|
report+addendum
|
Admission Date: [**2172-7-15**] Discharge Date: [**2172-7-31**]
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 46**] is an 84-year-old
woman with a history of hypertension and hypertrophic
cardiomyopathy, as well as an atrial arrhythmia requiring
placement of a pacemaker in [**2162**], who presented with a one
day history of generalized weakness and "feeling bad."
According to the patient, she did not have any pain or any
abnormal palpitations, but she did have some occasional chest
tightness and shortness of breath, mostly with exertion.
According to her family, she has had decreased appetite and
nausea for one to two days prior to presentation. She denied
any nausea, vomiting, diaphoresis or change in her bowel
habits. She had no pain with inspiration and no hemoptysis.
PAST MEDICAL HISTORY: Significant for atrial arrhythmia with
a DDI pacer with a rate of 70 paced in [**2162**], hypertension,
hypertrophic cardiomyopathy, mild to moderate tricuspid
regurgitation and a ventral hernia.
MEDICATIONS: Verapamil 240 mg a day, ranitidine 150 mg
b.i.d., Metoprolol 50 mg b.i.d.
ALLERGIES: Penicillin.
SOCIAL HISTORY: She lives alone in [**Location (un) 86**] with a cat, but
has family near by; multiple daughters, and one son.
PHYSICAL EXAMINATION: Physical examination shows a pleasant
woman lying in her gurney in no acute distress. Pupils
equal, round and reactive to light. Extraocular movements
intact. Mucous membranes were dry. She had evidence of
bilateral cataract surgery. There was no lymphadenopathy in
her neck. Her neck was supple. There was no jugular venous
distention. Her heart had a 2/6 systolic murmur in the upper
left sternal border. No rubs or gallops and the rate and
rhythm were regular. Lungs were clear to auscultation
bilaterally. The abdomen was soft, nontender and
nondistended with normal bowel sounds in all four quadrants.
Extremities had strong dorsalis pedis pulses bilaterally
without any edema. Rectal exam was performed showing guaiac
negative brown stool.
LABORATORY EXAMINATION: White blood cell count 7.6,
hematocrit 37.8, platelet count 327,000. Serum chemistries
were notable for a BUN of 29 and a creatinine of 1.4. Chest
x-ray showed no change from prior x-ray and no acute
infiltrate or effusion.
HOSPITAL COURSE: She was admitted to the Cardiac Medicine
Team and placed on telemetry to rule out myocardial
infarction. Multiple sets of CK enzymes and troponins were
normal. Her initial electrocardiogram showed a paced atrial
rhythm with normal QRS with a small S wave in lead I and a
small Q wave in lead III. On the telemetry, there were no
events overnight and the following day, the Electrophysiology
Team was requested to interrogate her pacemaker and found
that her pacer was functioning normally.
After this, she had an echocardiogram which revealed
significant elevation in right-sided in pulmonary artery
pressures with right ventricular dilatation and tricuspid
regurgitation. Immediately after the echocardiogram, she was
noted to be hypotensive. She was then, because of a
suspicion of a pulmonary embolism, she underwent a CT
angiogram of the lungs which showed a large pulmonary embolus
in the right main pulmonary artery, as well as some extending
into the left pulmonary artery. Immediately after this, the
patient was taken to the Medical Intensive Care Unit and
intravenous access was established in order to initiate TPA
therapy. Immediately after the first dose of TPA, she
developed significant hematomas in her right neck and groin
at the site of attempted central line placement. The TPA was
then stopped, and heparin was started instead.
While she was observed in the Medical Intensive Care Unit,
she did not have evidence of respiratory distress, and her
blood pressure was managed with intravenous fluids. On
[**2172-7-17**], her hematocrit was noted to decline to a
level of 29.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6756**], M.D. [**MD Number(1) 6757**]
Dictated By:[**First Name3 (LF) 35146**]
MEDQUIST36
D: [**2172-8-8**] 20:56
T: [**2172-8-8**] 20:56
JOB#: [**Job Number 95193**]
Name: [**Known lastname 208**], [**Known firstname 15062**] Unit No: [**Numeric Identifier 15063**]
Admission Date: [**2172-7-15**] Discharge Date: [**2172-7-31**]
Date of Birth: [**2088-3-24**] Sex: F
Service:
On [**2172-7-17**] patient's hematocrit was noted to drop from 37 to
29 and then again on [**2172-7-18**] her hematocrit decreased to
26.5 for which she received 2 units of packed red blood
cells. Shortly after this, she was noted to have melanotic
stools. She then had lower extremity Duplex studies which
showed deep venous thrombosis in the right common femoral
vein extending to the popliteal vein.
Shortly after this, she was taken to the Emergency Room
Radiology suite and an IVC filter was placed. Her hematocrit
continued to drop to 27.4 on [**7-18**], and the decision was then
made on [**2172-7-19**] to stop her anticoagulation since she was
having symptoms of a gastrointestinal bleed and had required
four units of packed red blood cells. She did well after the
placement of the IVC filter and required no further
transfusions.
GI consultation was obtained, and the GI team recommended an
endoscopic evaluation. Since her respiratory status was
stable, and her hematocrit was stable at 30 off of Heparin,
and she had an IVC filter in place, she was transferred out
of the Intensive Care Unit on [**2172-7-21**]. She was kept on
Protonix 40 mg [**Hospital1 **], iron, calcium gluconate, metoprolol, and
Tylenol.
The following day she had an EGD which revealed gastritis
that appeared somewhat hemorrhagic in nature. This was
described as granularity, friability, and erythema in the
antrum stomach body and fundus compatible with hemorrhagic
gastritis. Otherwise, the EGD was normal.
Recommendation was to check the serum H. pylori which was
positive, and H. pylori treatment was started with Flagyl and
clarithromycin for the H. pylori. She was also found to have
a positive urine culture from a sample sent from the
Intensive Care Unit and ciprofloxacin was started for the
urine culture. She continued to be stable on the floor with
her blood pressure under good control with the metoprolol,
and on Protonix for gastrointestinal prophylaxis as well as
antibiotics for treatment of her urinary tract infection and
her H. pylori. She was scheduled for colonoscopy and
underwent a bowel prep that was uneventful.
Colonoscopy on [**2172-7-24**] noted a 4 cm fungating lesion in the
region of the cecum. No acute clot was identified.
Following this, CT scan was obtained to stage what was
considered to be a likely malignancy, and no abnormal lesions
or adenopathy were identified. Of note, were filling defects
in the right external iliac, common femoral, and left common
femoral veins consistent with deep venous thrombosis.
Dr. [**Last Name (STitle) **] of Surgery was consulted for the cecal mass, and
discussion was initiated with consultation of Cardiology by
Dr. [**Last Name (STitle) 690**] and the Pulmonary service as well as the GI service
in order to discern in this complicated patient which would
be the most prudent course of action, balancing the risks of
anticoagulation related hemorrhage from either the colon mass
or the gastritis with the likelihood of extension of
pulmonary thrombus or clotting of the IVC filter without
anticoagulation. There was also a discussion about the time
of her surgery related to her right ventricular function.
Echocardiogram was repeated which showed improvement in her
right ventricular function, but still elevated right
pulmonary artery pressures. A VQ scan was completed which
showed multiple profusion deficits consistent with
nonpulmonary emboli.
Patient remained stable in the hospital with guaiac negative
stools tolerating a lower residue diet until [**2172-7-30**], when
it was decided to begin her a course of Lovenox treatment
with 60 mg of subQ [**Hospital1 **]. Lovenox was started and hematocrit
was repeated in the morning and found to be stable at 33.
Her stool was guaiaced by rectal examination, and a small
amount of green stool was guaiac negative.
She was then ready for discharge home, having completed her
seven day course of treatment for H. pylori and five day
course of treatment for her urinary tract infection.
She was discharged home with the support and help of her
family, who were instructed in the injection of subcutaneous
Lovenox.
She was discharged with the following instructions:
1. Lovenox 60 mg subQ [**Hospital1 **].
2. Metoprolol 12.5 mg po bid.
3. Protonix 40 mg po bid.
4. Low residue diet.
5. Follow up with Dr. [**Last Name (STitle) 15064**] in one week.
6. Follow up with Dr. [**Last Name (STitle) **] as scheduled.
7. Follow up with Radiology for mammogram on [**2172-8-5**] at 11
o'clock.
8. Do not continue verapamil or Zantac at home.
9. Please call Dr. [**Last Name (STitle) 15064**] or return to the hospital for any
evidence or any occurrence of shortness of breath,
respiratory distress, hemoptysis, abdominal pain, melena, or
guaiac positive stools, as well as any nausea or vomiting.
CONDITION ON DISCHARGE: Improved.
DISCHARGE STATUS: To home.
DIAGNOSES:
1. Pulmonary embolus.
2. Deep venous thrombosis.
3. Hemorrhagic gastritis.
4. Cecal mass, pathology villus adenoma with foci of high
grade dysplasia.
[**Name6 (MD) **] [**Last Name (NamePattern4) 8732**], M.D. [**MD Number(1) 8733**]
[**First Name11 (Name Pattern1) 672**] [**Last Name (NamePattern4) 15065**], M.D.
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2172-7-31**] 18:23
T: [**2172-8-7**] 06:05
JOB#: [**Job Number 15066**]
|
[
"425.4",
"535.01",
"427.31",
"153.4",
"402.90",
"599.0",
"998.12",
"453.8",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"38.7",
"45.25",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
2344, 9303
|
1316, 2326
|
132, 830
|
853, 1164
|
1181, 1293
|
9328, 9897
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,276
| 178,268
|
31970
|
Discharge summary
|
report
|
Admission Date: [**2120-4-5**] Discharge Date: [**2120-4-13**]
Date of Birth: [**2063-9-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Recurrent GIST
Major Surgical or Invasive Procedure:
[**2120-4-5**] Exploratory laparotomy, resection of recurrent GIST, w/
hand sown G-J and stapled J-J
History of Present Illness:
56F with history of perforated GIST in [**2117**] s/p subtotal
gastrectomy and
Roux-en-Y gastro-Jejunostomy presents with a recurrence of the
GIST.
Past Medical History:
PMH: GIST, HTN
PSH: lap cholecystectomy, subtotal gastrectomy/roux-en Y
gastro-jejunostomy [**10/2117**]
Social History:
She moved here from [**Country 4194**] approximately three years ago. She is
a widow. She has five healthy children. She denies tobacco,
alcohol or drug use. She lives on [**Hospital3 4298**] and
previously worked as a housecleaner. Independent of ADLS.
Family History:
Significant for father who died of a stomach tumor and a mother
and sibling who died of cardiac disease.
Physical Exam:
On Discharge:
Afebrile, Vital signs stable
No distress, alert and oriented x 3
PERLA, EOMI, anicteric
RRR, lungs clear
Abdomen soft, nontender, nondistended
Incision clean, dry, with minimal serosanguinous drainage, no
erythema
Ext without edema
Pertinent Results:
[**2120-4-5**] 03:00PM BLOOD Hgb-9.5* Hct-27.4*
[**2120-4-5**] 07:43PM BLOOD WBC-7.7# RBC-2.42*# Hgb-7.8* Hct-23.0*
MCV-95 MCH-32.2* MCHC-33.8 RDW-13.0 Plt Ct-106*
[**2120-4-5**] 10:00PM BLOOD Hct-26.4*
[**2120-4-6**] 03:49AM BLOOD WBC-5.7 RBC-3.73*# Hgb-11.6*# Hct-33.4*
MCV-90 MCH-31.2 MCHC-34.9 RDW-14.7 Plt Ct-80*
[**2120-4-6**] 03:28PM BLOOD WBC-7.0 RBC-3.64* Hgb-11.6* Hct-33.2*
MCV-91 MCH-31.9 MCHC-34.9 RDW-15.4 Plt Ct-86*
[**2120-4-7**] 07:51AM BLOOD Hct-26.0*
[**2120-4-7**] 04:17PM BLOOD WBC-6.2 RBC-2.72* Hgb-8.5* Hct-24.5*
MCV-90 MCH-31.4 MCHC-34.7 RDW-15.9* Plt Ct-73*
[**2120-4-8**] 01:49AM BLOOD Hct-27.3*
[**2120-4-8**] 10:57PM BLOOD Hct-29.4*
[**2120-4-11**] 07:55AM BLOOD Hct-30.6*
Brief Hospital Course:
Ms. [**Known lastname 74914**] [**Last Name (Titles) 1834**] a successful exploratory laparotomy with
resection of recurrent GIST with a hand sewn gastrojejunostomy
and stapled jejunojejunostomy on [**2120-4-5**]. Her immediate
post-operative course was complicated by bleeding. Her
hematocrit was 19 at it lowest value. Her intravascular
depletion caused her to be hypotensive requiring vasopressors.
She was admitted to the [**Hospital Unit Name 153**] for management. She did receive
transfusions of 4 units of PRBCs in the immediate post-operative
period. The vasopressors were able to be weaned off and she was
extubated successfully. She did begin to have melena, which was
attributed to bleeding from her anastomoses. Her hematocrits
remained relatively stable. Ultimately she did received
transfusions of 3 more units of PRBCS over the next 2 days. Her
melena resolved and her hematocrit remained stable after a total
of 7units of PRBCs. She remained normotensive and was able to
be transfered out of the ICU and to the surgical floor. A PPI
was started in the form of protonix. Her diet was advanced
slowly starting with sips and then culminating in a regular
house diet. She had the return of bowel function with nonbloody
bowel movement and was tolerating a regular diet. Pain control
was excellent with oral medications. She was able to void and
ambulate without difficulty. A physical therapy consult was
obtained to help with ambulation and she was cleared for
discharge to home without services. Her abdominal incision
remained clean with minimal serosanguinous drainage; there was
no erythema. She was discharged home on POD8 in good condition
with discharge instructions on danger signs to look out for.
Medications on Admission:
Ferrous sulfate
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
recurrent GIST
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call your physician if you experience:
- fever > 101
- chills
- persistent nausea or vomiting
- inability to eat or drink
- increasing abdominal pain not relieved by your medication
- continued bloody bowel movements
- abdominal distension or no bowel movements or gas
- increasing redness around or drainage from your incisions
.
Medications:
- continue taking all of your home medications
- you will be given a prescription for pain medication, do not
drive while taking this pain medication
- take a stool softener to prevent constipation while on pain
medication
- continue to take protonix daily
Incision:
- you may place dry gauze over your incion as needed
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**]
Date/Time:[**2120-4-24**] 1:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"285.1",
"238.1",
"998.0",
"401.9",
"287.5",
"553.29",
"518.5",
"276.4",
"V45.79",
"V13.02",
"998.11",
"E878.8",
"V87.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.3",
"43.7",
"53.59"
] |
icd9pcs
|
[
[
[]
]
] |
4375, 4381
|
2136, 3876
|
328, 431
|
4440, 4440
|
1411, 2113
|
5280, 5564
|
1023, 1130
|
3942, 4352
|
4402, 4419
|
3902, 3919
|
4591, 5257
|
1145, 1145
|
1159, 1392
|
274, 290
|
459, 608
|
4455, 4567
|
630, 736
|
752, 1007
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,247
| 126,588
|
4040+55537
|
Discharge summary
|
report+addendum
|
Admission Date: [**2116-10-20**] Discharge Date: [**2116-10-24**]
Date of Birth: [**2075-7-20**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7573**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
41yo RH M h/o idiopathic generalized tonic clonic seizures who
presents after having seven of them today. His first was at
6:30am on waking, lasting one min. He fell asleep after. He
subsequently had 6 more seizures throughout the day, all typical
for his generalized event and not preceeded by aura. The second
was at 8:30am and threw him out of bed but without significant
injury. He missed his am meds due to N/V but was groggy yet
interactive. At 11am he seized again, also 1min and afterwards
was disoriented for a bit of time. He then got up and went about
his day. His subsequent seizures were at 2pm, 2:45 and 3:20pm;
in between the latter two he was moaning and moving around in
bed.
On arrival here, he was awake, alert and agitated to the point
of needing to be restrained. He was given ativan 2mg IV at
5:50pm and has not seized since (it is now 7:30pm).
Please see Dr.[**Name (NI) 17796**] prior note for further details of
his history. In brief, he presented with two GTCs in [**5-10**] and
was started on DPH. He was switched to ZNS. He had a third
seizure in [**Month (only) 1096**] off of medications and was restarted on ZNS.
He has since then increased and decreased his dose on his own
[**Location (un) **] but most recently was seen in clinic in [**2116-9-5**] and
maintained on
ZNS 300mg daily. He was then started on lamictal and due to
titrate up to 75mg [**Hospital1 **] last week. His wife is unsure if this was
done.
ROS: On review of systems, the pt's wife denied recent fever or
chills. No night sweats or recent weight loss or gain. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denied arthralgias or myalgias. Denied rash.
Past Medical History:
Sz disorder as above
Social History:
married. Daily MJ use
Family History:
negative
Physical Exam:
VS 102.6 92 138/52 17 100%
Gen Awake, uncooperative, agitated intermittently
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
or meningismus. Neg kernig/brudzinski
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO
MS Awake, alert. Looking at examiner but not following commands.
Gets agitated with examination. Required one limb restraint.
CN
CN I: not tested
CN II: BTT bilaterally. Pupils 3->2 b/l. Fundi clear
CN III, IV, VI: EOMI no nystagmus
CN V: b/l corneal reflexes
CN VII: full facial symmetry and strength
Motor
Normal bulk and tone. Cannot cooperate with formal power
testing. Moves all limbs equally and purposefully to noxious
stimuli.
Sensory as above
Reflexes
Br [**Hospital1 **] Tri Pat Ach Toes
L 2+ 2+ 2+ 2+ 2+ down
R 2+ 2+ 2+ 2+ 2+ down
Coordination unable to assess
Gait unable to assess
Pertinent Results:
[**2116-10-20**] 05:25PM BLOOD WBC-21.8*# RBC-5.60 Hgb-16.4 Hct-48.5
MCV-87 MCH-29.2 MCHC-33.7 RDW-14.2 Plt Ct-269
[**2116-10-21**] 03:08AM BLOOD WBC-18.1* RBC-4.91 Hgb-14.7 Hct-42.3
MCV-86 MCH-30.0 MCHC-34.8 RDW-14.2 Plt Ct-327
[**2116-10-22**] 02:46AM BLOOD WBC-12.1* RBC-4.39* Hgb-13.0* Hct-36.5*
MCV-83 MCH-29.7 MCHC-35.7* RDW-14.4 Plt Ct-241
[**2116-10-23**] 06:16AM BLOOD WBC-9.1 RBC-4.89 Hgb-14.6 Hct-40.6 MCV-83
MCH-29.8 MCHC-35.9* RDW-14.3 Plt Ct-248
[**2116-10-22**] 02:46AM BLOOD PT-12.7 PTT-26.7 INR(PT)-1.1
[**2116-10-20**] 05:25PM BLOOD Glucose-147* UreaN-17 Creat-1.5* Na-141
K-4.9 Cl-105 HCO3-17* AnGap-24*
[**2116-10-21**] 03:08AM BLOOD Glucose-138* UreaN-16 Creat-1.3* Na-143
K-4.1 Cl-112* HCO3-21* AnGap-14
[**2116-10-22**] 02:46AM BLOOD Glucose-89 UreaN-13 Creat-0.9 Na-146*
K-3.5 Cl-113* HCO3-20* AnGap-17
[**2116-10-23**] 06:16AM BLOOD Glucose-96 UreaN-8 Creat-0.8 Na-142 K-3.9
Cl-109* HCO3-23 AnGap-14
[**2116-10-20**] 05:25PM BLOOD ALT-29 AST-35 LD(LDH)-435* AlkPhos-82
Amylase-114* TotBili-0.2
[**2116-10-21**] 03:08AM BLOOD CK(CPK)-352*
[**2116-10-20**] 05:25PM BLOOD Calcium-10.0 Phos-4.0 Mg-3.1*
[**2116-10-21**] 03:08AM BLOOD Calcium-9.0 Phos-3.7 Mg-2.8*
[**2116-10-22**] 02:46AM BLOOD Calcium-9.1 Phos-2.2* Mg-2.3
[**2116-10-23**] 06:16AM BLOOD Calcium-9.6 Phos-2.3* Mg-2.0
[**2116-10-21**] 03:08AM BLOOD Phenyto-25.3*
[**2116-10-21**] 11:05PM BLOOD Phenyto-13.3
[**2116-10-20**] 05:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2116-10-20**] 07:06PM BLOOD Lactate-2.6*
[**2116-10-20**] 08:05PM BLOOD ZONISAMIDE(ZONEGRAN)-PND
EEG:
Mildly abnormal EEG due to the infrequent subtle slowing in the
right fronto-central region. This suggests a focal subcortical
dysfunction in the right hemisphere, but there was no area of
persistent slowing. There were no epileptiform features.
MRI:
Similar focal T2-hyperintensity within the right mastoid air
cells, likely inflammatory in origin. Please note that
evaluation is quite limited by motion artifact and that axial
T2-weighted and post-contrast imaging sequences were not
performed.
CXR:
No definite evidence for aspiration, pneumonia or other acute
cardiopulmonary process.
Brief Hospital Course:
Mr. [**Known lastname 17797**] was admitted to the ICU for closer monitoring. He
was broadly cultured and empirically started on CTX, Vanco and
acyclovir. He had been loaded with dilantin in the ED. He did
not have further seizures during his admission. The following
day he had an LP. It had been attempted unsuccessfully earlier.
This showed elevated WBC and Protein but normal glucose. The
gram stain and culture were negative as was an HSV PCR. An MRI
did not show any pathology. He remained clinically stable and a
PICC was placed to treat empirically for bacterial meningitis as
the culture was obtained after 24 hours of antibiotics. He will
complete a 14 day course of vanco and CXT. His dilantin was
tapered prior to discharge and he will taper the Lamictal as an
outpatient. He was also seen by psychiatry for emotional
lability and no treatment intervention was recommended. He will
follow-up with Neurology and psychiatry as an outpatient.
Medications on Admission:
ZNS 300mg daily
Lamictal 50/75, ? 75/75
Omeprazole 40
Discharge Medications:
1. Zonisamide 100 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
[**Known lastname **]:*180 Capsule(s)* Refills:*1*
2. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Please use the lamictal tapering schedule you have at
home.
[**Known lastname **]:*60 Tablet(s)* Refills:*0*
3. Outpatient Lab Work
Please check a Vancomycin trough level on [**10-27**] and fax the
results to Dr. [**Last Name (STitle) **] (fax [**Telephone/Fax (1) 7020**])
4. PICC
PICC Care per protocol:
flush with saline 3-5cc
5. Ceftriaxone-Dextrose (Iso-osm) 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours) for 10 doses: LAST
DOSE 10/30.
[**Telephone/Fax (1) **]:*10 10* Refills:*0*
6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours) for 10 days: LAST DOSE 10/30.
[**Telephone/Fax (1) **]:*20 1* Refills:*0*
7. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once as needed
for Seizure for 1 doses: Place 1 tab under the tongue for if you
have had more than 1 seizure and call your doctor.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*1*
8. Heparin Flush 100 unit/mL Kit Sig: One (1) Intravenous twice
a day for 10 days.
[**Last Name (Titles) **]:*30 1* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Menigitis, Seizures
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as prescribed
Followup Instructions:
1. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1045**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 1047**]
Date/Time:[**2116-11-4**] 9:00
2. Provider: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 17798**], MD Phone:[**Telephone/Fax (1) 3506**]
Date/Time:[**2116-11-11**] 4:00
3. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**]
Date/Time:[**2116-11-24**] 9:00
4. Call Dr. [**Last Name (STitle) 1681**] (psychiatry) Phone: [**Telephone/Fax (1) 17799**] for a
follow-up appointment
[**Street Address(2) 17800**]
[**Location (un) 86**], [**Numeric Identifier 6425**]
Fax: [**Telephone/Fax (1) 17801**]
Name: [**Known lastname 2843**],[**Known firstname **] Unit No: [**Numeric Identifier 2844**]
Admission Date: [**2116-10-20**] Discharge Date: [**2116-10-24**]
Date of Birth: [**2075-7-20**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2845**]
Addendum:
Of Note, Mr. [**Known lastname 2846**] admission Cr was 1.5. This was likely
prerenal failure due to dehydration in the setting of repeated
seizures, fevers and lack of po intake. His Cr improved with IVF
and PO intake back to normal (0.8-0.9).
Chief Complaint:
.
Major Surgical or Invasive Procedure:
.
History of Present Illness:
.
Past Medical History:
.
Social History:
.
Family History:
.
Physical Exam:
.
Pertinent Results:
.
Brief Hospital Course:
.
Medications on Admission:
.
Discharge Medications:
.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
.
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**] MD [**MD Number(2) 2848**]
Completed by:[**2116-11-11**]
|
[
"584.9",
"314.01",
"320.9",
"345.10",
"276.51",
"335.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
9822, 9874
|
9741, 9744
|
9581, 9584
|
9919, 9922
|
9715, 9718
|
9972, 10133
|
9675, 9678
|
9796, 9799
|
9895, 9898
|
9770, 9773
|
9946, 9949
|
9693, 9696
|
9540, 9543
|
9612, 9615
|
9637, 9640
|
9656, 9659
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,397
| 132,108
|
44797
|
Discharge summary
|
report
|
Admission Date: [**2139-6-17**] Discharge Date: [**2139-6-20**]
Date of Birth: [**2062-8-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim / lisinopril
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 76 year old male with CAD, HTN, asthma, gout
TIA, CKD (baseline 1.8) who was doing well until 10 days ago. He
had right abdominal pimple that grew in size until ED
presentation on [**2139-6-8**] which led to I&D and discharge with
Bactrime. He saw his PCP [**Last Name (NamePattern4) **] [**2139-6-9**]. He reports since
starting Bactrim on [**2139-6-10**] he has had nausea and abdominal
discomfort so he stopped taking it yesterday. He reported
feeling dizzy for past two days. He was seen today by his PCP
for nausea, weakness and malaise for which electrolytes were
done. On these labs, a K was reported to be 7.2 with Cr of 3.5.
Thus the patient was sent to ED for evaluation.
In ED, initial VS were: 97.7 65 130/55 17 97%. EKG reported
showed peaked T waves and patient was given Calcium gluconate,
insulin/D50 and kayexalate. CXR was completed and was otherwise
unremarkable. He was given 1LNS. Repeat K initially was 3.8
however another sample taken at the same time was 6.6. Decision
was then made to admit patient to MICU for close monitoring.
On arrival to the MICU, he reports no complaints except urge for
bowel movement.
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) Hyperlipidemia
2) TIA: [**11-17**] yrs ago had intermittent R facial and R arm
numbness, lasting 10min. Carotid U/S, Echo, MRI showed no
significant abnormalities
3) Hypertension, benign
4) Gout: Affects bilateral great toes. Last attack 3 months ago.
Pt takes allopurinol as a prn rather than a daily med
5) COPD/Asthma: Takes albuterol regularly, but Advair prn.
6) Chronic kidney disease, baseline Cr 1.6
7) Tracheomalacia
8) Osteoarthritis of knees s/p Left TKR [**2134**], Right TKR pending
9) Lung nodule resected [**2123**]
10) CAD cath [**9-21**] showed 2-vessel disease s/p PTCA/stent LCx
Social History:
Previously smoked 5-packs per day for 20 years, quit at age 55.
No alcohol ior illicit drugs. Married and currently has a 10
year old adopted child. Previously truck driver, cab driver,
short order cook. Now retired. He does heavy yardwork without
any chest pain.
Family History:
Mother and father both had cancer, but died in elderly age at
ages 92 and 80, respectively.
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:
VS 98.2 114/81 58 16 100%
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g. Healing
incision on L abdomen w/ appropriate surrounding erythema.
Non-tender.
EXT WWP 2+ pulses palpable bilaterally, no c/c/e. TTP over right
great toe.
NEURO CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
[**2139-6-17**] 03:24PM BLOOD WBC-7.0 RBC-4.58* Hgb-12.4* Hct-38.3*
MCV-84 MCH-27.0 MCHC-32.3 RDW-15.5 Plt Ct-265
[**2139-6-17**] 03:24PM BLOOD Neuts-58.9 Lymphs-25.8 Monos-8.4 Eos-6.7*
Baso-0.2
[**2139-6-17**] 03:24PM BLOOD UreaN-59* Creat-3.5*# Na-139 K-7.2*
Cl-111* HCO3-20* AnGap-15
[**2139-6-20**] 06:03AM BLOOD WBC-4.9 RBC-3.82* Hgb-10.0* Hct-31.9*
MCV-83 MCH-26.3* MCHC-31.5 RDW-15.7* Plt Ct-144*
[**2139-6-19**] 05:21AM BLOOD WBC-6.7 RBC-4.13* Hgb-11.1* Hct-34.7*
MCV-84 MCH-26.9* MCHC-32.0 RDW-15.7* Plt Ct-176
[**2139-6-20**] 06:03AM BLOOD Plt Ct-144*
[**2139-6-19**] 05:21AM BLOOD Plt Ct-176
[**2139-6-17**] 09:00PM BLOOD Plt Ct-222
[**2139-6-20**] 02:37PM BLOOD Na-139 K-4.6 Cl-106
[**2139-6-20**] 06:03AM BLOOD Glucose-103* UreaN-23* Creat-1.6* Na-141
K-4.9 Cl-109* HCO3-23 AnGap-14
[**2139-6-19**] 03:00PM BLOOD Glucose-132* UreaN-28* Creat-1.9* Na-141
K-5.4* Cl-111* HCO3-19* AnGap-16
[**2139-6-19**] 05:21AM BLOOD Glucose-104* UreaN-32* Creat-2.0* Na-141
K-5.4* Cl-112* HCO3-19* AnGap-15
[**2139-6-18**] 08:39PM BLOOD Glucose-154* UreaN-38* Creat-2.2* Na-140
K-5.5* Cl-113* HCO3-22 AnGap-11
[**2139-6-18**] 02:19PM BLOOD Glucose-103* UreaN-44* Creat-2.4* Na-137
K-6.5* Cl-112* HCO3-22 AnGap-10
[**2139-6-18**] 08:57AM BLOOD Glucose-152* UreaN-46* Creat-2.6* Na-136
K-5.8* Cl-111* HCO3-21* AnGap-10
[**2139-6-18**] 05:42AM BLOOD Na-136 K-6.3* Cl-114*
[**2139-6-18**] 04:40AM BLOOD Glucose-96 UreaN-54* Creat-2.9* Na-136
K-7.0* Cl-113* HCO3-16* AnGap-14
[**2139-6-17**] 09:00PM BLOOD CK(CPK)-140
[**2139-6-17**] 03:24PM BLOOD LD(LDH)-202 CK(CPK)-150
[**2139-6-17**] 09:00PM BLOOD cTropnT-<0.01
[**2139-6-17**] 09:00PM BLOOD CK-MB-4 proBNP-161
[**2139-6-20**] 06:03AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.7 UricAcd-4.0
[**2139-6-19**] 03:00PM BLOOD Calcium-9.2 Phos-2.5* Mg-2.1
[**2139-6-17**] 09:00PM BLOOD Calcium-9.3 Phos-3.7 Mg-2.4
[**2139-6-17**] 10:48PM BLOOD Glucose-60* Na-141 K-5.5* Cl-117*
calHCO3-17*
[**2139-6-17**] 09:13PM BLOOD Lactate-1.1 K-6.6*
[**2139-6-17**] 10:48PM BLOOD Hgb-11.8* calcHCT-35
CHEST RADIOGRAPH PERFORMED ON [**2139-6-17**]
FINDINGS: Portable AP upright chest radiograph obtained. The
lungs appear clear without focal consolidation, effusion or
pneumothorax.
Cardiomediastinal silhouette is stable and normal. Bony
structures are intact though degenerative changes at both AC
joints are noted.
IMPRESSION: No acute findings in the chest.
Brief Hospital Course:
# Hyperkalemia in setting of [**Last Name (un) **]: Due to perfect storm of volume
depletion from poor oral intake and vomiting with GI side effect
of Bactrim, inability to physiologically compensate with
preglomerular effects of Bactrim and postglomerular effects of
ACE-I. Recieved calcium gluconate, kayexale, Insulin and D50 for
mild peaked T waves. Potasium down to 5.8 on [**6-18**] labs and 5.4
when he was transferred from MICU to floor where pt received
albuterol and calcium gluconate for presistent peaked T waves on
EKG. Also received another dose of kayexalate. On [**6-20**], K
measured at 4.9 and 4.6. EP EKG showed normalization of peaked T
waves.
# [**Last Name (un) **]: No admitted with a creatinine of 3.9; his baseline is
1.8. Cause of baseline CKD is unknown to the patient. CKD likely
due to both volume depletion and Bactrim toxicity. Creatinine
return to baseline with hydration and discontinuation of
Bactrim.
# Hypertension: Held lisinopril in setting of acute kidney
injury. Continued metoprolol.
# Abdominal wall abscess s/p I&D. His wound looked well drained
with good source control. No indication for antibiotics, so
discontinued doxycycline and clindamycin.
# Gout: Changed allopurinol to 100 mg po qdaily due to [**Last Name (un) **]. Had
not been taking at home because he was confused and thought he
should stop all meds, not just bactrim. started to develop mild
pain in 1st metatarsophalangeal joint on HD3, but pain had
improved by time of discharge.
# HLD: continued simvastatin
# CAD: continued ASA
# Asthma: continued albuterol PRN, Advair PRN
# Pain/insomnia: continued tramadol PRN
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 20 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Simvastatin 80 mg PO DAILY
5. Allopurinol 300 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH QID:PRN shortness of breath
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Simvastatin 80 mg PO DAILY
4. TraMADOL (Ultram) 50 mg PO QHS:PRN pain
hold for sedation, RR < 12
5. Albuterol Inhaler 2 PUFF IH QID:PRN shortness of breath
6. Allopurinol 300 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
8. Outpatient Lab Work
Please draw chem-10
Please fax results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD at [**Telephone/Fax (1) 6443**].
ICD-9: 276 (DISORDERS OF FLUID ELECTROLYTE AND ACID-BASE
BALANCE)
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperkalmeia
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 for hyperkalemia (high levels
of potassium in the blood) and for injury to your kidneys. We
believe that both of these problems, along with the nausea and
vomiting you were experiencing, were caused by the antibiotic
you were taking called Bactrim.
To lower the amount of potassium in your blood, we treated you
with kayexalate and with insulin and albuterol. All of these
medications helped to reduced your potassium. Today, your
potassium was back in the normal range.
To treat your kidney injury, we stopped the Bactrim and gave you
fluid through your IV. Today, your blood tests showed that your
kidneys are functioning just as well as they were before you
started taking the Bactrim.
We have made the following changes to your medications:
1. Bactrim - we have stopped this medication.
2. Lisinopril - we have temporarily stopped this medication.
Please discuss when to restart this medication with your primary
care doctor.
We would like you to get your potassium level checked again on
Monday, [**2139-6-22**]. He had given you a prescription for a blood
test. You can take it to any lab and they will fax the results
to you doctor's office.
Please make a follow-up appointment with your primary care
physician within one week.
Followup Instructions:
Please call to make an appointment with your primary care doctor
within the next week:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD
Phone: [**Telephone/Fax (1) 1144**]
|
[
"403.10",
"584.9",
"V12.54",
"274.9",
"493.20",
"585.3",
"682.2",
"E931.0",
"276.7",
"414.01",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9216, 9222
|
6552, 8188
|
308, 315
|
9299, 9299
|
4126, 4126
|
10781, 10994
|
2902, 2995
|
8629, 9193
|
9243, 9278
|
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|
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|
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|
10265, 10758
|
1531, 1979
|
256, 270
|
344, 1512
|
4142, 6529
|
9314, 9426
|
2001, 2603
|
2619, 2886
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,536
| 158,847
|
572
|
Discharge summary
|
report
|
Admission Date: [**2138-1-6**] Discharge Date: [**2138-1-14**]
Date of Birth: [**2074-6-8**] Sex: F
Service: MEDICINE
Allergies:
Tricor
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
pneumonia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
63F with type 2 diabetes, coronary artery disease s/p CABG
presents with 2 days history of productive cough, shortness of
breath, fever/chills and L-sided pleuritic chest pain. Chest CT
revealed dense multi-lobular L PNA. Patient was intubated in ED
because of increasing respiratory effort. Approximately 30mins
after intubation, she became hypotensive with mean arterial
pressure in high 50s requiring levophed. Sepsis protocol was
initiated & patient was given empiric ceftriaxone, Azithromycin
and Vancomycin. Initial labs were notable for a WBC of 7.6 with
18% bands, INR 1.8, Mg 1.1, fibrinogen 700, lactate 5.1 trending
down to 2.3 after 4L NS. EKG was without acute changes and CE x
1 negative. Sputum GS revealed 4+ GPC in chains making likely
diagnosis of streptococcus pneumonia
Past Medical History:
1.Diabetes mellitus x 20y
2.hypertension
3.Coronary artery disease s/p CABG x 4 '[**30**]
4.Right CEA
5.Hypercholesterolemia
Social History:
15 pack year tobacco (quit 30 yrs ago)
rare EtOH
lives with husband
Family History:
+ early CAD (father died in 40's of MI, mother had CAD in 50's)
+ DM (father)
stomach ca (MGM)
Physical Exam:
O: Tc/m 101.2, 94/52, 77, 18, 96% on 100% NRB
.
Gen: alert, mild respir distress using accessory muscles
CV: RRR, nl S1S2, No M/R/G
Lungs: crackles [**12-22**] way up L lung field with decreased BS at L
base, no wheezes
ABD: obese, soft, NT/ND, positive BS
Ext: [**1-23**]+ pitting edema, weak DP pulses
Neuro: AAO x 3, moving all 4 extr, equal DTRs
Pertinent Results:
[**2138-1-5**] 10:18PM TYPE-ART PO2-103 PCO2-38 PH-7.43 TOTAL CO2-26
BASE XS-0
[**2138-1-5**] 09:25PM WBC-7.6 RBC-4.14* HGB-11.8* HCT-34.0* MCV-82
MCH-28.5 MCHC-34.7 RDW-14.7
[**2138-1-5**] 09:25PM NEUTS-74* BANDS-18* LYMPHS-5* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2138-1-5**] 09:25PM PLT SMR-LOW PLT COUNT-143*
[**2138-1-5**] 09:25PM PT-17.0* PTT-32.4 INR(PT)-1.8
[**2138-1-5**] 09:25PM FIBRINOGE-702*
[**2138-1-5**] 10:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2138-1-6**] 12:00AM LACTATE-5.1*
Brief Hospital Course:
A/P: 63F w/ resp failure and hypotension likely [**1-22**]
pneumococcal PNA/sepsis.
.
#PNA
-- patient initially intubated for respiratory distress,
required 3 day ICU stay
-- patient was extubated [**2138-1-8**] without incident.
-- BCx and sputum Cx grew strep pneumoniae, sensitive to
levofloxacin
-- initially started on Vancomycin, ceftriaxone and
levofloxacin, tailored to PO levofloxacin after cx results
returned.
-- urine legionella negative
-- kept on ATC nebs initially, incentive spirometry, chest PT.
.
#Hypotension
--- likely [**1-22**] sepsis, given IVF and started on levophed,
patient on sepsis protocol, [**Last Name (un) 104**]. stim test < 9 (but am cortisol
> 50), started hydrocort and fludrocort for equivocal [**Last Name (un) 104**] stim
but were discontinued after 2 days as pt was clinically
improved.
.
#ARF
- Likely from pre-renal state from acute infection and ATN [**1-22**]
hypotension and decreased renal perfusion. resolved prior to
discharge.
.
#CAD
-- continued on ASA/statin/plavix, restarted ACEI
-- troponin peaked at 0.04 likely from ARF and stress event, no
EKG changes.
-- patient had some evidence of fluid overload on exam on
medical floor requiring 2 doses of 20mg IV lasix to help
mobilize anasarca.
-- fluid status should be closely monitored. goal input/output
should be even to slightly negative for next 3-4 days. (EF 60%
on TTE [**6-22**])
-- repeat TTE as outpatient.
.
#DM2 - insulin ss while inpt, change to oral hypoglycemics prior
to d/c.
.
#Proph - Hep SQ, prevacid, bowel regimen prn
.
#Code - FULL
Medications on Admission:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Multivitamin Capsule Sig: Five (5) ML PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Imdur 30 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
9. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
10. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
11. Glyburide 9 [**Hospital1 **] Oral
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
4. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Multivitamin Capsule Sig: Five (5) ML PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Imdur 30 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
10. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
12. Glyburide Oral (as before hospitalization, 9mg [**Hospital1 **])
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. pneumococcal pneumonia with bacteremia
2. septic shock
3. DM II
4. CAD
5. hyperlipidemia
Discharge Condition:
stable on room air.
Discharge Instructions:
If you experience fevers > 101.5, chills, shortness of breath,
cough, please call your primary care physician or go to ER.
Followup Instructions:
1. Please make an appointment with Dr. [**Last Name (STitle) 3707**] in next [**4-26**]
days.
2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2138-7-1**] 3:45
3. Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 3627**] [**Name12 (NameIs) 3628**] [**Name12 (NameIs) **] [**Name12 (NameIs) 3628**] Where: [**Name12 (NameIs) **]
[**Name12 (NameIs) 3628**] Date/Time:[**2138-7-22**] 10:00
4. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2138-7-22**] 10:45
Completed by:[**2138-1-14**]
|
[
"785.52",
"518.81",
"481",
"276.6",
"250.00",
"V45.81",
"995.92",
"401.9",
"038.2",
"584.5"
] |
icd9cm
|
[
[
[]
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] |
[
"38.91",
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"96.71",
"96.6",
"99.04",
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icd9pcs
|
[
[
[]
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5810, 5882
|
2458, 4023
|
274, 280
|
6018, 6039
|
1837, 2435
|
6210, 6984
|
1356, 1452
|
4873, 5787
|
5903, 5997
|
4049, 4850
|
6063, 6187
|
1467, 1818
|
225, 236
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308, 1107
|
1129, 1255
|
1271, 1340
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,994
| 107,331
|
26764
|
Discharge summary
|
report
|
Admission Date: [**2132-2-23**] Discharge Date: [**2132-3-2**]
Date of Birth: [**2084-12-19**] Sex: M
Service: MEDICINE
Allergies:
Flagyl
Attending:[**Known firstname 943**]
Chief Complaint:
Transfer to [**Hospital1 18**] MICU fr/OSH for ? TIPS procedure.
Major Surgical or Invasive Procedure:
TIPS (Transjugular intrahepatic portosystemic shunt)
Central venous line
History of Present Illness:
HPI: Pt in USOH, awoke on [**2-22**] c/o nausea, lightheadedness, and
SOB. These symptoms resolved on their own, however at 10:30am
had a dark/tarry BM, called his PCP which told pt to present to
the ED given his h/o previous GIB and transfusion requirements.
Pt denied any CP/palpitations, hematemesis or coffee ground
emesis. No intial abdominal pain (gassy abdominal pain post EGD
today at OSH). In [**Name (NI) **] pt's hct was 27, dropped to 23 and received
3UPRBC, started on Octreotide gtt and Pantoprazole gtt. Also s/p
gastric banding today at [**Hospital6 **]. VSS throughout
course at OSH with HR stable 70s-80s, SBP 100-130s.
Pt initially dx with Cryptogenic cirrhosis 3years ago in setting
of extreme weakness and anemia. In [**11/2130**] pt had 1st episode of
hematemesis and BRBPR which required variceal banding. Pt was
found to have grade 4 varices at that time. In [**12-4**]/[**2132**] pt
was hospitalized again for melena but no hematemesis or coffee
ground emesis. During that admission hct at presentation was 22
and at discharge hct increased to 28.7, unclear #PRBC
transfusion requirement. Pt does not know his baseline Hct nor
his current transfusion requirements but has noticed increasing
frequency of transfusions in the last year.
ROS: Pt denies any constitutional sx, no F/C/Cough. No
CP/palpitations/Diaphoresis. Mild Diarrhea however at baseline
[**2-7**] medications. No dysuria, polyuria.
Past Medical History:
PMH:
-Cryptogenic Cirrhosis
-Esophageal Varices s/p banding ([**11/2130**]-grade IV & [**1-/2132**]-grade
III)
-GERD
-DMII, dx 1 yr ago
.
PSH:
-Appy
Social History:
Married, no children. Previous occupation=truck driver,
currently unemployed.
-Denies any TOB-quit 10 years ago, denies any ETOH use
Family History:
-ETOH cirrhosis, alcoholism (father and two aunts), liver cancer
(two aunts [**2-7**] EtOH cirrhosis)
Physical Exam:
VS BP 129/61 HR 71 RR 15 100% 2LNC
GEN: comfortable, well nourished appearing man in NAD
SKIN: No spider angiomata, no jaundice
HEENT: PERRL, EOMI, Anicteric sclera, Dry MM
RESP: CTA B/L, No crackle, no wheezing
CV: reg, nml s1,s2, no M/R/G
ABD: soft, obese,mildly distended, mildly tender over epigastric
& RUQ area, minimal guarding, no rebound, loud BS, liver edge
difficult to appreciate
EXT: no C/C/E, warm, 2+DP pulses b/l
Pertinent Results:
[**2132-3-2**] 06:40AM BLOOD WBC-3.9* RBC-4.04* Hgb-10.2* Hct-31.3*
MCV-77* MCH-25.2* MCHC-32.6 RDW-21.4* Plt Ct-68*
[**2132-3-2**] 06:40AM BLOOD Plt Ct-68*
[**2132-3-2**] 06:40AM BLOOD PT-17.3* PTT-27.8 INR(PT)-1.6*
[**2132-3-2**] 06:40AM BLOOD Glucose-117* UreaN-5* Creat-0.7 Na-141
K-3.9 Cl-110* HCO3-21* AnGap-14
[**2132-2-23**] 06:07AM BLOOD ALT-25 AST-31 LD(LDH)-222 CK(CPK)-51
AlkPhos-72 TotBili-1.0
[**2132-2-25**] 05:20AM BLOOD TotBili-0.7
[**2132-2-26**] 05:30AM BLOOD ALT-26 AST-31 AlkPhos-71 TotBili-0.8
[**2132-2-27**] 08:20AM BLOOD TotBili-1.1
[**2132-2-28**] 05:30AM BLOOD TotBili-0.5
[**2132-2-29**] 04:33AM BLOOD ALT-64* AST-77* LD(LDH)-253* AlkPhos-96
TotBili-1.8*
[**2132-3-1**] 07:05AM BLOOD ALT-153* AST-163* LD(LDH)-232 AlkPhos-110
TotBili-1.5
[**2132-3-2**] 06:40AM BLOOD ALT-160* AST-144* AlkPhos-163*
TotBili-1.4
[**2132-3-1**] 07:05AM BLOOD Albumin-3.2* Calcium-7.8* Phos-2.2*
Mg-1.9
[**2132-2-24**] 06:45PM BLOOD calTIBC-410 Ferritn-6.7* TRF-315
[**2132-2-24**] 06:45PM BLOOD AFP-2.4
[**2132-2-24**] 06:45PM BLOOD AFP-2.4
[**2132-2-24**] 06:45PM BLOOD HCV Ab-NEGATIVE
[**2132-2-25**] 12:15PM BLOOD ALPHA-1-ANTITRYPSIN-Test
ALPHA-1-ANTITRYPSIN 152 83 - 199 MG/DL
Abd U/S [**2132-2-23**]
FINDINGS: Directed son[**Name (NI) 493**] examination demonstrated a patent
portal vein with appropriate hepatopetal flow. The hepatic veins
are also patent with appropriate direction of flow.
CTA [**2132-2-24**] 8:40 PM Abd/Pelvis:
IMPRESSION:
1. Several too small to characterize foci, low in attenuation,
within the left and right hepatic lobe at the dome. No enhancing
hepatic lesions. Two right hepatic lobe cysts.
2. Cholelithiasis.
3. Moderate amount of ascites, mesenteric stranding with small
nodes, consistent with portal hypertension.
4. Minimal colonic wall thickening likely due to portal
hypertension rather than colitis
5. Retroperitoneal lymphadenopathy.
6. Splenomegaly.
[**2132-2-28**] TIPS
PROCEDURE/FINDINGS: After the risks and benefits were explained
to the patient, written informed consent was obtained. The
patient was placed supine on the angiographic table. A
pre-procedure timeout was obtained to confirm the patient's
name, procedure and the site. The right neck was prepped and
draped in the standard sterile fashion. This procedure was
performed under general anesthesia and local anesthesia with 5
cc of 1% lidocane. Under ultrasonographic guidance, a 21-guage
needle was used to access the right internal jugular vein. A
0.018 guidewire was placed through the needle under fluoroscopic
guidance with the tip in the superior vena cava. The needle was
exchanged for a micropuncture sheath and the wire was exchanged
for a 0.035 [**Doctor Last Name **] guidewire with the tip in the inferior vena
cava. The venous access was dilated by using 10-French dilator.
A 10-French vascular sheath was then placed over the wire with
the tip positioned in the inferior vena cava under fluoroscopic
guidance. A 5-French C2 catheter was then advanced through the
sheath over the wire with its tip engaged into the hepatic vein
under fluoroscopic guidance. The catheter was advanced distally
and the venogram was performed. The catheter was then exchanged
for a balloon occlusion catheter over the wire and CO2 portogram
was performed after inflation of the balloon. This confirmed the
position of the balloon occlusion catheter within the right
hepatic vein. After the catheter was removed, a TIPS puncture
set was advanced through the sheath into the right hepatic vein.
A shunt was created between the right hepatic vein and the right
branch of the portal vein. A Glidewire was then advanced into
the main portal vein. A multi- side- hole catheter was placed
over the wire and venogram was performed which demonstrated
patent common portal vein, splenic vein and superior mesenteric
vein. Gastric varices were also noted. The pressure gradient
between the portal vein and the right atrium was 15 mmHg. The
liver parenchyma tract was dilated with an 8-mm balloon, with an
inflation pressure up to 12 atmosphere. A 10 mm x 68 mm
Wallstent was then deployed, extending from the main portal vein
into the hepatic vein. The stent was then dilated with 10 mm, 12
mm balloons. Pressure gradient between the portal vein and the
right atrium was decreased to 5 mmHg. The catheter was then
repositioned into the splenic vein and a followup venogram was
performed which demonstrated patent shunt. There was no
opacification of the previously seen small gastric varices. The
catheter and the sheath were then withdrawn into the IVC and
then exchanged for a 9- French trauma line over the wire. The
catheter was flushed and secured to the skin with sutures.
During the procedure, one pass caused a small liver capsule
perforation. The track was then embolized by using Gelfoam.
The patient was transferred to post-anesthesia unit in stable
condition.
MEDICATIONS: During the procedure approximately 250 mL Optiray
contrast were applied.
IMPRESSION: Successful transjugular intrahepatic portosystemic
shunt placement with reduction of a pressure gradient between
the portal vein and right atrium from 15 mmHg to the 5 mmHg.
[**2132-2-29**] Abd U/S
The liver parenchyma again contains a simple cyst corresponding
to that seen on CT. The amount of ascites has lessened. The
gallbladder contains extensive sludge but is otherwise normal.
TIPS is identified. This shows wall to wall flow. Peak systolic
velocities in the proximal TIPS approximately 40 cm per second,
from the mid TIPS approximately 150 cm per second, from he
distal TIPS approximately 119 cm per second are seen. There is a
reversal of flow within the anterior and right portal vein and
the left portal vein consistent with functional TIPS. The
hepatic veins appear patent.
MPV velocity of approx 40 cm/sec
CONCLUSION:
Functional TIPS with wall to wall flow and baseline parameters
estabilished as above.
2) Simple cyst.
3) Gallbladder sludge without other evidence of biliary
pathology.
[**2132-3-1**] 11:38 AM
LIMITED ABDOMINAL ULTRASOUND: The right upper, right lower, left
lower and left upper quadrants of the abdomen were examined to
assess for fluid. There is no ascites identified within the
abdomen, and therefore, a spot could not be marked.
Brief Hospital Course:
Mr. [**Known lastname 46630**] is a 47 year old man with cryptogenic cirrhosis and
a history of multiple GI bleeds who presented from an outside
hosptial s/p banding for upper GI bleed from variceal bleeding.
He was transferred here for a TIPS procedure. His problem list
included:
Problem [**Name (NI) **]:
1. GI bleed
2. ? Colitis
3. Thrombocytopenia
4. Cryptogenic cirrhosis
5. Diabetes Mellitus (Type II)
6. Peptic Ulcer Disease
7. GERD
8. Anxiety
In brief, his hospital course proceeded as follows:
(1) GI Bleed: On transfer, the patient was on an octreotide drip
and pantoprazole drip. He was also on levofloxacin for SBP
prophylaxis in the setting of GI bleed. Both the octreotide drip
and pantoprazole drip were continued while the patient was in
the MICU. He was switched to protonix [**Hospital1 **] on trasfer to the
floor and eventually taken off the octreotide drip and
levofloxacin. He was kept on propranolol to control his portal
hypertension and prevent variceal bleeding..
The patient received three units of PRBCs at the outside
hospital and banding of his esophageal varices. On transfer to
[**Hospital1 18**], he has two EGDs which showed 2 cords of grade II varices
in the lower third of the esophagus. 2 cords of grade I varices
were seen in the lower third of the esophagus. The stomach
mucosa showed erythema, friability and congestion of the mucosa
with contact bleeding noted in the stomach body, fundus and
antrum. The findings were compatible with severe portal
gastropathy. The patient was seen and evaluated by the liver
and transplant teams and scheduled for a TIPS procedure,
However, during his early hospital course, his hematocrit
dropped from 28.2 on admission to 25.0, likely from slow GI
bleeding. At this point he was transfused two units of PRBCs.
Following transfusion, his hematocrit remained stable in the low
30s. He continued to pass guaiac positive stools during his
hospital course. He was monitored on telemetry and remained
hemodynamically stable throughout his hosptial course. He was
started on FeSO4 for iron deficiency anemia. His vitamin B12
and folate levels were normal.
The patient underwent a successful TIPS procedure on [**2-28**].
During the procedure, one pass caused a small liver capsule
perforation. The track was then embolized by using Gelfoam. The
patient was transferred to post-anesthesia unit in stable
condition. A follow-up ultrasound on [**2-29**] showed patency of the
TIPS tract. He had serial hcts which remained stable from 30-32
at time of discharge.
(2) Colonic thickening on CT: Abdominal CT showed minimal
colonic wall thickening likely due to portal hypertension rather
than colitis. However, on physical exam the patient did have
some RUQ and RLQ abdominal pain. He also had consistently
positive guaiac positive, dark/tarry stools. The ob+ stools
were attributed to his portal hypertensive gastropathy and
thought to be due to old blood, as his hct remained stable. C.
diff was sent given that he had been on levofloxacin, but was
negative times 2. He is recommended to receive a colonoscopy as
an outpatient.
.
(3) Thrombocytopenia: This is likely secondary to his liver
disease. His platelet count has remained in the low 50-80s
since admission.
(4) Cryptogenic cirrhosis: The patient is Child??????s Class A
cirrhosis (MELD SCORE =10). His transaminase levels are normal.
His hepatits A, B and C serologies were negative. His
alpha-1-antitrypsin level was normal. His cirrhosis is
complicated by esophageal varices and severe portal hypertensive
gastropathy. He is not currently on the transplant list. The
patient was vaccinated for Hepatitis A and B. He was advised to
follow up with his PCP as an outpatient to complete the
vaccination course.
He is status post TIPS procedure on [**2-28**]. His ALT, AST, and
Tbili were slightly elevated from baseline following his TIPS
procedure. This is likely secondary to inflammation of the
liver parenchyma due to the TIPS procedure. These were stable
at time of discharge, though his bilirubin was trending down.
During his hospital course he was treated with his home regimen
of propranolol.
(5) Type II Diabetes Mellitus: His fingersticks remained stable
on regular insulin sliding scale. We held his metformin on
admission until his TIPS procedure. He was restarted on his
metformin as an outpatient.
(6) Peptic ulcer disease: Treated with Pantoprazole 40 mg PO
Q12H and sucralfate 1g QID.
(7) Anxiety: Patient was continued on his outpatient regimen of
Lexapro.
Medications on Admission:
MEDS at home:
-Protonix 40 Daily
-Inderal 20 [**Hospital1 **]
-Lexapro 20 daily
-Metformin 500mg [**Hospital1 **]
MEDS on Transfer:
-Octreotide gtt
-Protonix gtt
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days: To complete 7 day course on .
Disp:*5 Tablet(s)* Refills:*0*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Home dose.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Portal Hypertension
Esophageal varices
Severe portal hypertensive gastropathy
Secondary Diagnoses:
Cryptogenic cirrhosis
Type II Diabetes Mellitus
GERD
Iron deficiency anemia
Discharge Condition:
Afebrile, pain well controlled and stable for discharge home.
Discharge Instructions:
1. Please take all medications as prescribed.
2. Please keep all follow-up appointments.
3. Please seek medical attention if you develop fevers, chills,
nausea, vomiting, black or bloody stools, lightheadedness, chest
pain, shortness of breath or have any other concerning symptoms.
.
You will need to followup with Dr. [**Last Name (STitle) 497**] or Dr. [**Last Name (STitle) **] at the
Liver Center within 10 days after discharge.
.
You will need to continue Levoflox for a total of 7 days (4 more
days left). Continue your ferrous sulfate and use laxatives for
regular bowel movements.
Followup Instructions:
Please make a follow-up appointment with Dr. [**Last Name (STitle) 497**] at
[**Telephone/Fax (1) 2422**] for within the next 1-2 weeks.
Please make a follow up appointment with Dr. [**Last Name (STitle) 8338**] at
[**Telephone/Fax (1) 8340**] for within the next 1-2 weeks.
Please follow up with Dr. [**Last Name (STitle) 8338**] or Dr. [**Last Name (STitle) 497**] to schedule your
Hepatitis A and B boosters. You need a second booster for both
Hepatitis A and Hepatitis B at one month, and a third hepatitis
B booster in 6 months.
Completed by:[**2132-3-2**]
|
[
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"533.90",
"571.5",
"300.00",
"250.00",
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"E870.0",
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"998.2",
"789.5",
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91",
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icd9pcs
|
[
[
[]
]
] |
14635, 14641
|
9063, 13618
|
330, 405
|
14893, 14957
|
2764, 9040
|
15596, 16161
|
2197, 2300
|
13831, 14612
|
14662, 14765
|
13644, 13759
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14981, 15573
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2315, 2745
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14788, 14872
|
226, 292
|
433, 1859
|
1881, 2031
|
2047, 2181
|
13777, 13808
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,208
| 100,391
|
6419
|
Discharge summary
|
report
|
Admission Date: [**2138-12-7**] Discharge Date: [**2138-12-10**]
Date of Birth: [**2063-4-26**] Sex: F
Service: MEDICINE
Allergies:
Vioxx / Compazine / Phenergan
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 7474**] is a 75 y/oF with CKD Stage V (Renal=[**Location (un) 10083**] at
[**Last Name (un) **]), CAD, Pulm HTN, UC s/p colectomy with ileostomy, who
presents for shortness of breath and mental status changes. She
was brought to the ED by her husband and family. She and the
family report an increased ostomy output for the past several
days, without specific quantification. She does have some new
crampy lower abdominal pain which is new for her.
The shortness of breath is worse with exertion and especially
going up stairs, as well as worsened by supine position, but
this has been building for about one month. She specifically
denies chest pain or discomfort.
She was recently admitted to the medical service [**Date range (1) 24726**]
for UTI, and treated with ciprofloxacin.
She continues to have b/l LE swelling and edema with superficial
redness. On her left medial/inner thigh, she has a larger patch
of hyperemetous skin with development of papules, also seen on
her prior admission and treated with topical fungal medication.
She takes PRN tylenol 4-6 per day by report. No other new
medications and she and her husband deny other ingestions.
In the ED, T 98.3, HR 76, BP 160/75 RR 20 Sat 100% on RA.
Received 1l of bicarb in D5, vanc 2g IV x1, flagyl 500mg IV x1,
mag 2gm IV x1.
Past Medical History:
# Chronic UTI - as above
# End Stage Renal Disease - Cr 3.1-3.8 with GFR of 13ml/min
baseline 3.4 [**First Name8 (NamePattern2) **] [**Last Name (un) 387**] records. c/b renal osteodystrophy.
# History of Nephrolithiasis
# GERD with esophageal strictures and dysphagia.
# ULCERATIVE COLITIS status post colectomy and ileostomy
# CERVICAL SPONDYLOSIS with chronic low back pain
# HYPERTENSION
# VITAMIN D DEFICIENCY
# ANEMIA - B12 deficiency and CKD. baseline Hct 29 [**10-15**] (range
29-32)
# HYPERCHOLESTEROLEMIA
# CORONARY ARTERY DISEASE - last echo [**3-14**]. LVEF 70%. no h/o MI
# PULMONARY HYPERTENSION
# VENOUS INSUFFICIENCY
# SLEEP APNEA - uses CPAP at night.
# Chronic LE cellulitis - treated with bilat unaboot
mother died of MI at age 62, father died of stroke in 70s.
sister with HTN and DM.
Social History:
Patient married. Lives in [**Location 3915**], MA with husband. 2
children, 3 grandchildren. Never smoker. Denies EtOH use.
Patient ambulates with walker or uses wheelchair for very long
distances. Able to ADLs.
Family History:
Mother died of MI at age 62, father died of stroke in 70s.
sister with HTN and DM.
Physical Exam:
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: No(t)
Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Present), (Left DP
pulse: Present)
Respiratory / Chest: (Breath Sounds: Clear : , No(t) Crackles :
, Wheezes : )
Abdominal: Soft, Non-tender, Bowel sounds present, ostomy with
green liquid stool output
Extremities: Right: 3+, Left: 3+
Skin: Warm, Erythemous lesions on LE
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not
assessed
Pertinent Results:
Bicarb
Brief Hospital Course:
In summary, Mrs. [**Known lastname 7474**] is a 75 y/o female with advanced CKD and
ostomy, admitted with marked anion gap academia in setting of
increased ostomy output and some worsening of renal failure.
Anion Gap Acidosis. delta delta initially favoring slight mixed
gap-nongap component, no osmolar gap. Lactate normal. Likely
related to worsening of renal failure and increased ostomy
output . Does have a significantly low baseline (mid teens)
likely related to CKD and possibly RTA. Urine lytes and gap c/w
RTA.
- Hold further bicarb IV for now, likely restart PO bicarb.
will d/w renal.
- Management of CKD below.
ACUTE ON CHRONIC RENAL FAILURE, CHRONIC KIDNEY DISEASE STAGE V.
Worsened 3.0 ?????? 3.9 without appreciable drop in urine output
according to the patient and husband. Now with improvement to
3.3.
- Awaiting renal's decision re: initiation of HD timing
- If HD this admit will need access; likely tunneled line; has
seen transplant as outpatient for access options.
INCREASED OSTOMY OUTPUT
- consider c.diff enteritis given recent antibiotics, elevated
WBC which responded with flagyl initiation, though would be rare
to have enteritis without colon.
- Continue IV flagyl for now
- Check stool culture and c.diff (2nd today).
ANEMIA. Dropping steadily since admit; hct 22 today (30 at
admit). No obvious bleeding source or hematoma. Baseline B12
deficiency (repleted), MDS, CKD.
- check hemolysis panel today (?history of this in the past per
notes from several years ago)
- T&S, would not transfuse unless <21
- Consider restart of epo - both MDS and significant CKD.
- Guaiac ostomy output.
DYSPNEA. Mostly exertional; likely related to acidemia and need
for significant respiratory compensation for metabolic acidosis.
Lungs clear on exam and imaging; oxygenating well.
- Treatment of acidosis as above
► CELLULITIS. unclear if this is a new finding of
infection or related to venous stasis. Was being managed by
derm as outpatient for venous stasis.
- Received 1000mg IV Vancomycin in the ED, would continue given
her improvement. Add on vanco level today
- Continue topical antifungal powder
- Bilat LE ultrasounds to r/o collections - done, negative for
collections.
UTI. +U/A, cipro started. Culture not sent at the time of UA
- check culture
- continue cipro x ~7 day course.
MACROCYTOSIS. Ongoing x years. Does have history of B12
deficiency, getting monthly IM replacement and normal B12 (and
folate) levels here. Also with history of ?MDS, followed by Dr.
[**Last Name (STitle) 2148**] in the past.
HYPERTENSION. Normotensive currently
- Holding CCBs with peripheral edema; will monitor today and
possible restart.
CAD
- ?On aspirin daily ?????? will check into
GERD
- continue protonix 40mg [**Hospital1 **] (on at home)
MICU Course:
Patient noted to have shortness of breath in setting of low
bicarb and ongoing diarrhea. Likely secondary to worsening
renal failure and increased ostomy output. Patient initially
treated with IV bicarb, but as bicarb corrected, this was
stopped. Noted to have elevated WBC so treated with vanco for
cellulitis (b/l thigh cellulitis clinically improving on vanco),
cipro for positive ua (UCx not sent), and flagyl for increased
ostomy output (though patient is s/p colectomy for UC which has
improved with flagyl). Renal is still deciding whether or not
dialysis will be initiated.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:
Acute on Chronic Renal Failure
.
Secondary:
Metablic Acidosis
Urinary Tract Infection
Macricytic Anemia
GERD
Discharge Condition:
Good
Followup Instructions:
1) Please phone Dr. [**Last Name (STitle) 816**] to set-up a follow-up appointment to
take place within 10 days of your discharge. At that time,
please discuss HD axis options and ask him if he would like you
to continue your Na Bicarb medication.
.
2)Please phone Dr [**Last Name (STitle) 713**] at [**Telephone/Fax (1) 18593**] to set-up a follow-up
appointment to take place within 10 days of your discharge.
.
3) Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2138-12-19**] 11:15
.
4) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2138-12-26**] 11:00
.
5) Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2138-12-29**] 10:00
|
[
"288.60",
"272.0",
"403.11",
"585.5",
"530.81",
"459.81",
"599.0",
"416.8",
"787.91",
"289.89",
"584.9",
"268.9",
"276.2",
"281.1",
"414.00",
"V44.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6916, 6987
|
3492, 6893
|
295, 301
|
7149, 7156
|
3461, 3469
|
7179, 8105
|
2736, 2820
|
7008, 7128
|
2835, 3442
|
252, 257
|
329, 1660
|
1682, 2490
|
2506, 2720
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,556
| 108,784
|
29418
|
Discharge summary
|
report
|
Admission Date: [**2131-11-11**] Discharge Date: [**2131-11-25**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shaking.
Major Surgical or Invasive Procedure:
Central line placement
Intubation
Foley
History of Present Illness:
86 year old male with history of alcohol abuse, colon cancer
status post resection, and recent MI just discharged from
[**Hospital 1474**] Hospital on [**11-9**], who presented to [**Hospital 1474**] Hospital
early this morning with shaking and confusion. History is
mostly from the record as the patient is intubated and the wife
is a poor historian. Per the wife, she says he was doing well
just after discharge, and was walking around as much as he
could. She says he has not drank alcohol since he got home.
His only complaint has been profuse watery diarrhea, numerous
times a day, both in the hospital, and since discharge.
Otherwise he did not complain of chest pain, shortness of
breath, abdominal pain, fevers, or chills, prior to the day of
admission.
As mentioned above, he was recently admitted to [**Hospital 1474**]
Hospital from [**11-3**] to [**11-9**] after presenting with shaking. He
was found to have a cardiac enzymes leak, and underwent p-MIBI
on [**11-8**] that demonstrated transient ischemic dilatation of the
LV with a small to moderate sized region of ischemia involving
the lateral wall, as well as a small to moderate fixed inferior
defect with hypokinesis suggestive prior infarction. EF 50%.
No intervention was performed since he was in alcohol
withdrawal, and asymptomatic from a cardiac standpoint, however
plans were made for catheterization at [**Hospital1 18**] in the future. He
was discharged home on a prednisone taper for unclear reasons.
On arrival at [**Hospital 1474**] Hospital on the morning of admission,
vitals were T 104.3, HR 109, BP 116/59, 89% on 3L NC. His
hypoxia progressed and he was intubated. His blood pressure
declined to the 70s systolic and he was started on
norepinephrine via a left femoral line placed in their ED.
Given concern for meningitis an LP was performed, demonstrating
140 rbcs that cleared by tube 4, 2 WBC in tube 1, and 1 in tube
4, total protein of 80, glucose of 100 (interpreted as
negative). Gram stain was without bacteria or WBCs. Labs were
notable for a leukopenia of 2.5, with 12% bands. A UA had large
leukocyte esterase, positive nitrite, [**5-9**] WBC, and moderate
bacteria. He received a dose of ceftriaxone 2 grams (prior to
negative LP), vancomycin 1 gram, and flagyl 500 mg IV x 1 given
concern for clostridium difficile (bandemia). EKG demonstrated
ST depressions in V4-V6. BNP 53, troponin I < 0.1 and CK 35. He
was transferred to the [**Hospital1 18**] ER because of lack of beds in the
ICU at [**Hospital1 1474**].
Vitals in our ED were T 104.8, HR 101, BP 75/47, RR 32, 99% on
ventilator (AC 550 x 20, 60%, PEEP 5). He was continued on
norepinephrine, given 2.5 L IVF, and sent to the MICU.
Past Medical History:
1) CAD; ?MI, ?3VD: Patient presented to [**Hospital 1474**] Hospital in
early [**11-5**] with shaking and was noted to have a cardiac enzyme
leak. A p-MIBI revealed transient ischemic dilatation. He was
in alcohol withdrawal at the time, therefore he was started on
ASA, Plavix, Statin, and sent home with plans for
catheterization at [**Hospital1 18**] when able.
2) Type 2 diabetes
3) BPH
4) Alcohol abuse: Drinks [**1-1**] gallon of Whiskey a week, per
wife.
5) Colon cancer status post resection, details unclear.
Social History:
Quit smoking 10 years ago, smoked heavily previously - wife says
he does have 1 cigarette a week. Drinks [**1-1**] gallon of whiskey
per week. Lives with his wife of 59 years.
Family History:
Non-contributory
Physical Exam:
99.5, 108/76, 96, 20, 99% on AC 550 x 20, 60%, PEEP 5. Pip 19,
Pplat 15.
GENERAL: Elderly male, intubated, not sedated and writhing
around in bed. Withdraws to painful stimuli, purposeful
movements.
HEENT: Dry mucous membranes.
NECK: JVP 8-10 cm H20.
COR: RR, normal rate, no murmurs.
LUNGS: Difficult to auscultate over ventilator sounds.
ABDOMEN: Normoactive bowel sounds, soft, non-tender,
non-distended.
EXTR: Left groin with femoral line in place, adequate
hemostasis. Noon-edematous, warm.
Pertinent Results:
[**2131-11-11**] 09:34PM CK(CPK)-425*
[**2131-11-11**] 09:34PM CK-MB-4 cTropnT-0.18*
[**2131-11-11**] 03:49PM TYPE-ART PO2-160* PCO2-34* PH-7.34* TOTAL
CO2-19* BASE XS--6
[**2131-11-11**] 03:49PM GLUCOSE-178* LACTATE-1.6 K+-4.1
[**2131-11-11**] 03:49PM freeCa-1.12
[**2131-11-11**] 10:56AM TYPE-ART PO2-155* PCO2-35 PH-7.27* TOTAL
CO2-17* BASE XS--9
[**2131-11-11**] 10:56AM LACTATE-1.6
[**2131-11-11**] 08:54AM TYPE-ART PO2-267* PCO2-37 PH-7.27* TOTAL
CO2-18* BASE XS--8
[**2131-11-11**] 08:54AM LACTATE-1.5 K+-4.1
[**2131-11-11**] 08:54AM freeCa-1.09*
[**2131-11-11**] 08:47AM CK(CPK)-404*
[**2131-11-11**] 08:47AM CK-MB-3 cTropnT-0.40*
[**2131-11-11**] 08:47AM CORTISOL-9.9
[**2131-11-11**] 04:12AM LACTATE-2.6*
[**2131-11-11**] 04:05AM GLUCOSE-108* UREA N-49* CREAT-2.2* SODIUM-139
POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-19* ANION GAP-15
[**2131-11-11**] 04:05AM CK(CPK)-398*
[**2131-11-11**] 04:05AM CK-MB-2 cTropnT-0.69*
[**2131-11-11**] 04:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2131-11-11**] 04:05AM URINE HOURS-RANDOM
[**2131-11-11**] 04:05AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2131-11-11**] 04:05AM WBC-12.4* RBC-3.70* HGB-11.3* HCT-32.0*
MCV-87 MCH-30.7 MCHC-35.5* RDW-13.5
[**2131-11-11**] 04:05AM NEUTS-80* BANDS-16* LYMPHS-3* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2131-11-11**] 04:05AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2131-11-11**] 04:05AM PLT COUNT-318
[**2131-11-11**] 04:05AM PT-13.9* PTT-32.0 INR(PT)-1.2*
[**2131-11-11**] 04:05AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2131-11-11**] 04:05AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2131-11-11**] 04:05AM URINE RBC-[**3-4**]* WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0
Brief Hospital Course:
86 year old male with history of alcohol abuse, and recent MI
just discharged from [**Hospital 1474**] Hospital on Plavix on [**11-9**] with
steroid taper, who presented to [**Hospital 1474**] Hospital early this
morning with shaking, confusion, and profuse diarrhea, found to
have significant bandemia, sepsis requiring norepinephrine, as
well as perihilar infiltrates and hypoxic respiratory failure
requiring intubation.
1) Sepsis: Most likely sources were initially thought to be C.
Difficile and pneumonia, both nosocomially acquired. He was
treated initially with vancomycin and zosyn (to cover nosocomial
pneumonia), and flagyl empirically for C. Difficile.
Subsequently, however, a blood culture from [**Hospital 1474**] Hospital
returned with E. Coli, and his urine culture from [**Hospital1 18**] also
grew out E. Coli. He was therefore ultimately felt to have
urosepsis. Vancomycin and flagyl were discontinued, while zosyn
was continued. He was weaned off of norepinephrine within 24
hours. He had been started on stress dose steroids on admission
given that he had been on steroids for at least the last few
days prior to admission (prednisone 30), however these were
quickly tapered off.
2) Hypoxic respiratory failure: Most likely secondary to an
early acute lung injury, which is compatible with his bilateral
perihilar infiltrates. His ventilator settings were rapidly
weaned, and he was extubated 48 hours after arrival without
difficulty. Unfortunately the patient had to be reintubated due
to aggitation and was on the ventilation for 5 more days. He
was then weaned off the vent and extubated. At this point his
family made the patient DNR/DNI. The patient tolerated
face-mask oxygen delivery for 3 days and then again developed
respiratory distress and passed due to respiratory failure
3) Cardiac enzyme elevation, CAD: Cardiac enzymes were trended
and flat, and EKG was without changes concerning for an acute
process. He was continued on ASA, Plavix, and statin.
Cardiology followed the patient but he was not a candidate for
catheterization due to his poor prognosis otherwise.
4) Acute renal failure: Almost certainly pre-renal in the
setting of sepsis and hypotension, and improved with rehydration
to 1.4, which is likely his baseline.
5) Alcohol abuse: Per wife, he [**Name2 (NI) 9103**]'t drank in over a week
prior to admission. He did not exhibit any signs of withdrawal.
6) DM: He had finger sticks QID, with an insulin sliding scale.
Glyburide was held.
7) FEN: He had a diabetic, cardiac diet.
8) Prophylaxis: He was given SQ heparin, PPI.
9) Access: He arrived with a left femoral line that was removed
in exchange for an IJ central line. This, too, was removed once
he no longer had a pressor requirement.
10) Contact: Wife, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 70640**].
Medications on Admission:
Gabapentin 600 mg TID
Glyburide 1.25 mg daily
Finasteride 5 mg daily
Omeprazole 20 mg daily
Allopurinol 100 mg daily
Vitamin B12 injections monthly
Prednisone taper 30 mg [**11-9**] through [**11-11**], 20 mg through [**11-14**],
10 mg through [**11-17**], then 5 mg daily "until f/u with
pulmonologist."
Imdur 10 mg daily
Metoprolol 75 mg [**Hospital1 **]
Plavix 75 mg daily
Albuterol MDI 1 puff Q 4- 6 hours prn
Atorvastatin 80 mg daily
Aspirin 325 mg daily
Multivitamin daily
Thiamine 100 mg daily
Folate 1 mg daily
Discharge Medications:
.
Discharge Disposition:
Expired
Discharge Diagnosis:
.
Discharge Condition:
.
Discharge Instructions:
.
Followup Instructions:
.
|
[
"250.00",
"038.42",
"599.7",
"414.01",
"276.4",
"V58.67",
"995.92",
"599.0",
"401.9",
"427.31",
"486",
"V10.00",
"305.00",
"600.00",
"584.9",
"276.51",
"054.9",
"518.84",
"785.52",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"00.17",
"38.93",
"57.94",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9831, 9840
|
6371, 9235
|
273, 314
|
9885, 9888
|
4367, 6348
|
9938, 9942
|
3807, 3825
|
9805, 9808
|
9861, 9864
|
9261, 9782
|
9912, 9915
|
3840, 4348
|
225, 235
|
342, 3050
|
3072, 3596
|
3612, 3791
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,083
| 134,993
|
28711
|
Discharge summary
|
report
|
Admission Date: [**2192-11-20**] Discharge Date: [**2192-12-7**]
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Caffeine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Placement of Hickman Line for TPN administration
Upper GI scope study
History of Present Illness:
Pt is an 82 yo female with PMHx of SBO who presents from rehab
with hypotension.
.
Pt was admitted to [**Hospital1 **] end of [**7-6**] with partial SBO. She
was taken to the OR and no mechanical obstruction was found. She
did have a thickened terminal ileum. Biopsy revealed fibrosis.
Colonoscopy was attempted a few times, but was unable to get to
the ileum. TPN was started at that time as pt was nutritionally
at risk.
.
Pt was again recently d/cd from [**Hospital1 **] on [**2192-11-2**] after being
admitted to the surgery service with a partial SBO. Complicating
this was a upper extremity thrombus in right and left subclavian
veins and left internal jugular and brachiocephalic veins in the
setting of a PICC. The PICC line was pulled and a Hickman was
placed for pt's TPN. Additionally, pt was started on prednisone
for possible IBD as it was thought that the distal ileal
thickening was causing symptoms of SBO.
.
Per Rehab notes on [**2192-11-16**], pt was noted to have increased
edema and weight gain from 165-->179 lbs in 7 days. Also notes
dependent lungs with crackles at bases and that BPs in 80s-90s.
She was started on levaquin on [**2192-11-17**] (unclear per notes).
Lasix was increased from 20 mg qday to 40 mg qday but has been
held [**3-1**] hypotension. She complained of pain upon swallowing for
days. Strep test was negative.
.
For the last few days, BPs have remained consistently low. Pt
denies any F/C. No SOB/CP. No lightheadedness/dizziness. +stable
chronic cough x years. No sputum production. Pt states that she
feels "ok." No diarrhea. No dysuria.
.
In the ED, VS on arrival were: T: 97.2; HR: 90; BPs: 80s
systolic; O2: 99 RA. She was given 500 mg IV metronidazole, 500
mg IV levaquin, 1 g of vancomycin IV, ipratropium nebulizers,
albuterol nebulizers, and 10 mg of IV dexamethasone. She was
also given 75 mg of plavix and 1 L NS.
Past Medical History:
Asthma
Osteoarthritis in both knees
GERD
Ileitis
Exploratory Laparotomy with biopsies-[**9-2**];
Salpingotomy
Social History:
Married for 60 years with three children. Used to be in charge
of a school lunch program. No smoking. No etOH. No drugs.
Family History:
No CAD or DM in family.
Physical Exam:
VS: T: 96.8; BP: 87/48; HR: 70; RR: 17; O2: 96 RA
Gen: Speaking in full sentences in NAD
HEENT: PERRLA; EOMI; sclera anicteric; OP: unable to assess
tonsils even with tongue depressor.
Neck: No LAD. No thyromegaly. No carotid bruits. JVD to mandible
at 30 degrees.
CV: RRR. I/VI systolic murmur at LUSB and RUSB without radiation
Lungs: scattered wheezes throughout. Crackles at bases and [**2-1**]
up bilaterally.
Abd: NABs. soft, nt, nd. +LLQ entry site for catheter for TPN
Back: No spinal, paraspinal, CVA tenderness
Ext: 3+ pitting edema to above calves. + 5 eschar like area
non-blanchable. Mild erythema in LLE though no warmth,
induration.
Neuro: CN II-XII tested and intact.
Pertinent Results:
[**2192-11-19**] 10:10PM PLT COUNT-312
[**2192-11-19**] 10:10PM NEUTS-63.1 LYMPHS-27.3 MONOS-8.7 EOS-0.7
BASOS-0.2
[**2192-11-19**] 10:10PM WBC-4.1 RBC-2.71* HGB-9.1* HCT-26.6* MCV-98
MCH-33.5* MCHC-34.2 RDW-17.5*
[**2192-11-19**] 10:10PM ALBUMIN-2.6*
[**2192-11-19**] 10:10PM CK-MB-NotDone cTropnT-0.13* proBNP-3621*
[**2192-11-19**] 10:10PM CK(CPK)-62
[**2192-11-19**] 10:10PM GLUCOSE-93 UREA N-42* CREAT-0.8 SODIUM-136
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-30 ANION GAP-11
[**2192-11-19**] 10:15PM PT-11.9 PTT-28.8 INR(PT)-1.0
[**2192-11-19**] 10:19PM LACTATE-2.4*
[**2192-11-20**] 04:30AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-7.0 LEUK-NEG
[**2192-11-20**] 03:30AM WBC-4.3 RBC-2.38* HGB-7.9* HCT-23.3* MCV-98
MCH-33.2* MCHC-33.9 RDW-17.4*
[**2192-11-20**] 03:30AM NEUTS-62.2 LYMPHS-27.7 MONOS-9.2 EOS-0.9
BASOS-0.1
[**2192-11-20**] 04:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2192-11-20**] 12:12PM WBC-3.5* RBC-2.46* HGB-8.1* HCT-24.0* MCV-98
MCH-33.0* MCHC-33.8 RDW-17.6*
[**2192-11-20**] 12:12PM TSH-1.4
[**2192-11-20**] 12:12PM T3-77* FREE T4-1.3
[**2192-11-20**] 12:12PM CALCIUM-7.8* PHOSPHATE-4.6* MAGNESIUM-2.1
[**2192-11-20**] 12:12PM CK(CPK)-85
[**2192-11-20**] 12:12PM GLUCOSE-186* UREA N-38* CREAT-0.8 SODIUM-133
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-29 ANION GAP-10
[**2192-11-20**] 12:24PM TYPE-MIX PO2-32* PCO2-48* PH-7.43 TOTAL
CO2-33* BASE XS-6
.
CHEST (PORTABLE AP) [**2192-11-19**] 11:33 PM
1. No evidence of pulmonary edema or focal consolidations.
2. Possible small right pleural effusion.
3. Tip of the right IJ catheter in the right atrium. Recommend
retracting.
.
CT NECK W/CONTRAST (EG:PAROTIDS) [**2192-11-20**] 5:01 PM
1. No cervical lymphadenopathy.
2. Very slight asymmetry of left fossa of Rosenmuller and right
posterior pharyngeal wall, of uncertain clinical significance.
COMMENT: Given the clinical context, these findings could be
correlated with direct inspection by fiberoptic endoscopy.
.
UNILAT UP EXT VEINS US LEFT [**2192-11-20**] 4:12 PM
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the left jugular,
subclavian, axillary, brachial, and cephalic veins was
performed. These demonstrate normal compressibility, waveforms,
and flow. No intraluminal thrombus is identified. Previously
seen thrombus within the left axillary and subclavian veins is
no longer identified. Left basilic vein is not visualized.
IMPRESSION: No evidence of left upper extremity DVT.
.
CT PELVIS W/CONTRAST [**2192-11-29**] 4:04 PM
1. At least 20-cm length of thickened ileum likely from ileitis.
This is nonspecific and likely infectious or inflammatory. No
evidence for extension beyong the bowel wall.
2. Equivocal thickening of colon at the splenic flexure through
the descending colon and into the sigmoid, also nonspecific.
When the patients condition stablizes colonoscopy should be
performed.
3. Thickened distal esophageal wall. Endoscopy should be
considered.
4. Large simple-appearing left renal cyst.
5. Distended gallbladder without direct evidence of
cholecystitis.
.
MR HEAD W & W/O CONTRAST [**2192-12-5**] 6:59 PM
MRA OF THE CIRCLE OF [**Location (un) **]: 3D time-of-flight MRA of the circle
of [**Location (un) 431**] was performed. There is normal signal along the distal
vertebrobasilar circulation. Mild atherosclerotic changes are
seen involving the cavernous ICA. The visualized anterior,
middle, and posterior cerebral arteries were patent. There is no
significant intracranial vascular stenosis or occlusions. The
examination is insensitive to detect tiny aneurysms less than 3
mm in diameter. There is tortuosity involving the origin of the
PCA. 40% stenosis is noted involving the right cavernous ICA.
IMPRESSION: Mild 40% stenosis involving the right cavernous ICA.
No other significant intracranial vascular stenoses or
occlusions were present. The exam is insensitive to detect tiny
aneurysms less than 3 mm in diameter.
Brief Hospital Course:
82F with hx of partial SBO, ileitis on chronic steroids and TPN,
dysphagia, now with new inpatient diagnosis of GI amyloidosis as
a result of primary amyloidosis, placed on hospice due to
multiple comorbidities giving poor prognosis even with
treatment.
.
# Hypotension/third-spacing:
Ddx included sepsis (though no WBC, bld/urine NGTD, lactate 2.0,
no clear source of infection), cardiogenic (echo without wall
motion [**Last Name (LF) **], [**First Name3 (LF) **] nl), volume depletion or adrenal insufficiency.
Per pt's daughter, these sx started soon after her steroids were
tapered (started 3 weeks ago). Pt still has extensive 3rd
spacing due to poor nutritional status. s/p 3u pRBCs for colloid
replacement of volume. BP currently normotensive, with SBP 110s,
pt asymptomatic. Changed prednisone to decadron on [**11-24**] (60mg
pred = 9mg decadron). Evaluated primary adrenal insufficiency
with cosyntropin stim test. Consyntropin test normal, >9
increase in cortisol level post stim, thus no adrenal
insufficiency. Switched from decadron to PO prednisone taper x 5
weeks. Pt will require slow taper over 1 month to prevent
recurrence of hypotension. Today BP hypotensive with SBP
trending down in mid-80s, trigger called, bolused 500cc IV x1,
BP increased to 90s/60s. Likely due to poor intravascular volume
in setting of low albumin (2.4), low oncotic pressure. Gave 1u
blood which would also increase colloid pressure if pt becomes
hypotensive as BP has responded well to transfusions when pt was
in MICU (last bld txf on [**12-1**]). Urine protein/cr ratio suggests
protein-losing nephropathy with 24 hour urine protein elevated.
.
# Bacteremia/UTI:
[**11-23**] blood culture [**2-1**] bacteroides fragilis
[**11-28**] bloood culture [**3-3**] coag negative staph, sensitive to
vanc/gent
[**11-29**] hickman swab culture coag negative staph
11/5 blood culture [**2-1**] gram positive rods
[**12-3**] blood culture [**2-1**] enterococcus, resistant to vanc
[**12-4**] urine culture enterococcus
.
Hickman placed by Dr. [**Last Name (STitle) **] but he has evaluated and says he
would not like to d/c it at this time given her lack of fever,
no WBC and given that her IV access is so difficult.
- flagyl for b frag, 10 day course
- linezolid for enterococcus, 7 day course
.
# GI amyloidosis:
Pt's antrum biopsy with revealed [**Country **] red stain consistent with
amyloidosis. In general, GI amyloidosis found in 60% of cases
with secondary, AA, amyloidosis and rarely in primary
amyloidosis. Pt's symptoms of dysphagia, thickening of areas of
GI tract, and even bowel obstructions, though rare, can occur as
result of amyloidosis. Pathophysiology due to mucosal, muscular,
and neuromuscular infilitration of light chain amyloid proteins.
In some cases, autonomic neuropathy may also play a role in GI
dysmotility especially in context of systemic amyloidosis.
Protein-losing enteropathy may also result due to GI protein
loss, in addition to renal. Treatment generally symptomatic with
goal of improving bowel motility. Prognosis depends on extent of
systemic amyloidosis, ranging from months to years.
- SPEP/UPEP serologies consistent with primary amyloidosis
.
# CV
a. CAD
No evidence of ischemia, troponins trended down with flat CK
b. Pump
Echo done recently with normal EF, mild MR.
- strict I/O's, daily weights
- goal fluid balance +500cc as pt likely intravascularly
depleted with large amount of third-spacing post IVF in MICU for
hypotension
c. Rhythm
Normal sinus
- no events on telemetry
.
# ?IBD/ileitis/SBO:
Followed by Dr. [**First Name (STitle) 572**] and Dr. [**Last Name (STitle) **]. s/p ex-lap [**9-2**] which
was unrevealing, concerning for ileitis vs IBD, started on
steroids about a month ago and goal was to taper which resulted
in recurrent severe hypotension with SBP in 80s. On evening of
[**11-25**], pt with coffee ground emesis that was hemoccult positive
and BM guiaic positive. KUB showed non-dilated and mildly
dilated loops of small bowel w/o colonic distention, consistent
with persistent/resolving small-bowel obstruction. Pt refused
NGT placement. GI consulted to eval upper GI bleed and could
also determine cause of dysphagia. Appreciate nutrition eval for
TPN. Hematocrit remaining stable, active type and screen. EGD on
[**11-28**] revealed bleeding in distal esophagus, with multiple
nodularities in antrum concerning for carcinoma, biopsies taken.
Differential includes chron's, lymphoma, carcinoma. CT abdomen
done on [**11-29**] to eval source of blood bacterial infection, pt has
hickman line and site is erythematous concerning for abdominal
abscess, bacterial seeding from ileitis also possible.
Prelim biopsy result positive for [**Country **] red stain seen in
amyloidosis, final results pending. CT abdomen revealed thickend
ileum, distal esophagus, and descending colon without enlarged
lymph nodes, abscesses. CT scan with bowel wall thickening,
likely from fluid overload. Antrum biopsy consistent with
amyloidosis.
- cont TPN, on ground diet, not tolerating well
- on PPI [**Hospital1 **], sucralfate, reglan, bowel regimen
- cont steroid taper over 1 month
- plan to f/u with Dr. [**First Name (STitle) 572**], GI, outpt 2 weeks post discharge
.
# Dysphagia:
Evaluated by ENT, speech and swallow but no clear etiology. EGD
did not show any thrush but did show some erosions. Currently
tolerating PO without odynophagia or dysphagia while advancing
diet as tolerated. Pt without signs of fungal infection on EGD.
Pt had speech and swallow eval along with video study, noted for
worsening of dysphagia concerning for neurological etiology as
pt noted to have fasciculations of lips/tongue as well. ? CVA
versus neuromuscular disorder or bulbar neuropathy. Pt without
focal neurological deficits on exam, no difficulty working with
PT.
- changed diet to ground consistency, thin liquids
- cont TPN via hickman
- neurology recommended neuromuscular eval based on resutls as
concern for myasthenia [**Last Name (un) 2902**] and ALS
.
# Anemia:
Hct stable, up from 29 to 33 and stable, s/p 3u of blood to
increase oncotic pressure. Iron studies suggest anemia of
chronic disease. Hemolysis workup negative. Pt with prelim
antrum biopsy result of amyloidosis. Transfused 1u pRBCs ([**12-1**]),
appropriate elevation in Hct. Taken off iron supplements as it
may worsen pt's constipation and anemia likely secondary to
chronic disease.
- monitor serial Hcts q12h, guiaic +
- hematology consulted due to new diagnosis of systemic
amyloidosis
- retic count low, suggestive of bone marrow suppression
.
# Asthma:
Oxygen sats stable on RA, normal lung exam.
- continue albuterol nebs, montelukast, flovent
.
# History of bilateral UE DVT:
Repeat US done [**11-21**] shows no evidence of LUE DVT. On lovenox
given absence of active bleeding on EGD since pt has hx of upper
ext DVTs that occurred in [**10-3**] and [**11-2**] around site of PICC
lines in right and left arm, respectively. On [**12-3**], pt had L>R
swelling down to hands, with weak pulses. Bilateral upper
extremity ultrasounds negative for DVTs. ABIs/PVRs also normal.
-cont lovenox given hx of previous DVTs though no clots now,
-maintain elevation of arm/legs to reduce venous stasis
.
# DM:
Sugars remain elevated on high dose steroids, slightly aberrant
as being drawn when TPN running.
-cont humalog insulin sliding scale
-adjust TPN insulin as needed to aid in glycemic control, finger
sticks within normal
.
# F/E/N:
cont TPN
.
# Access: Hickman's catheter
Per Dr. [**Last Name (STitle) **], keep line in given lack of fever, no wbc
- catheter site appears slightly erythematous, monitor for
purulent drainage, contact Dr. [**Last Name (STitle) 32924**] regarding new blood
cultures
-swabbed site for infection, culture shows same bacteria as in
blood on [**11-30**]
.
# Contact:
[**Name (NI) 4906**] [**Name (NI) **] [**Name (NI) 69420**] [**Telephone/Fax (1) 69422**]
.
# Prophylaxis:
Lovenox sc, PPI
.
# Code Status:
DNR/DNI
.
# DISPO:
Family discussion on [**11-5**] with son and daughter. They have
fairly good understanding of patient's progress over the last
couple of months leading to progressive decline in clinical
condition during this hospital course. Given the new diagnosis
of amyloidosis on [**11-29**], discussed with family the poor, though
variable prognosis that may range from months to years based on
the extent of systemic involvement. The options include
chemotherapy if it there is systemic involvement and treating it
as if it were a cancer, expecting the the common adverse side
effects from chemo. The alternative is for patient to live
comfortably, keeping in mind the patient's quality of life at
her age. [**Name (NI) 1094**] husband prefers taking her home with hospice
services given poor prognosis.
- palliative care to setup home hospice
- decision made to [**Hospital **] [**Hospital **] medical treatments such as
antibiotics
- cont TPN while inpatient
- started comfort care
Medications on Admission:
Levaquin 500 mg po [**2192-11-17**]-
Albuterol nebs QID x 3 days ([**2192-11-18**]-)
Lasix 40 mg po qday-hold for SBP<85--held previous two days
RISS beginning at 121 at 3 units, inc 2 units every 20.
Aldactone 25 mg po qod
Diflucan 200 mg po x 5 days (day 1 [**2192-11-17**])
Prednisone 40 mg po qday
Montelukast 10 mg qday
Megest- will need to clarify dose.
Lovenox 60 mg q12 sc
pantoprazole 40 mg po qday
MVI
Compazine prn
Paxil 10 mg qday--recently d/cd
Discharge Medications:
1. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Transdermal
PRN (as needed).
Disp:*30 patches* Refills:*2*
2. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed.
Disp:*100 Suppository(s)* Refills:*0*
3. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO 1-2h
PRN.
Disp:*30 cc* Refills:*2*
4. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
5. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Rectal QD ().
Disp:*5 tubes* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] Hospice
Discharge Diagnosis:
Primary amyloidosis, diagnosed in GI tract
VRE urinary tract infection
Hypotension secondary to steroid taper
.
Secondary diagnoses:
* hx of bowel obstructions secondary to a stricture of the
distal ileum
* hx of upper ext clots (right and left subclavian veins, and
left internal jugular and brachiocephalic veins, the right
internal jugular vein was patent but narrowed at junction with
right subclavian vein)
* Ileitis
* Exploratory Lap to workup ileitis vs chronic SBO in [**9-2**] with
biopsies showing fibrosis, mesenteric LN: FNA negative
* s/p Salpingotomy
* Asthma
* Osteoarthritis in both knees
* GERD
Discharge Condition:
Fair.
Discharge Instructions:
You were admitted for low blood pressure and admitted to the
ICU. Once stable, you were transferred to the medical floor. You
also had difficulty swallowing and had an extensive evaluation
for this and recurrent bowel obstructions. You were found to
have a condition called primary amyloidosis that was affecting
your digestive system and possibly other organs of the body. No
treatment for this disease is recommended at this time given
your other medical problems, as your body will not be able to
tolerate the side effects. You also had a urinary tract
infection that was treated with antibiotics.
.
You are being discharged to home with hospice care.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Date/Time:[**2192-12-10**] 2:00
|
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icd9cm
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[
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[
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icd9pcs
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[
[
[]
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17327, 17385
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18041, 18049
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3254, 7269
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351, 2222
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2371, 2493
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,911
| 172,718
|
25588
|
Discharge summary
|
report
|
Admission Date: [**2126-7-31**] Discharge Date: [**2126-8-7**]
Date of Birth: [**2064-5-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
dysphagia
Major Surgical or Invasive Procedure:
[**2126-7-31**]
1. Minimally invasive esophagectomy with intrathoracic
anastomosis.
2. Buttressing of intrathoracic anastomosis with
pericardial fat pad.
3. Esophagoscopy.
History of Present Illness:
Mr [**Known lastname **] is a 62M with stage IIB GE junction esophageal
cancer. He had dysphagia, 27# wt loss over a few months and has
started on chemo. After resolution of recent neutropenia, pt
underwent a lap J-tube insertion [**2126-6-19**]. He tolerated the
procedure well, was discharged [**2126-6-21**] and reports tolerating J
tube feeds well (5a-11p by choice), able to swallow liquids but
gets heartburn and prox esoph pain so he avoids. Otherwise,
weight is stable, he has minimal J tube insertion site pain but
does have a small area at insertion site with occas tenderness
and serosang oozing. He presents now for surgical resection.
Past Medical History:
PMH: HTN, MI ([**2-/2125**]) s/p drug-eluting stent placement in the
LAD, GERD, IBS
PSH:
lap J tube insertion [**2126-6-19**]
Social History:
-Tobacco history: [**3-10**] cigars per day
-ETOH: previous heavy drinker, cut down significantly 10 yrs ago
-Illicit drugs: never
-lives with wife
-works as trucker
.
Family History:
Parents were healthy into old age. Is unaware of any hx of CAD
or SCD.
.
Physical Exam:
BP: 103/70. Heart Rate: 102. Weight: # (with shoes).
Temperature:
97.8. Resp. Rate: 16. Pain Score: 0. O2 Saturation%: 100.
Gen: NAD
Neck: no [**Doctor First Name **]
Chest:clear ausc
Cor:RRR no murmur
Abd:soft, nontender, L sided J tube insertion site small amt
induration with minimal serosang discharge, no organomeg
Extrem:no CCE
Pertinent Results:
[**2126-7-31**] 12:18PM HGB-10.5* calcHCT-32
[**2126-7-31**] 12:18PM GLUCOSE-138* LACTATE-1.7 NA+-135 K+-4.5
CL--101
[**2126-7-31**] 11:25PM WBC-8.7 RBC-2.83* HGB-9.0* HCT-26.6* MCV-94
MCH-31.8 MCHC-33.9 RDW-15.7*
[**2126-8-6**] Ba swallow :
No leak.
[**2126-8-6**] CXR :
No definitive evidence of pneumothorax post chest tube removal.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the hospital and taken to the
Operating Room where he underwent a minimally invasive
esophagectomy. See formal Op note for details. He tolerated
the procedure well and returned to the SICU in stable condition.
He maintained stable hemodynamics and his pain was controlled
with an epidural catheter.
Following transfer to the Surgical floor he continued to make
good progress. His J tube feedings began on post op day #1 and
were eventually increased to goal of Replete at 85 cc's/hr. over
18 hours. He otherwise remained NPO until his barium swallow on
[**2126-8-6**] which showed no leak. He had no obvious difficulty with
swallowing liquids but was evaluated by the Speech and Swallow
service due to his prolonged period of not eating pre
operatively. He had no problems with swallowing and was able to
eat all consistencies of food. He also could swallow his pills
whole, safely.
He underwent vigorous pulmonary toilet including chest PT and
incentive spirometry and remained free of any pulmonary
complications post op. His pain was minimal and following
removal of his epidural catheter he was managed with Tylenol and
minimal Oxycodone. The Physical Therapy service evaluated him
on numerous occasions and recommended that he have home Physical
Therapy to help increase his ambulation and endurance. His
Effient was resumed on [**2126-8-7**].
His port sites were dry along with his chest tube and JP sites.
He was tolerating a full liquid diet modestly and will continue
to receive all of his calories through his J tube feedings.
Both he and his wife reviewed J tube flushing and j tube
feedings. After an uneventful recovery he was discharged to
home on [**2126-8-7**] and will follow up in the Thoracic Clinic in 2
weeks.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Lorazepam 0.5-1 mg PO Q6H:PRN anxiety
4. Atenolol 25 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Nitroglycerin SL 0.4 mg SL PRN chest pain
7. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Fluoxetine 20 mg PO DAILY
11. Prasugrel 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Fluoxetine 20 mg PO DAILY
4. Prasugrel 10 mg PO DAILY
5. Acetaminophen (Liquid) 650 mg PO Q6H:PRN fever/pain
6. OxycoDONE Liquid 5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 5-10 mg by mouth every four (4) hours
Disp #*500 Milliliter Refills:*0
7. Docusate Sodium 100 mg PO BID
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Esophageal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers greater than 101 or chills
-Increased shortness of breath, cough or chest pain
-Nausea, vomiting (take anti-nausea medication)
-Increased abdominal pain
-Incision develops drainage
-Remove chest tube and j-tube site bandages Thursday and replace
with a bandaid, changing daily until healed.
Pain
-Oxycodone orally or via J-tube as needed for pain
-Take stool softners with narcotics
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tub until incision healed
-No driving while taking narcotics
-No lifting greater than 10 pounds until seen
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Diet:
Tube feeds: Replete Full Strength at 85 cc's/hr. x 18 hrs
Flush J-tube with water every 8 hours with 10 cc's of water,
before and after starting tube feeds and giving medications
through tube
Full liquid diet, may increase to soft solids over the next few
days as tolerated.
Eat small frequent meals. Sit up in chair for all meals and
remain sitting for 30-45 minutes after meals
Daily weights: keep a log bring with you to your appointment
NO CARBONATED DRINKS
Danger signs
Fevers > 101 or chills
Increased shortness of breath, cough or chest pain
Incision develops drainage
Nausea, vomiting (take anti-nausea medication)
Increased abdominal pain
Call if J-tube falls out (save the tube and bring with you to
the hospital to be re-placed) or suture breaks
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2126-8-20**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) **] of the [**Hospital Ward Name 23**] Clinical
Center for a chest xray.
Department: CARDIAC SERVICES
When: FRIDAY [**2126-9-13**] at 2:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2126-8-7**]
|
[
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"V87.41",
"401.9",
"458.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.42",
"96.6",
"42.52",
"42.23",
"03.90"
] |
icd9pcs
|
[
[
[]
]
] |
5170, 5219
|
2310, 4099
|
283, 465
|
5281, 5281
|
1942, 2287
|
7001, 7790
|
1497, 1571
|
4669, 5147
|
5240, 5260
|
4125, 4646
|
5432, 6978
|
1586, 1923
|
234, 245
|
493, 1143
|
5296, 5408
|
1165, 1294
|
1310, 1481
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,043
| 182,814
|
24077
|
Discharge summary
|
report
|
Admission Date: [**2117-8-27**] Discharge Date: [**2117-9-3**]
Date of Birth: [**2067-8-26**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Right sided clumsiness and heaviness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname 61229**] is a 50 yo RH M with a h/o melanoma with known mets
to spine (s/p neck surgery 9 mos ago) enrolled in an
experimental
chemotherapy protocol, who presented to OSH last night with
weakness (R > L) and clumsiness. Mr [**Known lastname 61229**] states that he was in
his usual state of health last night at 9pm when going to bed,
and awoke in the middle of the night and found himself unable to
rise from bed. He noted weakness of his R limbs. He was taken
by ambulance to [**Hospital6 **], where head CT demonstrated
a 6cm L parieto-occipital hematoma. He was transferred to [**Hospital1 18**]
for further evaluation, where he says he has felt "foggy."
Mr [**Known lastname 61229**] reports no changes in his health prior to the onset of
weakness last night, denying HA, NVD, visual changes, hearing
changes, vertigo, falls, trauma, difficulties with memory,
speech, or language comprehension or production. Per the pt's
family, the pt has moderate clumsiness of his left hand at
baseline, thought to be related to spinal metastases of his
melanoma and the surgeries performed on his spine. Per the pt
and his family, he does not have the R sided weakness with which
he presented at his baseline.
Past Medical History:
Metastatic melanoma, mets to spine, liver, and kidneys (dx [**2103**])
Anxiety
s/p laminectomy and cervical fusion
s/p multiple resections
Past Oncologic History:
Mr. [**Known lastname 61229**] was diagnosed with a 1.45 mm thick,
[**Doctor Last Name 10834**] level IV melanoma from his lower back in [**2104**]. He
underwent wide local excision and bilateral inguinal negative
sentinel lymph node biopsies. He developed left inguinal
recurrence in [**12/2111**], undergoing completion left inguinal lymph
node dissection on [**2112-2-8**] with pathology revealing melanoma
in four of nine nodes with extracapsular extension. He received
radiation therapy to the left inguinal region completing in
05/[**2111**]. He began interferon off protocol in [**5-/2112**] with
therapy discontinued on [**2112-10-19**] due to radiation colitis. In
[**2-/2113**], he underwent biopsy of a right clavicular lesion by Dr.
[**First Name (STitle) 1022**] revealing a 0.45 mm thick, [**Doctor Last Name 10834**] level III melanoma. He
underwent wide local excision in 04/[**2112**]. In [**6-/2114**], he had
biopsy of a left mandible skin lesion revealing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10834**] level
III, 0.51 mm thick melanoma with three mitoses per mm2. On
[**2114-7-23**], he underwent wide local excision and sentinel lymph
node biopsy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] with no residual
melanoma
at the primary site, but one of three lymph nodes showed a
microscopic deposit of melanoma. He underwent modified left
neck
dissection on [**2114-7-30**] with no melanoma noted in seven
additional nodes. In [**2115-6-4**], he underwent biopsy of a new
right chest wall skin lesion by Dr. [**First Name (STitle) 1022**] revealing metastatic
melanoma not seen at the margin without an epidermal component
and two mitoses per mm2. It was unclear whether this
represented
an in-tranist metastasis from his right clavicle melanoma or an
epidermatrophic metastasis. He underwent right chest wide local
excision and right axillary sentinel lymph node biopsy by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1924**] on [**2115-7-18**]. There was no evidence of residual
melanoma in the chest or in the sentinel lymph node. Staging
scans were negative and he began GM-CSF off protocol on
[**2115-9-4**], completing 13 cycles in [**2116-8-4**]. Torso CT in
[**9-11**] revealed new small bilateral pulmonary nodules and an
abnormal right kidney. CT guided biopsy of the right kidney on
[**2116-10-27**] confirmed metastatic melanoma. He began the Phase I/II
RAF 265 trial on [**2116-12-22**]. Therapy was held on C1W4, [**1-12**], due
to visual problems, fatigue and anorexia.
Social History:
Lives with wife, daughter, 10 and son, 8 in [**Hospital1 3597**], NH. Has a
pet cat at home. No tobacco, no alcohol, no illicit drug use.
His children have been at day camp this summer.
Family History:
noncontributory, no melanoma
Physical Exam:
At admission:
Vitals: 98.4 87 135/82 20 100% RA
Physical Exam:
Gen: [**Doctor Last Name **]-haired man lying flat in bed, appearing older than
his
stated age of 50
HEENT: No scleral icterus. No conjunctival injection. MMM.
Neck: Supple, no LAD in cervical chains.
Lungs: CTAB
CV: RRR, nl s1, s2, no m/r/g.
Abdomen: soft, NT, ND, NABS.
Extremities: LE cool to touch, no cyanosis, clubbing, edema in
LE.
Neurologic examination:
Mental status: Awake, alert, cooperative, affect appropriate
ORIENTATION: Oriented x 3
ATTENTION: performed DOW forward, DOW backward slow, unable to
perform MOYB, SPEECH/LANGUAGE: Speech fluent with intact
comprehension, repetition, naming. Can follow simple and 3-step
commands. No dysarthria. No paraphasic errors.
MEMORY: Registered [**2-3**], recalled 0/3 words at 5 minutes
CALCULATION: $1.75 = 7 quarters, $2.75 = 15 quarters
PRAXIS/NEGLECT: Used his hands as tools when simulating
hammering
a nail and combing his hair. Pt appeared unaware that he was
unable to move his RUE and RLE, believing that he had moved them
when he had not.
Cranial Nerves:
I - not tested;
II, III - PERRL 4-->3 mm b/l. Visual fields full to
confrontation bilaterally
III, IV, VI - EOMI, no nystagmus bilaterally, normal saccades
V - Sensation intact V1-V3
VII - Facial movement symmetric, no obvious facial droop
VIII - Hearing intact to finger rub bilaterally
IX, X - Voice normal, palate elevates symmetrically
[**Doctor First Name 81**] - Sternocleidomastoid, trapezius 4/5 strength on R
XII - Tongue protrudes midline, movements intact
Motor:
Normal bulk and tone, LUE bradykinesia, no pronator drift.
[**Doctor First Name **] Tri Bic WE FF FE IP Quad Ham AF AE TF TE
C5 C7 C6 C6 C7 C7 L2 L3 L4-S1 L4 S1 S2 L5
R - - - - - - - - - - - - -
L 4- 4+ 5 5 5 5 5 5 5 5 5 5 5
Coordination:
dysdiadokinesia with LUE (per wife at his baseline)
Reflexes:
No clonus, toes downgoing bilatrally
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
C5-6 C7-8 C5-6 L3-4 S1-2
Right 1 1 1 1 1
Left 1 1 2 1 1
Sensation:
Intact to LT, PP and position on left. Sensory level at ~C4
where PP is less below. Extinction with DS on right.
Gait:
Not assessed
Pertinent Results:
BRAIN MRI with and without contrast: Comparison was made with
the brain, MRI of [**2117-2-9**]. Comparison was also made with the
CT examination of [**2117-5-6**].
There is a large area of hyperacute and acute intra-axial
hematoma identified in the left parietal lobe with surrounding
edema and mass effect on the left lateral ventricle. Small fluid
level identified within the ventricle indicating
intraventricular extension. There is no midline shift. No
definite area of acute infarct identified. Restricted diffusion
visualized within the hematoma secondary to blood products.
Following gadolinium, there is no distinct enhancement
identified within the region of hematoma in its lower portion,
but there is subtle nodular enhancement seen in the superior
portion, series 28, image 21. Additionally, there is a 5-mm
focus of enhancement identified in the left frontal lobe
anterior to the hematoma. This is best visualized on series 28,
image 22. No other foci of abnormal brain enhancement
identified. There is no midline shift or hydrocephalus seen.
Note is made of a T1 hyperintense fluid within the pneumatized
bilateral
petrous apex air cells.
IMPRESSION:
1. Large intra-axial hematoma in the left parietal lobe with
blood products
suggestive of hyperacute/acute hematoma. The hematoma measures
approximately
6 x 4 cm. Surrounding edema and mass effect is seen. Small
amount of blood
within the ventricles indicate intraventricular extension.
2. Small nodular enhancement at the superior aspect of the
hematoma and an
additional 5-mm focus anterior to the hematoma in the left
frontal lobe are
suggestive of underlying metastatic disease.
MRA HEAD:
Head MRA demonstrates normal flow signal in the arteries of
anterior and
posterior circulation without stenosis, occlusion, or an
aneurysm greater than
3 mm in size. T1 hyperintense area adjacent to the carotid
arteries on the
source images are secondary to pneumatized petrous apex air
cells with high
protein content and T1 pre-gadolinium hyperintensities.
IMPRESSION: No significant abnormalities on MRA of the head.
MRA NECK:
The neck MRA demonstrates normal flow in the carotid and
vertebral arteries.
There is a 6-mm protuberance seen in the left subclavian artery
proximal to
the origin of left vertebral artery, which likely due to a small
aneurysm.
IMPRESSION: No evidence of carotid stenosis or occlusion on neck
MRA. 7-mm
protuberance in the left subclavian artery proximal to the
vertebral artery
origin could be a subclavian artery diverticulum or aneurysm.
CTA can help
for further assessment if clinically indicated.
NON-CONTRAST HEAD CT: A 6.2 x 3.7 cm left parietal hemorrhage
with peripheral zone of edema appears similar in configuration
as compared to [**2117-8-27**]. There is extension of blood
products into the left atrium and bilateral occipital horns, new
since prior CT. There is no significant increase in the extent
of sulcal effacement as compared to before. There is no new
focus of hemorrhage. There is no shift of normally midline
structures. Ventricles are similar in size as before.
Suprasellar and basilar cisterns are patent.
Paranasal sinuses and mastoid air cells are well aerated. Globes
and soft
tissues are unremarkable.
IMPRESSION: Overall unchanged appearance of left parietal
hemorrhage with
mild peripheral zone of edema, without increased mass effect as
compared to [**2117-8-27**]. No new focus of hemorrhage. See
prior MR report for
details reg. enhancement and metastatic disease.
3.7 | 29 | 1.1
Ca: 9.5 Mg: 2.1 P: 2.8
13.4
7.7 >--< 166
38.4
N:89.8 L:7.4 M:2.2 E:0.3 Bas:0.4
PT: 12.5 PTT: 27.3 INR: 1.1
Brief Hospital Course:
50 yo RHM with h/o metastatic melanoma presents with left
intraparenchymal hemorrhage.
NEURO:
Patient awoke in the middle of the night and found himself
unable to
rise from bed. He noted weakness of his R limbs. He was taken
by ambulance to [**Hospital6 **], where head CT demonstrated
a 6cm L parieto-occipital hematoma. He was transferred to [**Hospital1 18**]
for further management. MRI showed underlying contrast enhancing
nodular areas that were highly concerning for underlying
malignancy, especially given his metastatic melanoma. Pt was
started on dexamethasone, which was tapered and will continue to
be tapered per oncology recommendations. Patient was also
started on Keppra for seizure prophylaxis; there was no evidence
of seizures.
He was monitored in the neuro ICU, where bleed remained stable,
and he was transferred to the floor. Neurosurgery was consulted,
and no interventions were indicated. Patient had stable dense
right hemiparesis. PT/OT/speech swallow was consulted. Patient
was discharged to rehab. He will have repeat MRI/MRA in 6 weeks
and follow up in stroke clinic.
MELANOMA:
Patient was followed closely by his primary oncology team.
Radiation oncology saw patient and planned for whole brain
radiation beginning on day of discharge.
CV:
Patient was normotensive without any medications at discharge.
PAIN:
Patient had severe headaches, started on morphine SR [**Hospital1 **] and IR
prn with good effect.
CODE STATUS: confirmed full code with patient and family
Medications on Admission:
Pt was on an experimental chemotherapy protocol, but has
recently
been off of chemotherapeutics, per protocol. Pt states that he
is not currently on any medications.
Discharge Medications:
1. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
2. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
5. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for breakthough pain.
6. Baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Injection TID (3 times a day).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for fever, pain.
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Melanoma with metastases to your left parietal cortex and left
basal ganglia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
You have a right sided paresis.
Discharge Instructions:
You have a melanoma with metastases to your left parietal cortex
and left basal ganglia. The latter bled. We have treated you
medically (no surgical procedures were performed). You will
undergo radiation therapy for these lesions.
You were also started on anti-seizure medication for
prophylaxis, which you will need to continue indefinitely.
Followup Instructions:
You will have a repeat brain MRI and MRA
[**2117-10-18**]
[**Hospital Ward Name 517**] Clinical Center basement
2:00 pm
Nothing to eat or drink 4 hours prior
You will follow up with Dr. [**Last Name (STitle) 1693**] in the stroke clinic
[**11-1**] 1:30 pm
[**Hospital Ward Name 23**] Clinical Center [**Location (un) **]
[**Telephone/Fax (1) 1694**]
You also have other appointments lined up:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2117-9-3**] 11:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10837**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2117-9-7**]
9:00
Provider: [**Name10 (NameIs) 28909**],[**Name11 (NameIs) 8754**] DERMATOLOGY GEN-[**Doctor First Name 8754**] (NHB)
Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2117-9-24**] 11:30
|
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"197.7",
"198.0",
"198.3",
"V45.4",
"348.5",
"431",
"342.90",
"198.5",
"300.00",
"V15.3",
"V10.82",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
13811, 13858
|
10689, 12193
|
352, 359
|
13979, 13979
|
7019, 9636
|
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12410, 13788
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|
14195, 14540
|
4731, 5078
|
276, 314
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387, 1620
|
5765, 7000
|
9645, 10666
|
13994, 14170
|
5102, 5102
|
1642, 4399
|
4415, 4604
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,748
| 121,860
|
3320
|
Discharge summary
|
report
|
Admission Date: [**2179-4-17**] Discharge Date: [**2179-4-23**]
Date of Birth: [**2099-9-2**] Sex: M
Service: MEDICINE
Allergies:
Neomycin Sulfate/Hc / Tape / Beet
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
PICC line placement
IJ placed on [**2179-4-17**]
History of Present Illness:
79 yo male with PMH of CAD s/p stents in [**2170**] and EF 21% in
[**2174**]. Came in after telling PCP that systolic was 70s this am,
who wanted him to present to the ED. He keeps a chart of his
daily blood pressures, which have ranged 80s to 90s systolic
(long term baseline) until yesterday, when it was 74/43 and
today at 73/43. He is completely asymptomatic and specifically
denies LH, SOB, CP, palpitations, F/C, abd pain. He reports
that his UOP has been down and his urine has been darker. He
has intentionally limited his fluid intake per his
cardiologist's recommendations, but that has been over the
course of months. He endorses thirst.
.
He had a recent admission at [**Hospital **] hospital for UGIB with
gastric ulcers. He was placed on a PPI. On [**4-8**], his BUN/Cr
was 51/1.9. he was given 2U pRBCs with discharge HCT 30. An
abdominal u/s noted small to moderate acites in the upper
abdomen.
.
He has also undergone 2 mechanical falls in the last month. He
has residual left knee pain/swelling and left leg echymosis.
.
In the ED, initial VS were 97.1 57 68/47 18 89%RA. He was
given a 350cc of gentle fluid. Surgery was consulted and they
are following. His stool was guaiac positive and melenotic. GI
was consulted, but have not seen him yet. He had a CT pelvis
showing ascites with no other abnormalities. Bedside echo
showed no effusion. He had a LE u/s because of asymmetry in his
legs which showed no DVT. No CTA was done because of his renal
failure. Before transfer to the floor, VS were 75/54 48 100%
2L.
.
On arrival to the ICU, he is still asymptomatic. His systolic
BP is in the 80s.
Past Medical History:
MI and CABG in [**2153**] (SVG-D1-LAD, SVG-OM2, SVG-OM3, SVG-AM-PDA)
NSTEMI [**2170**]
BMS to 80% OM2 stenosis [**2176**]
Ejection fraction 21% by exercise MIBI [**2174**], 20% by echo [**2177**]
with moderate MR.
Status post appendectomy in [**2106**].
Seasonal allergies to ragweed, moth dust, and oak.
History of prostatitis.
Recently diagnosed herpes of the cornea OD.
prostate cancer-radioactive seeds placed in [**2176**]
gout
bladder cancer-s/pchemo and scrape
MGUS
cataracts
spinal stenosis
SVT, a-tach vs aflutter by holter [**10-19**]
Social History:
Lives with wife. Retired chemical engineer, Quit smoking [**2153**],
rare etoh.
Family History:
Father passed away of a MI at age 54, and numerous uncles had
coronary artery disease in their 50s.
Physical Exam:
Vitals: T: 96.0 BP: 84/47 P: 49 R: 18 O2: 97% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: JVP 10-12 cm, no LAD
Lungs: bilateral rales 1/2 up lung fields L>R
CV: bradycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present. no rebound tenderness or guarding. liver felt below
costal margin. No splenomegaly. + shifting dullness.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
LE edema. Diffuse echymoses over right leg. + effusion in
right knee.
Pertinent Results:
CXR [**2179-4-17**]:
IMPRESSION: Interval enlargement of the cardiac silhouette,
without evidence of pulmonary edema. Findings are concerning for
a pericardial effusion or early cardiac decompensation. Findings
discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11084**] at the time of
interpretation.
The study and the report were reviewed by the staff radiologist.
[**2179-4-17**] 02:01PM URINE HOURS-RANDOM UREA N-495 CREAT-81
SODIUM-39 TOT PROT-15 PROT/CREA-0.2
[**2179-4-17**] 02:01PM URINE U-PEP-NEGATIVE F
[**2179-4-17**] 01:20PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2179-4-17**] 01:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2179-4-17**] 01:20PM URINE RBC-[**7-21**]* WBC-[**7-21**]* BACTERIA-0
YEAST-NONE EPI-0
[**2179-4-17**] 01:20PM URINE HYALINE-0-2
[**2179-4-17**] 09:50AM GLUCOSE-111* UREA N-108* CREAT-4.0*#
SODIUM-143 POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-20
[**2179-4-17**] 09:50AM estGFR-Using this
[**2179-4-17**] 09:50AM ALT(SGPT)-19 AST(SGOT)-21 LD(LDH)-311*
CK(CPK)-80 ALK PHOS-188* TOT BILI-1.3
[**2179-4-17**] 09:50AM CK-MB-NotDone cTropnT-0.09*
[**2179-4-17**] 09:50AM ALBUMIN-3.7 GLOBULIN-3.0 CALCIUM-9.0
PHOSPHATE-5.7*# MAGNESIUM-3.0*
[**2179-4-17**] 09:50AM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
[**2179-4-17**] 09:50AM HCV Ab-NEGATIVE
[**2179-4-17**] 09:50AM WBC-6.3 RBC-3.30* HGB-10.6* HCT-32.0* MCV-97
MCH-32.0 MCHC-33.0 RDW-17.4*
[**2179-4-17**] 09:50AM NEUTS-70 BANDS-0 LYMPHS-14* MONOS-8 EOS-5*
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2179-4-17**] 09:50AM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL
TEARDROP-OCCASIONAL
[**2179-4-17**] 09:50AM PLT SMR-LOW PLT COUNT-104*
[**2179-4-17**] 09:50AM PT-18.0* PTT-34.2 INR(PT)-1.6*
.
[**4-21**] Echo: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
moderately dilated. No masses or thrombi are seen in the left
ventricle. Overall left ventricular systolic function is
severely depressed (LVEF= 20 %). There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
moderate global free wall hypokinesis. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2179-4-18**], the
degree of mitral and tricuspid regurgitation have slightly
decreased.
[**4-22**] Foot Xray: No localizing history is available. There is
mild diffuse osteopenia. There is probable mild soft tissue
swelling along the dorsum of the foot. No fracture or
dislocation is detected. Recommend correlation with specific
site of symptoms for full assessment.
Brief Hospital Course:
79 yo with PMH of CAD p/w acute on chronic heart failure
biventricular with EF 20%.
.
# Acute on Chronic Systolic and Diastolic Biventricular HEART
FAILURE: Patient was started on lasix gtt but was hypotensive
and had low UO. An IJ was placed and he was started on milranone
and phenylephrine. He diuresed well and his BP improved to his
baseline which in 80s/50s. He was weaned off the pressors but
kept on the lasix gtt with good diureses. He was net 10L
negative. His repeat echo showed overall improvement in MR [**First Name (Titles) **] [**Last Name (Titles) **]R but EF unchanged. His symptoms improved and he was able to be
weaned off oxygen. He was discharged on 40mg torsemide daily.
# ACUTE KIDNEY INJURY: FeUREA suggests pre-renal etiology which
is likely poor forward from heart failure, improved wih
diureses.
.
# GIB/Ulcers: Hct stable. Cont PPI, Restarted on 81mg ASA given
stability
.
# CAD: Cont ASA, statin
.
# Thrombocytopenia: Mild and stable throughout admission
.
# LLE injury: [**3-15**] to falls. Knee has effusion and is
erythematous. Joint tap negative. Afebrile without leukocytosis.
R foot painful with ambulation but improved with tylenol. Cont
cephalexin to complete 10 days course. R foot plain films were
negative for fracture. Follow PT recs for PT eval at home for
safety. Discontinued ambien as he had sundowning in the hospital
and ambien certainly was worsening disorientation.
.
# General Care: No IVF, replete electrolytes, cardiac diet,
Prophylaxis: pneumoboots, PPI, Access: 2 18G PIVs, PICC (d/ced
upon discharge), IJ (d/ced upon discharge). Code: DNR/DNI
confirmed with patient
Medications on Admission:
carvedilol 6.25 qday
carvedilol 3.125mg qday
enalapril 20 qday
lasix 120 and 80 every other day
simvastatin 40 mg qday
zolpidem 5mg qhs prn
amiodarone 100mg qday
EC ASA 325 qday
NTG 0.4 mg SL prn
folic acid 400 mcg qday
MVI
loratadine 10mg qday prn
omeprazole 40mg qday
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 5 days: Please discontinue on [**2179-4-28**]. .
Disp:*10 Capsule(s)* Refills:*0*
2. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
8. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Check on [**2179-4-28**]:
CBC, Chem 7 including BUN and Creatinine
Fax results to Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] office: office phone ([**Telephone/Fax (1) 3942**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Congestive Heart Failure Exacerbation
2. Acute on Chronic Renal Insufficiency
3. Cellulitis
Discharge Condition:
Stable. Patient has returned to his baseline condition.
Discharge Instructions:
You were admitted to the hospital with shortness of breath and
were found to have a congestive heart failure exacerbation. You
were treated aggressively with intravenous medications to help
remove your fluid. After doing this, your breathing, your blood
pressure, and your kidney function improved.
.
We made the following changes to your medications:
- cephalexin - this is an antibiotic to treat the skin infection
on your knee. Please continue this medication through [**2179-4-28**].
- change carvedilol to 3.125 mg twice a day
- your enalapril has been held because your blood pressure was
low and your kidney function was worse. Please follow up with
your cardiologist to restart this in the future.
- We started 40mg torsemide PO daily instead of the lasix
- You should stop taking ambien as this may be constributing to
your falls
.
Please return to the hospital if you develop fevers, shaking
chills, night sweats, shortness of breath, lower extremity
swelling, light-headedness, dizziness, or syncope.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L a day
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 437**] on [**4-26**] at 11:30am. [**Location (un) **], 7th [**Hospital Ward Name 23**] Building. Phone [**Telephone/Fax (1) 62**].
Please follow up with Dr. [**Last Name (STitle) **] within two weeks: [**Telephone/Fax (1) 6937**].
We could not make the appointment for you because Dr.[**Name (NI) 15419**]
office was unavailable.
OTHER APPOINTMENTS:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2179-6-1**] 2:30
Completed by:[**2179-4-23**]
|
[
"428.43",
"584.9",
"414.00",
"682.6",
"V45.81",
"287.5",
"785.51",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9691, 9754
|
6641, 8266
|
313, 364
|
9912, 9970
|
3436, 6618
|
11160, 11770
|
2713, 2814
|
8586, 9668
|
9775, 9775
|
8292, 8563
|
9994, 10317
|
2829, 3417
|
10346, 11137
|
262, 275
|
392, 2032
|
9794, 9891
|
2054, 2600
|
2616, 2697
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,195
| 175,377
|
29001
|
Discharge summary
|
report
|
Admission Date: [**2112-9-29**] Discharge Date: [**2112-10-3**]
Date of Birth: [**2058-4-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54F MR, tracheomalacia s/p tracheostomy in [**2107**], PVD, multiple
aspiration pneumonias, DM2 among other conditions who had low
oxygen saturations at her nursing facility
Patient is not able to provide further history, but denies pain.
Patient was succioneed by EMS with improvement in saturation;
however, she was found to have electrolyte abnormalities and a
drop in her HCT, and as such as admited. Per report, she was
guiaic negative in the ED.
In the ED, initial VS were: 98 98 102/43 18 98% 10L
On transfer, 96.1 ??????F (35.6 ??????C) (Axillary), Pulse: 72, RR: 17,
BP: 121/48, O2Sat: 100, O2Flow: (Room Air).
Labs were notable for Na 121, K 5.3, Cl 81, Bicarb 43, BUN 21,
Cr 1, HCT 25.4.
EKG showed NSR at 75, with TWI in V1.
CXR showed on prelim atelectasis vs. pna.
On arrival to the floor, she is in NAD, but only verbalizes
yes/no answers
REVIEW OF SYSTEMS:
(+) Unable to obtain [**1-14**] poor historian
Past Medical History:
Past Medical History:
Mental retardation
tracheomalacia s/p tracheostomy
h/o aspiration pneumonia
E.Coli bacteremia [**10-23**]
diabetes mellitus
h/o C. difficile infection
glaucoma
hypertension
HLD
osteoarthritis
depression/anxiety,
constipation
psychosis
PAST SURGICAL HISTORY:
Tracheostomy and PEG [**2107**],
R total knee replacement
R hip replacement
Right common iliac artery stent placement and right external
iliac recanalization with stent placement x2. [**1-/2111**]
Social History:
lives at nursing home
Father and Brother are [**Name2 (NI) **]-guardians
Family History:
unable to obtain
Physical Exam:
ADMISSION EXAM:
===================================
VS - T 98 BP 150/1 HR 86 RR 22 96% on 60% trach mask
General: would state shake head "yes or no" to questions, also
says "yes" and "no"
[**Name2 (NI) 4459**]: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, poor dentition
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops although exam limited due to coarse breath sounds
Lungs: diffuse coarse breath sounds, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. PEG tube located in LUQ
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact although disconjugate gaze especially
with right eye
LABS: Please see attached
DISCHARGE EXAM:
=====================================
VS - T 97.4 BP 138/52 HR 102 RR 24 98% on 40% trach mask
General: Responds to name, no acute distress, baseline MR
[**Last Name (Titles) 4459**]: Sclera anicteric, MM dry, EOMI
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bronchial breath sounds
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley
Ext: Cool hands, but otherwise warm, well perfused, 2+ pulses,
no clubbing. Bilateral hands/feet with edema.
Neuro: Answers yes/no questions. Intermittently follows
commands.
Pertinent Results:
ADMISSION LABS:
===============================
[**2112-9-29**] 01:00AM BLOOD WBC-9.4 RBC-2.72* Hgb-8.8* Hct-25.4*
MCV-93 MCH-32.5* MCHC-34.8 RDW-17.3* Plt Ct-291#
[**2112-9-29**] 01:00AM BLOOD Neuts-49.7* Lymphs-33.8 Monos-13.3*
Eos-2.6 Baso-0.6
[**2112-9-29**] 07:20AM BLOOD Ret Aut-8.4*
[**2112-9-29**] 01:00AM BLOOD Glucose-164* UreaN-21* Creat-1.0 Na-121*
K-5.3* Cl-81* HCO3-43* AnGap-2*
[**2112-9-29**] 07:20AM BLOOD TotProt-5.6* Albumin-2.8* Globuln-2.8
Calcium-8.6 Phos-3.5# Mg-2.1 Iron-44
[**2112-9-29**] 07:20AM BLOOD calTIBC-352 Hapto-141 Ferritn-304*
TRF-271
[**2112-9-29**] 01:02AM BLOOD Lactate-1.3
IMAGING:
=========================
CXR [**2112-9-29**]
FINDINGS: AP and lateral views of the chest. Tracheostomy tube
is seen in place. Mild cardiomegaly is unchanged. There are
bibasilar opacities that may represent atelectasis; however,
aspiration or pneumonia cannot be ruled out. Correlate
clinically. No large pleural effusion or pneumothorax.
IMPRESSION: Mild interstitial edema. Bibasilar opacities are
likely chronic. CT can be done to assess for subtle changes.
[**2112-10-1**] CHEST (PORTABLE AP): Tracheostomy tube remains in
satisfactory position. Overall, cardiac and mediastinal
contours are difficult to assess given marked patient rotation,
but are likely stable. Lungs remain low lung volumes with
overall improvement in aeration, suggesting that interstitial
edema has resolved. Basilar patchy opacities are unchanged and
may reflect chronic changes. No large pneumothorax, although
the sensitivity for detecting pneumothorax is somewhat
diminished given supine technique.
[**2112-10-1**] BILAT LOWER EXT VEINS: Limited study due to the
overlying edema. No DVT is seen in the common femoral veins or
proximal superficial femoral veins bilaterally. Flow was seen
in the superficial femoral veins and popliteal veins bilaterally
but technical limitations did not allow adequate assessment.
Other than the right posterior tibial veins which are patent,
the calf veins are not well visualized.
Microbiology:
=========================
[**2112-9-30**] GRAM STAIN (Final [**2112-9-30**]):
[**10-6**] PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final [**2112-9-30**]):
TEST CANCELLED, PATIENT CREDITED.
[**2112-10-1**] MRSA SCREEN (Final [**2112-10-2**]): POSITIVE
[**2112-10-1**] Blood Culture, Routine (Pending):
[**2112-10-2**] Blood Culture, Routine (Pending):
[**2112-10-1**] URINE CULTURE (Final [**2112-10-2**]): NO GROWTH.
[**2112-10-1**] SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2112-10-1**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
DISCHARGE LABS
============================
[**2112-10-3**] 03:00AM BLOOD WBC-6.7 RBC-2.59* Hgb-8.2* Hct-25.3*
MCV-98 MCH-31.8 MCHC-32.4 RDW-17.0* Plt Ct-190
[**2112-10-1**] 02:06AM BLOOD PT-9.4 PTT-26.1 INR(PT)-0.9
[**2112-10-3**] 03:00AM BLOOD Glucose-66* UreaN-23* Creat-1.3* Na-139
K-3.7 Cl-103 HCO3-30 AnGap-10
[**2112-10-3**] 03:00AM BLOOD Calcium-7.7* Phos-3.9# Mg-2.6
[**2112-10-2**] 03:40AM BLOOD Lactate-1.2
Brief Hospital Course:
54F MR, tracheomalacia s/p tracheostomy in [**2107**], PVD, multiple
aspiration pneumonias, DM2 among other conditions who had low
oxygen saturations at her nursing facility
.
# Hypoxemia - Pt initially was admitted due to low oxygen
saturations at her nursing home. It was initially felt this
could possibly due to infection and antibiotics were started.
However, later in her hospital course, her presentation seemed
more consistent with mucous plugging, and so antibiotics were
stopped. She was started on guaifenesin and NAC. She had a
hypoxic event where she desatted to 50% which brought her to the
MICU and she was put on the ventilator. Her improvement was
rapid and she was satting 98% on 40% face mask upon discharge.
PE was considered as a possible etiology of her hypoxia, and
LENIs were obtained which did not show evidence of clot, though
this was a limited study. Additionally, given her rapid
improvement on the ventilator, this was not felt to be a likely
etiology. Sputum culture showed pseudomonas, but this was felt
to be colonization rather than infection, and so antibiotics
were discontinued (as stated above). She was seen by IP given
her history of tracheobronchomalacia and it was decided that
intervention was not necessary. Overall, her etiology of hypoxia
was felt to be secondary to mucous plugging.
# Hyponatremia: Upon admission, patient has serum Na of 120
which improved with fluid resuscitation. Likely hypovolemic
hyponatremia; this is supported by exam, BUN/Cr ratio elevated
above 20, and metabolic alkalosis, which could very well be
contraction. Her Na improved to 129 with fluids supporting the
diagnosis of hypovolemic hypnatremia. As per nursing home, was
same as reported from [**8-29**] labs from facility. Her sodium upon
discharge was 139.
# Anemia: Patient has normal HR and BP, and per report was
guiaic negative. It was concerning for hemolysis versus anemia
of chronic inflammation. Her reticulocyte index indicates that
her bone marrow is responding appropriately. Her hemolysis labs
did not suggest hemolysis as the cause of her anemia. Fe studies
were only notable for elevated ferritin, which makes most likely
diagnosis of her Anemia to be anemia of chronic inflammation.
She did not require blood transfusions during this
hospitalization.
# Hyperkalemia: Upon presentation, patient had mild hyperkalemia
(5.3) which is likely secondary to decreased intravascular
volume, which caused a mild [**Last Name (un) **], possibly precipitating hyper K.
No EKG changes to suggest cardiac effects. Potassium improved to
4.7 from 5.3 with IVF. Her potassium was 3.7 upon discharge.
# Metabolic alkalosis: Likely contraction in the setting of
volume depeltion. There is also a possibility that this is a
compensatory metabolic alkalosis from a respiratory acidosis [**1-14**]
to mucus plugging of trach. Her alkalosis improved with IVF,
lending credence to the idea that it is secondary to volume
depletion with contraction alkalosis.
# DM: Pt was initially continued on her home regimen of 56 units
lantus qHS and insulin sliding scale. However, on the day of
discharge, she became hypoglycemic to 32 that increased to 213
with 1.5 amps of D5. Therefore, her home lantus was cut in half
to 28 units to start tonight and depending on what her sliding
scale requirements are, this should be titrated as necessary.
Chronic Problems:
====================================
#Hypothyroidism: she was continued on home levothyroxine
#H/o psychosis: cont on how valproate/seroquel.
#HTN: She was initially continued on home amlodipine/metoprolol,
but these were held upon transfer to the ICU. However, it is
felt safe to re-start these medications, as her BP was 130/67
upon discharge.
TRANSITIONAL ISSUES
=================================
# Pt has two blood cultures 10/20 and [**10-2**] that are pending
upon discharge that need to be followed-up on
# Pt's home lantus was decreased to 28 units qHS (down from 56
units qHS) due to hypoglycemia. Her insulin sliding scale
requirements should be monitored given this decreased dose of
lantus and be used to increase her lantus as necessary.
# Code Status: FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. valproic acid (as sodium salt) *NF* 500 mg/10 mL (10 mL) Oral
Daily
2. Vitamin D 400 UNIT PO DAILY
3. Amlodipine 10 mg PO DAILY
Hold for SBP <100, HR <60
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Metoprolol Tartrate 150 mg PO BID
Hold for SBP <100, HR <55
6. Glargine 56 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
7. Aspirin 325 mg PO DAILY
8. fenofibrate *NF* 54 mg Oral Daily
9. lactobacillus acidophilus *NF* 1 tablet Oral Daily
10. multivitamin with minerals *NF* 9 mg/15 mL iron Oral Daily
11. Polyethylene Glycol 17 g PO DAILY
12. Quetiapine Fumarate 200 mg PO TID
13. Quetiapine Fumarate 50 mg PO TID
14. valproic acid (as sodium salt) *NF* 750 mg Oral QHS
15. Albuterol 0.083% Neb Soln 1 NEB IH [**Hospital1 **]
16. latanoprost *NF* 0.005 % OU Daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Acetylcysteine 20% 1-10 mL NEB Q2H:PRN mucus
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Guaifenesin [**4-21**] mL PO Q6H
7. Heparin 5000 UNIT SC TID
8. valproic acid (as sodium salt) *NF* 500 mg/10 mL (10 mL) Oral
Daily
9. valproic acid (as sodium salt) *NF* 750 mg Oral QHS
10. Vitamin D 400 UNIT PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. multivitamin with minerals *NF* 9 mg/15 mL iron Oral Daily
13. Metoprolol Tartrate 150 mg PO BID
Hold for SBP <100, HR <55
14. latanoprost *NF* 0.005 % OU Daily
15. lactobacillus acidophilus *NF* 1 tablet Oral Daily
16. fenofibrate *NF* 54 mg Oral Daily
17. Albuterol 0.083% Neb Soln 1 NEB IH [**Hospital1 **]
18. Amlodipine 10 mg PO DAILY
Hold for SBP <100, HR <60
19. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
20. Quetiapine Fumarate 200 mg PO TID
21. Quetiapine Fumarate 50 mg PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
- mucous plug
- hypovolemic hyponatremia
- anemia of inflammation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 69887**],
It was a pleasure taking care of your here at [**Hospital1 771**].
You came into the hospital because you were having a hard time
breathing. We believe this was from mucus that was stuck in your
trach. You have been started on guaifenesin and acetylcysteine
to help prevent mucous plugging. It is important to make sure
you are breathing through humdified air to help prevent the
mucous clot from clogging your airways.
You were also found to have some electrolytes to be abnormal.
These were most likely from being dehydrated. They were normal
after you received some intravenous fluids.
You were also found to be slightly anemic. You have a history of
anemia and this is thought to be due to inflammation.
The following changes were made to your medications
*DECREASED your lantus to 28 units qHS (down from 56 units qHS)
*ADDED guaifenesin to help decrease mucous plugging
*ADDED acetylcysteine to help decrease mucous plugging
*ADDED heparin subq to help prevent clots while you are
bedbound.
*ADDED glucagon and dextrose to be administered per the insulin
sliding scale depending on your glucose levels
Followup Instructions:
Please have your extended care facility arrange follow up with a
MD.
Completed by:[**2112-10-4**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.71"
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icd9pcs
|
[
[
[]
]
] |
13727, 13798
|
7653, 11817
|
311, 318
|
13908, 13908
|
3344, 3344
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15216, 15316
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1881, 1900
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12703, 13704
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14042, 15193
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2711, 3325
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6440, 7630
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264, 273
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346, 1203
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3360, 5872
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13923, 14018
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1315, 1551
|
1790, 1865
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,127
| 149,659
|
19369
|
Discharge summary
|
report
|
Admission Date: [**2163-8-18**] Discharge Date: [**2163-8-24**]
Date of Birth: [**2087-11-12**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
79 yo Russian-speaking F with hx of IDDM, diverticulitis s/p
hemicolectomy presents with 2 days of black stools and
generalized weakness.
.
In ED, denied fevers, chest pain, dyspnea, abdominal pain.
Previous diverticulitis associated with abdominal pain, rectal
bleeding. She did have a normal colonoscopy 2 years ago at [**Hospital1 **] with diverticuli.
.
In the ED, initial VS: 97.6, 98, 102/74, 20, 96%. Exam with LLQ
TTP.
Labs significant for creatinine 1.2, BUN 33 (baseline unknown),
WBC 11.1 with normal differential, Hct 38.2, coags with PTT
21.9, INR 1.1.
She was started on a pantoprazole drip, given glargine 50. CT
abdomen showed partial colectomy, no diverticulitis or abscess.
EKG showed NSR without ST changes. Patient had coffee-ground
emesis. NG tube placed with 750cc coffee ground material which
cleared after 500cc of sterile water. She was seen by GI who
recommended prep tonight for EGD/colonoscopy tomorrow.
.
VS on transfer were: 94, 120/49, 23, 98%/2L
She has an 2 X 18G. Protonix gtt at 8mg/hr. She did have a Hct
drop to 31 and was crossmatched for 2 Units at that time.
Immediately prior to transport 1 L of NS hung for SBPs to 70s.
.
On the floor, she is here with her daughter. She states that
earlier she had lower crampy abdominal pain and indicates that
she now has epigastric pain. Denies nausea. Her biggest
complaint is the annoyance of her NG tube placement. As of late
she has had normal BMs daily without blood of black color.
.
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 dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
DM
HTN
Diverticulitis s/p sigmoid resection [**2151**]
s/p central hernia repair
colonic polyps
TAH and b/l SPO
GERD
Depression
Anxiety
Social History:
Divorced with 2 adult children. No tobacco or etoh.
Retired fashion designer.
Family History:
Parents died in their 60s. No siblings
Physical Exam:
Admission Physical Exam
Vitals: 94, 151/91, 100/2L
General: Alert, comfortable, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
At admission:
[**2163-8-18**] 01:15PM BLOOD WBC-11.1* RBC-4.78 Hgb-13.0 Hct-38.2
MCV-80* MCH-27.3 MCHC-34.1 RDW-12.8 Plt Ct-300
[**2163-8-18**] 01:15PM BLOOD Neuts-58.4 Lymphs-36.1 Monos-3.9 Eos-1.3
Baso-0.3
[**2163-8-18**] 01:15PM BLOOD PT-12.5 PTT-21.9* INR(PT)-1.1
[**2163-8-18**] 01:15PM BLOOD Glucose-251* UreaN-33* Creat-1.2* Na-142
K-4.2 Cl-103 HCO3-27 AnGap-16
[**2163-8-18**] 01:15PM BLOOD ALT-24 AST-19 LD(LDH)-156 AlkPhos-66
TotBili-0.3
[**2163-8-19**] 03:12AM BLOOD Calcium-8.0* Phos-3.5 Mg-1.5*
[**2163-8-18**] 01:15PM BLOOD Albumin-3.8
[**2163-8-18**] 01:32PM BLOOD Glucose-234*
[**2163-8-18**] 01:32PM BLOOD Hgb-12.9 calcHCT-39
[**2163-8-18**] 10:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.047*
[**2163-8-18**] 10:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2163-8-18**] 10:30PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.047*
[**2163-8-18**] 10:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2163-8-20**] SEROLOGY/BLOOD HELICOBACTER PYLORI ANTIBODY
TEST-PENDING INPATIENT
[**2163-8-19**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2163-8-18**] URINE URINE CULTURE-FINAL INPATIENT
CT abd/pelvis
[**8-18**]
IMPRESSION:
1. Status post sigmoid colectomy without evidence of
complication. No
evidence of diverticulitis.
2. Right lower lobe pulmonary nodule, 6 mm. In the setting of no
risk
factors (non-smoker and no cancer history), follow-up CT in one
year is
recommended to document stability.
3. Bilateral adrenal nodules; a dedicated adrenal CT or MR may
be considered
for further evaluation.
Findings discussed with [**First Name5 (NamePattern1) 12132**] [**Last Name (NamePattern1) 52686**] 12:05 AM on [**2163-8-19**]
by [**First Name8 (NamePattern2) 449**]
[**Last Name (NamePattern1) 11623**] over the phone.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) 814**] [**Name (STitle) 815**]
Approved: FRI [**2163-8-19**] 8:51 PM
EGD [**8-19**]:
Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Erythema of the mucosa was noted in the antrum.
Erosions and two small (5mm) clean based, non-bleeding ulcers
were seen in the antrum. A large (2cm) ulcer with three visible
vessels and stigmata of recent bleeding was noted in the lesser
curvature of the stomach. Five clips were placed around the
ulcer with one over a visible vessel. Electrocautery was applied
to another visible vessel which resulted in some mild oozing.
Epinephrine 1:10,000 was injected (total of 7cc) with resolution
of the oozing. Despite this therapy this is a high risk ulcer
to re-bleed.
Other Sub mucosal mass (8cm) was seen in the body of the
stomach.
Duodenum: Normal duodenum.
Impression: Erythema in the antrum
Erosions and two small (5mm) clean based, non-bleeding ulcers
were seen in the antrum in the stomach
Large 2cm ulcer with three visible vessels and stigmate of
recent bleeding in the lesser curvature of the stomach. This
ulcer is at a high risk to re-bleed.
Sub mucosal mass (8mm) was seen in the body of the stomach.
Otherwise normal EGD to third part of the duodenum
Recommendations: Continue protonix drip for now (72 hours)
Please send H. pylori serology and treat if positive
If re-bleeds call GI on call for evaluation for re-EGD. Patient
may require MAC for repeat procedure.
Transufse one unit of blood now
Trend hct
Continue to monitor in ICU for now
IR and surgery consult
Additional notes: The attending was present for the entire
procedure. FINAL DIAGNOSES are listed in the impression section
above. Estimated blood loss = zero. No specimens were taken for
pathology
EGD [**2163-8-22**]
Findings: Esophagus:
Mucosa: Normal mucosa was noted.
Stomach:
Excavated Lesions A single healing non-bleeding 4 cm ulcer was
found in the stomach body with 4 clips adjacent to it.
Duodenum:
Other Loss of vilious architecture was noted in the duodenum.
Biopsies were obtained. Cold forceps biopsies were performed for
histology at the Duodenum .
Other
procedures: Cold forceps biopsies were performed for histology
at the stomach body.
Impression: Normal mucosa in the esophagus
Loss of vilious architecture was noted in the duodenum. Biopsies
were obtained. (biopsy)
Ulcer in the stomach body
(biopsy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Avoid all nsaid usage
Continue high dose [**Hospital1 **] ppi therapy
Repeat EGD in 6 weeks to confirm healing
Avoid alcohol
Follow up biopsy results, and treat if they come back positive
for hpylori
Additional notes: The attending was present for the entire
procedure. The patient's home medication list is appended to
this report. FINAL DIAGNOSIS are listed in the impression
section above. Estimated blood loss = zero. Specimens were taken
for pathology as listed.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
# GI Bleed: 75F with hx of diverticulosis s/p hemicolectomy,
diabetes, admitted to MICU with large volume coffee ground
emesis and anemia. She had an EGD which demonstrated a
nonbleeding submucosal mass, and large lesser curvature ulcer
with 3 large vessels. She was intervened upon with multiple
clips and was noted to have continued ooze. She was treated with
a PPI drip. She was transferred to the floor and rescoped due to
the continued ooze on first EGD. Rescope showed multiple clips
in place, no bleeding and multiple ulcers. Biopsies were taken.
H pylori serology was positive and she was started on triple
therapy with amoxicillin, clarithromycin and pantoprazole. Her
H/H remained stable and was ~36 upon discharge to rehab.
- Continue amoxicillin, clarithromycin until [**9-7**].
- Restart Enablex and glucotrol [**9-7**]
- Monitor for signs of myalgias (simvastatin and clarithromycin
interaction)
- Follow-up with GI, and rescope in 6 weeks to ensure healing
- DO NOT administer
# Transient Hypoxia: She would desaturate to 88% on RA while
sleeping. This resolved with activity and on waking the patient.
This was likely a combo of obesity hypoventilation vs. OSA vs.
atelectasis. Would recommend outpatient sleep evaluation.
# DM type 2: Patient is on Lantus 42 units at night, metformin
1000mg [**Hospital1 **] and Glucotrol 5mg daily. Please hold glucotrol until
[**9-7**] and cover with humalog SSI
# HTN: Normotensive in house. Held Benicar and Metoprolol in
setting of GI bleed. Restarted on transfer to rehab.
# Migraine: Tylenol, max 2gm daily, PRN fioricet
# Depression: Cymbalta at home was dosed at 60mg, however, new
recommendations are for a max dose of 40mg daily. We dose
reduced her to 40mg and she tolerated this change.
# Communication: Patient, [**Name (NI) 52687**], son [**Telephone/Fax (1) 52688**]
# Code: Full (discussed with patient)
TRANSITIONAL ISSUES
# Repeat EGD in 6 weeks to confirm no more bleeding.
# Desaturation to 80s overnight requiring 2.5 L O2 by nasal
cannula. Potential sleep apnea. Recommend following up as
outpatient.
Medications on Admission:
Cymbalta 60 mg Cap
1 Capsule(s) by mouth once a day
.
Enablex 15 mg 24 hr Tab
1 Tablet(s) by mouth once a day
.
Benicar HCT 40 mg-25 mg Tab
1 Tablet(s) by mouth daily
.
glyburide 5 mg Tab
2 Tablet(s) by mouth twice a day
.
metformin 1,000 mg Tab
1 Tablet(s) by mouth twice a day
.
metoprolol succinate ER 100 mg 24 hr Tab
1 Tablet(s) by mouth once a day
.
Ibuprofen 600mg occassionally for pain
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
3. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 13 days: Finish [**9-16**].
4. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 13 days: Finish [**9-16**].
5. olmesartan-hydrochlorothiazide 40-25 mg Tablet Sig: One (1)
Tablet PO once a day.
6. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
8. Insulin
Lantus 42 units SQ at bedtime
9. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Outpatient Lab Work
Please check CK in 5 days
11. multivitamin Capsule Sig: One (1) Capsule PO once a day.
12. diazepam 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
13. Glucotrol 5 mg Tablet Sig: One (1) Tablet PO once a day:
Restart on [**9-7**].
14. Enablex 15 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day: RESTART [**9-7**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Upper GI bleed
H. Pylori infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 29773**],
It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] for weakness and dark stools. You had an endoscopy which
showed blood in your stomach from multiple ulcers. This was
treated with clips and you your bleeding stopped. You were found
to have an infection called H. pylori which is associated with
ulcers. We started you on antibiotics for this infection.
You had a repeat endoscopy which showed the clips were in the
correct place and there was no further bleeding. You will need
repeat endoscopy in 6 weeks to ensure healing.
We made the following changes to your medications:
START Pantoprazole 40mg by mouth 2x a day
START Amoxicillin 1g by mouth 2x a day for 14 days, ending on
Tuesday, [**9-6**].
START Clarithromycin 500mg by mouth 2x a day for 14 days, ending
on Tuesday, [**9-6**].
CHANGE your Celexa (Citalopram) to 40 mg/day. This is the
maximum recommended dose for treatment of depression.
RESTART your Enablex after you finish the clarithromycin (start
on [**9-7**]) due to interactions between the medications
RESTART your glucotrol after you finish the clarithromycin
(start on [**9-7**]) due to interactions between the medications
Please take all other medications as prescribed and follow-up at
your appointments below.
Followup Instructions:
Name: [**Last Name (LF) 52689**],[**First Name3 (LF) **]
Address: 1272-[**Location (un) 52690**]., [**Street Address(1) 4323**],[**Numeric Identifier 4325**]
Phone: [**Telephone/Fax (1) 35276**]
*Please call primary care physician and book [**Name Initial (PRE) **] follow up
appointment within 1 week of discharge from rehab.
Please follow-up in the Russian [**Hospital 43084**] Clinic on
[**2163-9-6**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2163-9-14**] at 3:00 PM
With: [**First Name8 (NamePattern2) 4503**] [**Last Name (NamePattern1) 4504**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2163-8-24**]
|
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41,040
| 118,624
|
39112
|
Discharge summary
|
report
|
Admission Date: [**2135-5-7**] Discharge Date: [**2135-5-17**]
Date of Birth: [**2055-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Nephrolithiasis, urosepsis
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placed by IR, [**2135-5-7**]
History of Present Illness:
80 yo man with from h/o CHF, HTN, afib, h/o DVT, on coumadin who
presented to OSH with 1 day history of R flank pain and dysuria,
found to have renal stone. Pt reports dysuria and hematuria 1
week ago; he was treated with a short course of an unknown abx
with resolution. OSH renal ultrasound on [**2135-5-5**] was negative
per wife. His coumadin was also held initially, then restarted.
However, patient woke up yesterday ([**2135-5-6**]) with acute onset
of [**10-23**] R flank pain. He also had dysuria, gross hematuria,
chills, and significant fatigue. His coumadin was once again
held yesterday. He presented to [**Hospital3 **] Hospital where he was
febrile to 102.4. CT abdomen showed a 7mm stone a R UPJ
junction. UA was c/w infection. He received ceftriaxone.
Patient was also given dilaudid and dropped his SBP to 80s. He
was given 2500cc NS with BP recovery to 120s. He was
transferred to [**Hospital1 18**].
.
In our ED, initial vs were: T 99.3, P 118, BP 109/63, RR 16,
O2sat 94% 2L. Patient was given Azithromycin 500mg IV x 1 (for
PNA coverage), and Gentamycin 80mg IV x 1. Urology was
consulted and recommended perc nephrostomy. IR consulted and
agreed to take pt this afternoon for perc nephrostomy.
Patient's SBP dropped to 80-90s, so CVL placed and Levophed
started.
.
On the floor, pt with 5/10 R lateral abdominal pain. No f/c,
N/V.
.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Treated for pneumonia in [**2-/2135**] and reports stable nonproductive
cough since. On 1L NC at baseline per pt. Denies chest pain,
chest pressure, palpitations. Denies diarrhea. Lower abdominal
discomfort which he attributes to constipation; no BMs in
several days. Denies arthralgias or myalgias. Denies rashes or
skin changes.
Past Medical History:
HTN
Hyperlipidemia
CAD s/p CABG about 5 years ago
Atrial Fibrillation on Coumadin
CHF
COPD
H/o bilateral DVTs, on Coumadin (none since)
Pneumonia in [**2-/2135**]
BPH
Social History:
Pt is a retired chicken farmer. Lives with wife. [**Name (NI) **] 3 children.
- Tobacco: Quit 30-40 years ago.
- Alcohol: Very occasional.
- Illicits: Denies.
Family History:
Mother with CAD.
Physical Exam:
Vitals: T 97.9, P 103, BP 142/94, RR 16, O2sat 91% 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP 12cm, no LAD
Lungs: Bibasilar rales L>R with mild coarse breath sounds b/l,
no wheezes
CV: Iregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops appreciated
Back: No CVA tenderness
Abdomen: Soft, mild TTP over right lateral abdomen without
guarding or rebound, non-distended, bowel sounds present
GU: Foley with straw-colored urine
Ext: Warm, well perfused, 2+ pulses, 2+ BLE edema
Pertinent Results:
LABS ON ADMISSION:
[**2135-5-7**] 09:15AM URINE RBC-[**12-3**]* WBC-[**12-3**]* BACTERIA-MANY
YEAST-NONE EPI-0
[**2135-5-7**] 09:15AM URINE BLOOD-NEG NITRITE-POS PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-MOD
[**2135-5-7**] 09:15AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.017
[**2135-5-7**] 09:15AM PT-16.2* PTT-26.7 INR(PT)-1.4*
[**2135-5-7**] 09:15AM PLT SMR-NORMAL PLT COUNT-199
[**2135-5-7**] 09:15AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2135-5-7**] 09:15AM NEUTS-83* BANDS-12* LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2135-5-7**] 09:15AM WBC-18.6* RBC-3.75* HGB-10.7* HCT-32.7*
MCV-87 MCH-28.7 MCHC-32.9 RDW-16.9*
[**2135-5-7**] 09:15AM URINE GR HOLD-HOLD
[**2135-5-7**] 09:15AM URINE HOURS-RANDOM
[**2135-5-7**] 09:15AM ALBUMIN-3.4*
[**2135-5-7**] 09:15AM LIPASE-22
[**2135-5-7**] 09:15AM ALT(SGPT)-62* AST(SGOT)-43* ALK PHOS-57 TOT
BILI-0.8
[**2135-5-7**] 09:15AM estGFR-Using this
[**2135-5-7**] 09:15AM GLUCOSE-151* UREA N-32* CREAT-1.3* SODIUM-139
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2135-5-7**] 09:25AM LACTATE-3.2*
[**2135-5-7**] 01:25PM O2 SAT-54
[**2135-5-7**] 01:25PM LACTATE-1.9
[**2135-5-7**] 07:00PM PT-17.1* PTT-30.7 INR(PT)-1.5*
[**2135-5-7**] 07:00PM PLT COUNT-176
[**2135-5-7**] 07:00PM WBC-18.7* RBC-3.79* HGB-10.7* HCT-33.3*
MCV-88 MCH-28.3 MCHC-32.3 RDW-16.8*
[**2135-5-7**] 07:00PM CALCIUM-8.0* PHOSPHATE-4.2 MAGNESIUM-1.6
[**2135-5-7**] 07:00PM CK-MB-NotDone cTropnT-0.07*
[**2135-5-7**] 07:00PM CK(CPK)-35*
[**2135-5-7**] 07:00PM GLUCOSE-116* UREA N-33* CREAT-1.4* SODIUM-142
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
[**2135-5-7**] 07:00PM GLUCOSE-116* UREA N-33* CREAT-1.4* SODIUM-142
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-27 ANION GAP-15
[**2135-5-7**] 07:16PM LACTATE-2.7*
[**2135-5-7**] 07:16PM TYPE-MIX COMMENTS-GREEN TOP
[**2135-5-7**] 10:55PM URINE HOURS-RANDOM UREA N-215 CREAT-17
SODIUM-104
[**2135-5-7**] 10:59PM URINE HOURS-RANDOM UREA N-433 CREAT-103
SODIUM-43
[**2135-5-7**] 11:13PM O2 SAT-92
[**2135-5-7**] 11:13PM LACTATE-1.9
========
MICROBIOLOGY:
- Urine culture ([**5-7**]):
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 8 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
- [**2135-5-7**] Blood culture: No growth
========
IMAGES/STUDIES:
.
[**2135-5-7**] CXR: SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The
cardiomediastinal contour is within normal limits for technique.
There has been prior midline sternotomy with intact sternal
wires in the expected location. The aortic arch demonstrates
moderate calcification. Lung volumes are low, and there are
bilateral small pleural effusions and atelectasis. Osseous
structures and soft tissues are otherwise unremarkable.
IMPRESSION: Bilateral small effusions and atelectasis.
.
[**2135-5-7**] CXR: FINDINGS: As compared to the previous examination,
the right-sided jugular vein catheter has been inserted. The tip
of the catheter projects over the inflow tract of the right
atrium. No evidence of complications, notably no pneumothorax.
Unchanged bilateral basal areas of atelectasis.
.
[**2135-5-7**] Percutaneous nephrostomy:
.
LENI ([**5-8**]): IMPRESSION: Short segment of non-occlusive thrombus
within the left popliteal vein.
.
Echo ([**5-7**]): The left atrium is markedly dilated. The right
atrium is markedly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. There is mild to moderate
global left ventricular hypokinesis (LVEF = 40 %). The reduced
ejection fraction may be due primarily to irregularity and
rapidity of heart beat with inadequate filling period. There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats.
The right ventricular cavity is dilated with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is a minimally
increased gradient consistent with minimal aortic valve
stenosis. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild to moderate ([**1-15**]+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension.
.
[**2135-5-10**] (CXR): IMPRESSION:
1. Left PICC tip projects over the mid SVC. IV nurse [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 86663**] was notified of the results at 10:16 on [**2135-5-10**].
No pneumothorax.
2. Bilateral low lung volumes with bibasilar atelectases and
retrocardiac
opacity.
.
[**2135-5-12**] Renal US: No evidence of hydronephrosis on ultrasound.
Brief Hospital Course:
Assessment and Plan: 80 yo man with h/o CAD, CHF, afib, h/o DVT
on coumadin treated 1 week ago for UTI presents from OHS with
recurrent dysuria and hematuria, found to have nephrolithiasis
and UTI with sepsis.
.
# UTI with sepsis: Patient presented with pyelonephritis in the
setting of nephrolithiasis complicated by sepsis given
fever/bandemia, hypotension requiring pressors despite attempted
volume resuscitation (total 4L NS). He was initially treated
with ceftriaxone and gentamicin in the ER, but then transitioned
to zosyn in the MICU. He underwent a percutaneous nephrostomy
tube placement in IR on [**2135-5-7**]. After the percutaneous
nephrostomy tube placement he was able to be weaned off his
levophed. On [**5-9**] outside hospital cultures and
sensitivities returned, with proteus mirabolis that was
sensitive to ceftriaxone so his antibiotic regimen was changed
from zosyn to ceftriaxone. Urology continued to follow with
plans for lithotripsy of the renal stone after the 14 day
antibiotic course. Patient is discharged with nephrostomy tube
in place. Pain well controlled with acetaminophen. Strongly
recommend discontinuing foley catheter at earliest possible
convenience. Patient states he is unable to urinate without the
foley catheter unless he is standing up and is currently too
weak to stand. Follow up with Urologist Dr. [**Last Name (STitle) 770**] at [**Hospital1 18**]
[**Hospital Ward Name **] on [**2135-5-25**] at 8am for pre-operative evaluation.
Patient's coumadin will likely need to be discontinued prior to
his procedure with a lovenox bridge.
.
# Hypoxia: Patient with h/o COPD on 1L NC at home since a
pneumonia a few months ago. After volume resuscitation
patient's oxygen requirement increased to 4 L NC. His hypoxia
returned to baseline prior to discharge with daily lasix 80 mg
po and scheduled nebulizer treatments.
.
# Renal failure: Baseline Cr unknown. Likely has acute renal
failure in setting of pyelonephritis/nephrolithiasis as well as
prerenal or ATN given hypotension on presentation. Patient's
creatinine improved with volume resuscitation and was 1.1 at
time of discharge. Would continue to trend on his increased
dose of lasix.
.
# CHF: Patient became grossly volume overloaded during his ICU
admission. He was subsequently diuresed on the medicine floor.
He appears only slightly volume overloaded on exam on day of
discharge with significant chronic bilateral lower extremity
edema. An echo was performed showing left ventricular
hypokinesis with EF of 40%. He was continued on beta blocker,
lasix, and statin. Would recommend adding and ace inhibitor as
tolerated.
.
# COPD: Patient with history of COPD. No acute exacerbation on
presentation, though he intermittently had hypoxia and dyspnea
during his hospitalization. Respiratory symptoms improved
largely with diuresis and schedule nebs. Continued scheduled
nebs and supplemental oxygen to maintain oxygen saturations >
94%.
.
# H/o DVTs: Pt reports h/o multiple DVTs but none since coumadin
initiation "a while ago." INR was subtherapeutic on
presentation in setting of being held for microscopic hematuria.
Due to decreased INR, leg edema and oxygen requirement, lower
extremity ultrasounds were performed showing short segment of
non-occlusive thrombus within the left popliteal vein. Coumadin
was restarted at a decreased dose with goal INR [**2-16**]. INR 1.8 on
day of discharge. Recommend monitoring INR on [**2135-5-20**] for
adequate coumadin dosing.
.
# Chronic Afib: Pt with borderline RVR in setting of urosepsis.
Metoprolol was titrated up with resolution of urosepsis.
Coumadin was restarted at a lower dose after nephrostomy tube
placement. INR trend up to 1.8 on day of discharge. Recommend
monitoring INR on [**2135-5-20**] and adjusting coumadin dosing
accordingly to maintain goal INR [**2-16**]. Patient will likely need
to hold coumadin prior to lithotripsy and be strarted on a
lovenox bridge. The timing of holding coumadin and starting
lovenox will be determined at patient's Urology follow up
appointment on [**2135-5-25**].
.
# CAD: No evidences of ACS during admission. Continue aspirin,
beta blocker, and statin after discharge. Consider starting low
dose ace inhibitor if further blood pressure control is
warranted.
.
# HTN: Patient was hypotensive on presentation. Blood pressure
well controlled on day of discharge with lasix and metoprolol.
.
# HL: Continued on atorvastatin 80mg daily
.
# Access: PICC placed [**2135-5-7**]
# Communication: Patient, wife, son [**Name (NI) **] ([**Telephone/Fax (1) 86664**] C)
# Code: Full (discussed with patient). HCP is wife, [**Name (NI) **]
([**Telephone/Fax (1) 86665**] H).
# Disposition: Rehab
.
Medications on Admission:
KlorCon 20mEq daily
ASA 81mg daily
Metoprolol 25mg [**Hospital1 **] (had been getting Coreg 25mg [**Hospital1 **] while at
Rehab 3 weeks ago)
Imdur 30mg daily (not taking recently)
Lasix 80mg daily (40mg daily at Rehab but increased recently due
to LE edema)
Lipitor 80mg qhs
Coumadin 3mg qhs (held last night)
Trazodone 25mg qhs
Advair 250/50 [**Hospital1 **]
Albuterol Inhaler prn
Home O2
Mucinex 600mg [**Hospital1 **]
Finasteride 5mg daily
Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
2. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
3. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 3 days: Last
dose on [**2135-5-20**].
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Not to exceed 4 grams per 24 hours.
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): Hold for SBP < 100 or HR < 55.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
13. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours) as needed for cough.
14. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily) as needed for constipation .
17. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q4H (every 4 hours) as needed for
SOB/wheezing .
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
20. Outpatient Lab Work
Please have INR, hematocrit, creatinine, potassium, and BUN
monitored on [**2135-5-20**].
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
Urosepsis
Nephrolithiasis
Secondary Diagnosis:
Atrial fibrillation
COPD
Chronic DVTs
CHF/CAD
Discharge Condition:
Hemodynamically stable, requiring 1-2L NC to maintain oxygen
saturations > 95%, afebrile, tolerating po diet and medications,
requires assistance for ambulation.
Discharge Instructions:
You were transferred to [**Hospital1 18**] after you were found to have a
large obstructing kidney stone and a severe urinary tract
infection. A drain was placed to relieve the obstruction and
you were treated with IV antibiotics. You infection improved
and you were discharged to rehab to improve your mobility before
returning home. Because the kidney stone is still present you
will likely require a procedure call lithotripsy to break up the
stone after you have completed a two week course of antibiotics.
.
The following changes were made to your home medications:
1) START Ceftriaxone 1 g IV daily for three days (last dose
[**2135-5-20**]) to treat your urinary tract infection.
2) DECREASE Coumadin to 1.5 mg daily.
3) INCREASE Metoprolol tartrate to 50 mg by mouth three times a
day.
4) START Ipratropium and Xopenex nebulizer treatments to help
your shortness of breath.
5) START Docusate, Senna, and Miralax for treatment and
prevention of constipation.
Followup Instructions:
Please follow up with your new urologist Dr. [**Last Name (STitle) 770**] at the
[**Hospital 18**] [**Hospital 159**] Clinic located in the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] building
on [**2135-5-25**] at 8am.
.
Please have your INR, hematocrit, and renal function monitored
prior to [**2135-5-20**]. Your coumadin dose will be adjusted accordingly
for goal INR [**2-16**].
.
Please follow up with your primary care provider within two
weeks of discharge to review your medications.
|
[
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"592.1",
"584.5",
"272.4",
"518.0",
"591",
"041.6",
"564.00",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
15851, 15956
|
8618, 13331
|
340, 400
|
16112, 16276
|
3219, 3224
|
17293, 17802
|
2611, 2629
|
13825, 15828
|
15977, 15977
|
13357, 13802
|
16300, 16856
|
2644, 3200
|
16874, 17270
|
1818, 2229
|
274, 302
|
428, 1799
|
16043, 16091
|
15996, 16022
|
3238, 8595
|
2251, 2419
|
2435, 2595
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,628
| 134,082
|
587
|
Discharge summary
|
report
|
Admission Date: [**2145-6-27**] Discharge Date: [**2145-7-2**]
Service: [**Location (un) 259**]
HISTORY OF PRESENT ILLNESS: On admission, the patient is an
86[**Hospital 4622**] nursing home resident who reports recent fevers
and coughs productive of white sputum as well as right sided
chest pain. She developed dyspnea saying that her breathing
is all right. She denied chest pain and abdominal pain. At
her nursing home, she was diagnosed with pneumonia, was given
Zithromax on [**6-26**], initially 500 per day, then 250 mg
thereafter. Yesterday she continued to spike fevers. She
was given ceftriaxone 1 gm. Her fevers curtailed throughout
the day. Her blood pressure was recorded to be 84/40 and was
transferred to [**Hospital6 256**] for
further evaluation. At [**Hospital3 **], she was given fluid to
support her blood pressure. Her cultures were drawn and was
given levofloxacin and Flagyl for presumed pneumonia. The
Medical Intensive Care Unit was called to evaluate the
patient for low blood pressure and after 4 liters of fluid,
her blood pressures did not significantly improve.
PAST MEDICAL HISTORY:
1. Severe rheumatoid arthritis
2. Lower gastrointestinal bleed from gastritis in '[**36**]
3. Decubiti ulcers
4. Congestive heart failure
MEDICATIONS:
1. Zithromax 250 mg
2. Albuterol nebulizers q6
3. Robitussin 10 cc qid for five days
4. Ceftriaxone 1 gm multivitamin qd
5. Lasix 2 mg po qd
6. Iron 325 mg po qd
7. Prevacid 50 mg [**Hospital1 **]
8. Tylenol 650 mg po tid
9. Capoten 6.25 mg po tid
ALLERGIES: She is not allergic to any medication.
SOCIAL HISTORY: She is a nursing home resident. She quit
smoking 60 years ago.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAM:
VITAL SIGNS: On admission, her temperature was 101.8??????. Her
heart rate was 103. Her blood pressure was measured on the
left and noted to be systolic pressures 70s to 80s in the
left arm and systolically 90s to 100s in her right arm with a
diastolic ranging in the 40s.
GENERAL APPEARANCE: Alert, pleasant, tachypneic with a
respiratory rate of 30, mentating well, no accessory muscle
use.
HEAD, EARS, EYES, NOSE AND THROAT: He has anicteric sclera,
moist mucous membranes. Her oropharynx is clear.
THORAX: She had bibasilar rales with bibasilar egophony.
CARDIAC: She had a radial pulse on the left side, but was
diminished on the right, S1, S2 tachypneic with no gallops
appreciated.
ABDOMEN: Soft, nontender, nondistended with positive bowel
sounds.
EXTREMITIES: She had multiple flexion contractures with
subluxations. No edema, warm extremities.
NEUROLOGIC: Alert, pupils equal, speech fluent.
ADMISSION LABS: Her sodium was 3.4. Her initial potassium
was 6.0. The blood sample was hemolyzed, re-tested and found
to be 3.6. Her chloride was 100, bicarbonate 21, BUN 26,
creatinine 0.8, glucose 105. White blood cell count was
17.7, hemoglobin 11.6, hematocrit 35.8, platelets 276. The
differential was 88 neutrophils, 6 bands, 5 lymphocytes, 1
monocyte. Her urinalysis specific gravity is 1.025 with
small leukocyte esterase, large blood, on nitrites, 30
protein, no glucose, negative for ketones, greater than 50
red blood cells, 21 to 50 white blood cells with moderate
bacteria with 3 to 5 bacteria seen per field. Her chest
x-ray showed bilateral lobar opacities with air bronchograms
on the right. Her electrocardiogram was sinus tachycardia,
no ischemic ST-T changes.
IMPRESSION: An 86-year-old with fever, cough, chest x-ray
with lower lobe infiltrates started on azithromycin and
ceftriaxone at nursing home over the last one to two days for
pneumonia. Exam and chest x-ray consistent with a pneumonia,
possible aspiration pneumonia, given lower lobe infiltrates
versus community nursing home acquired pneumonia. Patient
with tachycardia and tenuous blood pressures. She is
mentation, has no anion gap. Urine output is poor. She does
not want mechanical ventilation or CPR due to form. She
would accept pressors to support her. She likely sepsis
secondary to underlying pneumonia as the cause of her low
blood pressures and poor urine output. At the time, the
patient was given intravenous antibiotics for pneumonia,
Levaquin and clindamycin, sputum cultures drawn, ............
drawn, nebulizer given. O2 saturations were followed. As
far as her blood pressure, blood sugar mean arterial pressure
is in the high 50s, low 60s. The patient received multiple
liters of fluid with poor urine output suggestive of renal
hypoperfusion. She was aggressively treated with intravenous
fluids and was carefully monitored for a possibility of need
for pressors and patient developed systolic blood pressures
in the 70s, mean arterial pressure of 49 and was given
Neo-Synephrine.
The patient's PT/PTT were closely followed and the patient
was started on appropriate prophylactic treatment of
subcutaneous heparin and Protonix. Overnight, the patient's
blood pressure improved with intravenous fluids and was off
Neo-Synephrine. Her urine output as improving. The patient
remained tachycardic with low voltage on electrocardiogram
and an echocardiogram was performed to rule out effusion.
That echocardiogram was negative for effusion. The patient
was maintaining adequate oxygenation and was then transferred
to the floor.
At this time, the patient maintained an adequate blood
pressure of 121/60, but was still tachycardic with a pulse of
120 and was, at times, also tachypneic. Electrocardiogram at
this time showed sinus tachycardia as well as T-waves. Her
chest x-ray revealed congestive heart failure with small
pleural effusions and interstitial pulmonary edema. She was
continued on levofloxacin. Flagyl was started, although
discontinued a day later because the patient is edentulous.
It was found Flagyl was not providing any needed coverage.
At 6:25 in the morning, the night resident was called, as the
patient was tachycardic with a heart rate of 124 and a
respiratory rate of 40. At the time, the patient denied
shortness of breath, chest pain or any type of distress. On
exam, she is found to have no jugular venous distention with
bilateral rales. Chest x-ray was ordered with no significant
changes from previous x-ray and was consistent with bibasilar
consolidations with effusion. Lasix 20 mg intravenous was
given later that morning.
The patient continued to remain tachycardic with a pulse of
112 on [**6-29**] and was called that evening. The patient
remained tachypneic and tachycardic throughout the day,
though her tachypnea was markedly improved as her respiratory
rate was down to 24. Early in the morning on [**6-30**], the
overnight resident was called again to see the patient for
tachypnea. Again, the patient denied any shortness of
breath, chest pain or abdominal pain. Her respiratory rate
was 36 at the time and she is resting comfortably. Another
repeat chest x-ray was done to evaluate for failure; 20 mg of
Lasix was given intravenous. The patient's findings was
............. the day with Lasix with a high urine output and
the patient's condition continued to improve throughout [**6-30**].
On [**7-1**], early in the evening, the resident was called
to see the patient again for low urine output. She put out
60 cc of urine over the nighttime shift and was started on
gentle hydration to attempt to improve output so that
intravenous fluid was discontinued thereafter and the patient
was given another 20 mg of Lasix with improved urine. The
patient also spiked a temperature to 101.6?????? that evening and
her urinalysis, UC and blood culture were drawn. The urine
culture and blood culture with no growth to date at this time
and the urinalysis was negative for nitrites, glucose,
ketones, leukocyte esterase and no microbes seen.
Secondary sources of infection were considered with the
resolving pneumonia. The patient was inspected for any
decubiti ulcers and liver function tests were drawn on the
morning of [**7-2**] to see if the gallbladder was present as a
source of infection. The patient's condition continued to
improve and we decreased her O2 supplementation and is
preparing to be discharged this morning on [**7-2**] in fair
condition.
DISCHARGE DIAGNOSIS: Pneumonia
[**Doctor First Name 4623**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4624**], MD [**MD Number(2) 4625**]
Dictated By:[**Last Name (NamePattern1) 4626**]
MEDQUIST36
D: [**2145-7-2**] 10:42
T: [**2145-7-2**] 10:50
JOB#: [**Job Number 4627**]
|
[
"427.89",
"038.11",
"707.0",
"428.0",
"599.0",
"276.3",
"507.0",
"714.0",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1704, 1722
|
8253, 8562
|
1768, 2683
|
1742, 1753
|
137, 1117
|
2700, 8231
|
1139, 1605
|
1622, 1687
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,288
| 152,937
|
47928
|
Discharge summary
|
report
|
Admission Date: [**2113-8-11**] Discharge Date: [**2113-9-4**]
Date of Birth: [**2037-1-14**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Bactrim Ds
Attending:[**First Name3 (LF) 678**]
Chief Complaint:
Nausea, Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 101121**] is a 76 year old male with h/o pancreatic
cancer (dx [**2113-1-2**]) s/p Whipple procedure in [**12-28**] found to be
metastatic on CT in [**6-27**], COPD, and HTN who presented to the ED
early yesterday a.m. N/V and abdominal pain. He had been
admitted on [**8-1**] to the medicine service for decreased PO intake,
felt to be multifactorial. He was then readmitted from
[**Date range (1) 6106**] to the surgery service for partial SBO that appeared
to resolve. Of note, his anion gap during that admission was
elevated to 19, and 15 on discharge. He was tolerating small
amounts of PO on discharge. He says that he still had abdominal
pain on discharge, but over the last day he also developed
nausea and vomitted 3 times, prompting his return to the ED.
His vomitus is non-bloody, non-bilious, with food particles.
His last bowel movement was 2 days ago while inpatient. He
denies any melena or hematochezia. No fevers, chills, SOB,
cough, urinary frequency or dysuria.
.
He has had decreased appetite with occasional N/V for the last
month or so, and per report, has had a 40 pound weight loss
since [**12-28**]. He has intermittent band-like abdominal pain and
takes dilaudid/percocet PRN.
.
In the ED the patient appeared comfortable, with a mildly tender
abdomen. VS were 96.3, 94, 122/74, RR 16, 97% RA. A KUB showed
dilated small bowel loops improved since last KUB. Surgery did
not feel the patient had a surgical abdomen. His labs were
notable for an HCO3 of 18, with a gap of 20, a glucose of 286,
and a WBC count of 23 which is actually lower than usual. A UA
showed ketonuria and glucosuria. He was given 5 U SQ regular
insulin and admitted to the medicine floor. On the floor he
received 2x 10U of insulin. His AG increased to 21, with a
glucose of 300, and he was transferred to the [**Hospital Unit Name 153**].
Past Medical History:
1. Intraductal papillary mucinous tumor and cholangitis -pT3N1
pancreatic adeno-squamous carcinoma (stage IIb)
2. S/P Whipple (cholecystectomy, pancreatotomy, splenectomy,
hepatojejunostomy and duodenojejunostomy) in [**12-28**].
3. Colon Ca - stage III s/p L hemicolectomy in 98, s/p chemo
with 5FU, leucovorin.
4. COPD
5. HTN
6. Asthma
7. Gout
8. s/p Appendectomy
9. thrombocytosis of unclear etiology since [**2106**]
10. leukocytosis of unclear etiology since [**2103**]
11. depression
12. Diabetes (recent episodes of hypoglycemia per OMR)
Social History:
Originally from [**Country 532**]. He lives at home with his wife.
Ambulates with a cane.
Family History:
Non-contributory
.
Physical Exam:
Vitals: 126/57, HR 75, RR 18, 100% RA
GEN: Cachectic male appearing comfortable but tired, resting in
bed with knees tucked toward chest.
HEENT: Anicteric sclerae, dry mucous membranes.
Chest: Rales at R base, otherwise diffusely decreased air
movement.
Cor: RR, normal rate, no m/r/g.
Abdomen: Hyperactive bowel sounds. Soft, scaphoid. Tender to
palpation diffusely but most pronounced in RLQ. No guarding or
rebound. Horizontal scar extending across epigastrium.
Ext: Atrophic. No c/c/e.
Neuro: A&O x 3.
Pertinent Results:
[**2113-8-10**] 12:45PM CK-MB-NotDone
[**2113-8-10**] 12:45PM CK(CPK)-75
[**2113-8-10**] 03:45PM cTropnT-0.02*
[**2113-8-11**] 09:35AM PT-13.1 PTT-24.4 INR(PT)-1.1
[**2113-8-11**] 09:35AM PLT COUNT-827*
[**2113-8-11**] 09:35AM NEUTS-92.5* BANDS-0 LYMPHS-4.3* MONOS-2.7
EOS-0.6 BASOS-0
[**2113-8-11**] 09:35AM WBC-24.6* RBC-5.13 HGB-12.5* HCT-39.7*
MCV-77* MCH-24.4* MCHC-31.6 RDW-15.7*
[**2113-8-11**] 09:35AM LIPASE-8
[**2113-8-11**] 09:35AM ALT(SGPT)-16 AST(SGOT)-23 ALK PHOS-134*
AMYLASE-103* TOT BILI-0.5
[**2113-8-11**] 09:35AM GLUCOSE-286* UREA N-20 CREAT-1.0 SODIUM-128*
POTASSIUM-5.1 CHLORIDE-90* TOTAL CO2-18* ANION GAP-25*
AXR [**8-10**]: Decreased dilatation of bowel when compared to
[**2113-8-7**] with interval passage of air to the rectum and colon.
.
AXR ([**8-6**]): IMPRESSION:
1. Postsurgical changes with note of pneumobilia.
2. Dilated loops of small bowel with air-fluid levels, which is
concerning for small bowel obstruction, possibly. This would be
better characterized with CT scan.
.
EKG [**8-7**]: NSR at 75 bpm, Q waves in the inferolateral leads
suggestive of old inferolateral MI, unchanged. ? T wave
flattening in lateral leads, likely related to globally
decreased amplitude when compared to prior. Otherwise, no
diagnostic change.
.
CT chest/abd/pelvis - [**2113-8-18**]
IMPRESSION:
1) Mechanical small bowel obstruction involving the stomach,
afferent loop leading from the hepaticojejunostomy, and the
proximal small bowel with a transition point in the right mid
abdomen, and new pneumobilia, likely related to the small bowel
obstruction.
2) Essentially unchanged bulky lymphadenopathy in the
periportal, periaortic, and mesenteric regions.
3) Decreased conspicuity of multiple hepatic metastatic foci.
Brief Hospital Course:
76 yo M with h/o metastatic pancreatic cancer (dx [**2113-1-2**]) s/p
Whipple procedure, COPD, and HTN who presented with N/V and
abdominal pain after discharge on [**8-10**] s/p treatment of SBO
admitted for management of DKA and continued decreased PO intake
at home. He was admitted and transfered twice to the ICU early
in his course. He changed his code status to DNR/DNI after the
second unit transfer. He was not transfered out of the hospital
due to inability to find placement that the family was ammenable
to.
.
The patient died comfortably in the hospital on [**2113-9-4**].
.
HOSPITAL COURSE:
1) DKA: Anion gap elevated at 21 on transfer, ketones in the
urine. Unclear as to exactly what precipitant had been. In
terms of etiology, cultures sent, CXR obtained, though patient
without localizing signs of infection and WBC actually lower
than usual, afebrile. Family reports that patient had missed at
least one dose of home glargine PTA. The pt was started on an
Insulin drip at 2 U / hour initially (glucose 150 on arrival to
[**Hospital Unit Name 153**]) with D51/2NS 1L over 2 hours. Once the patient's anion gap
had closed the the insulin drip was stopped and sc insulin was
started. Patient has had minimal po intake so home dose of
glargine was decreased to 6U and patient was maintained on
regular insulin sliding scale for glucose control. Electrolytes
were repleted accordingly. Anion gap remained closed and
symptoms improved over course of admission. Patient was
transferred out of the unit when AG had closed. On the floor pt
continued to have hiccups and was started on decadron. 2 days
later morning labs showed AG of 30 he was again given IVF, and
insulin. His AG closed to 18, however was transferred to ICU
for insulin drip. After stay in ICU for 1 day he returned to
the floor with AG of 15. His Lantus was changed to 12 units QAM
and he was continued on HISS. Chemistries were checked twice a
day and AG remained stable. The patient's code status was
changed to DNR/DNI and labs were no longer drawn on the floor
with the exception of fingersticks. Because the pt could
tolerate less and less oral intake due to painful hiccoughs, his
BG remained low and insulin was cut back. Fingersticks were
reduced to 4 times per day over time. They remained low even as
insulin glargine was cut back to 4units qam. The insulin was
stopped and fingersticks were cut back to qday as the patient's
status declined.
.
2) N/V/Abdominal Pain: Likely related to DKA in part, however
patient with extensive intra-abdominal procedures and recent
hospitalization for small bowel obstruction (SBO). For now,
abdomen doesn't appear surgical, and AXR demonstrates some
improvement in bowel distention although still evidence of
dilated loops of small bowel. Patient has been passing flatus
but was not moving bowels during his stay in [**Hospital Unit Name 153**]. Serial
abdominal exams did not reveal any evidence of further
obstruction. Patient was tolerating clear liquids while in the
[**Hospital Unit Name 153**] with no further abdominal pain, nausea or vomiting. Patient
was not requiring antiemetics during [**Hospital Unit Name 153**] admission. He has had
chronic hiccups since his Whipple procedure which respond well
to Prochloroperazine initially. However hiccups were [**Last Name (un) **]
difficult to control on the floor requiring several agents. He
was on thorazine and reglan initially. Decardron was started
which did not improve symptoms much. Baclofen tid was also
added and seemed to help, however pt was very sleepy on a
combination of these medications. Medications doses were
titrated to avoid hiccups and at the same time be awake and
interactive. PO doses of medications were tried, but IV
medication was required as the hiccoughs themselves prevented PO
intake. Thorazine and reglan were used, primarily. Baclofen
was orally available but not well tolerated - the patient only
took this medication periodically. Morphine concentrated elixer
was tolerated and reduced pain. This was changed to IV morphine
as the pt became more ill and began to refuse even the elixer.
The pt was comfortable.
.
3) Hyponatremia: Hypo-osmolar, likely related to mild volume
depletion in setting of DKA with possible component of SAIDH.
Admission CXR showed mild initial CHF so reluctant to give
significant amounts IVF during his stay. Sodium improved from
admission while in the [**Hospital Unit Name 153**]. Was not an issue thereafter. Labs
were eventually d/c'd. The patient received fluids by PICC line
to prevent dehydration. There was no indication of progressive
hyponatremia. Lab draws were stopped at least a week prior to
discharge.
.
4) Pancreatic Cancer: Increase in abdominal LAD on recent CT
scan. Patient has had numerous appointments to discuss chemo
options with Dr. [**First Name (STitle) **] but had not been feeling up to going.
Cancer is well advanced at this point and would probably get the
most benefit from palliative care. [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] from palliative
care was consulted who gave several recommendations around
managing hiccups. Family is pursuing to get pt stable for
transfer to rehab. When patient was readmitted to [**Hospital Unit Name 153**] for DKA,
family discussed pt's prognoris and his code status was changed
from Full to DNR/DNI. Labs were not drawn thereafter. There
were long discussions regarding post-hospital placement.
Because of recurrant partial SBO, the patient's family wanted
care that could include NGT placement in case of discomfort.
They also wanted placement that would ensure that he could get
IV medications. Eventually appropriate arrangements were made.
.
5) COPD: At home patient on albuterol prn. Patient's O2
saturations were maintained in the high 90's on room air during
his stay with no respiratory problems.
.
6) Depression: Possibly contributing to his weight loss and
lack of appetite. Patient was started on Zoloft but had
difficulty taking it regularly because there is no parenteral
formulation of SSRI.
.
7) Decreased appetite: Likely cancer related but admitted with
N/V from DKA/SBO that seem to have exacerbated his lack of
appetite. Patient placed on megace during last hospitalization,
however was not listed on d/c medications. Megace was restarted
during his [**Hospital Unit Name 153**] stay. There had been some talk of a PEG tube
during his previous admission to relieve his SBO but this seems
to have improved somewhat. Patient has very poor po intake but
in discussion with PCP [**Last Name (NamePattern4) **].[**First Name (STitle) 216**] we would not place one for
nutritional purposes alone. Nutrition is following patient and
we encouraged him to increase his po intake as best as he can.
In the end, TPN was not thought to be a good option given the
poor prognosis, however PICC was placed for IVF administration
to maintain hydration. Fluids were maintained until the last
day of his life when he became anuric and pulmonary edema was a
concern.
.
9) End of Life Care: Palliative care was consulted during his
last hospital stay. They discussed hospice care with patient and
his daughter. At that time, the family declined hospice care.
[**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] knows the patient and was reconsulted prior to his
discharge. Family, Dr. [**First Name (STitle) 216**] and [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] had a discussion
regarding disposition and an agreement was made that pt would
benefit from stay at [**Last Name (un) **] house, which is very close to pt's
house. Home hospice care was also offered however family
declined. [**Last Name (un) 1188**] house was discussed and seemed to be a good
option, however in the end, the family was concerned that if he
was d/c'd to a lower level of care, he would need to be
readmitted and the ER was thought to be a large barrier to
lifestyle. In the end, the pt was thought to benefit from
Medical Acute Care Unit level care where NGT could be placed and
there would be no reason for return to the ED (as the pt would
be hospice level care).
.
The patient was kept as an inpatient at [**Hospital1 **] after family refused
a number of placements and no appropriate placement could be
made. He was cared for with the goal of both extending life
while respecting DNR/DNI and providing comfort to the patient as
he died. He remained comfortable throughout the course of his
hospitalization and died on [**2113-9-4**].
.
10) Code: DNR/DNI
Medications on Admission:
Prednisone 5 mg daily
Lipitor 10 mg daily
Zoloft 100 mg p.o. q.a.m.
Protonix 40 mg p.o. daily
Flomax 0.4 mg p.o. nightly
Percocet 5/325 mg 1-2 tablets p.o. q.4-6h. for pain
Dexamethasone 10 mg p.o. q.6-8h. p.r.n. nausea.
Lipram(pancreatic enzymes) CR20
Insulin Lantus 12 Q AM/ humalog scale
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Pancreatic Cancer s/p Whipple - cause of patient's eventual
death in the hospital.
SBO
DKA
Secondary Diagnoses:
Coon Ca
COPD
HTN
Asthma
Bout
Thrombocytosis
Depression
DM2
Discharge Condition:
Dead
Discharge Instructions:
Patient Died in the Hospital [**1-25**] pancreatic cancer.
Followup Instructions:
Pt died in the hospital.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]
Completed by:[**2113-9-7**]
|
[
"560.89",
"496",
"428.0",
"V63.8",
"250.11",
"253.6",
"995.92",
"157.8",
"707.03",
"427.5",
"786.8",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14196, 14211
|
5255, 5845
|
296, 303
|
14427, 14433
|
3462, 5232
|
14540, 14685
|
2898, 2918
|
14232, 14324
|
13880, 14173
|
5862, 13854
|
14457, 14517
|
2933, 3443
|
14345, 14406
|
240, 258
|
331, 2206
|
2228, 2775
|
2791, 2882
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,147
| 143,490
|
37540
|
Discharge summary
|
report
|
Admission Date: [**2133-3-9**] Discharge Date: [**2133-3-16**]
Date of Birth: [**2067-3-19**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 10644**]
Chief Complaint:
hypotension on IL-2
Major Surgical or Invasive Procedure:
s/p central line placement
s/p intubation and mechanical ventilation [**2133-3-15**]
History of Present Illness:
65yo F with metastatic melanoma admitted [**2133-3-9**] for IL-2
therapy complicated by dermatitis, myocarditis, neurotoxicity,
and hypotension from capillary leak transferred to ICU for
persistent hypotension. Patient was on high dose IL-2 which
finished yesterday with complications as stated above. Because
of the hypotension patient was started on dopamine
(6mcg/kg/min), however, last night she went into wide complex
tachycardia (cards fellow thinks SVT) which resolved with
down-titration of dopamine. However, she was still hypotensive
so started on neosynephrine. Unfortunately over the course of
the night, despite max dose of neo on floor she was persistently
hypotensive to 70s and the risk of arrhythmia with starting
dopamine was thought too high so transferred to ICU for levophed
instead.
Since yesterday she has also been noted to be neurotoxic on
IL-2 and has AMS - baseline is A+OX3.
On transfer to the floor patient was transiently hypoxic and on
admission to the ICU she was started on a 100% face mask with
sats in the high 90s. Per her attending she has not had any UOP
since yesterday morning.
.
Review of sytems: Unable as patient is encephalopathic.
Past Medical History:
Metastatic melanoma with multiple widespread metastases, mainly
in the adipose tissue of the neck, chest, abdomen, and pelvis,
bony lesion in the right occipital condyle as well as a 4-mm
enhancing right cingulate gyrus lesion. A possible mass of the
intracranial segment of the left mandibular nerve was also seen.
Anxiety
Acid reflux
Osteopenia
Cataract surgery [**9-3**]
Social History:
She is married, but has no children. She is a retired payroll
worker. She denies tobacco or illicit drug use. She does drink
one shot glass of alcohol daily.
Family History:
Her mother had multiple myeloma and died at the age of 69. Her
father died at the age of 89 from old age. Her paternal
grandmother died from either gastric or pancreatic cancer. Her
sister is alive and healthy.
Physical Exam:
Vitals: T:98 BP:92/37 (with doppler 110/60) P:108 R:18 18 O2: 98
on 100% FM pulsus 4
General: Alert, oriented to person only, agitated
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, 6cm diameter purple
raised papule on left shoulder, non tender
Lungs: wheezes bilaterally, with no rales, rhonchi but unable to
have thorough exam [**1-27**] patient moving
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, slight tender to palpation in epigastrium,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ edema bilaterally
.
Pertinent Results:
[**2133-3-9**] 09:38AM GLUCOSE-91 UREA N-15 CREAT-0.4 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13
[**2133-3-9**] 09:38AM estGFR-Using this
[**2133-3-9**] 09:38AM ALT(SGPT)-40 AST(SGOT)-34 LD(LDH)-376*
CK(CPK)-24* TOT BILI-0.2
[**2133-3-9**] 09:38AM ALBUMIN-3.3* CALCIUM-8.7 PHOSPHATE-3.8
MAGNESIUM-2.0
[**2133-3-9**] 09:38AM WBC-7.3 RBC-2.28* HGB-6.6*# HCT-21.6* MCV-95
MCH-29.0 MCHC-30.6* RDW-15.4
[**2133-3-9**] 09:38AM NEUTS-80.4* LYMPHS-14.9* MONOS-4.3 EOS-0.2
BASOS-0.2
[**2133-3-9**] 09:38AM PLT COUNT-677*#
[**2133-3-9**] 09:38AM PT-12.9 PTT-22.4 INR(PT)-1.1
.
EKG:
[**2133-3-9**]: sinus tachycardia with normal axis and intervals
without ST/TW changes
[**2133-3-15**] 5:11am: Wide complex tachycardia at ~130bpm with P wave
after QRS, right axis deviation and RBB pattern, p wave after
QRS consistent with vtach vs SVT with aberrancy (likely AVNRT
given short RP interval)
[**2133-3-15**] 10:17am: NSR with low voltage, 2mm ST depressions V3-V6,
1mm STE V1 and V2.
Brief Hospital Course:
65yo F with h/o metastatic melanoma recently finished IL2
therapy with neurotoxicity, dermatitis, capillary leak,
hypotension, and myocarditis transferred to the [**Hospital Unit Name 153**] for
hypotension and found to have hypoxia as well.
The hypotension/shock was felt to be from IL-2 therapy. Patient
had not been febrile to suggest sepsis and hypoxia was thought
to be due to capillary leak. Other etiology might include heart
failure given hypoxia and myocarditis with arrhythmia and echo
on day of admission was consistent with this, showing global
hypokinesis of the LV. The patient was also noted to be
increasingly hypoxic, likely [**1-27**] capillary leak and CHF,
requiring intubation soon after admission. For her hypotension,
she was started on empiric antibiotic treatment with
vanc/cefepime/flagyl and stress dose steroids. She required
increasing amounts of pressor support, and eventually was on
maximum doses of three pressors with persistent hypotension
noted on the evening of admission. Her husband and HCP, [**Name (NI) 6107**],
and her sister were called and informed of the patient's
decompensation. It was decided, given the patient's grim
prognosis and chance of surviving to make the patient CMO.
The patient was subsequently extubated and pressors were
withdrawn. She expired comfortably shortly thereafter with her
sister and brother-in-law at her bedside.
Medications on Admission:
HOME MEDS:
Oxycodone 5-10mg PRN
Zantac 150mg [**Hospital1 **]
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Metastatic melanoma - s/p C1W1 HD IL-2 therapy
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2133-3-18**]
|
[
"458.29",
"198.3",
"693.0",
"E934.8",
"518.81",
"V58.12",
"998.0",
"198.5",
"422.93",
"349.82",
"427.89",
"196.2",
"197.0",
"V10.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.15",
"38.91",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
5671, 5680
|
4136, 5531
|
292, 378
|
5771, 5780
|
3102, 4113
|
5836, 5874
|
2176, 2392
|
5643, 5648
|
5701, 5750
|
5557, 5620
|
5804, 5813
|
2407, 3083
|
233, 254
|
1545, 1585
|
406, 1527
|
1607, 1983
|
1999, 2160
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,341
| 108,504
|
2450+2451
|
Discharge summary
|
report+report
|
Admission Date: [**2144-3-10**] Discharge Date: [**2144-3-27**]
Date of Birth: [**2082-1-26**] Sex: F
Service: #58
CHIEF COMPLAINT: Abdominal pain, nausea, vomiting, diarrhea.
HISTORY OF PRESENT ILLNESS: This patient was transferred
from the medical service to the surgical service on [**2144-3-19**],
postoperatively. She is a 62 year old female with a history
of sarcoidosis with pulmonary involvement and hepatic
involvement who was initially admitted to the medical service
on [**2144-3-10**], with a five day history of nausea, vomiting and
diarrhea and a one day history of epigastric pain.
Right upper quadrant ultrasound showed at the time showed a
thickened gallbladder with a common bile duct of 1.2
centimeters and elevated liver enzymes. Of note, her liver
enzymes have been elevated in the past. She underwent an
endoscopic retrograde cholangiopancreatography which showed
portal hypertensive gastropathy and compression of the portal
vein by the common bile duct without any stones.
She was treated with antibiotics and then underwent a MRCP.
She continued to have crampy abdominal pain and a CT scan of
the abdomen was performed on [**2144-3-12**], which showed ascites
and a large ventral hernia.
She was seen by the hepatology service at this point
regarding operative risks for possible hernia repair. The
hepatology consult suggested 30% risk mortality and also
suggested conservative treatment with Actigall, Aldactone and
paracentesis.
She continued to have emesis and a nasogastric tube was
placed by Dr. [**Last Name (STitle) 519**] on [**2144-3-13**]. She continued to have high
nasogastric output and pain and nausea and then underwent an
upper gastrointestinal and small bowel follow through on
[**2144-3-18**], which revealed high grade ileal obstruction. At
this point, the decision was made to operate on her and she
was subsequently transferred to the surgical service
postoperatively.
PAST MEDICAL HISTORY:
1. Sarcoidosis with pulmonary and hepatic involvement
diagnosed in [**2137**], and treated with steroids.
2. Cirrhosis diagnosed [**10-30**], by CT with grade II esophageal
varices.
3. Osteoporosis.
4. Cholelithiasis diagnosed [**10-30**], on CT.
5. Hypertension.
6. Hypercholesterolemia.
7. Aortic stenosis with left ventricular dysfunction.
8. Status post umbilical hernia repair.
9. Hip fracture, status post open reduction, internal
fixation on [**2142**].
10. Right total knee replacement [**2141**].
11. Right total hip replacement in [**2133**].
12. Status post total abdominal hysterectomy with bilateral
salpingo-oophorectomy.
13. Bilateral cataracts.
MEDICATIONS ON TRANSFER TO SERVICE:
1. Actigall 300 mg p.o. t.i.d.
2. Aldactone 50 mg p.o. q.d.
3. Hydrocortisone 25 mg b.i.d.
4. Protonix 40 mg p.o. q.d.
5. Toradol.
6. Zofran.
MEDICATIONS AS OUTPATIENT.
1. Evista.
2. Prednisone 10 mg p.o. q.d.
HOSPITAL COURSE: The patient underwent an exploratory
laparotomy with ventral herniorrhaphy with competent
separation and lysis of adhesions on [**2144-3-19**].
Postoperatively, she was transferred to the Intensive Care
Unit intubated because of her prior history. She was stable
overnight and was extubated in the early a.m. of [**2144-3-20**].
She continued to be stable and was deemed ready for discharge
to the regular floor on [**2144-3-21**].
Subsequently, her postoperative course has been
uncomplicated. She was started on sips on [**2144-3-23**], after
passing flatus and having a bowel movement. She tolerated
the sips well. She was on peripheral nutrition during this
time. She was slowly advanced over the next couple of days
to a regular diet which she tolerated well.
She did have some ascites which had slightly increased in
size postoperatively. She has two [**Location (un) 1661**]-[**Location (un) 1662**] drains in
the abdomen which have been draining probable ascitic fluid.
She continues to be followed by the liver service while on
the floor postoperatively.
She was deemed ready for discharge by both services on
[**2144-3-27**]. She was discharged home with the [**Location (un) 1661**]-[**Location (un) 1662**] in
situ with a plan to discontinue them during the postoperative
visit. She had a visiting nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 1661**]-[**Location (un) 1662**] care.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. q.d.
2. Lopressor 12.5 mg p.o. b.i.d.
3. Aldactone 50 mg p.o. b.i.d.
4. Prednisone 10 mg p.o. b.i.d. times two days and then 10
mg p.o. q.d.
5. Protonix 40 mg p.o. q.d.
6. Actigall 300 mg p.o. t.i.d.
TREATMENT: She is to have q.d. dressing changes to
[**Location (un) 1661**]-[**Location (un) 1662**] sites by VNA. Record [**Location (un) 1661**]-[**Location (un) 1662**] output.
FOLLOW-UP:
1. Dr. [**Last Name (STitle) 519**] on [**2144-4-10**], at 9:45 a.m.
2. Follow-up with the liver service, appointment set up.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2144-3-28**] 09:18
T: [**2144-3-29**] 10:46
JOB#: [**Job Number 12568**]
Admission Date: [**2144-3-10**] Discharge Date: [**2144-3-27**]
Date of Birth: [**2082-1-26**] Sex: F
Service: #58
CHIEF COMPLAINT: Abdominal pain, nausea, vomiting, diarrhea.
HISTORY OF PRESENT ILLNESS: This patient was transferred
from the medical service to the surgical service on [**2144-3-19**],
postoperatively. She is a 62 year old female with a history
of sarcoidosis with pulmonary involvement and hepatic
involvement who was initially admitted to the medical service
on [**2144-3-10**], with a five day history of nausea, vomiting and
diarrhea and a one day history of epigastric pain.
Right upper quadrant ultrasound showed at the time showed a
thickened gallbladder with a common bile duct of 1.2
centimeters and elevated liver enzymes. Of note, her liver
enzymes have been elevated in the past. She underwent an
endoscopic retrograde cholangiopancreatography which showed
portal hypertensive gastropathy and compression of the portal
vein by the common bile duct without any stones.
She was treated with antibiotics and then underwent a MRCP.
She continued to have crampy abdominal pain and a CT scan of
the abdomen was performed on [**2144-3-12**], which showed ascites
and a large ventral hernia.
She was seen by the hepatology service at this point
regarding operative risks for possible hernia repair. The
hepatology consult suggested 30% risk mortality and also
suggested conservative treatment with Actigall, Aldactone and
paracentesis.
She continued to have emesis and a nasogastric tube was
placed by Dr. [**Last Name (STitle) 519**] on [**2144-3-13**]. She continued to have high
nasogastric output and pain and nausea and then underwent an
upper gastrointestinal and small bowel follow through on
[**2144-3-18**], which revealed high grade ileal obstruction. At
this point, the decision was made to operate on her and she
was subsequently transferred to the surgical service
postoperatively.
PAST MEDICAL HISTORY:
1. Sarcoidosis with pulmonary and hepatic involvement
diagnosed in [**2137**], and treated with steroids.
2. Cirrhosis diagnosed [**10-30**], by CT with grade II esophageal
varices.
3. Osteoporosis.
4. Cholelithiasis diagnosed [**10-30**], on CT.
5. Hypertension.
6. Hypercholesterolemia.
7. Aortic stenosis with left ventricular dysfunction.
8. Status post umbilical hernia repair.
9. Hip fracture, status post open reduction, internal
fixation on [**2142**].
10. Right total knee replacement [**2141**].
11. Right total hip replacement in [**2133**].
12. Status post total abdominal hysterectomy with bilateral
salpingo-oophorectomy.
13. Bilateral cataracts.
MEDICATIONS ON TRANSFER TO SERVICE:
1. Actigall 300 mg p.o. t.i.d.
2. Aldactone 50 mg p.o. q.d.
3. Hydrocortisone 25 mg b.i.d.
4. Protonix 40 mg p.o. q.d.
5. Toradol.
6. Zofran.
MEDICATIONS AS OUTPATIENT.
1. Evista.
2. Prednisone 10 mg p.o. q.d.
HOSPITAL COURSE: The patient underwent an exploratory
laparotomy with ventral herniorrhaphy with competent
separation and lysis of adhesions on [**2144-3-19**].
Postoperatively, she was transferred to the Intensive Care
Unit intubated because of her prior history. She was stable
overnight and was extubated in the early a.m. of [**2144-3-20**].
She continued to be stable and was deemed ready for discharge
to the regular floor on [**2144-3-21**].
Subsequently, her postoperative course has been
uncomplicated. She was started on sips on [**2144-3-23**], after
passing flatus and having a bowel movement. She tolerated
the sips well. She was on peripheral nutrition during this
time. She was slowly advanced over the next couple of days
to a regular diet which she tolerated well.
She did have some ascites which had slightly increased in
size postoperatively. She has two [**Location (un) 1661**]-[**Location (un) 1662**] drains in
the abdomen which have been draining probable ascitic fluid.
She continues to be followed by the liver service while on
the floor postoperatively.
She was deemed ready for discharge by both services on
[**2144-3-27**]. She was discharged home with the [**Location (un) 1661**]-[**Location (un) 1662**] in
situ with a plan to discontinue them during the postoperative
visit. She had a visiting nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 1661**]-[**Location (un) 1662**] care.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. q.d.
2. Lopressor 12.5 mg p.o. b.i.d.
3. Aldactone 50 mg p.o. b.i.d.
4. Prednisone 10 mg p.o. b.i.d. times two days and then 10
mg p.o. q.d.
5. Protonix 40 mg p.o. q.d.
6. Actigall 300 mg p.o. t.i.d.
TREATMENT: She is to have q.d. dressing changes to
[**Location (un) 1661**]-[**Location (un) 1662**] sites by VNA. Record [**Location (un) 1661**]-[**Location (un) 1662**] output.
FOLLOW-UP:
1. Dr. [**Last Name (STitle) 519**] on [**2144-4-10**], at 9:45 a.m.
2. Follow-up with the liver service, appointment set up.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2144-3-28**] 09:18
T: [**2144-3-29**] 10:46
JOB#: [**Job Number 12569**]
|
[
"998.2",
"E870.0",
"571.5",
"424.1",
"572.3",
"135",
"552.20",
"517.8",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.59",
"54.11",
"54.59",
"46.73",
"51.10"
] |
icd9pcs
|
[
[
[]
]
] |
9553, 10379
|
8104, 9527
|
5340, 5385
|
5414, 7137
|
7159, 8086
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,021
| 132,769
|
49357
|
Discharge summary
|
report
|
Admission Date: [**2116-8-11**] Discharge Date: [**2116-8-16**]
Date of Birth: [**2047-11-28**] Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
malignant melanoma of the oral cavity
Major Surgical or Invasive Procedure:
[**2116-8-11**]: Right transoral/transfacial partial maxillectomy with
Right modified radical neck dissection, placement of palatal
prosthesis and Right thigh STSG to Right buccal mucosal wall for
reconstruction.
History of Present Illness:
Mrs. [**Known lastname 3708**] is a lovely 68 year-old female who initially presented
to her dentist when she had noticed a fractured right lower
wisdom tooth, and this was associated with gum changes. Her
dentist intially prescribed antibiotics, and then she was seen
by an oral surgeon who pulled the wisdom tooth and biopsied the
oral cavity lesion. Pathology from this procedure, which was
performed on [**2116-6-10**], showed tumor cells that were reactive
for HMB-45, MART-1 and S1-100, consistent with malignant
melanoma. She underwent a CT scan of the head with contrast,
which showed no evidence of metastatic disease and a CT
Abdomen/Pelvis with contrast, which revealed no evidence of
metastatic disease.
On [**2116-7-1**] she was seen in Multidisciplinary Cutaneous
[**Hospital **] Clinic for evaluation of her malignant melanoma of the
oral cavity, by Dr. [**First Name (STitle) **].
She has had a CT scan of the sinus and neck with contrast on
[**2116-7-9**] which showed a soft tissue mass centered in the right
maxillary alveolar ridge with extension via the gingivobuccal
sulcus into the buccal mucosa and also soft tissue extension
into the retromolar trigone on the right. There was a
large defect in the anteroinferior wall of the right maxillary
sinus. Additionally, there were enlarged right level 1 and level
2 lymph nodes, many with internal necrosis. The largest node
measured approximately 15 x 21 mm. Erosion was noted in the
region of the right retromolar trigone and the ramus in the
mandible.
The patient was seen in clinic and noted she felt well and had
no specific
complaints. She denied chest pain, dyspnea, cough, abdominal
pain, nausea, vomiting, diarrhea, constipation, and fever.
On [**2116-8-11**] she admitted for Right transoral partial
maxillectomy, with Right modified radical neck dissection,
placement of palatal prosthesis and Right thigh STSG to Right
buccal mucosa wall for reconstruction.
Past Medical History:
Mucosal melanoma of the oral cavity, status post myocardial
infarction in [**2084**] and had no further cardiac trouble since,
hypertension, hypercholesterolemia, status post Left breast mass
excision, status post exploratory laparotomy (unclear reason)
Social History:
She lives with her husband with whom she has been married for 48
years. They have no children. She worked for an electric
company and retired approximately five years ago. She is a
nonsmoker, but for a few years of smoking in her teens.
She does not drink alcohol.
Family History:
Father died at age [**Age over 90 **]. Her mother died at age 82. Mother had
hepatocellular carcinoma and her father died of "natural
causes." There is no family history of mucosal or cutaneous
melanoma. She is one of five children. One of her
brothers died in his 40s. He did not have cancer. She has two
brothers age 56 and 65, four living and reasonably well. She
has a 73-year-old sister who is reasonably well.
Physical Exam:
PHYSICAL EXAM (UPON DISCHARGE):
VITALS: T 98.9 98.6 BP 146/78 HR 67 RR 20 O2SAT 98RA
HEENT: Normocephalic, atraumatic. Extraocular muscles intact
with symmetrically reactive pupils. Nares clear. Right
transfacial incision is clean, dry and well-approximated with no
evidence of drainage or infection. Her right cervical neck
incision is clean, dry and well-approximated with no evidence of
neck flap hematoma and no erythema or drainage. Cranial nerves
VII on the right with marginal mandibular branch weakness and
buccal branch weakness, noted post-op. No difficulty with eye
closure. CN [**Doctor First Name 81**] and XII bilaterally intact.
CVS: Regular rate and rhythm, no murmur, rub or gallop.
RESP: Clear to auscultation bilaterally. No adventitious
wheezing, rhonchi or rales.
GI: soft, non-tender, non-distended with normoactive bowel
sounds.
EXTR: 2+ peripheral pulses with no cyanosis, clubbing or edema.
Right thigh STSG donor site clean and dry with minimal
serosanguinous drainage and xeroform with tegaderm placed as
dressing.
Pertinent Results:
[**2116-8-12**] 03:44AM BLOOD WBC-12.9* RBC-3.68* Hgb-11.6* Hct-33.7*
MCV-92 MCH-31.5 MCHC-34.4 RDW-13.3 Plt Ct-175
[**2116-8-12**] 03:44AM BLOOD Glucose-147* UreaN-12 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-25 AnGap-14
[**2116-8-12**] 03:44AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.2
[**2116-8-14**]: CXR
There is significant elevation of the right hemidiaphragm,
chronicity
undetermined and might reflect paralysis of the right
hemidiaphragm, please correlate with surgery and the potential
for damage to phrenic nerve. The mediastinum is unremarkable.
The heart size is normal. Upper lungs are clear. There is no
appreciable pneumothorax demonstrated.
[**2116-8-15**]: CXRThere is no change in the opacification of the
right lower lung that as previously described most likely
consistent with elevation of right hemidiaphragm and less likely
atelectasis (potentially partial). The rest of the lungs are
clear. Cardiomediastinal silhouette is unremarkable and there is
no evidence of appreciable pleural effusion or pneumothorax.
Brief Hospital Course:
NEURO/PAIN/INCISION: Given the need to sacrifice the maxillary
division of cranial nerve V, the patient's post-operative pain
was minimal. She was offered oxycodone elixir and morphine IV
for breakthrough pain, and she required minimal. She did note
some post-op pain at her incision. On exam post-op she had
weakness in the marginal mandibular and buccal branches of her
right facial nerve. Her incision at the right neck was stable
post-op with no evidence of erythema, infection or hematoma
collection. Bacitracin was applied to incision sites twice
daily. The facial incision was clean, dry and well-approximated
with bacitracin applied to the incision twice daily.
Erythromycin ophthalamic was applied to the right eye for
antibiotic prophylaxis, given that operative incision was near
the right globe.
CARDIOVASCULAR: The patient remained hemodynamically stable in
the post-op period. She was maintained on her home
beta-blocker/Atenolol dose given her cardiac history and the
preference for peri-operative beta blocker therapy. She was also
restarted on her home Lipitor dose and her HCTZ 25 mg PO daily.
She spent HOD#1 in the [**Hospital Ward Name 332**] ICU for close airway monitoring
and was transfered to the floor on telemetry. She had no ryhthm
disturbances of note on the floor.
RESPIRATORY: The patient was extubated in immediately post-op
and a left nasal trumpet was placed to maintain her airway. She
was admitted to the [**Hospital Ward Name 332**] ICU for close airway observation and
transferred to the floor on POD#1. She was given supplemental
oxygen and humidified face mask for support with continuous O2
monitoring. She had some episodic and intermittent desaturations
to the 88-90% range but had no respiratory complaints. We
started Atrovent nebs INH, incentive spirometry, encouraged
ambulation and completed a CXR on POD#3 which showed some
evidence of Right hemidiaphgram elevation. We initiated chest
physiotherapy and repeated the CXR on POD#4 showing unchanged
right hemidiaphragm elevation. Her oxygen saturations improved
with the above treatments and her saturations were > 95% on room
air POD#4 and 5.
FEN/GI: The patient was kept NPO except medications and on POD#1
initiated a clear liquid diet without issue. IVF hydration was
provided until she tolerated adequate PO intake and then she was
hep-locked. By POD#2 she was tolerating soft mechanical diet
without issue.
ENDORCINE: The patient received Decadron for prophylaxis against
airway swelling in the OR, but required no post-op steroids. She
remained euglycemic.
HEME/ID: The patient's post-op hematocrit was 33.7 and remained
stable post-op. She remained hemodynamically stable. She had a
WBC of 12.9 post-op, attributed to glucocorticoid leukocytosis.
She remained afebrile post-op.
GENITOURINARY: A Foley catheter was placed intra-operatively
without issue. She had adequate urine output and the Foley was
removed POD#2 without issue. Her creatinine remained stable with
a baseline value of 0.7.
TLD: The patient had two [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains placed in the
right neck intra-operatively. These drains had minimal
serosanguinous output. JP drain #2 was removed on POD#5.
PROPHYLAXIS: The patient was maintained on Heparin 5000 units SQ
TID for DVT prophylaxis and pneumatic compression boots were in
place until she was ambulating independently.
Medications on Admission:
ASA 81 mg PO daily, HCTZ 25 mg PO daily, Lipitor 40 mg PO daily,
Atenolol 25 mg PO QPM, 50 mg PO QAM
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO QPM (once a day
(in the evening)).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
4. Erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) gtt
Ophthalmic QID (4 times a day) for 14 days: Apply to right eye
for 2 weeks.
Disp:*56 gtt* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain: Do NOT take narcotics
with alcohol or if you anticipate driving.
Disp:*300 ML(s)* Refills:*0*
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 10 days: Complete 10 day course of antibiotics.
Disp:*40 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
malignant melanoma of the oral cavity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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. OK to shower but do not soak incision until follow up
appointment, at least. No strenuous exercise or heavy lifting
until follow up appointment, at least. Do not drive or drink
alcohol while taking narcotic pain medications. Narcotic pain
medications may cause constipation, if this occurs take an over
the counter stool softener. Resume all of your home medications.
You should apply bacitracin twice daily to your facial and your
right neck incisions. Keep these areas clea and dry. Do not soak
the wound areas and no tub bathing for 4-6 weeks.
You should take the antibiotics provided, as prescribed, for
prophylaxis against infection. Continue use of the erythromicin
ophthalamic eye drops as prescribed given your recent surgery.
Followup Instructions:
** You should return to [**Hospital1 69**] on
Wednesday, [**2116-8-19**] before 7:00 AM for a schedule
surgical procedure with Drs. [**Name5 (PTitle) 1837**]/[**Doctor First Name **] ** Please call
Dr.[**Name (NI) 20390**] office on [**Last Name (LF) 766**], [**2116-8-17**] to obtain
the details of the operation time **
Please call Dr. [**First Name (STitle) 1661**] at [**Telephone/Fax (1) 103384**] at Mass Eye & Ear
Infirmary regarding your prosthesis and a follow-up appointment.
Please call him [**Last Name (LF) 766**], [**2116-8-17**].
Please call Dr.[**Name (NI) 20390**] office in Otolaryngology at
[**Telephone/Fax (1) 41**] to schedule a follow-up appointment 7-10 days after
your discharge date.
Please see your primary care physician [**Last Name (NamePattern4) **] [**1-4**] weeks post-op.
|
[
"197.3",
"198.89",
"143.0",
"412",
"401.9",
"196.0",
"272.0",
"170.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"76.39",
"27.56",
"76.92",
"40.41"
] |
icd9pcs
|
[
[
[]
]
] |
10203, 10209
|
5687, 9101
|
360, 574
|
10291, 10291
|
4638, 5664
|
11390, 12202
|
3126, 3551
|
9252, 10180
|
10230, 10270
|
9127, 9229
|
10442, 11367
|
3566, 4619
|
283, 322
|
602, 2548
|
10306, 10418
|
2570, 2826
|
2842, 3110
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,072
| 152,181
|
17850+56898
|
Discharge summary
|
report+addendum
|
Admission Date: [**2104-2-27**] Discharge Date: [**2104-3-15**]
Date of Birth: [**2046-3-16**] Sex: M
Service: GENERAL SURGERY/GREEN
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old man
with amyotrophic lateral sclerosis which has rendered him
ventilator dependent and requiring chronic care. He has a
gastric tube which is used for tube feedings. He can only
communicate through a series of eye blinks. He was admitted
to the Medical service on [**2104-2-27**], with a lower
gastrointestinal bleed. He had required a transfusion of six
units of blood over the four months beginning in the year
[**2103**]. While on the Medical service, he was prepared for
colonoscopy. Colonoscopy revealed an ulcerated mass at 20
centimeters in the sigmoid colon. Biopsies would later prove
to be adenocarcinoma.
PAST MEDICAL HISTORY:
1. Amyotrophic lateral sclerosis, ventilator dependent.
2. Pulmonary embolus, [**2103-12-15**].
3. Placement of inferior vena cava filter following
pulmonary embolus.
4. Lower gastrointestinal bleed.
5. Occasional tachyarrhythmias which are self resolving.
6. Hypertension.
7. Depression.
8. Status post percutaneous endoscopic gastrostomy tube.
Although the patient suffers from amyotrophic lateral
sclerosis, he is quite capable of making his own medical
decisions and does so with the help of his brother, [**Name (NI) **],
who is quite involved.
MEDICATIONS ON ADMISSION:
1. Colace 100 mg p.o. twice a day.
2. Prevacid 30 mg p.o. twice a day.
3. Senna two tablets p.o. twice a day.
4. Tylenol 650 mg p.o. q4hours p.r.n.
5. Dulcolax one per rectum once daily p.r.n.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: At the time of discharge revealed the
patient to be afebrile with a heart rate of 80 and a blood
pressure of 140/80. He is on a ventilator with the following
settings: Respiratory rate 12, tidal volume 550, FIO2 30%,
PEEP 5. The patient has a gastrostomy tube and is receiving
Promote with fiber tube feeds at a goal rate of 70cc per
hour. On neurologic examination, the patient is atrophic and
has no motor tone. He is capable of moving his eyes and
communicates by eye blinking. He is competent and capable of
making his own medical decision making but often does so with
the help of his family. Lungs are clear to auscultation
bilaterally. The heart is regular rate and rhythm, normal S1
and S2. Abdomen is soft, nondistended, nontender. His
staples in the wound can be taken out one week postdischarge.
His wound is healing quite well and his stoma is functioning
well. The mucosa of the stoma is well appearing.
Extremities - no edema, 2+ dorsalis pedis and posterior
tibial pulses bilaterally.
LABORATORY DATA: White blood cell count 11.0, hematocrit
29.0, platelet count 470,000. Chem7 revealed sodium 141,
potassium 4.0, chloride 111, CO2 21, blood urea nitrogen 8,
creatinine 0.2, blood sugar 121, calcium 7.9, magnesium 1.4,
phosphorus 3.0.
HOSPITAL COURSE: Given the adenocarcinoma complicated by
bleeding, the family and the patient decided to proceed with
surgery. Two nights prior to the operation, he had a
nonsustained run of ventricular tachycardia, 22 beats in
length. Cardiology evaluated the patient and recommended no
further workup. His only other cardiac rhythm abnormality
was a short run of atrial bigeminy on postoperative day
number six which was also self limited.
On [**2104-3-7**], the patient was taken to the operating room
after a bowel prep and underwent a low anterior resection,
permanent end colostomy. Preoperatively, a Foley catheter
could not be placed secondary to urethral strictures.
Urology service placed a suprapubic tube preoperatively in
the operating room. The patient received 24 hours of
perioperative antibiotics. His remaining postoperative
course was unremarkable. He was started on tube feeds three
days postoperatively and slowly advanced to a goal rate of
70cc per hour. His wound looked swell and there was no
evidence of a wound infection. His stoma began to function
on postoperative day number six and he will require a bowel
regimen to keep his colon empty. We have suggested
discharging him on Colace 100 mg p.o. twice a day, Senna two
tablets p.o. twice a day and p.r.n. Lactulose. This regimen
may be adjusted to effect as needed. He has been on a
ventilator for several years and his discharge ventilator
settings were a respiratory rate of 12, tidal volume 550,
FIO2 30%, and PEEP 5. His staples should be discontinued in
one week. He had a negative urinalysis on the day of
discharge. He will be at risk for developing urinary tract
infection and, if he develops a fever, this should be
considered. We recommend follow-up with Dr. [**Last Name (STitle) 519**] in two
weeks. Please call his office for an appointment, telephone
number is supplied on page one.
MEDICATIONS ON DISCHARGE:
1. Heparin 5000 units subcutaneous twice a day.
2. Colace 100 mg p.o. twice a day.
3. Prevacid 30 mg p.o. twice a day.
4. Senna two tablets p.o. twice a day.
5. Magnesium Oxide 400 mg p.o. once daily times one week.
6. Tylenol 650 mg p.o. q4hours p.r.n. If this is not
adequate for pain control, then one could consider Percocet
or Roxicet Elixir 5 to 10cc p.o. q6hours p.r.n. However, he
seems to be doing quite well with the Tylenol at this time.
7. Lactulose 30cc p.o. twice a day p.r.n.
8. Albuterol two to four puffs q4hours p.r.n.
DISCHARGE DIAGNOSES:
1. Colorectal cancer.
2. Amyotrophic lateral sclerosis, chronic ventilator
dependence.
3. Hypertension.
4. Urinary retention.
5. Lower gastrointestinal bleed.
6. Status post lower anterior resection and suprapubic tube
placement.
7. Depression.
DISCHARGE INSTRUCTIONS: The instructions are detailed on
page one and in the text of this discharge summary. In
short, please call Dr.[**Name (NI) 1745**] office at [**Telephone/Fax (1) 49516**], to
make an appointment for approximately two weeks from now for
follow-up. The staples should be discontinued at the
rehabilitation facility one week from now. His tube feeds
presenting are Promote with fiber at a goal rate of 70cc per
hour. His ventilator settings are respiratory rate 12, tidal
volume 550, FIO2 30% and PEEP 5. He will require standard
colostomy care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 11232**]
MEDQUIST36
D: [**2104-3-15**] 09:51
T: [**2104-3-15**] 10:17
JOB#: [**Job Number **]
Name: [**Known lastname 9184**], [**Known firstname 885**] Unit No: [**Numeric Identifier 9185**]
Admission Date: [**2104-2-27**] Discharge Date: [**2104-3-17**]
Date of Birth: [**2046-3-16**] Sex: M
Service:
ADDENDUM: On hospital day eight Mr. [**Known lastname **] had routine
laboratories checked and his white blood cell count was found
to be 15. A chest x-ray revealed a left lower lobe opacity.
Given the white count and x-ray finding the diagnosis of
pneumonia was made. For this he was treated with
Levofloxacin 500 mg po q day for a total of ten days.
Postoperative day Mr. [**Known lastname **] began having to have some stool
out of his ostomy. By postop day number nine Mr. [**Known lastname **] was
ready to be discharged to rehabilitation.
DISCHARGE INSTRUCTIONS:
1. Tube feeds, ProMod with fiber at 70 cc an hour.
2. Vent settings assist control mode, respiratory rate 12,
tidal volume 500, FIO2 of 30%, 5 of PEEP.
3. Please remove staples in one week.
4. Follow up with Dr. [**Last Name (STitle) 1180**] in two weeks. Please call to
arrange an appointment.
DISCHARGE DIAGNOSIS:
Cancer status post low anterior resection.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**], M.D. [**MD Number(1) 3712**]
Dictated By:[**Last Name (NamePattern1) 2383**]
MEDQUIST36
D: [**2104-3-17**] 11:09
T: [**2104-3-17**] 11:39
JOB#: [**Job Number 9186**]
|
[
"335.20",
"V12.51",
"401.9",
"V46.1",
"518.83",
"598.9",
"153.3",
"486",
"578.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"45.42",
"58.6",
"96.72",
"45.13",
"57.17",
"38.93",
"45.25",
"48.62",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
5460, 5713
|
7703, 7747
|
4892, 5439
|
1444, 1681
|
2988, 4866
|
7381, 7682
|
1704, 2970
|
183, 836
|
858, 1418
|
7772, 8064
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,436
| 118,481
|
13934
|
Discharge summary
|
report
|
Admission Date: [**2131-12-19**] Discharge Date: [**2131-12-29**]
Date of Birth: [**2080-8-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
calf claudication/LE edema
Major Surgical or Invasive Procedure:
[**2131-12-19**] AVR (CE 23mm pericardial)/CABG x 3 (LIMA to LAD, SVG to
OM1, SVG to OM3)
History of Present Illness:
51 year old man who presents with symptoms
of calf claudication, bilateral lower extremity pain who was
found to have pulmonary vascular congestion on CXR, an EKG with
an intraventricular conduction delay of left bundle morphology,
poor RWP progression, Q in III. Echo done showed EF 20-25%,
critical AS. Cardiac enzymes have been flat. He reports B/l calf
"fatigue" x several months, relieved by rest and associated with
some shortness of breath. He denied any significant LE edema in
the past. In the week prior to admission, he had a significant
increase in B/L LE edema, making it difficult for him to
ambulate. He also reports increase in DOE with the LE edema.
Cardiac surgery consulted for evaluation for valve replacement
Past Medical History:
tobacco abuse
MVA in [**2130**]
Social History:
Currently smokes half a pack daily. Smoked over a pack daily for
about 20 years. Drinks several days for week. Only beer. The
most he will drink is 6 when watching a game, but usually just
2. Works in property management. Lives by himself. Divorced 10
years ago.
Family History:
Hyperlipidemia
Says his father had "blockage" and a stent in his 60s
Physical Exam:
Pulse: Resp:12 O2 sat: 97% RA
B/P Right: 107/74 Left:
Height: Weight: 79
General:
Skin: Dry [x] intact [x] LE chronic venous stasis changes B/L
HEENT: PERRLA [x] EOMI [x] Front tooth chipped
Neck: Supple [x] Full ROM [x] Transmitted murmur
Chest: Lungs with fine basilar crackles, diffuse exp wheezes
Heart: RRR [x] Irregular [] Murmur III/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [] 2+ LE Edema B/L
Varicosities: [x] RLE
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:1+ Left:1+
PT [**Name (NI) 167**]:1+ Left:1+
Radial Right:1+ Left:1+
Carotid Bruit Right: Left:
Transmitted murmur
Pertinent Results:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
moderately dilated with mild global hypokinesis and more severe
hypokinesis of the inferior wall (LVEF = 30-35 %). The right
ventricular cavity is mildly dilated with depressed free wall
contractility. A well-seated bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis leaflets
appear to move normally. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2131-12-12**],
the aortic valve has been replaced with a normal functioning
bioprosthesis. Global LVEF is improved.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2131-12-25**] 08:12
[**2131-12-28**] 05:59AM BLOOD WBC-6.8 RBC-2.93* Hgb-8.7* Hct-26.0*
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.6 Plt Ct-253
[**2131-12-28**] 05:59AM BLOOD Glucose-80 UreaN-6 Creat-0.6 Na-130*
K-4.3 Cl-99 HCO3-25 AnGap-10
Echo, [**2131-12-26**]
Conclusions
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The diameters of aorta at the sinus, ascending and
arch levels are normal. A bioprosthetic aortic valve prosthesis
is present. The aortic valve prosthesis appears well seated,
with normal leaflet/disc motion and transvalvular gradients.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. Trivial mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of [**2131-12-12**],
the aortic valve has been replaced with a normal functioning
bioprosthetic AVR. Left ventricular cavity is smaller/now
smaller, and systolic function is improved.
CLINICAL IMPLICATIONS:
Based on [**2129**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
Admitted [**12-19**] and underwent surgery with Dr. [**Last Name (STitle) 914**]. Please see
operative note. Transferred to the CVICU in stable condition on
titrated levophed, milrinone, and amiodarone drips. Extubated
the following morning. PICC placed for IV access. All drips
weaned off by POD #5. Early AM [**12-25**], he developed VT and was
unresponsive. He was immediately shocked X 1 with good response.
IV amiodarone continued for his Hx of ectopy intraop and postop.
EP consulted for further management. Medical management of
rhythm was optimized and cardiac meds were titrated as
tolerated. EP concluded that episode was related to
non-ischemic cardiomyopathy (secondary to EtOH), and this
combined with CHF did not warrant an ICD at this time. EP
recommended a defibrillator vest on discharge. The patient
remained stable through the remainder of the hospital course
without further rhythm disturbance. The Life Vest was
implemented and will be managed by Dr. [**Last Name (STitle) **] on discharge.
The patient was discharged home with VNA on POD 10.
Medications on Admission:
naproxen 500 mg TID (recently started for calf pain)
ASA 81 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg 2x/day for 1 week, then 200mg 2x/day for 1 week,
then 200mg/day until further instructed.
Disp:*120 Tablet(s)* Refills:*2*
5. Captopril 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
Disp:*270 Tablet(s)* Refills:*2*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
AS/CAD (s/p AVR/CABG)
tobacco abuse
MVA [**2130**]
chronic systolic heart failure
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] Tuesday [**2132-1-22**] @ 1:00 PM [**Telephone/Fax (1) 170**]
Primary Care Dr.[**First Name (STitle) **] in [**1-12**] weeks [**Telephone/Fax (1) 250**]
Cardiologist Dr.[**First Name (STitle) 437**] in [**2-13**] weeks [**Telephone/Fax (1) 62**]
Dr. [**Last Name (STitle) **] 1 month [**Telephone/Fax (1) 7332**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2131-12-29**]
|
[
"425.5",
"E878.2",
"998.0",
"443.9",
"427.1",
"424.1",
"305.1",
"414.01",
"428.0",
"997.1",
"305.00",
"427.89",
"427.5",
"428.23",
"285.9",
"746.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.15",
"39.61",
"35.22",
"92.05",
"39.64",
"99.62",
"36.12",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7187, 7193
|
4948, 6018
|
349, 441
|
7319, 7319
|
2421, 4669
|
8065, 8604
|
1556, 1626
|
6137, 7164
|
7214, 7298
|
6044, 6114
|
7464, 8042
|
1641, 2402
|
4692, 4925
|
283, 311
|
469, 1204
|
7333, 7440
|
1226, 1259
|
1275, 1540
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,032
| 181,382
|
41166
|
Discharge summary
|
report
|
Admission Date: [**2122-11-30**] Discharge Date: [**2122-12-8**]
Date of Birth: [**2056-3-10**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
hypoxia, tachycardia, respiratory secretion
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
66 yo F with history of traumatic brain injury with left
hemiplegia, s/p meningioma resection with residual speech/motor
deficits, presenting originally to ortho service following fall
from chair where she broke her left femur. Medicine consult was
approached for management of sinus tachycardia. Ortho had
thought tachycardia was secondary to pain. She was also found
to have a lot of respiratory secretions at that time, but no
mention in charts prior to medicine involvement of secretions.
Patient had been saturating 89% on 2L, but once deep suctioned,
O2 saturation improved to 97% on 2L. She required frequent deep
suctioning on the floor, about every 2 hours. As the nasal
passage became more inflammed with each episode of suctioning,
the suction catheter was no longer able to be passed nasally by
respiratory therapy. Patient unable to cough up secretions on
her own as she has a weak cough, nothing able to be suctioned
with the yankauer catheter. As the night progressed, she had
more labored breathing, saturating 89-91% on 5 L NC, then
requiring 10 L on facemask to maintain saturation. Transferred
to the MICU for worsening respiratory status.
.
On transfer to the ICU, patient is very fatigued, mental status
waxing and [**Doctor Last Name 688**]; usually able to answer questions but very
difficult to understand. Breathing slightly labored on
facemask.
.
Review of systems:
Patient unable to answer review of system questions
Past Medical History:
-severe osteoporosis
-left hip fracture and repair [**4-27**] yrs ago
-Traumatic brain injury after fall [**4-27**] yrs ago / she fell
striking the right side of her head where cranial defect is
/resulting in left hemiplegia
- right sided meningioma resection 47 yrs ago Dr. [**First Name (STitle) 12795**] at
[**Hospital1 2025**] / then second procedure to remove bone flap "because it was
calcified" per husband. She does not wear a helmet at home / she
never has.
Social History:
Lives at home with husband / has home aides to assist with
bathing / walks with a cane and or assistance of her husband/
cannot use a walker [**12-23**] left hand weakness according to husband.
Family History:
unknown
Physical Exam:
Gen: appears anxious, slightly fatigued, AAOx2, difficult to
understand speech, following simple commands
HEENT: +lateral nystagmus, limited gaze downward, OP clear
Neck: no JVD, no LAD
CV: S1S2, tachycardic, no m/r/g
Chest: CTAB in anterior fields, decreased BS at bases b/l
GI: soft, NT, ND, no HSM, +BS
Ext: no c/c/e, LLE rotated inwards
Neuro: left side weaker than right
Pertinent Results:
Femur XR -
IMPRESSION:
1. Acute comminuted distal femoral fracture, with varus
angulation and posterior displacement of the distal fracture
fragment by one-half shaft width.
2. Hardware fixation of old healed left intertrochanteric
fracture, with marked heterotopic ossification.
3. Left proximal tibial enchondroma.
.
CT T&L-spine
CONCLUSION:
- Severe loss of height associated with compression fractures at
T7 and T12 with kyphosis. Fracture of the superior endplate of
L2 without angulation. These fractures are of indeterminate age.
- Left lower lobe consolidation or atelectasis.
- Cystic lesions in both kidneys.
- Status post left femoral neck fracture repair.
Brief Hospital Course:
66 yo F with traumatic brain injury with left hemiplegia
transferred to the MICU with persistent sinus tachycardia and
worsening respiratory status in setting of femur fracture
sustained from a fall
.
# Respiratory distress - Patient with increasing O2 requirement,
has trouble clearing secretions. Saturations had been improved
with deep suctioning. She is unable to clear secretions on her
own given weak cough, possibly due to the high doses of
narcotics that she received on the floor. Pt intubated at
admission to the MICU for respiratory distress. Started on
antibiotics for presumed PNA. During the course of her stay,
attempted extubation twice, however required reintubation for
tachycardia, agitation, and inability to protect airway. After
discussion with the family, pt was made DNR/DNI, and the
decision was made to extubate on [**12-8**], with plans for no
re-intubation. After extubation, pt became tachypneic and
distressed; morphine drip was started for comfort, and patient
passed away that afternoon.
.
# Sinus tachycardia - likely multifactorial. Originally thought
to be due to pain, but was not been responsive to increased
doses of narcotic medication prior transfer to the ICU. Pain
likely still plays a part in the sinus tachycardia. Patient
appeared volume down, so hypovolemia may also have played a
role. Tachycardia improved with fluids, better pain control,
and increase in metoprolol dose.
.
# h/o TBI - phenytoin was continued for the duration of
hospitalization.
.
# Femur fracture - pt had repair of femur fracture by
orthopedics on [**12-2**], which she tolerated well.
Medications on Admission:
Phenytoin
Evoxac
Omeprazole
Simvastatin
Metoprolol 12.5mg in AM and 12.5mg in PM
Folic Acid
Tramadol
MVI
Cosamin, ASU
Tylenol
calcium, vitamin D
Discharge Medications:
pt passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
pt passed away
Discharge Condition:
pt passed away
Discharge Instructions:
pt passed away
Followup Instructions:
pt passed away
Completed by:[**2122-12-9**]
|
[
"486",
"821.01",
"345.90",
"V15.52",
"518.81",
"E929.3",
"V49.86",
"907.0",
"733.00",
"518.0",
"427.31",
"276.52",
"E884.2",
"710.2",
"427.89",
"342.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.65",
"96.04",
"33.24",
"79.35",
"38.97",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5526, 5535
|
3675, 5292
|
348, 360
|
5593, 5609
|
2981, 3652
|
5672, 5717
|
2561, 2570
|
5487, 5503
|
5556, 5572
|
5318, 5464
|
5633, 5649
|
2585, 2962
|
1789, 1843
|
264, 310
|
388, 1770
|
1865, 2333
|
2349, 2545
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,321
| 183,246
|
52485+59429
|
Discharge summary
|
report+addendum
|
Admission Date: [**2180-3-13**] Discharge Date: [**2180-3-22**]
Date of Birth: [**2098-5-24**] Sex: F
Service: SURGERY
Allergies:
Prochlorperazine / Celexa / Dilaudid / Ambien / Methotrexate
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
abdominal pain, fever, diarrhea
Major Surgical or Invasive Procedure:
Left hemi-colectomy, end colostomy
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
c/o diarrhea for the last 4 days. Today at nursing home,
noted blood in stool. Also with fever to 104 this morning.
c/o diffuse abdominal pain. Pt is a poor historian but
denies dysuria, nausea, vomiting, cough.
Timing: Gradual
Quality: Sharp
Severity: Moderate
Duration: 4 Days
Location: diffuse abdomen
Associated Signs/Symptoms: diarrhea, bloody stool
Past Medical History:
Papillary thyroid carcinoma with lymph node metastases
Syncope due to recurrent polymorphic ventricular tachycardia
CAD s/p CABG
Diabetes
HTN
PVD
Left CEA for carotid stenosis
Rheumatoid arthritis
Factor V Leiden
Depression
Iron def anemia
Hypothyroidism
Failure to thrive
Cholecystectomy
Urinary incontinence
Interstitial lung disease
Restless leg syndrome
Seizure 30 years ago
Recurrent Anemia requiring multiple tranfusions as per son,
details unknown (possible GI losses w/negative work-up)
Social History:
Patient lives at the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. Patient uses a wheelchair
due to knee pain. She denies tobacco, ETOH use.
Family History:
Her son had a papillary thyroid cancer that was removed. Her
sister has a rare throat cancer.
Physical Exam:
PHYSICAL EXAMINATION: upon admission: [**2180-3-13**]
Temp:08.8 HR:97 BP:83/34 Resp:20 O(2)Sat:100 Normal
Constitutional: uncomfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, mild diffuse tenderness
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: orinteed to person only, moves all extremities.
follows commands
Vital signs: 97, bp=164/63, hr=75, resp. rate 20, oxygen
satuation 98% room air
General: Oriented to place, follows commands, sleepy
CV:Ns1, s2, -s3, -s4
LUNGS:Clear
ABDOMEN: Soft, ostomy with light brown stool, midline incisonal
staples removed with large amount of rust colored drainag, upper
aspect of wound clean, lower aspect small amount of rust colored
drainage, moist to dry dressing applied
EXT: no pedal edema bil., + dp bil
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2180-3-22**] 11:00 7.7 3.51* 10.0* 30.2* 86 28.4 33.0 16.4*
[**Numeric Identifier 108404**]/09/[**2180**] 11:00 158*1 11 0.9 139 3.2* 100 28 14
[**2180-3-19**] 06:30AM BLOOD WBC-6.6 RBC-2.97* Hgb-8.6* Hct-26.4*
MCV-89 MCH-29.1 MCHC-32.8 RDW-16.3* Plt Ct-252
[**2180-3-18**] 02:03AM BLOOD WBC-5.8 RBC-3.06* Hgb-8.7* Hct-25.9*
MCV-85 MCH-28.5 MCHC-33.6 RDW-16.0* Plt Ct-193
[**2180-3-17**] 01:41AM BLOOD WBC-9.2 RBC-3.28* Hgb-9.3* Hct-28.2*
MCV-86 MCH-28.4 MCHC-33.1 RDW-16.3* Plt Ct-191
[**2180-3-13**] 05:32PM BLOOD WBC-7.0# RBC-3.62* Hgb-10.0* Hct-30.9*
MCV-85 MCH-27.7 MCHC-32.5 RDW-17.6* Plt Ct-196
[**2180-3-13**] 07:58AM BLOOD WBC-16.1*# RBC-3.28* Hgb-9.4* Hct-28.2*
MCV-86 MCH-28.7 MCHC-33.4 RDW-17.9* Plt Ct-257
[**2180-3-13**] 05:32PM BLOOD Neuts-68.0 Lymphs-28.0 Monos-2.1 Eos-1.6
Baso-0.4
[**2180-3-13**] 07:58AM BLOOD Neuts-80.9* Lymphs-12.4* Monos-5.9
Eos-0.2 Baso-0.5
[**2180-3-19**] 06:30AM BLOOD Plt Ct-252
[**2180-3-18**] 02:03AM BLOOD Plt Ct-193
[**2180-3-18**] 02:03AM BLOOD PT-11.7 PTT-29.6 INR(PT)-1.0
[**2180-3-19**] 06:30AM BLOOD Glucose-169* UreaN-17 Creat-0.9 Na-140
K-3.6 Cl-98 HCO3-35* AnGap-11
[**2180-3-18**] 02:33PM BLOOD Glucose-174* UreaN-15 Creat-0.9 Na-139
K-3.9 Cl-96 HCO3-34* AnGap-13
[**2180-3-18**] 02:03AM BLOOD Glucose-155* UreaN-14 Creat-1.0 Na-135
K-3.4 Cl-93* HCO3-33* AnGap-12
[**2180-3-19**] 06:30AM BLOOD ALT-19 AST-31 AlkPhos-95 TotBili-0.4
[**2180-3-13**] 07:58AM BLOOD ALT-17 AST-27 AlkPhos-68 TotBili-0.4
[**2180-3-19**] 06:30AM BLOOD Calcium-7.9* Phos-1.0* Mg-2.2
[**2180-3-18**] 02:33PM BLOOD Calcium-8.3* Phos-1.9* Mg-2.2
[**2180-3-16**] 02:08AM BLOOD Type-ART pO2-79* pCO2-46* pH-7.38
calTCO2-28 Base XS-0
[**2180-3-15**] 10:33AM BLOOD Type-ART pO2-83* pCO2-39 pH-7.36
calTCO2-23 Base XS--2
[**2180-3-16**] 02:54PM BLOOD Glucose-119* Lactate-1.0 K-3.5
[**2180-3-16**] 02:08AM BLOOD freeCa-1.14
[**2180-3-14**] 02:13AM BLOOD freeCa-1.20
[**2180-3-13**]: EKG:
Baseline artifact. Irregularly irregular rhythm with
considerable artifact may be atrial fibrillation with controlled
ventricular response. ST-T wave
abnormalities are less prominent and QRS voltage is diminished.
Clinical
correlation is suggested.
TRACING #2
[**2180-3-13**]: EKG:
Sinus rhythm. Leftward axis. ST-T wave abnormalities. Since the
previous
tracing of [**2180-1-28**] the rate is faster. The Q-T interval is
shorter. Early
precordial and lateral limb lead T wave inversions are new.
Clinical
correlation is suggested.
TRACING #1
[**2180-3-13**]: chest x-ray:
IMPRESSION: Bibasilar bronchovascular opacities likely due to
bronchovascular crowding and atelectasis. Cardiomegaly
[**2180-3-13**]: cat scan of abdomen and pelvis:
IMPRESSION:
1. Bowel wall thicking involveing the descending and sigmoid
colon without
pneumatosis or significant fat stranding. This appearance may be
seen with infectious vs ischemic colitis.
2. Extensive atherosclerosis
[**2180-3-15**]: chest x-ray:
Small bilateral pleural effusions right greater than left and
mild pulmonary edema worse in the lower lobes in the presence of
a moderate cardiomegaly, probably due to worsening cardiac
decompensation. No pneumothorax. Pneumonia could be missed in
the lower lungs.
Right internal jugular line ends in the right atrium.
Nasogastric tube is
looped widely in the stomach and tip in the fundus.
[**2180-3-18**]: chest x-ray:
Mild pulmonary edema which developed between [**3-13**] and
[**3-15**],
subsequently improved, is minimal, unchanged since [**3-17**].
Bilateral
infrahilar consolidation is probably atelectasis. Moderate
cardiomegaly is
stable. Pleural effusion is small on the left if any. No
pneumothorax.
Nasogastric tube ends in the stomach. Right jugular line in the
upper right atrium. No pneumothorax.
[**2180-3-18**]: chest x-ray:
Nasogastric tube passes to the mid stomach and out of view.
Minimal
interstitial edema, unchanged. Mild cardiomegaly, stable. Small
left pleural effusion is presumed. Right jugular line ends in
the upper right atrium. No pneumothorax.
Brief Hospital Course:
81 year old female presented to the Acute care service with
abdominal pain, fever, and diarrhea. Upon admission, she was
made NPO, had intravenous fluids, and imaging studies of her
abdomen which showed bowel wall thickening suggestive of
ischemic colitis. During this time, she required additional
intravenous fluids for hypotension. She was taken to the
operating room on [**3-13**] where she had a left hemi-colectomy with
end colostomy. Her operative course was uneventful.
Her post-operative course was monitored in the intensive care
unit where she required an additional blood transfusion for a
decreased hematocrit. Her nutritional status was maintained with
tube feedings via [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube. She was extubated on [**3-15**].
Shortly afterward, she developed pulmonary overload and required
lasix and albumin to improve her pulmonary status. She
developed a fever on [**3-16**], had blood cultures drawn, and was
started on zosyn which was discontinued in 5 days. Since then,
she has been afebrile. Her [**Last Name (un) **]-gastric tube was discontinued
and her diet was slowly advanced to a regular diet. Her appetite
is diminished and she has been started on megace to help
stimulate her appetite. Her vital signs are stable. She has been
incontinent of urine. She was noted to have erythema at the
incisonal site and the staples were removed on [**3-22**] with a large
amount of rust colored drainage. The wound was left open and
she has been ordered for dressing changes. Because of her
ostomy, she was evaluated by the ostomy nurse. A physical
therapy consult was undertaken. She was also evalulated by the
nutritionist who has made recommendations regarding the addition
of nutritional supplements to diet. Her white blood cell count
in normal. Her electrolytes have been repleted today.
She is preparing for discharge back to her rehabilitation
facility where her pulmonary and hemodynamic status will be
monitored and her rehabilitation resumed. She will follow up
with the Acute care service in 1 week for her wound assessment.
Medications on Admission:
[**Last Name (un) 1724**]:
1. levothyroxine 100 mcg PO DAILY
2. lidocaine 5 %(700 mg/patch) Adhesive Patch
3. multivitamin PO DAILY
4. prednisone 5 mg PO EVERY OTHER DAY
5. simvastatin 20 mg Tablet PO DAILY
6. donepezil 10 mg PO HS
7. mirtazapine 15 mg PO HS
8. trazodone 25 mg PO HS
9. amiodarone 200 mg PO EVERY OTHER DAY
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB/Wheezing.
11. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB/Wheezing.
12. RISS
13. acetaminophen 650 mg as needed for Pain
14. omeprazole 40 mg PO DAILY
15. aspirin 81 mg Delayed Release PO DAILY
16. lisinopril 10 mg PO DAILY
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze.
3. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. trazadone Sig: Twenty Five (25) mg at bedtime.
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO every other
day.
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day:
hold for systolic blood pressure <100, hr <60.
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
13. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours: as needed for pain.
14. prednisone 5 mg Tablet Sig: One (1) Tablet PO every other
day: please follow up in 1 week with your PCP prior to starting.
15. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. insulin regular human 100 unit/mL Solution Sig: 0-14 units
as per sliding scale Injection ASDIR (AS DIRECTED).
17. Ultram 50 mg Tablet Sig: 0.5 Tablet PO every six (6) hours:
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
18. megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
colitis
mesenteric ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with abdominal pain, fever,
and diarrhea. You had a cat scan of the abdomen which showed
ischemic colitis. You were taken to the operating room where
you had a left hemi-colectomy and end colostomy. You are now
preparing for discharge to an extended care facility. Please
follow these instructions upon discharge:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*Weigh daily, report #3 pound weight gain to PCP/Cardiologist
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day
Daily ostomy care, cleanse around stoma and appliance
application
Abdominal wound care: moist to dry dressing ( please ring out
gauze before application), follow with dry sterile dressing.
Please change twice daily
Followup Instructions:
Please follow up with the Acute care service in 1 week. You can
schedule this appoinment by calling # [**Telephone/Fax (1) 600**].
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
in 1 week to address resuming your steroids. The telephone
number is # [**Telephone/Fax (1) 608**]
[**2180-4-25**] 03:30p [**Last Name (LF) **],[**First Name3 (LF) **] V.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
ENDOCRINOLOGY (SB)
Completed by:[**2180-3-22**] Name: [**Last Name (LF) **], [**Known firstname **]
Unit No: [**Numeric Identifier 17727**]
Admission Date: [**2180-3-13**]
Discharge Date: [**2180-3-22**]
Date of Birth: [**2098-5-24**]
Sex: F
Service: [**Last Name (un) **]
ADDENDUM TO DISCHARGE SUMMARY
The patient was in fact in sepsis when she was admitted to
the hospital on [**3-13**], and this was left out of her discharge
summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 6630**]
Dictated By:[**Last Name (NamePattern4) 6631**]
MEDQUIST36
D: [**2180-5-8**] 15:46:42
T: [**2180-5-9**] 07:56:50
Job#: [**Job Number 17728**]
|
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"427.31",
"995.92",
"518.4",
"515",
"414.00",
"289.81",
"V45.81",
"311",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.75",
"46.10",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11496, 11618
|
6924, 9051
|
351, 388
|
11690, 11690
|
2806, 6899
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1637, 1732
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9838, 11473
|
11639, 11669
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|
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|
1770, 1772
|
280, 313
|
13632, 13761
|
12225, 13620
|
416, 916
|
1787, 2787
|
11705, 11849
|
938, 1435
|
1451, 1621
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,200
| 114,292
|
8490
|
Discharge summary
|
report
|
Admission Date: [**2126-6-23**] Discharge Date: [**2126-6-29**]
Date of Birth: [**2060-9-21**] Sex: M
Service: SURGERY
Allergies:
Rabies Immune Globulin
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Left proximal deep venous thrombosis
Major Surgical or Invasive Procedure:
1. Ultrasound-guided vascular access of the right common
femoral vein.
2. First order catheterization into the inferior vena cava.
3. Inferior vena cava filter insertion of a Cook Celect
History of Present Illness:
65M s/p anterior exposure for laminectomy on [**6-10**] and
posterior fusion [**6-14**], presents with hypotension to the 70s,
severe abdominal pain that acutely began this am. His pain is
focused in the LLQ withradiation toward the left leg. He denies
emesis, SOB, and has had BM and gas. No melena or hematochezia.
Of note, intraop anterior exposure involved a small tear to the
left iliac vein which required figure of eight suture for
repair.
Post op course was uneventful. Patient was in rehab with acute
LLE swelling noted yesterday. Duplex revealed a DVT in CFV. He
was started on Dalteparin (Fragmin) with last dose 11pm last
night. He was hypotensive this am at rehab to the 70s and was
transferred to the ER at [**Hospital1 18**] for further management. In ED
patient was hypotensive to the 80s. Hct returned at 14 with Ct
showing RP bleed away from site of iliac vein repair. He was
transfused 3 units, given FFP and Vitamin K for Fragmin
reversal.
Past Medical History:
1. Diabetes. Excellent A1c. Up to date on screening. Of note,
EMG
did not show diabetic neuropathy.
2. Hypertension.
3. Hypothyroidism.
4. Chronic pain-lumbar polyradiculopathy followed by pain
clinic.
Recent EMG reviewed.
5. Atypical chest pain/left upper extremity paresthesias and
weakness-EMG reveals C5-T1 radiculopathy. ETT/echo negative.
6. Rheumatoid arthritis. Followed by Dr.[**Last Name (STitle) **], [**Hospital1 112**]. On
prednisone,
recently started on remicaid for uveitis.
7. Hepatitis C, elevated LFTs.
8. Colon polyps-adenoma [**2113**], normal colonoscopy [**2118**].
9. Foot pain-now followed by Dr. [**Last Name (STitle) **] for multiple issues
including tendon rupture
10. Sleep disorder-uses trazodone for zolpidem.
11. History of positive PPD.
12.? osteoporosis. On alendronate, prescribed by his
rheumatologist. He does not recall a recent bone density study.
Social History:
Ex smoker
2 beers daily
No illicit drug use
Family History:
1. Father: CAD s/p stent, chronic angina, 1st MI at age 70s
2. Mother: deceased from natural causes
3. Sister: DM
4. Brother: emphysema + tobacco
Physical Exam:
98.5 97.6 97 136/76 20 97% RA
Gen: alert and oriented x3, CV: RRR
Pulm: CTAB
Abd: soft, no tender to palpation to palpation
Abdominal and back wound in healing process, clean, dry and
intaact
Foley in place.
Ext: WWP
Pertinent Results:
CXR: Widened appearance of the mediastinum. Recommend repeat
upright PA
radiograph when patient is more stable. Atelectasis at the
bases and low lung volumes. Possible mild pulmonary congestion.
( preoperative xray considered throid mass).
[**2126-6-23**] 09:30AM PT-12.6* PTT-31.9 INR(PT)-1.2*
[**2126-6-23**] 09:30AM WBC-3.9* RBC-1.55*# HGB-4.9*# HCT-14.8*#
MCV-96 MCH-31.7 MCHC-33.2 RDW-15.0
[**2126-6-23**] 09:30AM cTropnT-0.13*
[**2126-6-23**] 01:44PM HCT-16.5*
[**2126-6-23**] 03:34PM HGB-8.3* calcHCT-25
[**2126-6-23**] 03:34PM TYPE-ART PO2-158* PCO2-42 PH-7.38 TOTAL
CO2-26 BASE XS-0 INTUBATED-INTUBATED
[**2126-6-23**] 04:07PM HGB-8.3* calcHCT-25 O2 SAT-97
[**2126-6-23**] 06:44PM PT-10.3 PTT-30.1 INR(PT)-0.9
[**2126-6-23**] 06:44PM PLT COUNT-181
[**2126-6-23**] 06:44PM WBC-5.4 RBC-3.72*# HGB-11.3*# HCT-33.1*#
MCV-89# MCH-30.4 MCHC-34.3 RDW-15.6*
[**2126-6-23**] 06:44PM CALCIUM-7.1* PHOSPHATE-4.3 MAGNESIUM-2.1
[**2126-6-23**] 06:44PM CK-MB-10 MB INDX-2.0 cTropnT-0.12*
[**2126-6-23**] 10:31PM HCT-30.7*
[**2126-6-26**] 06:20PM BLOOD WBC-6.1 RBC-3.25* Hgb-10.0* Hct-29.7*
MCV-92 MCH-30.9 MCHC-33.8 RDW-15.2 Plt Ct-189
[**2126-6-27**] 09:00AM BLOOD WBC-6.1 RBC-3.69* Hgb-11.5* Hct-34.2*
MCV-93 MCH-31.1 MCHC-33.6 RDW-14.9 Plt Ct-212
[**2126-6-28**] 07:20AM BLOOD WBC-5.0 RBC-3.46* Hgb-11.0* Hct-32.3*
MCV-94 MCH-31.9 MCHC-34.1 RDW-14.8 Plt Ct-236
[**2126-6-26**] 06:20PM BLOOD PT-11.6 PTT-30.0 INR(PT)-1.1
[**2126-6-26**] 06:20PM BLOOD Glucose-107* UreaN-11 Creat-1.0 Na-137
K-3.7 Cl-103 HCO3-29 AnGap-9
[**2126-6-27**] 09:00AM BLOOD Glucose-111* UreaN-9 Creat-1.0 Na-140
K-3.3 Cl-102 HCO3-24 AnGap-17
[**2126-6-28**] 07:20AM BLOOD Glucose-86 UreaN-8 Creat-1.0 Na-136 K-3.8
Cl-102 HCO3-26 AnGap-12
[**Last Name (NamePattern4) **] Hospital Course:
Hematoma:
Mr. [**Known lastname **] is a 65yo man s/p laminectomy with anterior exposure
on [**6-10**] complicated by a small tear to the iliac vein which
oversew and takeback for fusion on [**6-14**] with wound vac
placement. He was discharged to rehab and presented with
hypotension to the 70's systolic nd lower abdominal/left lower
extremity pain for the previous day. He began to have LLE
swelling the previous day and underwent duplex ultrasound
demonstrating a DVT in his left common femoral vein. He was
started on dalteparin for this yesterday. Upon presentation to
the ED, he was hypotensive to 80's with Hct 14.8. He was given
3u pRBC, FFP, and Vitamin K. CT scan demonstrated large RP
hematoma and he was taken to IR for possible embolization. They
performed a flush aortogram. Catheterization of left lumbar
arteries at L2, L3 and L4 with
angiography,Common iliac artery angiogram, left internal iliac
artery angiogram and a left internal epigastric artery
angiogram.No source of bleeding was identified despite
catheterization of all visualized lumbar vessels, the left
common iliac, internal and external iliac and left internal
epigastric arteries. He was thereafter transferred to the ICU
where he was resuscitated with four units of PRBCs his first
night. Because of his DVT and his demonstrated tendency to bleed
he required an IVC filter. The hematoma also appeared to
compress the left ureter and Urology was consulted because ehis
creatinine was trending downwards it was determined that the
patient did not require a ureteral stent. There were no acute
events overnight and he was made NPO for his IVC filter
placement. Interventional radiology declined draining the
hematoma because there was no evidence of extravasation. On
[**2126-6-26**] he received his IVC filter placement with no
complications. Post operatively his groin was stable with no
hematoma. He was started on a regular diet and resumed his home
medications. Postoperatively he was re-evaluated by physical
therapy and sent to rehab on [**2126-6-29**]. Urology evaluated the
patient for L ureter compression. Patient d/c with foley, will
do voiding trial if fail to void foley will be replaced and
patient will follow with Dr. [**Last Name (STitle) **] as out patient. Patient will be
follow up with Dr. [**Last Name (STitle) 15492**] in [**12-28**] weeks.
Medications on Admission:
Amoxcillin 500mgq 12hr, tylenol 540,Alendronate 70 mg q
weekly,Amlodipine 10mg', Bisacodyl 10mg", Calcium carbonate
1000mg', Docusate, hydrochlorothiazide 25 mg, levothyroxine 75
mcg, lisinopril 20 mg, metoprolol tartrate 25mg'", oxycodone
15-45 mg q3h, pregabalin 150mg'", prednisone 5 mg , tocilizumab
80 mg/4 mL, trazodone 50 mg, zolpidem 5 -10mg, Nystatin 100,000
brimonidine 0.1, econazole 1 ", ergocalciferol (vitamin D2)
50,000 unit capsule,
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
Hold for SBP<100
2. Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dry
etes
3. Bisacodyl 10 mg PO DAILY:PRN Constipation
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES [**Hospital1 **]
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID
7. Furosemide 40 mg PO DAILY Duration: 3 Days
Re evaluate after dose. Titrate dose to according wiht patient
fluid status
8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
9. Heparin 5000 UNIT SC TID
10. HYDROmorphone (Dilaudid) 1-2 mg IV Q1H:PRN pain
11. Glargine 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
13. Levothyroxine Sodium 75 mcg PO DAILY
14. OxycoDONE (Immediate Release) 45 mg PO Q4H:PRN pain
This is the actual dose the patient receives at home. Confirmed
with the patient.
15. PredniSONE 5 mg PO DAILY
16. Pregabalin 150 mg PO TID
17. Senna 1 TAB PO BID:PRN Constipation
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. traZODONE 50 mg PO HS
20. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
21. Zolpidem Tartrate 5 mg PO HS:PRN sleep
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
DVT on anticoagulation complicated by retroperitoneal bleeding
Diabetes
History of Hep C, Hypertension, Hypothyroidism, Chronic
pain-lumbar Atypical chest pain/left upper extremity
paresthesias and
weakness-EMG reveals C5-T1 radiculopathy, Rheumatoid arthritis
(on prednisone). Remicaid for uveitis, Hepatitis C, PPD,
osteoporosis.
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:
Division of Vascular and Endovascular Surgery Lower Extremity
Angioplasty
Medications:
?????? Continue all other medications you were taking before
surgery, unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**12-28**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**1-27**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Please follow up with your Primary care regarding your widened
mediastinum on CXR.
Followup Instructions:
PLease schedule an appointment with Dr. [**Last Name (STitle) 1391**] in [**12-28**] weeks.
[**Last Name (LF) 1391**], [**First Name3 (LF) **] R.
[**Telephone/Fax (1) 4852**]
Office Location: [**Hospital1 18**] [**Last Name (NamePattern1) **]; Ste 9A, [**Location (un) 86**] [**Numeric Identifier **]
Department: Surgery
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3640**] at [**Last Name (un) **] Center for blood sugar
control.
Phone: ([**Telephone/Fax (1) 3258**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2126-7-17**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2126-8-28**] 10:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2126-10-16**] 10:00
Completed by:[**2126-6-29**]
|
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icd9cm
|
[
[
[]
]
] |
[
"38.7",
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icd9pcs
|
[
[
[]
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8783, 8853
|
319, 511
|
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|
2899, 4675
|
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|
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|
540, 1508
|
9246, 9390
|
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|
2434, 2479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,078
| 148,894
|
48854
|
Discharge summary
|
report
|
Admission Date: [**2163-3-15**] Discharge Date: [**2163-3-25**]
Date of Birth: [**2086-5-28**] Sex: F
Service: SURGERY
Allergies:
Keflex
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
Sigmoid diverticulitis, Ovarian cyst
Major Surgical or Invasive Procedure:
[**2163-3-15**]: Laparoscopic converted to open sigmoid colectomy with
mobilization of splenic flexure and right salpingo-oophorectomy,
lysis of adhesions, isolation of the ureter.
History of Present Illness:
The patient is a 76-year-old woman with at least two episodes of
severe diverticulitis with prolonged course requiring long
courses of antibiotics. Intraoperatively, an adnexal mass was
identified on the right side. This mass was attached to the
mesentery of the rectosigmoid. It required resection in
order to proceed safely with the rectosigmoid resection.
Past Medical History:
Hypertension, Anemia requiring blood transfusions, Rheumatoid
arthritis on prednisone x 6 months, Irritable bowel syndrome,
GERD, gallstones, now s/p cholecystectomy, s/p tubal ligation,
Atrial fibrillation, chronic kidney disease
Social History:
Patient denies smoking, alcohol or IV drug use. She moved here
from [**Country 3587**] 50 years ago and worked mostly factory jobs
while here. She has been retired for 7 years and currently lives
with her son and boyfriend, who takes care of her.
Family History:
Father died of leukemia, mother had DM and CAD, no h/o thoracic
aneurysm, brother died of MI at age 69, niece with breast cancer
Physical Exam:
PHYISCAL EXAM (upon discharge):
VITALS: T 98.6 HR 69 BP 116/52 RR 20 O2sat 95%RA
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist. Neck supple without lymphadenopathy.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2.
RESP: Clear to auscultation bilaterally without adventitious
sounds, but minimally decreased breath sounds anteriorly. No
wheezing, rhonchi or crackles.
ABD: obese-appearing, soft, non-tender, non-distended, with
normoactive bowel sounds. No masses or peritoneal signs.
Abdominal binder in place.
EXTR: 2+ peripheral pulses, without cyanosis, clubbing or edema.
INCISION/WOUND: clean, dry and intact with no erythema or
drainage
Pertinent Results:
[**2163-3-21**] 12:00AM BLOOD WBC-9.0 RBC-3.40* Hgb-9.4* Hct-29.1*
MCV-85 MCH-27.8 MCHC-32.5 RDW-14.6 Plt Ct-330
[**2163-3-18**] 03:53AM BLOOD PT-13.9* PTT-30.1 INR(PT)-1.2*
[**2163-3-23**] 03:25PM BLOOD Glucose-103* UreaN-12 Creat-1.3* Na-137
K-4.1 Cl-105 HCO3-24 AnGap-12
[**2163-3-21**] 06:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2163-3-23**] 03:25PM BLOOD Calcium-8.4 Phos-3.4 Mg-2.1
[**2163-3-15**] 03:04PM BLOOD TSH-2.8
[**2163-3-16**] 03:38AM BLOOD Type-ART Temp-36.8 Rates-/15 Tidal V-502
PEEP-5 FiO2-40 pO2-89 pCO2-42 pH-7.37 calTCO2-25 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU Comment-PS = 5
[**2163-3-15**] 08:43PM BLOOD Lactate-1.1
[**2163-3-15**] PORTABLE CXR: Persistently widened mediastinum with
interval shift of the trachea from the right to the midline,
concerning for ascending aortic pathology.
[**2163-3-20**] ADOMEN SUPINE & ERECT X-RAY: Three frontal views of the
supine abdomen and two of the left decubitus abdomen demonstrate
moderate, proportionate dilatation of large and small bowel with
fluid levels indicating stasis, probably due to a paralytic
ileus. There is no free intraperitoneal gas.
[**2163-3-17**] 12:32 am URINE Source: Catheter.
**FINAL REPORT [**2163-3-20**]**
URINE CULTURE (Final [**2163-3-20**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
AZTREONAM REQUESTED BY G.SATYANARAYANA ([**Numeric Identifier 38654**]).
AZTREONAM SENSITIVE sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
[**2163-3-23**] 5:18 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2163-3-24**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2163-3-24**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2163-3-20**] 8:51 am SWAB Source: abdominal wound. ABSCESS.
**FINAL REPORT [**2163-3-24**]**
GRAM STAIN (Final [**2163-3-20**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2163-3-24**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2163-3-24**]):
UNABLE TO R/O OTHER PATHOGENS DUE TO OVERGROWTH OF
SWARMING PROTEUS
SPP..
Brief Hospital Course:
The patient was transferred to the intensive care unit in the
[**Hospital Ward Name 332**] building following her operative case give some
hypotension issues. During her case, she developed a junctional
arrhythmia with hypotension and decreased urine output, and 4
liters of crystalloid were given, 1 unit of packed red cells
were given and the EBL was 300 during the case. The patient had
100 mL of urine output during the case as well. A transthoracic
echo was performed intra-op which showed decreased ventricular
filling.
NEURO/PAIN: The patient was maintained on IV pain medication in
the immediate post-operative period while in the ICU and
transitioned to PO narcotic medication with adequate pain
control on POD#8. The patient remained neurologically intact and
without change from baseline. The patient remained alert and
oriented to person, location and place.
CARDIOVASCULAR: As mentioned above, the patient had developed
intra-op hypotension requiring pressor support during the
immediate post-op period, but this was quickly weaned in the
unit POD#1. The patient was volume resuscitated with ample
crystalloids, albumen and packed red cells with good effect. She
received a total of one unit of packed red cells in the post-op
period. She had cardiac enzymes were negative in the ICU.
Cardiology was consulted and gave recommendations regarding her
rhythm and hypotension which included cardiac enzyme evaluation,
serial EKG's which were stable and blood pressure medication
recommendations. Once transferred from the ICU, hypertension
became the issue. At times she escalated to pressures of
200/100s and required multiple doses of Hydralazine and IV
Lopressor for control. By HOD#[**7-22**] she was transitioned to PO
blood pressure medication, including her home Carvedilol and
Norvasc (which she had taken in the past according to oupatient
cardiology notes) with good effect. This had stabilized on
discharge. Vitals signs were closely monitored via telemetry.
Cardiology was involved with medical decision making related to
blood pressure medications.
** Of note, the patient had a known thoracic aortic aneurysm
which was noted on previous admissions and CXR on this admission
confirmed mediastinal widening given this history. She was
encouraged to follow-up with cardiothoracic surgery with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] clinic she will need a CTA of the Torso prior to
this appointment ***
RESPIRATORY: The patient was extubated in the immediate post-op
period successfully. The patient had no episodes of desaturation
or pulmonary concerns. The patient denied cough or respiratory
symptoms. Pulse oximetry was monitored closely and the patient
maintained adequate oxygenation. The patient was given nebulized
albuterol and ipratropium given some wheezes on exam during
HOD#[**5-20**], but she had no other concerns. Incentive spirometry was
encouraged. She did have concern for a developing right lower
lobe PNA versus atelectasis initially but antibiotics resolved
these concerns.
GASTROINTESTINAL: The patient was NPO following their procedure
and transitioned to sips and a clear liquid diet on POD#[**2-17**].
Subsequently, the patient developed nausea and 300 cc of bilious
emesis on POD#3 and a nasogastric tube was placed and her diet
was withheld at that time. Serial abdominal exams were
performed. The NGT was removed and her diet was advanced on
POD#[**6-21**] when she began passing flatus and had significantly less
abdominal distention. Her diet was advanced at that time and she
was tolerating a regular diet by POD#8. The patient experienced
no further episodes of nausea or vomiting. IV fluids were
discontinued once adequate PO intake was established. Her
abdominal incisions were healing well and an abdominal binder
was maintained while she was in the hospital.
GENITOURINARY: The patient's urine output was closely monitored
in the immediate post-operative period. A Foley catheter was
placed intra-operatively and removed on POD#6, at which time the
patient was able to successfully void without issue. The
patient's intake and output was closely monitored for > 30 mL
per hour output. The patient's creatinine was stable, but
closely monitored given her chronic renal insufficiency. A
urinalysis revealed evidence of infection on HOD#3 and she was
started on Macrobid for a [**7-24**] day course. Her cultures
indicated E.coli >100,000 colonies on culture from [**2163-3-17**].
HEME: The patient's pre-op hematocrit was 26.2 and post-op it
was 24.4. The patient only required 1 unit of packed red cells
for transfusion in the ICU but serial hematocrits were obtained
and stabilized following this. The patient's coagulation profile
remained normal. The patient had no evidence of bleeding from
their incision.
ID: There were concerns for atelectasis vs. right lower lobe
pneumonia in the ICU and post-ICU period initially although she
had no pulmonary symptoms. Given her complicated case,
antibiotics were initiated in the post-op period with IV
Linezolid, Ciprofloxacin and Flagyl and these were continued
until [**2163-3-24**]. The patient's white count was stable
post-operatively and their incision was closely monitored for
any evidence of infection or erythema. The patient developed
some inferior wound erythema and fluctuance and the her incision
was opened with wet-to-dry dressing placement initially on
HOD#[**4-20**]. A wound VAC was placed on [**2163-3-21**] and later replaced on
[**2163-3-24**] given the open wound. Her wound culture on gram stain
had 1+ PMNs and no organisms with mixed bacterial flora present.
A urinalysis revealed evidence of infection on HOD#3 and she was
started on Macrobid for a [**7-24**] day course. Her cultures
indicated E.coli >100,000 colonies on culture from [**2163-3-17**].
ENDOCRINE: The patient's blood glucose was closely monitored in
the post-op period with Q6 hour glucose checks. Blood glucose
levels greater than 120 mg/dL were addressed with an insulin
sliding scale.
PROPHYLAXIS: The patient was maintained on heparin 5000 units SQ
TID for DVT/PE prophylaxis and encouraged to ambulate
immediately post-op. The patient also had sequential compression
boot devices in place during immobilization to promote
circulation. GI prophylaxis was sustained with
Protonix/Famotidine. The patient was encouraged to utilize
incentive spirometry, ambulate early and was discharged in
stable condition.
Surgical Wound/ Skin: The patient's surgical wound was noted to
be draining and on [**2163-3-20**] was opened at the bedside, a culture
was sent, and a VAC dressing was applied on [**2163-3-21**]. The VAC
dressing was changed by the surgical team on [**2163-3-24**] and the
wound base appeared clean. The wound culture was back on [**2163-3-24**]
and showed: P. aeruginosa, S. aureus, beta strep, and proteus.
Because the wound was open with VAC therapy, the patient had
received broad spectrum antibiotics and wound appeared stable
and clean no antibiotic therapy was initiated. The microbiology
lab was asked to preform susceptibilities on the proteus and if
concerning results are reported, the rehabilitation facility
will be notified. The patient was noted to have a significant
burn on her left lower arm which was present from home
preoperatively. The patient was treated with Silvadene ointment
and dry sterile gauze dressings for comfort.
Medications on Admission:
Carvedilol 25mg [**Hospital1 **]
Hyoscyamine 0.125 mg sl prn cramps
Latanoprost 0.005% 1 drop OU QHS
ASA 81mg daily
Iron 65mg daily
MVI
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day): Continue DVT
prophylaxis per rehabilitation facility protocol.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
3. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) for 5 days.
5. oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO Q6H (every 6
hours) as needed for pain for 5 days.
6. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for LUE burn: apply until burn heals,
burn aquired prior to admission.
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
9. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. nitrofurantoin (macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 7 days: Continue until
[**2163-4-1**], will complete 2 week course for urinary tract
infeciton. .
11. latanoprost 0.005 % Drops Sig: One (1) drop Ophthalmic daily
at bedtime: 1 drop OU daily at bedtime.
12. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
1. Sigmoid diverticulitis.
2. Ovarian cyst.
3. Possible Pnuemonia
4. UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a Left Sided Colectomy
for surgical management of your diverticular disease and ovarian
cyst. You have recovered from this procedure well and you are
now ready to return home. Samples from your colon were taken and
this tissue has been sent to the pathology department for
analysis. You will receive these pathology results at your
follow-up appointment. If there is an urgent need for the
surgeon to contact you [**Name2 (NI) 19605**] these results they will
contact you before this time. You have tolerated a regular diet,
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You have had a bowel
movement prior to your discharge which is acceptable, however it
is important that you have a bowel movement in the next [**3-18**]
days. After anesthesia it is not uncommon for patient??????s to have
some decrease in bowel function but your should not have
prolonged constipation. Some loose stool and passing of small
amounts of dark, old appearing blood are explected however, if
you notice that you are passing bright red blood with bowel
movments or having loose stool without improvement please call
the office or go to the emergency room if the symptoms are
severe. If you are taking narcotic pain medications there is a
risk that you will have some constipation. Please take an over
the counter stool softener such as Colace, and if the symptoms
does not improve call the office. If you have any of the
following symptoms please call the office for advice or go to
the emergency room if severe: increasing abdominal distension,
increasing abdominal pain, nausea, vomiting, inability to
tolerate food or liquids, prolonges loose stool, or
constipation.
You have a long vertical incision on your abdomen that is closed
with staples.Part of this incision was not healing which
required treatment with a VAC sponge dressing which will remain
in place and changed every three days. The staples will stay in
place until your first post-operative visit at which time they
can be removed in the clinic, most likely by the office nurse.
Please monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. [**Last Name (STitle) 1120**] or Dr. [**Last Name (STitle) **]. You may
gradually increase your activity as tolerated but clear heavy
excersise with Dr. [**Last Name (STitle) **].
You will be prescribed a small amount of the pain medication
Oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
Please make a follow-up appointment with Dr. [**Last Name (STitle) **] in 14 days
after discharge.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2163-3-30**]
3:00
Please call Dr. [**Last Name (STitle) 914**] for a follow-up appointment with him to
evaluate your known ascending arotic aneurysm. Call [**Telephone/Fax (1) 170**]
to make this appointment. * You will need a CT-angiography of
your torso before your clinic appointment. *
Completed by:[**2163-3-25**]
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16,883
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24852
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Discharge summary
|
report
|
Admission Date: [**2110-10-13**] Discharge Date: [**2110-11-19**]
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Head bleed
Major Surgical or Invasive Procedure:
intubation
NG tube placement
History of Present Illness:
87 year-old man with a history of afib on coumadin, old
stroke, HTN, rectal cancer transferred from [**Hospital3 7569**]
with
left posterior parietal bleed.
Pt was reportedly in usual health at ~2pm the day of admission
when he took a
nap. When he awoke about 4:30pm he had "difficulty talking".
Reportedly no headache, nausea or vomiting. Wife has Alzheimer's
disease, and daughter who lives with them is currently
unavailable. It is not clear if pt had any other neurological
symptoms, nor exactly how he had trouble talking. According to
medical record, pt had similar symptoms in [**Month (only) 404**], considered
"TIA" at the time. Per sons, he may also have had some trouble
understanding them when they arrived at OSH. However, he was
quite awake, and then became somewhat agitated.
At OSH, BP 209/103 on arrival, had left facial droop and
"expressive aphasia" but moved all extremities per ED note. INR
was 3.0, head CT with round posterior parietal bleed. Pt was
given 2U FFP and 10mg vitamin K sc. He was also given 4mg ativan
for agitation, loaded with 1gm dilantin, and started on
labetalol
gtt for blood pressure control, though BP remained elevated in
180s-200.
On arrival in our [**Name (NI) **], pt sleepy. Blood pressure still quite
elevated. As labetalol was titrated, pt with increased wheezing
so labetalol was stopped and pt started on nicardipine instead.
He is also getting an additional 4U FFP for INR 2.2.
Additionally, he received lasix 40 IV x1 for increased crackles
after getting the FFP. He was admitted to the ICU for BP
control and somnolence.
Past Medical History:
1. Atrial fibrillation, on coumadin
2. Embolic stroke last year. Family reports he had trouble
speaking, poor coordination and balance, but cannot tell me
where stroke was located. They deny any hemiparesis. Report he
has no residual deficits.
3. BPH s/p ablation
4. HTN
5. Rectal CA, dx'd [**2110**], s/p chemo/XRT but no resection.
He has no known mets.
Social History:
Lives with wife (who has [**Name (NI) 2481**]) and daughter.
Family History:
unknown
Physical Exam:
BP 172/107 HR 70s O2 sat 98% RA
General: Appears stated age, somnolent, snoring
HEENT: NC/AT Sclera anicteric.
Neck: Supple
Lungs: Anterolaterally with lots of upper airway sounds
CV: RRR, nl S1, S2, no murmur. 2+ carotids without bruit
Abd: Soft, nontender, normoactive bowel sounds
Extr: No edema, warm
Neurologic Examination: s/p 4mg ativan
Mental Status: Deeply somnolent, will wake to loud voice or
noxious. Opens eyes to voice. Intermittently follows commands,
will show thumb. Occasional speech in response to command,
perhaps mild dysarthria. No neglect
Cranial Nerves: Does no tblink to threat bilaterally. Pupils
equally round and reactive to light, 4 to 2 mm bilaterally,
brisk. Did not move eyes to command or spontaneously, VOR
negative. Mild right NLF flattening. Grimaces to noxious
bilaterally.
Motor: Normal bulk and tone bilaterally, fasiculations absent in
upper and lower extremities. No tremor. Unable to formally
assess
strength given mental status, but moves all 4 limbs
spontaneously
and with good strength.
Sensation: Brisk withdrawal to noxious, all 4.
Reflexes: DTRs intact biceps, decreased at right knee and at
ankles bilaterally. Toes withdrew bilaterally
Unable to assess coordination and gait given mental status.
Pertinent Results:
**Pt's MRSA and VRE screen during this admission was negative.
CBC: 5.6/42.9/141
Coags: 17.6/36.5/2.2**
Na 140 K 3.7 Cl 102 HCO3 27 BUN 15 Cr 1.0 Gluc 167
Ca 8.7 Mg 2.0 PO4 3.0
Head CT [**2110-10-12**]: ~3x5cm (over 7 slices, ~50cc) left posterior
parietal
bleed with edema and mass effect but no midline shift, no
intraventricular extension. Possible subarachnoid hemorrhage or
contusion at R temporal lobe.
Head CT [**10-14**]: unchanged; evidence of mild brain atrophy and
patchy decreased attenuation c/w microvascular angiopathy.
Head CT [**11-3**]: resolving area of hemorrhage; possible ectatic
basilar tip
MRI of brain (w/ susceptibility) [**2110-10-30**]:
This study is severely limited by motion artifact. The left
parietal hematoma measures 45 x 23 mm in size, with a thin rim
of hypointensity on gradient echo images, consistent with a
hemosiderin ring. On T1 sagittal imaging, the hematoma
demonstrate a rim of hyperintensity, with central isodense
material.
[**2110-10-18**] 11:29 pm URINE Site: CATHETER Source:
Catheter.
**FINAL REPORT [**2110-10-24**]**
URINE CULTURE (Final [**2110-10-24**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2110-11-3**] 8:48 pm URINE
**FINAL REPORT [**2110-11-5**]**
URINE CULTURE (Final [**2110-11-5**]): <10,000 organisms/ml.
[**2110-11-3**] 08:48PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019
[**2110-11-3**] 08:48PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2110-11-3**] 08:48PM URINE RBC-0-2 WBC->50 Bacteri-FEW Yeast-OCC
Epi-0-2
Brief Hospital Course:
87yo M h/o afib on coumadin, old stroke (stroke in '[**08**]; TIA in
[**11-28**] and [**1-29**]), HTN, rectal cancer s/p XRT presented w/ acute L
parietal bleed. He was admitted initially to the ICU, and
transferred to the stroke service on the neurology floor when he
became stable. His hospital course is detailed per system, as
follows:
NEURO:
Exam at OSH was notable for somnolence and expressive aphasia;
however, when awake, he appeared to follow commands and had some
fluent spontaneous speech. It was initially thought that his
hemorrhage was due to amyloid angiopathy, especially given the
location of the bleed. Alternate etiologies were also
considered such as coumadin use (INR 3.0 at admission) and
hypertension (although this would cause more lacunar infarcts).
On transfer to [**Hospital1 18**], he was admitted to the ICU for blood
pressure control (209/103), to reverse INR w/ 6 U total FFP and
10mg vit K, and for airway protection. A repeat CT on [**10-13**]
showed stable hemorrhage, and on [**10-14**], CT revealed a slight
increase w/ very small extension into the posterior [**Doctor Last Name 534**] of L
lateral ventricle. MRI of the brain was attempted, but there
was too much motion artifact for adequate interpretation.
Started seizure prophylaxis w/ dilantin - this was continued for
one month, then, with no seizure activity during that time.
A full neurological exam could not be completed until approx 2
weeks after admission as pt remained lethargic: He was found to
have UMN pattern on R side w/ strength 4-/5. He also had
dysarthria, inattentiveness, and confusion (orientation to time
and place) and sensory deficits to gross touch on R side. At
times, he was found to be conversing w/ persons not in the room.
He has had slow improvement in his attentiveness and
orientation, but son reports that after TIA in [**1-29**], pt was
similarly confused and had generalized weakness - he could not
walk or swallow. Son does not recall which region of the brain
was affected but pt had reported R hand pin and needles
sensation at that time. His confusion finally resolved and was
able to ambulate w/out assistance several months after the
stroke. From outside records ([**Hospital3 7569**]), pt has hx of
stroke in [**2108**] and TIA in [**11-28**] and [**1-29**]. There was no evidence
of hemorrhage, but his MRI showed extensive white matter
ischemic disease. His carotid duplex and TTE did not show
embolic source; he was started on coumadin in [**1-29**] for ?emboli
from his paroxysmal Afib.
He was started on thiamine and folate for ?confabulation
attributable to alcohol-induced dementia although he and his
family deny any alcohol history. Also, his sleep cycle was
reversed, so we have attempted to keep him awake during the day
by moving him to chair and by giving zyprexa 2.5mg qhs. The
issue of re-starting coumadin was addressed, and although the
risk for embolic stroke from his PAF remains elevated, the
possibility of another ICH on coumadin was more concerning. His
mental status waxed and waned during the admission; some days he
could follow commands including "raise your arms" and "close
your eyes." He occasionally verbalized and at one point
remembered (from redirection minutes before) that he was in a
hospital, but at other times said "I don't know" to "where are
you now?" Other times he did not speak at all. At his best, he
can say several words and [**2-27**] word sentences at times, but his
exam varies greatly depending on time of day and physical state.
Often, when seen by the team in the morning, he appeared
"frozen," staring forward with his mouth open (and usually quite
dry) with heavy breathing; two hours later, when seen on rounds,
he would be responsive to questions. This was thought to be
potentially related to EPS from Zyprexa, and this was
discontinued. On one occasion, he was seen by the team and
appeared to be staring to the right with head devation to the
right, blinking, mouth open; although he was responsive to
noxious stimuli (with grimace and moan) he did not respond to
any verbal stimuli. This was felt to be due to possible seizure
activity (now that he was off dilantin). He was given ativan,
and dilantin loaded, with a post-load level in the range of 14
and with a level of 7.0 the following morning, corrected to 11.4
by albumin, prior to maintenance dosing of dilantin 100 mg tid.
Levels should checked by rehab within one week of arrival, and
dose increased or decreased accordingly. An EEG was performed
on [**11-17**] which revealed: "mild to moderate diffuse
encephalopathy manifest mainly by the slowing of the background
frequency. There is also higher voltage potential epileptiform
activity in the form of sharp theta activity seen over the
frontal central regions. It, however, was not organized nor did
it evolve throughout the record but remained as a fairly fixed
finding. In addition, there is a cardiac arrhythmia." He was
continued on dilantin and had no recurrence of activity
suspicious for seizures.
CV:
Pt's BP at OSH was 209/103; by the time he arrived at [**Hospital1 18**], his
SBP was 180s to 190s. He was given labetolol to control his BP,
but was d/c'd for subsequent wheezing. He was transferred to
the ICU on nicardipine drip which helped to decrease his BP to
the 130s - 140s. He was switched to lisinopril and metoprolol
(pt was on lisinopril and atenolol prior to admission), and his
BP dropped down to high 90s. Eventually, the ACEI was
discontinued, and later the BB was also stopped for BP in low
100s. He has had documented low BP on anti-hypertensives in the
past. Currently, pt in PAF w/ BP in 110s and receiving daily
aspirin.
RESP:
CXR initially showed mild pulmonary edema; was intubated for
?agitation and somnolence on [**10-14**]. ?LLL infiltrate, was started
on Levofloxacin [**10-15**] and completed a 7 day course. On [**10-21**], CXR
showed multifocal infiltrates c/w aspiration PNA after emesis
[**10-20**]. Extubated [**10-24**] and satting well (99%) on RA. After
transfer to step-down, notable for multiple episodes of apnea
while sleeping ([**3-6**] minute intervals lasting approx 15 seconds
each). Likely [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing - pt's O2 sat remained
99% during these episodes. He has no noted hx of OSA, but his
symptoms were c/w this diagnosis. Last CXR on [**11-3**] suggested
resolution of both his pulmonary edema and aspiration pneumonia.
On 10/24th, several days after he had been tolerating tube
feeds, he was found to have a low grade temperature and a cough.
Chest xray at that time showed a new left lower lobe
infiltrate. A repeat chest xray performed later that night for
vomiting tube feeds showed some resolution of the former left
lower lobe opacity, which was now being called "atelectasis."
However, the patient's symptoms suggested new pneumonia, and he
was started on Levaquin and Flagyl (initially Vancomycin, which
was discontinued after two doses) to target gram negative and
anaerobic pathogens. He is allergic to penicillins. His sats
remained in the high 90s (97-100%) both on room air and 2L O2.
Head of the bed was kept elevated at 45 degrees at all times to
prevent recurrence of what seemed to be a likely aspiration.
His breathing pattern on [**11-18**] seemed to suggest a recurrence of
[**Last Name (un) 6055**]-[**Doctor Last Name **], with high sats once again. This was monitored
clinically and pulse-ox was checked frequently and was in the
mid-to high nineties.
FEN/GI:
Pt was somnolent; therefore, NG tube placed for enteral feeds,
which was well-tolerated. He failed the first swallow eval on
[**10-29**], and also failed the most recent eval w/ video swallow on
[**11-7**]. However, he had some improvement during this interval -
he can now tolerate very small sips w/o coughing. A Dobhoff was
re-inserted (after pt pulled out NG on [**11-5**]) on [**11-7**] to ensure
adequate nutrition until his swallow function can be
re-evaluated in the next week or so. Repeated evaluations of
swallow function, both at the bedside and by video showed no
improvement. He had difficulty (or possibly reluctance) pushing
the food bolus to the posterior oropharynx. NG tubes were
repeatedly inserted and pulled by the patient during moments of
confusion or discomfort. His family discussed feeding options
and decided to pursue PEG tube placement. GI was consulted and
PEG was inserted on [**11-14**]. The patient tolerated the procedure
well, and GI recommended daily dressing changes, binding wound
so the patient does not remove the tube, and starting feeds on
[**11-15**]; feeds were started, and he tolerated the feeds well and
free water flushes. On [**11-17**] he vomited his tube feeds once,
but did well when they were restarted at a low dose.
ID:
Pt was started on Levaquin [**10-15**] - [**10-21**] for question of
aspiration pneumonia - now resolved. Additionally, urine grew
proteus mirabilis resistant to Levaquin and antibiotics were
changed to Trimethoprim [**10-21**] by the ICU team. A repeat U/A on
[**10-29**] showed that he still had infection, now resistant to
Bactrim. He received 2 doses of ceftriaxone prior to his last
U/A on [**11-3**] which showed resolution of his UTI. He continues
to have >50 WBC which may reflect chronic inflammation from XRT
and TUNA for rectal CA and BPH, respectively. On [**11-11**] he
spiked a temperature of 101, but no clear source was identified.
UA was negative, and blood cultures were negative as well.
Once again on [**11-17**] he had a low grade temperature and cough;
cxr suggested pneumonia and he was treated with Levaquin and
Flagyl for aspiration risk and lower suspicion resistant
nosocomial pneumonia. UA was negative at the time.
RENAL:
Initially, he had an increased BUN to 43, which has since been
normal or only mildly elevated. Creatinine has been normal, thus
this was not considered related to intrinsic renal disease.
Since then, electrolytes have stable, with signs of mild
dehydration whenever his NG Tube has been out for more than one
day. We suggest that if tube feeds are held for any reason, his
midline (access) should be used for gentle hydration.
HEME:
Initially, INR was 3.0 at OSH - he had not had regular INR
checks. He was noted to bleed easily in the past by the
urologists who evaluated him for hematuria. However, he was
continued on both coumadin and aspirin for PAF and stroke
prevention. On admission, he was given FFP and vitamin K for
full reversal to INR 1.3 on [**10-13**]. His urine was positive for
blood (x2), but his Hct remained stable and hematuria was
attributed to manipulation of his bladder previously. Coumadin
was not restarted at the time of discharge, because of the
intraparenchymal brain hemorrhage. If this is to be restarted,
risks and benefits should be considered.
Prophylaxis - Pneumoboots, Protonix, SC heparin, colace were
instituted throughout the admission.
Dispo - acute rehab followed by transfer to [**Hospital6 46972**]
per family and PCP's request.
DNR - discussed w/ family - HCP.
Medications on Admission:
Atenolol 25mg [**Hospital1 **]
coumadin 5mg qd
lisinopril 10mg qd
prilosec 20mg qd
FeSo4 325mg qd
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day: by PEG tube.
2. Ipratropium Bromide 18 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed.
3. Clotrimazole 10 mg Troche [**Last Name (STitle) **]: One (1) Troche Mucous membrane
QID (4 times a day).
4. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
7. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
8. Multi-Vitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
9. Phenytoin 100 mg/4 mL Suspension [**Last Name (STitle) **]: One (1) PO Q8H (every
8 hours).
10. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed for agitation.
11. Metronidazole 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3
times a day) for 5 days.
12. Levofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
left posterior parietal lobe hemorrhage
aspiration pneumonia
urinary tract infection
prior stroke, multiple TIAs
hypertension
atrial fibrillation
h/o rectal cancer
Discharge Condition:
stable, intermittently confused
Discharge Instructions:
Mr. [**Known lastname 15499**] has had new bleeding in your brain that could occur
again should he take coumadin. You will not take this medication
again unless your doctor advises you to restart it.
Please check a dilantin level in one week.
Followup Instructions:
Please follow-up as the staff at rehab arranges for you. You
should see your neurologist after you are discharged from rehab.
You should also follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27542**].
Follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] (neurology at [**Hospital1 1535**]) in [**3-30**] months; rehab facility
or family should call to make an appointment. ([**Telephone/Fax (1) 7394**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2110-11-19**]
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56,549
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41908
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Discharge summary
|
report
|
Admission Date: [**2179-11-20**] Discharge Date: [**2179-11-27**]
Date of Birth: [**2097-4-20**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Confusion, headache, speech difficulties
Major Surgical or Invasive Procedure:
intubation at previous hospital and extubation
History of Present Illness:
82M with PMH of right cerebellar stroke with no residual
deficits, CAD s/p CABGx5. T2DM, HTN, HLD presents as intubated
transfer from OSH with L temporal ICH without mass effect.
Patient was in his usual state of health until am of [**11-20**] when
he had slept on eth sofa overnight and on waking was sitting in
the chair and wife found him to be pale and did not feel
himself. He had no recent falls or head injury. He had also
vomited at some point overnight with vomitus on the floor beside
the sofa
but had not recalled that he had done this. He then got up to
have lunch and was noted to be confused and was clutching his
head due to headache. He then at one point attempted to drink a
cup of soapy dish water and then at one point thought he was
holding a cup although he was not. His wife called EMS and by
this point, his speech had deteriorated to only be able to say
"yes" as a response.
He was taken to OSH where he was noted to be markedly
hypertensive initially in 190s and then lattterly as high as
249/90. He was given labetalol which transiently decreased his
BP and was intubated with etomidate/midazfor airway protection
with no documented worsening GCS for [**Location (un) **]. Prior to
intubbation
OSH documentation states moving all 4 extremities and GCS 13 E3
V4 M6 with good power and no particular decline of mental status
noted.
At [**Hospital1 18**] he was intubated and markedly hypertensive with SBP
200s, started on propofol and nicardipine infusion which
decreased SBP to 170s. He was spontaneously moving all 4 limbs
and moving his head, resisting eye opening.
Past Medical History:
T2DM on oral meds
HTN
HLD
CAD s/p CABG
Previous stroke with no residual deficit [**2166**]/99 where he was
noted to be dizzy and incoordinated. Old right cerebellar
infarct
is currently present on CT.
Past Surgical History:
CABGx5
Hernia op many years ago
Social History:
Lives with wife. Retired [**Name2 (NI) 90999**]. Uses cane to mobilise
Never smoked. Minimal alcohol. No illicits
Family History:
Mother - stroke in 80s
Father - died CAD
Only child
Physical Exam:
Initial Exam:
Vitals: T: 100.1 P: 50 SR R: 15 on vent BP: Initially 206/60
then
after nicardipine 176/56 SaO2: 100% on 100% vent
CMV f 14 Vt500
General: Intubated oving all 4 limbs spontaneously. Moving head
and forecfully closing eyes.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally save decreased BS right base
Cardiac: RRR, HS 1+2+ loud ESM ? loudset at aortic area but
presnet throughout praecordium and radiates to carotids no R/G
noted
Abdomen: soft, ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C bilaterally. Mild pitting edema to mid shn
1+
bilaterally. 2+ radial, DP pulses on right easily palpable and
PT
on left. Good cap refill. Calves soft.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: GCS E2 (resisting eye opening) VT M4-5 in UE
Intubated, sedated and ventilated. Will grimmace to pain. No
tracking. Movving all 4 limmbs spontaneously.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Funduscopic exam revealed no
papilledema.
III, IV, VI: No spontaneous eye movements.
V: Unable to assess
VII: No facial droop, facial musculature symmetric intubbated.
VIII: Unable to assess.
IX, X: Good gag and cough.
[**Doctor First Name 81**]: Not assessed.
XII: Not assessed.
-Motor: Normal bulk, tone throughout.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Moving all 4 limbs spontaneously perhaps right less than left.
Withdraws to pain in both LE and flexes in RUE and almmost
localises in LUE.
-Sensory: Grimaces and withdraws all 4 limbs.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2+ 2+ 2+ 3 1
R 2+ 2+ 2+ 3 1
Reflexes brisk throughoutt save ankle jerks.
Plantar response was equivocal on left and prob extensor on
right.
Discharge Exam:
Awake and alert, communicative. A+Ox3. Some memory difficulty
[**2-11**] at 5 minutes. Good strength all 4 limbs, weaker on the
right. Extensor plantar on right. PERRL. Receptive aphasia with
more problems with body parts. At times perseverative. Follows
simple, not complex commands.
Able to walk independently with walker (w/ supervision)
Pertinent Results:
Admission Labs:
[**2179-11-20**] 04:47PM TYPE-ART TIDAL VOL-500 O2-100 PO2-429*
PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-1 AADO2-243 REQ O2-48
-ASSIST/CON INTUBATED-INTUBATED
[**2179-11-20**] 03:30PM GLUCOSE-285* UREA N-28* CREAT-1.1 SODIUM-138
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
[**2179-11-20**] 03:30PM WBC-5.3 RBC-4.45* HGB-12.6* HCT-38.2* MCV-86
MCH-28.3 MCHC-33.0 RDW-13.2
[**2179-11-20**] 03:30PM PLT COUNT-127*
[**2179-11-20**] 03:30PM PT-13.2 PTT-21.0* INR(PT)-1.1
[**2179-11-20**] 03:30PM ALBUMIN-4.1 CALCIUM-8.8 PHOSPHATE-3.8
MAGNESIUM-2.0
Urine:
[**2179-11-20**] 07:38PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Other Pertinent Labs:
[**2179-11-20**] 09:52PM CK(CPK)-96
[**2179-11-20**] 09:52PM CK-MB-4 cTropnT-0.02*
[**2179-11-20**] 03:30PM ALT(SGPT)-13 AST(SGOT)-24 ALK PHOS-46 TOT
BILI-0.9
[**2179-11-20**] 03:30PM cTropnT-0.01
[**2179-11-20**] 03:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Labs at discharge:
[**2179-11-24**] 05:05AM BLOOD WBC-5.6 RBC-4.45* Hgb-12.5* Hct-38.4*
MCV-86 MCH-28.0 MCHC-32.4 RDW-13.1 Plt Ct-164
[**2179-11-24**] 05:05AM BLOOD Plt Ct-164
[**2179-11-24**] 05:05AM BLOOD PT-12.3 PTT-24.6 INR(PT)-1.0
[**2179-11-24**] 05:05AM BLOOD Glucose-187* UreaN-23* Creat-1.0 Na-145
K-3.2* Cl-106 HCO3-28 AnGap-14
[**2179-11-22**] 03:05AM BLOOD CK(CPK)-389*
[**2179-11-24**] 05:05AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.1
Imaging:
[**2179-11-20**] CT HEAD W/O CONTRAST
FINDINGS: A 2.3 x 0.9 cm oblong left temporal intra-axial
hematoma is
redemonstrated, with minimal peripheral rim of edema, unchanged
as compared to the preceding reference examination. There is no
significant mass effect, edema, or shift of normally midline
structures. A large area of right cerebellar encephalomalacia is
again noted. The [**Doctor Last Name 352**]-white matter
differentiation elsewhere in the brain appears maintained.
Ventricles and
sulci are prominent, compatible with age-related involution.
Periventricular white matter hypoattenuation is consistent with
small vessel ischemic disease. Suprasellar and basilar cisterns
are patent.
With the exception of minimal ethmoidal air cell and posterior
right maxillary mucosal thickening, paranasal sinuses and
mastoid air cells are well aerated. Vascular calcifications are
seen in cavernous carotid arteries and right vertebral artery.
The globes and soft tissues are unremarkable.
IMPRESSION:
1. Stable left temporal hematoma with minimal peripheral edema
and no
significant mass effect, midline shift, or herniation.
2. No new focal intra-axial or extra-axial hemorrhage.
3. Right cerebellar encephalomalacia.
4. Age-related involution and small vessel ischemic disease.
5. Ethmoidal and right maxillary sinus disease, mild.
[**2179-11-21**] CT HEAD W/O CONTRAST
FINDINGS: Again seen is a 2.3 x 1 cm ovoid hyperdensity in the
left temporal lobe, compatible with acute hemorrhage. There is
surrounding rim of vasogenic edema, with effacement of regional
sulci. There is no significant shift of the normal midline
structures.
Severe global atrophy persists, with prominent ventricles and
sulci.
Periventricular and subcortical white matter hypodensities
reflect small
vessel ischemic disease. There are dense calcifications in the
bilateral
cavernous carotid arteries and vertebral arteries. Again noted
is a large
area of encephalomalacia in the right lateral cerebellum,
reflecting remote infarct.
Minimal mucosal thickening persists in the ethmoid and maxillary
sinuses.
Middle ear cavities and mastoid air cells are clear. Note is
made of
disconjugate gaze/strabismus.
IMPRESSION:
1. Stable left temporal hematoma.
2. Severe global atrophy and right cerebellar encephalomalacia.
[**2179-11-22**] ECHO
IMPRESSION: Mild aortic stenosis. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Dilated thoracic aorta.
Pulmonary artery hypertension.
CLINICAL IMPLICATIONS:
The patient has mild aortic valve stenosis. Based on [**2174**]
ACC/AHA Valvular Heart Disease Guidelines, a follow-up
echocardiogram is suggested in 3 years.
[**2179-11-22**] MRI head:
Again seen is an acute-early subacute hematoma in the left
temporal
lobe with surrounding edema. The study is limited because of
extensive motion artifacts. Within these limitations, there are
no other foci of abnormal susceptibility seen. There is no acute
intracranial infarction. Assessment of diffusion abnormality in
the hematoma/vicinity is confounded by the presence of blood
products.
A moderate sized area of encephalomalacia is again seen in the
right
lateral cerebellum with foci of abnormal susceptibility
suggestive of remote infarction with mineralization. Diffuse
prominence of ventricles and sulci are consistent with volume
loss. There are multiple confluent periventricular
hyperintensities seen likely representing small vessel ischemic
disease. Major intracranial flow voids are preserved.
[**2179-11-20**] ECG:
Sinus bradycardia with first degree A-V delay. Left atrial
abnormality.
Intraventricular conduction delay of the left bundle-branch
block type.
Left axis deviation. Prominent U waves in the anterior
precordial leads.
Consider hypokalemia. No previous tracing available for
comparison.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
56 [**Telephone/Fax (3) 91000**]/495 53 -52 111
[**2179-11-21**] ECG:
Probable sinus rhythm with frequent atrial premature beats and
first degree A-V delay. Baseline artifact. Intraventricular
conduction delay of the left bundle-branch block type. Left axis
deviation. Compared to tracing #2 lateral T wave changes are
less prominent. There is now frequent atrial ectopy and the rate
is faster.
TRACING #3
Intervals Axes
Rate PR QRS QT/QTc P QRS T
69 332 144 460/475 94 -56 118
[**2179-11-21**] ECG:
Sinus bradycardia. Compared to tracing #1 the P-R interval is
shorter.
Anterolateral T wave inversions are more prominent and U waves
are less
pronounced. The other findings are similar.
TRACING #2
Intervals Axes
Rate PR QRS QT/QTc P QRS T
47 188 142 558/535 86 -58 -167
[**2179-11-20**] Chest Xray:
FINDINGS: There is an orogastric tube whose side port is above
the GE
junction. This could be advanced 5-10 cm for more optimal
placement. The
endotracheal tube is at the level of the aortic knob
appropriately sited.
There is some coarsening of bronchovascular markings without
overt pulmonary edema, focal consolidation or pleural effusions.
No pneumothoraces are seen.
Brief Hospital Course:
82 RHM with PMH of right cerebellar stroke with no residual
deficits, CAD s/p CABGx5. T2DM, HTN, HLD presents as intubated
transfer from OSH with L temporal ICH without mass effect.
Patient had been confused at admission (OSH), with headache and
vomiting; in addition to visuospatial deficit and considerable
speech problems, latterly with perseveration and on arrival to
OSH was markedly hypertensive up to SBP 240s. CT showed a left
temporal 2.5x1.2cm hemorrhage without significant mass effect or
edema and no intraventricular extension and hypodensity in R
cerebellum in keeping with old infarct. He was given labetalol
and intubated for airway protection for [**Location (un) **]. Prior to this
OSH documentation states moving all 4 extremities and GCS 13 E3
V4 M6 with good power.
At [**Hospital1 18**] he arrived intubated and markedly hypertensive, started
on propofol and nicardipine infusion which decreased SBP 200s to
170s. Repeat CTs were stable at [**Hospital1 18**]. Patient was weaned off
nicardipine infusion and extubated on [**11-21**]. MRI w and w/o
contrast showed left temporal hematoma- acute-early subacute,
with mild surrounding edema and no definite underlying enhancing
lesion seen and old right cerebellar stroke. Etiology likely
amyloid. Patient was hypertensive and was transitioned to home
anti-HTN but transfer to floor had to be delayed due to
persistent hypertension. Added and uptitrated hydral and
amlodipine and transferring to the floor [**11-23**].
He persisted hypertensive, Metoprolol was increased to 25 mg tid
however concerns for bradycardia led to stopping betablockers.
Neurologic deficit significantly improved, awake and alert,
communicative. A+Ox3. Poor memory for recent events. Good
strength all 4 limbs, weaker on the right.
On discharge his BP were better controlled with SBP 140s. His
blood glucose was less well controlled and he will be restarting
glipizide 10mg [**Hospital1 **] (outpt medication) in addition to insulin
sliding scale.
He did not have pain or headache on discharge.
=
=
=
=
=
=
=
=
=
=
=
================================================================
.
Transitional issues:
1. Intraparenchymal hemorrhage: likely [**2-10**] amyloid. He will need
tighter control of his modifiable risk factors including BP,
blood glucose, dyslipidemia. He will be discharged with his home
dose stating, BP meds and glipizide with insulin Sliding scale.
He will continue on aspirin 81mg. He will have follow up with
Neurology in [**6-16**] weeks.
Medications on Admission:
Glipizidde 10mg [**Hospital1 **]
Valsartan 320mg qd
Clonnidine 0.2mg [**Hospital1 **]
Simvastatin 40mg qd
Aspirin ? dose qd
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. insulin regular human 100 unit/mL Solution Sig: see below
units Injection qACHS: please administer sliding scale insulin
for FS >150 qACHS.
6. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Pavilion - [**Location (un) **]
Discharge Diagnosis:
left temporal intraparenchymal hemorrhage
amyloid angiopathy
hypertensive emergency
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro: ao x [**2-11**]; language is fluent with intact naming. follows
simple but not complex commands. Sundowns at night. Gait is
unsteady.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you during your hospital stay.
You were admitted to the hospital for evaluation of confusion
and speech troubles. You were found to have a small bleed in the
left side of your brain in the temporal lobe. The etiology of
the bleed is most likely due to a condition called amyloid
angiopathy, which means that the blood vessels in your head are
more likely to bleed. Your blood pressure was very high when you
first arrived at the hospital and sometimes very high blood
pressures can also cause brain blood vessels to bleed.
It is very important for you to try to keep your blood pressure
under control. We have started one new blood pressure medication
during your stay and continued your previous medications.
Medication changes:
STARTED AMLODIPINE 10MG by mouth DAILY
RESTART GLIPIZIDE 10mg on discharge and continue insulin sliding
scale
Please continue taking all your previous medications including
aspirin 81mg, valsartan 320mg po daily, clonidine 0.2mg po bid,
simvastatin 40mg po daily.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in the [**Hospital 18**] [**Hospital 878**] clinic,
you have an appointment on [**2180-1-5**] at 1:30 pm. The
clinic is located on the [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) **]. Phone:[**Telephone/Fax (1) 657**].
Before you go to your appointment you have to ask your PCP for
an insurance referal.
Also, call registration (phone: [**Telephone/Fax (1) 10676**]) to update your
information.
|
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|
2328, 2444
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,476
| 104,434
|
7356
|
Discharge summary
|
report
|
Admission Date: [**2173-4-9**] Discharge Date: [**2173-4-13**]
Date of Birth: [**2089-12-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lipitor / Nembutal Sodium / Zocor / Lescol / Midazolam
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Exertional angina
Major Surgical or Invasive Procedure:
[**2173-4-9**] Coronary artery bypass grafting x4:
1. Left internal mammary artery grafted to the left
anterior descending artery.
2. Reverse saphenous vein graft to the posterior descending
artery of the right.
3. Reverse saphenous vein graft to the first obtuse
marginal branch of the circumflex.
4. Reverse saphenous vein graft to the first diagonal
branch of the left anterior descending.
History of Present Illness:
83 year old male with prior negative exercise stress test in
[**2163**], now presents with one month history of increasing
exertional angina, relieved by rest. Had positive exercise
stress test in [**Month (only) **] and underwent cardiac catherization that
revealed coronary artery disease.
Past Medical History:
hypertension
dyslipidemia
anxiety
gastroesophageal reflux disease
benign prostatic hypertrophy
osteoarthritis
history of renal calculi
history of concussion secondary to motor vehicle accident in
[**2162**]
s/p tonsillectomy
Social History:
Retired
ETOH no in last 10years
Tobacco denies
Widow, lives with son
Family History:
Father deceased at 82 myocardial infarction
Physical Exam:
HR 64, 144/82, 63.5kg
General no acute distress, thin
Skin multiple nevi/moles throughout chest and back
HEENT PERRLA, EOMI, anicteric sclera, oral pharynx unremarkable
Neck supple full range of motion
Chest clear to ausculation bilaterally
Heart regular no murmur
Abdomen soft, non tender, nondistended, + bowel sounds, no
heptamegaly
extremities warm well perfused no edema
Bilateral lower extremity spider veins
Neurological grossly intact moves all extremities, 5/5 strength
non focal exam
Pulses femoral +2, DP +2, PT +2, radial +2 no carotid bruits
Pertinent Results:
[**2173-4-12**] 06:35AM BLOOD WBC-13.6* RBC-3.35* Hgb-10.5* Hct-30.5*
MCV-91 MCH-31.4 MCHC-34.5 RDW-13.4 Plt Ct-133*
[**2173-4-9**] 01:21PM BLOOD WBC-9.4 RBC-3.05*# Hgb-9.2*# Hct-27.8*#
MCV-91 MCH-30.3 MCHC-33.3 RDW-13.1 Plt Ct-131*
[**2173-4-12**] 06:35AM BLOOD Plt Ct-133*
[**2173-4-9**] 02:39PM BLOOD PT-15.4* PTT-33.3 INR(PT)-1.4*
[**2173-4-12**] 06:35AM BLOOD UreaN-20 Creat-1.2 K-3.8
[**2173-4-9**] 02:39PM BLOOD UreaN-14 Creat-0.8 Cl-109* HCO3-25
PA AND LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: SP CABG.
Comparison is made to prior study performed on [**4-10**].
Small left hydropneumothorax is still present. There is mild
right pleural
effusion. Mild basilar atelectasis has minimally improved and
greater on the
right side. Moderate degenerative changes are in the thoracic
spine. Sternal
wires are aligned. There is no pulmonary edema.
EKG
Sinus bradycardia. Indeterminate QRS axis. Low voltage in the
limb leads.
Probable inferior wall myocardial infarction of indeterminate
age. Right
bundle-branch block. There is slight QTc interval prolongation.
Compared to the
previous tracing of [**2173-4-1**] a right bundle-branch block
morphology is now
present with associated QRS widening and QRS voltage is also
slightly lower.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
58 154 116 446/442 20 0 3
[**Known lastname 27115**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 27116**] (Complete)
Done [**2173-4-9**] at 11:44:40 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: [**2089-12-18**]
Age (years): 83 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 745.5, 440.0, 424.0, 424.3, 424.2
Test Information
Date/Time: [**2173-4-9**] at 11:44 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW4-: Machine: AW1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.9 cm <= 4.0 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 70% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 1.9 cm
Mitral Valve - Mean Gradient: 1 mm Hg
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA
ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mild spontaneous echo contrast
in the body of the RA. No spontaneous echo contrast or thrombus
in the body of the RA or RAA. A catheter or pacing wire is seen
in the RA and extending into the RV. Aneurysmal interatrial
septum. PFO is present.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness, cavity size,
and global systolic function (LVEF>55%).
RIGHT VENTRICLE: Dilated RV cavity. Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Focal calcifications in ascending aorta. Simple atheroma in
aortic arch. Normal descending aorta diameter. Simple atheroma
in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**11-20**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Significant 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. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE BYPASS The left atrium is moderately dilated. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. Mild spontaneous echo contrast is seen in the
body of the right atrium. No thrombus is seen in the body of the
right atrium or the right atrial appendage. The interatrial
septum is aneurysmal. A patent foramen ovale is likely present.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). The right ventricular
cavity is dilated with normal free wall contractility. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. Mild to
moderate pulmonic regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in
the operating room at the time of the study.
POST BYPASS Normal biventricular systolic function. Mitral
regurgitation may be slightly worse. Likely PFO remains.
Thoracic aorta appears intact. No other changes from pre-bypass
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Brief Hospital Course:
Admitted same day and went to operating room for coronary artery
bypass graft surgery. Please see operative report for further
details. He received cefazolin for perioperative antibiotics.
He was transferred to the intensive care unit for hemodynamic
management. In the first 24 hours he required vasoactive
medications and fluids for hemodynamic management. He was also
weaned from sedation, awoke neurologically intact and was
extubated without complications. On post operative day one he
was started on lasix and betablockers. He was transfered to the
post op floor the remainder of his stay. Physical therapy
worked with him on strength and mobility. On post operative day
two he had short episode of atrial fibrillation which he
converted back to sinus rhythm without intervention, but
betablockers were increased for heart rate control. He was ready
for discharge home on post operative day four with services.
Started on crestor and to follow up with Dr [**Last Name (STitle) 27117**].
Medications on Admission:
Aspirin 81 mg daily
Atenolol 25 mg daily
NTG sl prn
Norvasc 5 mg daily
Xanax 0.125 mg prn
Protonix prn
Tylenol ES prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 3 days.
Disp:*3 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Crestor 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Xanax 0.25 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed
for anxiety .
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease s/p CABG
post operative atrial fibrillation
hypertension
dyslipidemia
anxiety
gastroesophageal reflux disease
benign prostatic hypertrophy
osteoarthritis
history of renal calculi
history of concussion secondary to motor vehicle accident in
[**2162**]
s/p tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in [**12-22**] weeks at [**Hospital1 **] heart center [**Telephone/Fax (2) 6256**]
please call to schedule appointment
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] please call for appointment
Dr [**Last Name (STitle) 3659**] in [**12-22**] weeks ([**Telephone/Fax (1) 6256**]) please call for
appointment
Completed by:[**2173-4-13**]
|
[
"997.1",
"401.9",
"427.31",
"E879.9",
"715.00",
"414.01",
"413.9",
"300.00",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.63",
"39.61",
"36.13",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10349, 10408
|
8053, 9055
|
339, 750
|
10745, 10752
|
2060, 8030
|
11263, 11653
|
1423, 1468
|
9224, 10326
|
10429, 10724
|
9081, 9201
|
10776, 11240
|
1483, 2041
|
282, 301
|
778, 1072
|
1094, 1321
|
1337, 1407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,929
| 117,147
|
4972
|
Discharge summary
|
report
|
Admission Date: [**2141-5-19**] Discharge Date: [**2141-5-25**]
Date of Birth: [**2083-10-25**] Sex: M
Service: [**Doctor Last Name 1181**]
CHIEF COMPLAINT: The patient was referred from outside
hospital for further management of hypoglycemia, acute on
chronic renal failure, and fever of unknown origin.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old man
who presents to the [**Hospital **] Hospital on [**2141-5-18**] after
being found unresponsive by his wife. By report, the patient
awoke feeling poorly and had one episode of emesis on the
date of admission. His temperature at that time was 102
degrees (of note the patient has had a long history of fever
of unknown origin with an extensive workup including
fluoroscopic lung [**Year (4 digits) **]).
The patient was found by his wife unresponsive after she left
the house to run errands and returned approximately 90
minutes later, he was diaphoretic as well.
When the EMS arrived in his home, he had one further episode
of emesis, was cyanotic, and had good pulses. His
fingerstick blood glucose was 17. He received one ampule of
dextrose 50.
The patient was intubated upon arrival to [**Hospital **] Hospital,
and was still unresponsive despite fingerstick blood glucose
of 170. Computed tomography of the head was unrevealing at
that time. He was admitted to the Intensive Care Unit and
was extubated. He was restless, complained of abdominal pain
(but had a benign examination), and had a desaturation of a
pulse oxygen to 88% on 100% nonrebreather face mask, and he
was reintubated. The patient received stress dose of
steroids as he is on chronic prednisone for his transplant.
His BNP was found to be markedly elevated, and he was given a
dose of intravenous furosemide.
He was started on Unasyn for aspiration pneumonia and had
blood and urine cultures attained as well. He was started on
Heparin intravenously for a deep venous thrombosis of his leg
as his INR was found to be subtherapeutic.
PAST MEDICAL HISTORY:
1. Type 1 diabetes complicated by triopathy.
2. End-stage renal disease status post transplant from a
living related donor in [**2130**] complicated by rejection and
transient dialysis for two months. He is now currently off
dialysis. His baseline creatinine is approximately 5.0.
3. Coronary artery disease status post myocardial infarction.
He has a stent in the left anterior descending artery placed
in [**2139-10-10**].
4. Congestive heart failure with a diastolic dysfunction and
an ejection fraction of 45%.
5. History of empyema status post VATS.
6. Recurrent pneumonias.
7. History of Clostridium difficile colitis.
8. Multiple myeloma.
9. Blindness OD.
10. History of FEO with extensive workup.
11. Obstructive-sleep apnea, wears CPAP at night.
12. History of deep venous thrombosis of the left thigh
currently on warfarin.
13. History of Barrett's esophagus.
14. History of bacteremia and septic emboli with
Staphylococcus aureus.
ALLERGIES: Dicloxacillin causes nausea and vomiting.
Compazine causes hallucinations.
MEDICATIONS ON TRANSFER:
1. Unasyn 1.5 grams every 24 hours.
2. Protonix 40 mg IV every 24 hours.
3. Erythropoietin 20,000 units twice weekly.
4. Niferex 150 mg [**Hospital1 **].
5. Aspirin 325 mg daily.
6. Heparin intravenously.
7. Versed and Fentanyl sedation.
8. Decadron 2 mg IV every eight hours.
9. Metoprolol 25 mg every six hours.
10. Insulin glargine and regular insulin-sliding scale.
EXAMINATION: Temperature 96.0, heart rate 72, blood pressure
136/50, respiratory rate 16, and oxygen saturation of 96%.
Fingerstick glucose 233. Generally, opening eyes following
commands with encouragement. Neck: No jugular venous
distention. Heart: Normal S1, S2, 1/6 systolic murmur, no
S3, S4. Lungs are clear to auscultation bilaterally.
Abdomen: Normal bowel sounds, soft, nontender, nondistended,
slightly obese. Extremities: No rash, no clubbing,
cyanosis, or edema, +2 dorsalis pedis pulses. Neurologic:
Essentially unresponsive, he opens his eyes briefly and moves
all extremities on command.
LABORATORY VALUES ON PRESENTATION: White blood cell count
7.1, hematocrit 29, platelets 149. Chemistry panel is
significant for increase in BUN to 113 and creatinine to 6.5.
INR was 1.5.
LABORATORY EVALUATION AT THE OUTSIDE HOSPITAL: He had a
computed tomograph of the head which was not revealing in
terms of acute hemorrhage and a chest x-ray on [**5-18**] showing
fluffy alveolar and interstitial markings consistent with
congestive heart failure. He had an abdominal computer
tomograph on [**5-18**] as well, which showed multiple nonspecific
pretracheal and mediastinal lymph nodes, extensive
consolidation throughout both lung fields. Nodular lesions
were also seen in the right upper lobe, cardiomegaly, large
dilated gallbladder, and a density in the right transplanted
kidney, hematoma versus cyst was on the differential.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit. We were following 1.5 days. The patient self
extubated (i.e., the patient pulled the orotracheal tube
himself. He complained of some throat pain on several days
following extubation. His palate elevated symmetrically.
Computed tomography of the neck did not reveal a hematoma or
airway narrowing).
He underwent minor changes to his insulin scale specifically
increasing his glargine dose in the evenings as his
fingerstick blood glucose in the hospital ran as high as 300.
There was no evidence of ketoacidosis.
Pneumonia was treated initially with levofloxacin and
metronidazole. However, a sputum culture revealed
methicillin-resistant Staphylococcus aureus. Levofloxacin
was discontinued, Vancomycin intravenously was administered
(dose was 750 mg intravenously every 48 hours).
The patient's oxygen requirement decreased such that he was
able to breathe and maintain oxygen saturation on room air.
He was evaluated by the Physical Therapy service and deemed
safe to go home.
Patient's renal function stabilized with a creatinine ranging
between 5.2 and 5.6. Placement of the peritoneal dialysis
catheter was deferred until later date, given that the
patient was not oliguric at this point. A midline catheter
was placed in his arm for completion of his Vancomycin
course.
DISCHARGE DIAGNOSES:
1. Aspiration pneumonia.
2. Type 1 diabetes mellitus complicated by hypoglycemic coma.
Type 1 diabetes complicated by triopathy.
3. End-stage renal disease status post transplant from a
living related donor in [**2130**] complicated by rejection and
transient dialysis for two months. He is now currently off
dialysis. His baseline creatinine is approximately 5.0.
4. Coronary artery disease status post myocardial infarction.
He has a stent in the left anterior descending artery placed
in [**2139-10-10**].
5. Congestive heart failure with a diastolic dysfunction and
an ejection fraction of 45%.
6. History of empyema status post VATS.
7. Recurrent pneumonias.
8. History of Clostridium difficile colitis.
9. Multiple myeloma.
10. Blindness OD.
11. History of FEO with extensive workup.
12. Obstructive-sleep apnea, wears CPAP at night.
13. History of deep venous thrombosis of the left thigh
currently on warfarin.
14. History of Barrett's esophagus.
15. History of bacteremia and septic emboli with
Staphylococcus aureus.
DISCHARGE MEDICATIONS:
1. Metronidazole 500 mg po tid x10 days.
2. Levofloxacin 250 mg po q4-8h x10 days starting on
[**2141-5-25**].
3. Vancomycin 750 mg IV q4-8 for seven days starting on
[**2141-5-25**].
4. Niferex 150 mg po bid.
5. Warfarin 2.5 mg po q day.
6. Calcium carbonate 500 mg po tid.
7. Furosemide 40 mg po q am and 60 mg po q pm.
8. Prednisone 5 mg daily.
9. Atenolol 175 mg daily.
10. Midodrine 5 mg po tid.
11. Pravastatin 40 mg po q day.
12. Sodium bicarbonate 1.3 grams po tid.
13. Nitroglycerin 0.3 mg po q5 minutes if needed.
14. Multivitamin one capsule po daily.
15. Isosorbide mononitrate sustained release 30 mg po q24h.
16. Gabapentin 300 mg po tid.
17. Amlodipine 5 mg po q24h.
18. Aspirin 325 mg po daily.
19. Pantoprazole 40 mg po q24h.
20. Erythropoietin 20,000 units q Monday and Thursday.
DISPOSITION: The patient was discharged home to complete a
seven day course of Vancomycin, specifically received doses
on [**5-27**] and [**2141-5-29**]. He should have his INR checked
weekly as well as his BUN and creatinine. Heparin flushes
should be administered in his midline.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D. [**MD Number(1) 11866**]
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2141-5-25**] 17:05
T: [**2141-5-26**] 07:19
JOB#: [**Job Number 20631**]
|
[
"250.41",
"428.32",
"507.0",
"518.81",
"996.81",
"585",
"584.9",
"453.8",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6294, 7324
|
7347, 8683
|
4931, 6273
|
179, 328
|
357, 2008
|
3088, 4913
|
2030, 3063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,336
| 104,586
|
32718
|
Discharge summary
|
report
|
Admission Date: [**2122-2-16**] Discharge Date: [**2122-2-28**]
Date of Birth: [**2087-6-23**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
1. Gastric pacer placement
2. Jejunostomy tube placement
3. PICC placement
History of Present Illness:
This is a 34 y/o M w /h/o diabetes, on insulin pump,
gastroparesis, peptic ulcer disease, who is transferred from OSH
([**Hospital 794**] Hospital, [**Hospital1 789**] RI), after 6 week stay for nausea,
vomiting and abdominal pain, for gastric pacemaker placement.
In brief, the patient reports ongoing pain symptoms for the past
one year, with difficulty tolerating POs and constant nausea.
This most recent admission resulted after he had several
episodes of vomiting and acute mid-epigastric abdominal pain not
relieved with outpatient pain meds. The pain ranges from [**2124-6-8**]
to [**11-13**] in intensity. It is similar to prior pain episodes. No
radiation to the flank or back. No associated fever, chills,
night sweats, brbpr or melanotic stools.
For the past two months he had been only taking in only limited
POs and had been on chronic TPN. TPN discontinued at OSH and
started on J tube with tube feedings. Pain controlled with IV
dilaudid. Attempt to wean over last week from 4mg q3 to 3mg q3
to 1.5mg q3, however have had difficulty weaning due to rebound
abdominal pain, nausea. Plan to transfer for evaluation of
gastric pacmeaker.
Of note, hospital course complicated by PICC infection with coag
neg staph ([**4-6**], last positive [**2-12**]) treated with 14 days of
vanco.
On arrival, patient tearful, complaining of [**11-13**] mid-epigastric
pain, nausea. No fever, chills, chest pain, shortness of breath.
ROS: as per hpi, otherwise negative
Past Medical History:
diabetesI- on subcutaneous insulin pump
peptic ulcer disease
h/o shingles
anxiety
depression
?h/o celiac sprue
GERD
gastroparesis
h/o seizure
asthma
Social History:
denies tobacco or ETOH. lives at home.
Family History:
mother with dm, gastroparesis, breast ca. brother, sister with
bipolar disorder
Physical Exam:
vitals- afebrile, VSS
gen- awake, NAD
heent- eomi, op clear, sclera non-icteric
neck- supple
pulm- cta b/l. no r/r/w
cv- rrr. normal s1/s2. no m/r/g
abd- benign
ext- no c/c/e. warm, 2+ dp
neuro- alert and oriented x 3. CNII-XII intact
skin- normal
Pertinent Results:
[**2122-2-17**] 05:00AM BLOOD Glucose-309* UreaN-13 Creat-0.7 Na-132*
K-4.8 Cl-95* HCO3-29 AnGap-13
[**2122-2-18**] 03:06AM BLOOD Glucose-126* UreaN-11 Creat-0.7 Na-133
K-3.9 Cl-95* HCO3-30 AnGap-12
[**2122-2-20**] 06:36PM BLOOD Glucose-445* UreaN-15 Creat-0.9 Na-133
K-4.9 Cl-97 HCO3-14* AnGap-27*
[**2122-2-21**] 04:24AM BLOOD Glucose-42* UreaN-12 Creat-0.8 Na-138
K-3.3 Cl-108 HCO3-23 AnGap-10
.
[**2122-2-17**] 05:00AM BLOOD ALT-17 AST-21 AlkPhos-89 Amylase-22
TotBili-0.5
[**2122-2-17**] 05:00AM BLOOD Albumin-4.0 Calcium-9.6 Phos-5.0* Mg-1.6
.
[**2122-2-20**] 05:30AM BLOOD Acetone-MODERATE
.
[**2122-2-20**] 06:50PM BLOOD Type-ART pO2-213* pCO2-28* pH-7.26*
calTCO2-13* Base XS--12
[**2122-2-20**] 11:36AM BLOOD Lactate-1.1
.
[**2122-2-17**] 05:00AM BLOOD WBC-9.7 RBC-4.12* Hgb-12.4* Hct-35.7*
MCV-87 MCH-30.2 MCHC-34.8 RDW-12.9 Plt Ct-322
[**2122-2-17**] 05:00AM BLOOD PT-12.6 PTT-27.0 INR(PT)-1.1
[**2122-2-17**] 05:00AM BLOOD Plt Ct-322
CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: There is minimal
dependent atelectasis in the left lower lobe. The imaged portion
of the heart and pericardium appears unremarkable. In the
subcutaneous tissues of the right upper abdominal wall, a
metallic structure is consistent with the implanted gastric
pacemaker. The pacemaker lead the enters the peritoneum via a
right upper abdominal approach, and courses anteriorly adjacent
to the abdominal wall before diving to terminate at the greater
curvature of the stomach. There is a small amount of free
intraperitoneal air adjacent to the pacemaker lead just deep to
the pacer pocket (2:42), a finding that could be associated with
surgical introduction of the lead. A jejunal feeding tube is in
place via a left paramedian approach terminating in the left
mid-abdomen. The large and small bowel loops are normal in
caliber. No intra-abdominal abscesses are identified. The liver,
spleen, gallbladder, and adrenal glands appear unremarkable. The
pancreas is atrophic. No renal masses are identified, and there
is no hydronephrosis. The abdominal aorta is normal in caliber.
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The appendix is
normal. The bladder, distal ureters, rectum and sigmoid colon,
prostate and seminal vesicles appear unremarkable. There are no
pathologically enlarged pelvic or inguinal lymph nodes.
BONE WINDOWS: Bone windows show no lesions worrisome for osseous
metastatic disease.
IMPRESSION:
1. Status post placement of a gastric pacemaker with a small
amount of free intraperitoneal air, a nonspecific finding that
could relate to postsurgical state .
2. No evidence of abscess or bowel obstruction.
Discharge Labs:
[**2122-2-28**] 05:27AM BLOOD WBC-10.6 RBC-3.71* Hgb-10.9* Hct-33.4*
MCV-90 MCH-29.4 MCHC-32.7 RDW-13.7 Plt Ct-380
[**2122-2-25**] 05:16AM BLOOD PT-12.1 PTT-29.0 INR(PT)-1.0
[**2122-2-28**] 05:27AM BLOOD Glucose-163* UreaN-25* Creat-0.7 Na-139
K-4.2 Cl-98 HCO3-33* AnGap-12
[**2122-2-28**] 05:27AM BLOOD ALT-51* AST-81* AlkPhos-76 TotBili-0.2
[**2122-2-28**] 05:27AM BLOOD Albumin-3.8 Calcium-9.9 Phos-5.4* Mg-1.9
Brief Hospital Course:
A/P: This is a 34 y/o M w /h/o diabetes I, on insulin pump,
gastroparesis, peptic ulcer disease, who was transferred to the
[**Hospital1 18**] from an OSH ([**Hospital 794**] Hospital, [**Hospital1 789**] RI), after a 6
week stay for nausea, vomiting and abdominal pain, for gastric
pacemaker placement.
.
# gastroparesis- acute on chronic abdominal pain, felt secondary
to gastroparesis. Gastroenterology consulted and recommended
gastric pacer placement given duration of symptoms and failure
of medical therapy. Gastric pacer placed by Dr. [**Last Name (STitle) **] on
[**2122-2-18**]. Post-operatively he went to the hospitalist service
for recovery and further management. However, on the hospitalist
service, attempts had been made to control his hyperglycemia
with boluses from the patient's insulin pump as well as SC
insulin on a scale. Unfortunately despite intensive efforts this
was not successful in lowering the glucose and narrowing the
anion gap, and the patient remained in DKA.
.
MICU course:
The patient was transferred to the [**Hospital Ward Name 332**] ICU in DKA, where he
was put on an insulin drip, and his glucose came under control
overnight, and his anion gap narrowed to within normal limits.
He continued to have significant pain which was treated with a
hydromorphone PCA. He received tube feeds and was transitioned
to subcutaneous insulin scale. He was transferred back to the
hospitalist service.
Post-MICU course:
The patient's diet was advanced, while tube feeds were
continued, for his malnutrition. The patient's pain significant
improved and his hydromorphone PCA was rapidly tapered over 3
days. A plan was made that the patient would not continue any
opioids on discharge. He was instructed to remain on J-tube
feeds until further evaluation by his gastroenterologist.
Medications on Admission:
reglan 10mg qid
trazadone 75mg qhs
protonix 40mg [**Hospital1 **]
dilaudid 1.5mg q3 hours prn
promethazine 25mg q4 prn
[**Last Name (un) **] 0.125mg q4hours
atenolol 12.5mg [**Hospital1 **]
claritin 10mg qhs
insulin pump 1unit per hour with boluses durin meals
dronabinol 10mg 3x/d AC
ativan 1mg q6prn
meat tenderizer (adolphs) 2xday prn
ondansetron 4mg IV q6prn
suralfate 1g 3x/day
Discharge Medications:
1. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
Disp:*120 Tablet, Sublingual(s)* Refills:*1*
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
Disp:*240 Tablet(s)* Refills:*1*
3. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day) for 1 weeks.
Disp:*qs * Refills:*0*
4. 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:*1*
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*1*
6. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
Disp:*180 Capsule(s)* Refills:*1*
7. Insulin
by pump as previously ordered.
Discharge Disposition:
Home With Service
Facility:
OptionCare
Discharge Diagnosis:
1. Type 1 diabetes mellitus with gastroparesis with placement of
gastric pacer
2. Chronic abdominal pain
3. Gastroesophageal reflux disease and peptic ulcer disease
4. Depression with anxiety
5. Hypertension
6. Diabetic ketoacidosis, resolved
7. Chronic asthma
8. History of shingles
Discharge Condition:
Stable, tolerating diabetic diet
Discharge Instructions:
Please contact your primary care physician if you develop
worsening abdominal pain, nausea, vomiting, or fevers, sweats
and chills.
Followup Instructions:
You will need a follow up appointment with your primary care
physician [**Last Name (NamePattern4) **] [**2-4**] weeks, with LFT check at that time.
Please arrange follow up with Dr. [**Last Name (STitle) 10689**] at [**Telephone/Fax (1) 17075**] in [**5-10**]
weeks.
Readdress tube feed duration with your gastroenterologist at the
next appointment.
|
[
"338.29",
"V16.3",
"250.63",
"V44.4",
"263.9",
"536.3",
"789.00",
"V18.0",
"530.81",
"401.1",
"300.4",
"V12.71",
"250.83",
"250.13",
"493.90",
"V58.67",
"V85.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.95",
"04.92",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8672, 8713
|
5551, 7367
|
283, 360
|
9041, 9076
|
2471, 5096
|
9256, 9612
|
2106, 2188
|
7800, 8649
|
8734, 9020
|
7393, 7777
|
9100, 9233
|
5113, 5528
|
2203, 2452
|
229, 245
|
388, 1862
|
1884, 2034
|
2050, 2090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,844
| 168,279
|
25582
|
Discharge summary
|
report
|
Admission Date: [**2132-4-9**] Discharge Date: [**2132-8-20**]
Date of Birth: [**2095-9-5**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Enterocutaneous Fistula
Major Surgical or Invasive Procedure:
Resection of the abdominal wall desmoid;
exploratory laparotomy, lysis of adhesions (3/1/2 hours),
takedown ileostomy, small bowel resection, resection of
fistula and end ileostomy. Drainage of abdominal abscess.
Closure of enterotomies x2. Feeding jejunostomy.
History of Present Illness:
This is a 37 year old female with a past medical hostory
significant for an abdominal wall desmoid tumor since [**2119**]. She
underwent her first resection of this mass in [**2121**], but this was
not successful. On [**2131-11-20**] she underwent an exploratory
laparotomy, lysis of adhesions, resection of desmoid,
enterectomy of ileostomy, closure of enterotomy and re-doing of
ileostomy and repair of abdomial wall with [**Doctor Last Name 4726**]-Tex mesh. She
also had a balloon dilatation of a stricture in her ileum on
[**2132-1-29**]. Omn [**2132-2-26**], she had a complex revision of her
ileostomy and debridement of granulation tissue. She returns to
clinic on [**2132-4-9**] with fever and right lower quadrant tenderness.
Past Medical History:
Gardners Syndrome
Uterine fibroid s/p myomectomy- [**2118**]
Desmoid tumor resection- [**2121**]
Right Breast mass, s/p excision- [**2125**]
Total Colectomy w/ ileostomy- [**2126-8-5**]
s/p port-a-cath placment
Atrial tachycardia secondary to doxarubacin toxicity
h/o DVT LLE- [**2127**]
h/o Hodgkins, s/p MOPP chemo- [**2117**]
GERD
Social History:
Pt is single, w/o children. Lives in [**State 531**], works as an
insurance account represenative. Denies tobacco and drinks ETOH
rarely.
Family History:
Father, 65, w/ prostate ca
Mother, 66, w/ breast ca, sister w/ lupus
Physical Exam:
Vital signs- 97.8, 105, 114/80, 16, 99% RA
General: NAD, comfortable
Lungs: CTA b/l
Heart: RRR, S1S2
Abdomen: soft, slightly tender to palpation in the RLQ
Pertinent Results:
Admission Labs
[**2132-4-9**] 06:16PM BLOOD WBC-5.9# RBC-3.52*# Hgb-10.7*# Hct-30.1*
MCV-85# MCH-30.3 MCHC-35.5* RDW-16.5* Plt Ct-380#
[**2132-4-9**] 06:16PM BLOOD Glucose-93 UreaN-23* Creat-0.7 Na-138
K-4.0 Cl-106 HCO3-23 AnGap-13
[**2132-4-9**] 06:16PM BLOOD Albumin-2.5* Calcium-8.2* Phos-3.8 Mg-1.6
Iron-19*
[**2132-4-9**] 06:16PM BLOOD calTIBC-235* Ferritn-73 TRF-181*
Nutrition Labs:
------- Fe------TIBC-----[**Last Name (un) **]----Albumin--TRF
[**4-9**]----19--------235------73-------2.5------181
[**4-14**]---13--------174------71-------2.0------134
[**4-21**]---15--------163------53-------1.9------125
[**4-28**]---12--------133------195------2.7------102
[**5-5**]----15--------221------163------2.6------170
[**5-12**]----17--------267------172------3.4------205
[**5-19**]---17--------256------115------3.1------197
[**5-26**]---29--------270------128------3.2------208
[**6-2**]---23--------233-------64------2.7------179
[**6-9**]----25--------238-------70------2.5------183
[**6-16**]---86--------183-------147-----2.4------141
[**6-23**]---141-------182-------302-----2.4------140
[**6-30**]---51--------134-------593-----2.3------103
[**7-7**]----110-------192-------703-----2.8------148
[**7-14**]---106-------199-------736-----2.9------153
[**7-21**]---116-------226-------980-----3.1------174
[**7-28**]---90--------[**Telephone/Fax (1) 63857**]-----2.9------157
[**8-4**]---97--------[**Telephone/Fax (1) 63858**]---- 3.6------182
[**8-10**]---81--------[**Telephone/Fax (1) 63859**]-----3.9------192
[**8-11**]---59--------[**Telephone/Fax (1) 63860**]-----3.6------175
[**8-18**]---87--------[**Telephone/Fax (1) 63861**]-----3.6------213
Discharge Labs
WBC 5.8 RBC 3.77 Hgb 11.6 HCT 33.8 MCV 90 MCH 30.9 MCHC 34.4 RDW
17.4*
PLT 208
Glucose 75 UreaN 29 Creat 0.7 Na 139 K 4.5 Cl 107 HCO3 26
AnGap 11
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) **] E.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) **] E on [**Doctor First Name **] [**2132-5-15**] 8:59
AM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 63862**]
Service: [**Last Name (un) **] Date: [**2132-4-22**]
Date of Birth: [**2095-9-5**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD 2362
PREOPERATIVE DIAGNOSIS: Gastrointestinal cutaneous fistula,
desmoid tumor of abdominal wall and desmoplastic reaction
throughout her abdomen.
POSTOPERATIVE DIAGNOSIS: Gastrointestinal cutaneous fistula,
desmoid tumor of abdominal wall and desmoplastic reaction
throughout her abdomen.
PROCEDURE: Resection of the abdominal wall desmoid;
exploratory laparotomy, lysis of adhesions (3/1/2 hours),
takedown ileostomy, small bowel resection, resection of
fistula and end ileostomy. Drainage of abdominal abscess.
Closure of enterotomies x2. Feeding jejunostomy.
INDICATIONS: This patient has had a terrible situation with
desmoids throughout her abdominal wall, including one which
we partially resected and one which we did not resect last
time. She fistualized following the last operation with an
enterotomy which probably was not closed quite as well as it
might have been, owing to the difficulty of where it was in
the loop below the ileostomy. She continued to have an
abscess through her abdominal wall on the Vicryl mesh. We did
remove the Vicryl mesh here and then found the fistula. We
were able to resect that loop and bring up a new loop of
ileum for a new ileostomy which was patent and was not
involved with the desmoid. It seemed to be pretty reasonable.
There were 1 and possibly 2 enterotomies and we also closed
serosal denudation. The following procedure was carried out.
DESCRIPTION OF PROCEDURE: Under satisfactory general
anesthesia the patient was placed supine and prepped and
draped in the usual manner. The place where the fistula had
leaked through the abdominal wall was oversewn and we opened
up the abdominal wall to enter an abdominal abscess and also
an abscess within the abdomen which was then drained. The
Vicryl which was still present was removed and was involved
in the abscess cavity. However, it was still sewn in place.
This had given some ability to perform an area of fascia
which we used finally for closure.
We then turned our attention to the right side and then freed
up the subcutaneous tissue and a very vascular abdominal wall
with a desmoid which was approximately 13-15 cm long and
probably 10 cm wide. This was resected. The abdominal wall
was left intact. We gave it to pathology to ink the margins.
We then entered the abdomen from above and from below,
getting into free abdominal tissue. Dr. [**Last Name (STitle) **] was kind
enough to act as the first assistant for part of the
procedure. We began by lysing adhesions and this took about 3-
1/2 hours. After the adhesions were lysed and we had taken
down some of the desmoid and freed up the entire small bowel
although not from the desmoid mass, which was in the
mesentery actually from the top to the bottom, we had been
able to resect the ileostomy and bring it back and see that
there were several areas of fistula in the ileostomy which we
had 3 in all, including 2 which were chronic and 1 which I
suspect we did taking down the ileostomy. We were able to
resect this segment of the ileostomy and get back to
reasonable bowel all of the desmoid was in the base of the
mesentery. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler was then placed across the
ileostomy about I would imagine 6 to 8 inches proximal and
fired. The ileostomy was then grasped with three 3-0 silks
but we could not maneuver it into the old ileostomy because
it would not reach and so we would close that later and then
create a new opening for the ileostomy about 4 inches down
the abdomen and this was done by making a cruciate incision
in the abdominal wall which had a desmoplastic reaction as
everything else she had did. We then continued with lysis of
adhesions until we were certain that we had gotten the
ileostomy down to the end and that we could do a new
ileostomy and also to try and eliminate as many areas of
obstruction with the desmoid as we could. The desmoid was
huge and it was not possible to be absolutely certain that we
could eliminate all the sites of obstruction. Two areas of
enterotomy, 1 on the right side, and 1 which I am certain was
an enterotomy but may have simply been an area where she had
an old abscess were then closed with interrupted 4-0 silk and
5-0 Prolene. Drain was placed down to the left lower quadrant
where the questionable enterotomy was. This was so imbedded
in the scar that closure with one layer of 5-0 Prolene was
all that I could manage whereas the other enterotomy, which
clearly was an enterotomy, I was able to close with 2 layers
of interrupted silk. After this I carried out a feeding
jejunostomy in the right upper quadrant in a loop that I
thought was close to the ligament of Treitz that I could
find. We then were able to irrigate the abdomen and place [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 406**] drain in the lower quadrant so the jejunostomy would
Witzel with five or six 4-0 silk sutures and bring it up out
through a stab wound of the anterior abdominal wall in the
left upper quadrant. Gloves, gowns and drapes were then
changed. The wound was closed in layers with a #1 Prolene on
the old ileostomy site which we closed horizontally with
interrupted #1 Prolene. We later closed this with 3-0 Vicryl
and 4-0 Monocryl. We then brought the ileostomy out through
the lower wound finally and maturing it after the manner of
[**Doctor Last Name **] with four three-part sutures and then taking out the
staple line and then two-part sutures which we then amplified
to get a good fit from the ileostomy. The wound was then
closed in layers with #1 Prolene to the anterior abdominal
wall. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] [**Last Name (NamePattern1) 1661**]-[**Location (un) 1662**] drain was then placed over the
fascia, 3-0 Vicryl to the subcutaneous tissue and 4-0
Monocryl with subcuticular closure. The drains were sewed in
place with 3-0 nylon. The #19 [**Doctor Last Name 406**] drain was placed on her
right and left lower quadrants.
ESTIMATED BLOOD LOSS: 3035 cc owing to the vascularity of
the desmoid situation.
REPLACEMENT: She received 6 units of packed cells, 4 units
of fresh frozen plasma, 500 cc of 5% Albumisol and 1500 cc of
crystalloid.
URINE OUTPUT: 415 cc.
She received vancomycin, gentamicin and Fluconazole. The
patient was returned to the recovery room in good condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 26005**]
Dictated By:[**Last Name (NamePattern1) 63863**]
MEDQUIST36
D: [**2132-4-22**] 14:22:36
T: [**2132-4-22**] 19:05:26
Job#: [**Job Number 63864**]
cc:[**Last Name (NamePattern1) 63865**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 955**], M.D. (Res)
[**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 26321**], MD (RES)
OPERATIVE REPORT
[**Last Name (LF) **],[**First Name3 (LF) 275**] C.
Signed Electronically by [**Last Name (LF) **],[**First Name3 (LF) 275**] C on MON [**2132-6-16**]
6:54 AM
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 63862**]
Service: Date: [**2132-6-10**]
Date of Birth: [**2095-9-5**] Sex: F
Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 559**]
PREOPERATIVE DIAGNOSES: Bilateral hydronephrosis.
POSTOPERATIVE DIAGNOSES: Bilateral hydronephrosis.
PROCEDURE: Cystoscopy, bilateral retrograde pyelogram, left
ureteral stent placement, left ureteroscopy.Attempted right
STent Placement
ASSISTANT: [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 63866**], MD.
ANESTHESIA: LMA.
ESTIMATED BLOOD LOSS: Minimal.
INDICATIONS FOR PROCEDURE: This is a 36-year-old female with
a history of multiple surgeries, external beam radiation and
desmoid tumor throughout her retroperitoneum who has long
standing
bilateral hydronephrosis (right worse than left). She presents
for bilateral ureteral
stent placement.
DESCRIPTION OF PROCEDURE: The patient was seen in the
preoperative area and marked and consented as per hospital
policy and brought to the operating room. After adequate
general anesthesia, she was placed in the dorsal lithotomy
position and 120 grams of Gentamycin was given intravenously.
Her genitalia were prepped and draped in a standard sterile
manner; the vagina was filled with a whitish discharge which was
thoroughly cleaned before the procedure began. The cystoscope
was
placed per her urethra. The
bladder was fully inspected and no abnormalities were noted.
First retrograde pyelograms were performed using the cone tip
catheter in bilateral ureteral orifices. These were sent for
plain films and then attention was given to the right
ureteral orifice.
A 0.038 stent wire was attempted to be placed up into the
ureteral orifice up to the kidney, however, this failed. Due
to this attention was given to the left ureteral orifice
where again this was intubated. The wire was easily passed up
to the kidney and a 6x24 ureteral [**Last Name (un) 63610**] stent was placed over
this
wire. After this was performed, it was noted that the
curl of the ureteral stent was
migrating into the ureter. Attempts at grabbing the stent was
futile and the decision was made to place a second wire into
the ureteral orifice and perform ureteroscopy. A second
[**Location (un) **] wire was placed up into the ureter freely and the
balloon dilator was used to balloon open the ureteral
orifice. After the orifice was dilated, the semi rigid
ureteroscope was placed per her urethra and up into the
ureter. The ureteral stent was visualized [**Last Name (un) 63867**] forceps
was used to grab it atraumatically and to bring it down into
the bladder. After this was in notably good position, it was
reinspected using fluoroscopy and the upper curl was in the
renal pelvis. At this point, attention was given again to the
right ureteral orifice where a angled glide wire was used to
intubate the ureteral orifice which passed into the renal pelvis
with some difficulty; an open ended ureteral
stent was placed approximately half way up the ureter.
Retrograde pyelogram was performed noting a very tight
stricture at the mid and upper ureter. After many attempts,
the angled glide wire was finally passed up into the kidney,
however, we were unable to pass the 6 French open ended
catheter. At this point, it was decided that we were not
going to be able to place a stent into that kidney and the
decision was to abort that side.
At this point, the bladder was then again visualized. The
stent was in good position and films were taken of the curl
in the renal pelvis and in the bladder of the left ureteral
stent. The bladder was emptied and the patient was awoken.
She tolerated the procedure well. Dr. [**Last Name (STitle) **] was present and
scrubbed throughout the entire procedure. She was transferred
to the PACU in stable condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 559**]
Dictated By:[**Last Name (NamePattern1) 63868**]
MEDQUIST36
D: [**2132-6-10**] 18:59:40
T: [**2132-6-11**] 06:38:28
Job#: [**Job Number 63869**]
Addendum: I agree with the above narrative and was present and
scrubbed throughout the entire procedure.
WCD
Date: [**2132-4-21**]
Signed by [**Name6 (MD) **] [**Name8 (MD) 8848**], MD on [**2132-5-2**] Affiliation: [**Hospital1 18**]
NEEDS COSIGN
FOLLOWUP HEMATOLOGY/ONCOLOGY CONSULTATION NOTE
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 36-year-old woman
who has had a long history of desmoid tumors. She was initially
diagnosed with this in [**2117**] and has had multiple desmoids
removed
from her foot and her back. In [**2121**], she had a desmoid in her
abdomen, which was resected. She was subsequently treated for a
long period of time with Gleevec. She was also treated with
interferon for about two and a half years and then sulindac
remotely. Her most recent treatment last year was with Doxil
with an unknown number of treatments. She has also had radiation
to the abdomen in the past in the adjuvant setting in [**2122**] after
the first abdominal desmoid was resected.
Interestingly, she has also had Hodgkin's disease diagnosed in
[**2117**] as well, which is reported to us as being stage IV. She is
currently considered to be cured from this.
She was admitted to the hospital in [**Month (only) **] with a desmoid
tumor
of the abdomen that was causing obstruction. She had this
diverted by colostomy and has had multiple problems since. She
has an enterocutaneous fistula in her abdomen, which has not
healed. She was eventually discharged after many months in the
hospital; however, spent about a month at home and then began to
have fevers and chills and was re-admitted on [**2132-4-9**] with
probable intra-abdominal infection. She has been treated with
antibiotics with amp, gent, and Flagyl for several days. She had
a fifth CT of the abdomen on [**2132-4-10**], which revealed an
enterocutaneous fistula in the mid-abdomen. There was no gas or
fluid collection or abscess in the abdomen and pelvis. There was
a 7 x 3.9 enhancing right anterior abdominal wall mass, which
has
decreased in size since the prior examination. She also had a
fistulogram on [**2132-4-15**], which reveals the persistent
enterocutaneous fistula between the ileum and the skin.
Midway through her hospital course, she had an increase in her
fever curve and blood cultures did reveal Enterobacter cloacae
and she has been treated with antibiotics.
With regard to her desmoid tumor, she has been on tamoxifen 120
mg daily and sulindac 300 mg daily for this and she has had some
decrease in size by the CT on [**2132-4-10**].
She is eating intermittently only small volume. She is on TPN.
She is not having nausea. She does feel very tired. She is
having hot flashes due to tamoxifen, and in general, feeling not
so well and having insomnia.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature of 100.3, blood pressure 108/64,
respiratory rate is 18, and pulse is 92.
GENERAL: She is awake, alert, and oriented in no apparent
distress.
HEENT: Pupils are equal, round, and reactive to light and
accommodation. Extraocular muscles are intact. Sclerae are
clear. Oral cavity and oropharynx without lesion.
NECK: Supple. No JVD, lymphadenopathy, or thyromegaly.
PULMONARY: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or gallops.
GASTROINTESTINAL: Exam is abnormal with a large palpable mass of
approximately 10 to 12 cm in the right lower abdomen. This is
about 3 or 4 cm on its medial edge from the area of the fistula.
There is a catheter in the fistula as well as an ostomy bag
overlying it. She also has the ileostomy bag in the left
abdomen, which is draining normal-looking stool. Her abdomen is
mildly tender. There are good bowel sounds. No
hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema.
LABORATORY DATA: Today, white blood cell count is 5.1,
hemoglobin 7.2, hematocrit 22.3, and platelet count is 326,000.
PT 14.9, INR 1.3, and PTT 28.3. Albumin 1.9, calcium 7.4, TIBC
163, and ferritin 53.
ASSESSMENT AND PLAN:
1. Large desmoid tumor of the abdomen. Mrs. [**Known lastname **] continues to
have problems with the enterocutaneous fistula. She has had an
episode of bacteremia during this hospital course, which has
apparently been controlled. She continues to have fistula output
and persistence of the fistula on the fistulogram and CT. She is
going to go to surgery tomorrow to potentially fix this.
We discussed with her the tamoxifen and sulindac and we feel
that
she is not getting any benefit with 120 mg daily of tamoxifen
and
that the dose could be decreased to 20 mg daily and this will
help to decrease her hot flashes.
We agree with continuing the tamoxifen and sulindac while she is
dealing with the infectious and enterocutaneous complications of
the tumor and surgery. Once she is improved and healed from
these complications, we would entertain using chemotherapy to
induce a response. She is having a very slow and expected small
response to tamoxifen and sulindac, and if she has a
stabilization of the response or actual growth, it would be
beneficial to start chemotherapy with a doxorubicin-based
regimen. In addition, vincristine and methotrexate on occasion
have shown to be beneficial. Currently, though, she is not in a
position to receive cytotoxic chemotherapy with the ongoing
fistula and infectious issues.
With regard to her anemia, she likely has an anemia of chronic
disease and would benefit from Procrit. In addition, some iron
supplementation will be beneficial. Her ferritin is 53 in the
setting of this active inflammation and bacteremia, which is
probably falsely elevating it, so giving her a dose of iron with
a Fergon daily or b.i.d. with Procrit will be beneficial and
probably improve her overall sense of well being.
After she is discharged from the hospital, we will see her in
followup for the desmoid tumors and help to manage these
long-term. She does have an oncologist local to her in
Schenectady, [**State 531**] and we will try to be in contact with
these
practitioners when the time comes.
I saw this patient with Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 1692**] [**Last Name (NamePattern1) 63870**] MD
eScription document:[**4-/2132**]
cc:[**Hospital1 63871**]
Brief Hospital Course:
[**Known firstname 1154**] [**Known lastname **] was admitted to the surgical service of Dr.
[**Last Name (STitle) 957**] at [**Hospital1 18**] on [**2132-4-9**] with the diagnosis of an
enterocutaneous fistula. She is well know to Dr. [**Last Name (STitle) 957**]. She
was kept NPO on TPN (cycled over night). There was a high
suspicion for an intra-abdominal abscess at this time because
she was spiking fevers and had abdominal tenderness. A CT scan
on HD 2 showed no evidence for discrete rim-enhancing or
gas-containing fluid collection/abscess within the abdomen or
pelvis. Please see full report for further details. On HD 3
she was given a soft solids diet. On HD 4, she developed a new
fistula just above the old one, probably from the same loop.
She spiked a fever to 101.5 overnight. On HD 7, she had a
fistulogram which revealed filling of the previously
demonstrated enterocutaneous fistula, retrograde from the
location of the ostomy site, consistent with a fistula between
the ileum and the enterocutaneous fistula. Her TPN was
increased to 35 kcal/kg/day. She spiked to 102.2. She was
started on Ampicillin, Gentamycin and Flagyl empirically. On HD
9, she was afebrile. Her cultures had Gram negative bacteria in
the blood (septicemia). She was switched form Ampicillin to
Fluconazole. On HD 10 her RLQ tenderness was diminished. On HD
13, she was switched to clears only and NPO after midnight for
an operation to be done the next day. On HD 14 Meropenem was
added and she had the following operations: Resection of the
abdominal wall desmoid; exploratory laparotomy, lysis of
adhesions (3/1/2 hours), takedown ileostomy, small bowel
resection, resection of fistula and end ileostomy. Drainage of
abdominal abscess. Closure of enterotomies x2. Feeding
jejunostomy. Please see operative note for details. She was
transferred to the ICU following this operation. She had an
epidural for pain. She was continued on
Gentamycin/Fluconazole/Flagyl. She was kept NPO with an NG
tube. She had 2 JP drains. On POD 1, she did well. Her
ileostomy was viable. Flagyl and Gentamycin were discontinued.
On POD 2 tube feeds were started at 10cc/ hour and advanced to
20cc/ hour. She had a small amount of stool in her ostomy.
Later that day she had a bowel movement. Fluconazole was
stopped and she was off all antibiotics. She remained afebrile.
On POD 3, tube feeds were advanced to 30cc/ hour. Her
ileostomy put out 950 cc. She had 2 episodes of emesis. On POD
4, she was much less nauseous, however a KUB showed multiple
loops of dilated small bowel with air-fluid levels indicating
ileus versus obstruction. She tolerated sips. Her ostomy
output was high (3225) and 1:1 fluid replacements were begun.
She had increased abdominal pain and distension. On POD 5 she
was kept NPO and tube feeds were held. She felt better. On POD
6 her 1:1 fluid replacements were discontinued. Her ostomy
output was 1475. On POD 7 her epidural was removed and she was
started on PO Dilaudid. On POD 8 her JP drain output increased
to 925cc. Her J-tube was opened and put out 1200cc. On POD 9
she was started on PO iron and epogen for anemia. Her JP
outputs decreased but her J-tube output continued to be heavy.
On POD 10, she developed acute onset upper abdominal pain and
pleuritic chest pain. A chest X-ray revealed a right lower lobe
opacity. A KUB showed improved obstruction, non-specific bowel
gas pattern. Since a PE was high on the differential, a CTA was
obtained that showed multi-subsegmental right pulmonary emboli.
A CT of the abdomen demonstrated marked diffuse abdominal
inflammatory process with multiple fluid collections is grossly
unchanged from [**2132-4-10**], without definite evidence for
perforation. She was bolused 5000 U heparin. She was
transferred to the ICU. A heparin drip was started (goal PTT
60-80). On POD 11, upper and lower extremity ultrasounds were
negative for DVT. On POD 12, she was stable and was transferred
to the floor. Her ostomy output was encouraging (275). On POD
13 her ostomy output was 45 and her J-tube output was 1900. On
POD 14 she was started on 40cc/h rehydration. She was started
on coumadin. On POD 15 she felt good. She was started on sips.
A KUB was unremarkable. She was started on Minocycline. Her
fistula output was decreased (75cc) and her J-tube output was
decreased (850). On POD 19, her JP outputs were low (70 and
20). Her fistula was believed to be closed. On POD 20 her
albumin was up to 3.4. On POD 22, an ultrasound of her abdomen
showed a right lower quadrant abdominal wall collection with
echogenic fluid and a slightly thick wall. This is approximately
50% smaller by measurement compared to prior CT scan of [**2132-5-2**].
A trace amount of fluid was aspirated from the abdominal wall
fluid collection (this likely represents an organizing
hematoma). A KUB was unremarkable. On POD 23, her ostomy
output was increasing and her J tube output was decreasing. On
POD 24 her JP output was decreasing (30, 5). On POD 26, she was
started on clears. Her J-tube was clamped as a trial 1 out of
every 4 hours. On POD 28 she was given sips of tomato soup.
Her J tube put out 1100 and her ostomy put out 560. On POD 29,
her J tube was clamped every 2 of 4 hours. On POD 30, a KUB was
unremarkable. Her J-tube clamp trials were stopped since the
drainage was unchanged. On POD 33, her right JP was pulled. On
POD 34, she had a renal ultrasound which showed bilateral grade
2 hydronephrosis, which is unchanged when compared to [**2132-5-2**]. It also showed cortical parenchymal loss in the right
kidney suggesting chronicity. Her JP drain culture showed
Enterobacter cloacae and Stenotrophomonas that was pan
sensitive. On POD 35 her Tamoxifen was restarted. On POD 43 her
J-tube outputs continued to rise with question of possible
fistula with JP drain. On POD 47 a fistulogram was performed
which showed a RLQ enterocutaneous fistula that fills the bowel
from the distal JP, with a small surrounding abscess. A renal
scan was also performed which showed hydronephrosis, left
greater than right. On POD 48 she was taken to the operating
room where she underwent cystoscopy, bilateral retrograde
pyelogram, left ureteral stent placement, left ureteroscopy, and
attempted right stent placement. They were unable to place the
right ureteral stent due to stricture. She tolerated the
procedure well. On POD 49 an abdominal CT scan was done
showing no new abscess. The scan also showed that the desmoid
tumor was getting smaller. Gentamycin irrigation of JP drain was
started. On POD 55, Ciprofloxacin and Aztreonam were started for
the previous JP drain culture of Enterobacter cloacae and
Stenotrophomonas. On POD 63 she complained of nausea and
vomiting. Her J-tube was found to be twisted and was not
allowing fluid to flow to gravity. This improved upon untwisting
tube. On POD 64 a PICC line was placed. On POD 65 she developed
a fever to 101.9. Cultures were taken and infectious disease was
consulted. Vancomycin and Flagyl started, one dose of gentamycin
was given. As she continued to have fevers and was tachycardic,
a septic source was questioned. She was transferred to the
T/SICU for closer monitoring. Fluconazole was added to her
antibiotic regimen. She responded well to antibiotic treatment
and hydration, and on POD 68 she was taken back to the floor. On
POD 69 her foley catheter was removed, a fistulogram was
performed, and her J-tube was replaced. On POD 78 she was doing
better. She was afebrile, her nutrition was improving, and her
JP output was decreased. On POD 79 she was seen by the oncology
service and they recommended continuing tamoxifen, as the
desmoid lesion seemed to be regressing on this therapy. On POD
84 her repeat cultures had not grown out anything. By POD 91 she
continued to improve. She remained afebrile, her nutritional
status was good and her JP drainage was decreasing. On POD 97
she was experiencing some RUQ tenderness. An ultrasound was
performed which showed biliary sludge in a non-distended
gallbladder. No stones were noted. A dose of cholecystokinin was
given to clear out the gallbladder. On POD 98 there was
decreased output from her ostomy. Her ostomy was dilated; a
catheter was placed and sutured to keep her ostomy open. On POD
106 her TPN amino acids were decreased, as her BUN was elevated.
After this change, her BUN stabilized and started to trend
downward. On POD 106 her BUN was 27, down from 31. On POD 111,
in planning for discharge, we stopped her Aztreonam and started
PO Ciprofloxacin. On this day, she spiked a temperature of
102.8. Urine and blood were sent for analysis and culture. Her
Aztreonam was restarted and a CXR was ordered which was negative
for infective process. Her urine was found to be grossly
costive for infection, with urine culture positive for yeast.
She was started on Meropenem and Fluconazole. By POD 118 she
was afebrile and doing well. A trial of Bactrim DS was given,
which she tolerated well, and her Aztreonam was discontinued.
She was discharged home on POD 119 ([**2132-8-20**]) with services. Her
oncologist office was contact[**Name (NI) **] with regard to monitoring her
Coumadin therapy and other medical issues.
Medications on Admission:
TPN
Coumadin
Toprol
Prevacid
Zofran
Kytril
Zelnorm
Flonase
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
2. Metoclopramide 10 mg Tablet Sig: 0.25 Tablet PO BID (2 times
a day).
Disp:*15 Tablet(s)* Refills:*2*
3. Warfarin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Tamoxifen 10 mg Tablet Sig: Twelve (12) Tablet PO QDAY ():
Clamp J-tube for 45 minutes after giving this medication.
Disp:*360 Tablet(s)* Refills:*0*
7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR ([**Name (NI) 766**] -Wednesday-Friday) for 2 weeks.
Disp:*6 * Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. Heparin Lock Flush 100 unit/mL Solution Sig: Two (2) ml
Intravenous PRN: 10 ml NS followed by 2 ml of 100 Units/ml
heparin (200 units heparin) each lumen Daily and PRN. Inspect
site every shift.
11. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR: [**Name (NI) 766**]-Wednesday-Friday.
Disp:*13 * Refills:*0*
12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Schenectady
Discharge Diagnosis:
Desmoid Tumor
Enterocutaneous Fistula
Discharge Condition:
Good
Discharge Instructions:
Please contact or return for fevers, chills, abdominal pain,
nausea, vomiting, increased drainage from JP drain, or for any
other concerns.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**] by phone and in clinic on
[**Last Name (LF) 766**], [**9-1**] at 2:15pm. The office number is ([**Telephone/Fax (1) 4336**] to verify your appointment.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**1-7**] weeks.
Completed by:[**2132-8-20**]
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icd9cm
|
[
[
[]
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[
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33046, 33187
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1967, 2124
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18494, 21960
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253, 278
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16026, 18472
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1372, 1708
|
1724, 1866
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,342
| 158,987
|
36697
|
Discharge summary
|
report
|
Admission Date: [**2110-1-6**] Discharge Date: [**2110-1-18**]
Date of Birth: [**2053-3-23**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered Mental Status/[**Location (un) **]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Presenting Illness: Ms. [**Known firstname **] [**Known lastname 15979**] is a 56 year
old female with HCV cirrhosis c/b portopulmonary HTN,
hepatopulmonary syndrome (on 4L home O2), and hepatic
encephalopathy, admitted 3 weeks prior to presentation for
altered mental status who presented to the ED with altered
mental status and left lower extremity pain concerning for
cellulitis.
.
Pt was in usual state of health until [**1-5**] when she developed
LLE cellulitis and was started on Keflex. Her partner, [**Name (NI) 5036**],
stated she has been doing fine last time she saw her on [**1-5**].
Her son visited yesterday and reported she was in her normal
state of mental status. History was obtained though partner as
patient was confused. She states that over past week her legs
have become more swollen, increased abdominal distension and
then she developed a rash over las couple days. Pt is usually
AOx3 with some baseline confusion but acutely worsened overnight
last night into this morning.
.
Per nursing notes from [**Location (un) 582**]. Patient was initially started on
Keflex on [**2110-1-4**] for cellulitis of let thigh but then began
having "creeping" erythema which was thought to be reaction to
keflex. Keflex was discontinued and patient given Benadryl at
0100 early this morning. At 0400 pt crying, restless somplaining
of discomfort. She then began acutely decompensating with
yelling, thrashing, hitting bed rails saying "I just cant stop
and I dont know why" Per report her lactulose has been
uptitrated on [**2110-1-5**] to Q4hours and she had 4 large BMs since
that time.
.
Of note, patient has had multiple admissions for hepatic
encephalopathy Since [**2109-9-5**] despite rifaximin and
lactulose administration. She currently lives at [**Hospital 582**] Rehab
and is inactive on transplant list
.
In the ED, Vitals were 97.9F| 88bpm| 111/64 mmHg| RR16| 94% on
4L. Vitals prior to transfer to floor 96.1ax 80 112/63 18 96%
vent mask. Patient was too disoriented to relay a history, but
did say she was having abdominal pain as well. Labs showed WBC
of 6.7 with baseline leukopenia in the [**2-/3098**] range, 89% PMN's
on differential, normal hematocrit of 40.3, and thrombocytopenia
which is chronically in the 40-70 range. Lactate of 3.0. LFT's
showed ALT of 30, AST of 107 (baseline 50-70's), AlkP of 168,
TBili 6.7 (baseline [**3-10**]), INR of 2.0. Metabolic panel
significant for creatinine of 1.4 (baseline 0.6), BUN of 27
(Baseline around 10), as well as hyponatremia of 127 (baseline
low 130's). Hyperkalemic to 5.6, although specimen was grossly
hemolyzed. Urine studies did not show evidence of UTI.
Paracentesis was performed which showed 175 WBC and 125 RBC's.
Serum tox was negative, and APAP level was 18. CXR showed low
lung volumes, pulmonary vascular prominence, without evidence of
PNA or effussions. A CT of the lower extremity was performed
which showed no evidence of necrotizing fasciitis or fluid
collection, however large amounts of anasarca and ascites was
seen. Patient was given 1 gram Vancomycin,
Piperacillin-Tazobactam 4.5 g and 500cc bolus
.
Upon Transfer to the floor vitals 119/67, 81, 24 and 96% on 40%
ventimask. She is confused, disoriented and mumbling. At times
she moans in pain and says "I didnt do anything" when reoriented
she is appropriate and follows commands.
.
On arrival to the MICU service, she is on levo 0.06 and fentanyl
75, intubated and sedate. She is not arousable and is unable to
provide history.
Past Medical History:
# Hepatitis C cirrhosis -- inactive on transplant list
-- No reported h/o varices, though no EGD in our system
-- Stable arterially enhancing 8.7mm lesion in segment VII
concerning for HCC
# Hepatopulmonary syndrome (on 4L O2 at home)
# Pulmonary hypertension (on sildenafil, followed by pulm)
# Bipolar disorder
# Hysterectomy for fibroids
# Herniorrhaphy
Social History:
Currently living in [**Hospital 582**] Rehab in [**Location (un) 5176**], MA since [**Month (only) **]
[**2109**]. Previously lived with her longtime partner in [**Name (NI) 5289**]. Her
partner is her HCP and works full time at school program. Pt has
1 son in [**Name (NI) 5289**], and 1 daughter in [**Name (NI) 3844**].
Family History:
Mother deceased (unknown cause).
Physical Exam:
VS: 97.8 119/57 81 24 96% 40% Venti-mask
Gen: Diffusely jaundiced, Asterixis, eyes closed, lethargic but
arousable. Oriented to person, to place "[**Hospital1 3278**]" to day of the
week "[**12-17**]" to month "[**12-17**]" to year "[**12-17**]" Mumbles incoherent
words during examination, occasionally saying "I didnt even do
anything" follows commands appropriately, when oriented she is
more appropriate.
HEENT: NCAT. +scleral icterus.
CV: RRR S1, S2 clear and of good quality 3/6 systolic murmur
heard best at LUSB.
Chest: Respiration unlabored, no accessory muscle use. Poor
respiratory effort but no rales or wheezes heard.
Abd: Normal bowel sounds. Distended but Soft, NTTP. Tympanic to
peruccusion anteriorly but dull over dependent areas. +Ventral
hernia (at umbilicus, fully reducible).
Ext: WWP, 3+ [**Location (un) **] bilaterally. Erythema marked over anterior and
posterior left thigh blanching, non-raised, painful to
palpation.
Skin: Jaundiced. Spider angiomas on chest.
.
Pertinent Results:
Admission Labs:
[**2110-1-6**] 06:30AM BLOOD WBC-6.7# RBC-4.01* Hgb-13.4 Hct-40.3
MCV-101* MCH-33.4* MCHC-33.2 RDW-17.9* Plt Ct-57*
[**2110-1-6**] 06:30AM BLOOD Neuts-89.5* Lymphs-7.1* Monos-2.7 Eos-0.4
Baso-0.2
[**2110-1-6**] 06:30AM BLOOD PT-21.2* PTT-39.7* INR(PT)-2.0*
[**2110-1-6**] 06:30AM BLOOD Glucose-94 UreaN-27* Creat-1.4* Na-127*
K-5.6* Cl-92* HCO3-25 AnGap-16
[**2110-1-6**] 09:30AM BLOOD Glucose-93 UreaN-27* Creat-1.0 Na-128*
K-3.7 Cl-94* HCO3-25 AnGap-13
[**2110-1-6**] 06:30AM BLOOD ALT-30 AST-107* LD(LDH)-720* CK(CPK)-98
AlkPhos-168* TotBili-6.7*
[**2110-1-6**] 09:30AM BLOOD ALT-26 AST-47* LD(LDH)-274* AlkPhos-172*
TotBili-6.5* DirBili-3.8* IndBili-2.7
[**2110-1-6**] 06:30AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.2
[**2110-1-6**] 09:30AM BLOOD Osmolal-270*
[**2110-1-6**] 06:42AM BLOOD Lactate-3.0*
[**2110-1-6**] 09:50AM BLOOD Lactate-2.5*
[**2110-1-6**] 06:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-18
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ARF/Hypo Natremia work up
[**2110-1-6**] 06:30AM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.019
[**2110-1-6**] 06:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-2* pH-5.0 Leuks-NEG
[**2110-1-6**] 06:30AM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
[**2110-1-6**] 06:30AM URINE CastGr-1* CastHy-151*
[**2110-1-6**] 12:05PM URINE Hours-RANDOM UreaN-398 Creat-146 Na-LESS
THAN K-26 Cl-LESS THAN TotProt-51 Prot/Cr-0.3*
[**2110-1-6**] 12:05PM URINE Osmolal-362
Ascites:
[**2110-1-6**] 07:50AM ASCITES WBC-175* RBC-125* Polys-5* Lymphs-13*
Monos-0 Eos-2* Mesothe-2* Macroph-77* Other-1*
Micro:
BCx NGTD x2 [**2110-1-6**]
UCx NGTD x1 [**2110-1-6**]
Ascites Fluid NGTD [**2110-1-6**]
Imaging
CXR [**2110-1-6**]: FINDINGS: Lung volumes are low. There is pulmonary
vascular prominence. No focal consolidation, pleural effusion,
or pneumothorax is appreciated on this single frontal view.
Deformity of the right humerus is again noted, partially imaged.
CT Scan [**2110-1-6**]: IMPRESSION:
1. No soft tissue gas in the left lower extremity. Extensive
fascial and subcutaneous edema but no intramuscular edema. No
drainable fluid collection.
2. Moderate to severe anasarca and moderate to large amount of
ascites, both increased since [**2109-10-5**]
RUQ u/s ([**1-6**]):
1. Partial thrombosis of the right portal vein, probably
decreased somewhat.
2. Bidirectional but predominantly hepatofugal flow in the right
portal vein.
3. Large patent umbilical collateral vein.
4. Moderate-to-large amount of ascites.
5. Splenomegaly.
6. Unchanged cholelithiasis with gallbladder wall edema. No
evidence of cholecystitis.
.
CT LE ([**1-6**]):
IMPRESSION:
1. No soft tissue gas in the left lower extremity. Extensive
fascial and subcutaneous edema but no intramuscular edema. No
drainable fluid collection.
2. Moderate to severe anasarca and moderate to large amount of
ascites, both increased since [**2109-10-5**].
Non-contrast head CT ([**1-8**]):
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or infarction. The ventricles and sulci are normal in
size and configuration. Mild bifrontal cortical atrophy is
present and likely related to underlying chronic liver disease
and multiple prior episodes of encephalopathy. No fracture is
identified. The visualized paranasal sinuses, mastoid air cells,
and middle ear cavities are clear.
IMPRESSION: No acute intracranial process.
Renal ultrasound ([**1-8**]): PRELIMINARY REPORT
FINDINGS: The right kidney measures 10.7 cm. The left kidney
measures 11 cm. Both kidneys are normal in size and echogenicity
with no evidence of hydronephrosis, stone, or renal lesion
bilaterally. There is a moderate amount of ascites which is
unchanged from previous ultrasound. The bladder is collapsed
with a Foley catheter in situ, limiting evaluation.
IMPRESSION:
1. Normal renal ultrasound.
2. Moderate ascites unchanged from previous US of [**2110-1-6**].
3. Foley catheter within a collapsed bladder.
Brief Hospital Course:
Patient is a 56 year old female with HCV cirrhosis c/b
portopulmonary HTN, hepatopulmonary syndrome and repeated
episodes of hepatic encephalopathy presenting with altered
mental status, LLE cellulitis, and acute kidney injury.
.
SICU course:
[**1-9**] - Lasix gtt not improving UOP. Increasingly confused,
hypotensive and tachypneic. A-line placed. Intubated, sedated.
Bedside TTE done - pHTN, good LV fxn. CVL with Swan, HD line
placed. Hypotensive o/n requiring neo gtt, 250cc 5%albumin
bolus.
[**1-10**] - Paroxysmal arrhythmias - EKG.
[**1-11**] - patent foramen ovale on bubble study; continues on CMV,
making 30-60 cc/hr urine; C diff neg x 1; paracentesis not done;
TF restarted
[**1-12**] - increasing levo gtt requirement, low UOP. Gave 250cc 5%
albumin. Changed to Replete TFs, advance to goal.
[**1-13**] - d/c'd L IJ HD cath, miniBAL sent for VAP eval
[**1-14**] - lasix 40 w min response; FiO2 40->60 for incr SaO2 goal
to 90; midaz prn agitation, Vanco: 16.3, MELD 32 (without
hepatopulm exceptions), cont pressor dependence
[**1-15**] - albumin 25gm, lasix 80 x1. Began having emesis of stool.
NG to suction, ~600cc came out, then NG to gravity. STAT KUB.
restarted fentanyl gtt for comfort. Patient taken off transplant
list and transferred to MICU. Tolerating 10/5 PSV for several
days. On 0.06 levo.
[**1-17**]: Decision was made to extubate and make CMO. The patient
passed away on the morning of [**1-18**].
.
#AMS: Given her history this was considerd related to hepatic
encephalopathy, likely exacerbated by cellulitis. In addition,
Benadryl given night prior to admission may have acutely
worsened mental status. Ascites negative for SBP, urine clean
and CXR negative for focal consolidations. Tox screen negative.
This may also be delirium in addition to hepatic encephalopathy
as patient has had episodes of acute delirium during past
admission. She continued to be confused, despite lactulose and
treatment of her infection. Non-contrast head CT showed no sign
of bleeding or other acute process.
.
#LLE Cellulitis: Admitted with large cellulitis on left thigh
extending almost complete circumference of thigh, superior to
knee. As the patient had been hospitalized frequently and lives
at extended living facility, she was treated empirically for
MRSA infection with Vancomycin. LE ultrasound ruled out DVT.
.
# Increase in LFTs: Initial labs with AST elevated from baseline
and ALT at baseline, this was associated with an elevated LDH
and total bilirubin. RUQ ultrasound revealed non-occlusive
portal vein thrombus.
.
#Acute Kidney Injury: Baseline creatinine of 0.9 though
discharged most recently at 0.6. Initially presented to ED with
creatinine of 1.4. This was pre-renal in etiology supported by
a FeUrea 14% and response to volume challenge. Diruetics were
held and she was treated with albumin with little improvement.
Renal ultrasound ruled out obstruction, leading to concern for
HRS vs. ATN.
#HCV cirrhosis: MELD of 25 biochemically on admission, 33 with
exception points for HPS. Complicated by ascites, portopulmonary
syndrome, hepatopulmonary syndrome and refractory ascites and
likely developing HCC mass. Admitted grossly volume overloaded
with anasarca. Not on active transplant list because of
pyschosocial issues including inability to care for herself,
requiring 24 hour care. Ascites negative for SBP, but
significant. Received therapeutic paracentesis [**1-7**], took of 1.8
L. Diuretics initially held because of [**Last Name (un) **] and hyponatremia.
Home lactulose and rifaximin continued.
.
#Hyponatremia: Baseline sodium in low 130's, admitted with value
of 127. Likely dilutional from cirrhosis, anasarca indicating
volume overload status. Diuretics were held, Albumin challenge
given and she was free water restricted with a low Na diet.
Sodium normalized.
.
# Anemia: Total drop from 40.3 to 28.8. Patient was
hemodynamically stable, guaiac negative. B12 and folate normal,
retic 3.4% which may be inappropriately low given drop, MCV
high. No clear etiology found.
.
# UTI: UA positive for UTI, culture pending. Treated with 5 day
course of Cipro.
.
#Portopulmonary hypertension/Hepatopulmonary syndrome: Chronic,
stable on 4L home O2 and Sildenafil. Right heart cath during
recent admission showed PAPs with mPAP of 34, PVR of 272.
.
#Bipolar Disorder: Chronic, stable. Continued Seroquel 150 mg HS
and Lamotrigine 100 mg PO BID with Haldol 2.5 mg PO/IM/IV for
severe agitation (combative, immediate harm to self/staff)
.
#Thrombocytopenia: Chronic sequelae of chronic liver
disease/portal hypertension.
.
#Psychosocial: Social support system is a limiting factor in
transplant candidacy. Pt is rehab dependent and needs 24 hour
care. Have applied for long term housing with aggressive PT as
patient severely decompensated from baseline.
.
# Hepatic Mass: Stable 10mm found on RUQ US, likely HCC but not
biopsy proven. Pt scheduled for imaging follow-up of lesion in
[**2110-1-5**]
.
Medications on Admission:
-lactulose 10 gram/15 mL 30 PO TID
-rifaximin 550 mg PO BID
-sildenafil 20 mg PO TID
-furosemide 20 mgPO qday
-spironolactone 100 mg PO DAILY
-quetiapine 150 mg PO QHS
-lamotrigine 100 mg PO BID
-folic acid 1 mg PO qday
-omeprazole 20 mg 1 PO BID
-cholecalciferol 400 unit PO qday
-magnesium oxide 400 mg PO BID
-multivitamin PO DAILY
-senna 8.6 mg PO DAILY
-thiamine HCl 100 mg PO DAILY
-calcium carbonate 200 mg calcium (500 mg) Tablet po qday
-diphenhydramine HCl 25 mg Capsule 1 po Q6hrs prn restless legs
-SUPPLEMENTAL OXYGEN - - 4L continuous at home, 4L pulsed
for portable ongoing patient needs concentrator and portable
equipment
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
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4,699
| 159,743
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9570
|
Discharge summary
|
report
|
Admission Date: [**2148-4-3**] Discharge Date: [**2148-4-12**]
Date of Birth: [**2111-4-15**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Fosamprenavir
Attending:[**First Name3 (LF) 21114**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
37 yo F w/ HIV (CD4 177 and VL <50 on HAART [**3-26**]), HCV, HBV
presents with severe dyspnea on exertion. The patient was at
her usual good state of health when a week ago she began to have
malaise and HA. As the week progressed her malaise and HA
worsened and she developed increasing DOE (difficult walking
across her house). At baseline she is able to climb stairs with
ease. She also reported fevers and chills. Her symproms
continued to worsen and she reocrded a temp of 102 2 days prior
to admission which did not respond to 500mg tylenol.
.
At this point in time she also developed cough productive of
clear, but blood tinged sputum. The night prior to admission
she would wake up gasping for air. She has no history of heart
disease, PND or orthopnea.
.
Also she reports mild L. sided CP worse with inspiration.
Denies diaphoresis or light headedness. Pain does not worsen
with exertion and does not radiate. She has had sick contacts
at the day program she attends. No flu vaccine this year. On
dapsone for PCP [**Name Initial (PRE) 1102**]. Also reports complete adherence
with her HIV meds (but has not yet taken am dose due to mild
nausea).
.
On arival to the floor the patient was extremely short of breath
and had difficulty speaking. Her voice was extremely horse
which is a deviation from her baseline. She improved markedly
with an albuterol and atrovent neb.
.
ROS: Her [**Name Initial (PRE) **] has been dark and stools are light tan. chronic
rash related to liver disease with recent superimposed
photosensitivity rash due to fosamprenavir (resolving). guaiac
positive stools (planned for colonoscopy
and repeat EGD, last one [**3-25**] with portal gastropathy), Denies
weight loss, dysuria, N, V, diarrhea, abd pain,
numbness/tingling, focal weakness
Past Medical History:
1. HIV: diagnosed in [**2133**] while hospitalized in a psych facility
in the setting of IVDU. CD4 nadir approx 100. No h/o OI's. Pt is
heavily ARV experienced since [**2136**] including what she believes
was AZT monotherapy, stc, NVP(severe myalgias), IDV, saquinavir,
d4t, and nelfinavir. she was on d4t/3tc/nfv from 99 through 01
with cd4 400s-800s and vl <10K. Genotype done on this regimen
reportedly showed 3tc, ddi, and several PI mutations; these are
not specifically documented. Meds stopped in the context of
treating hep C; reinitiated ARVs in [**9-23**] with tdf/3tc/rtv/atv.
brief change to tdf/3tc/fosamprenavir/ritonavir but developed
photosensitivity rash (changed back to atazanavir regimen)
2. HCV: diagnosed approx [**2141**]; genotype IA; Bx [**2-20**] with grade 4
fibrosis/cirrhosis and grade [**1-25**] inflammation. s/p 42 wks peg-
IFN/ribavirin rx; initial response with undetectable hep C VL
[**3-22**] but VL rebound to 14 million in [**9-22**]; 18.6 million in
[**2-23**]. followed by dr [**Last Name (STitle) **]. Signs of advancing liver disease
with palmar erythema, spider angiomata, SM, thrombocytopenia.
u/s shows cirrhosis with no focal liver masses, splenomegaly,
patent portal vein. estimated portal pressure not documented,
but +gastropathy on EGD. labs show mild transaminitis (ast>alt)
and alk phos elevation, total bili intially normal now elevated
in the setting atazanavir. Of note, she undergoing HIV/SOT
transplant evaluation and followed by Dr. [**Last Name (STitle) 724**] and Dr. [**Last Name (STitle) 497**] in
this capacity.
3. h/o lipodystrophy on PIs
4. neuropathy
5. ?genital herpes, not active
6. seasonal allergies responsive to claritin in the past
7. depression with h/o suicide attempt: followed by psych
(offsite)
8. substance abuse on meth maint: followed at [**Hospital3 635**] meth
clinic
9. h/o abNL PAP, NL on f/u in [**2143**]
10. vaginal candidiasis
11. h/o hypophosphatemia (1.9) on TDF; high urinary PO4
documented concurrently. improved on phosphate repletion.
12. guaiac positive stools, planned for colonoscopy/EGD.
followed by GI (Dr [**Last Name (STitle) 497**]
13. GERD
.
vaccines/prevention:
flu: pt declined [**2143**]4/[**2143**]5
pneumovax: [**11-24**]
PAP: wnl [**11-24**]
PPD: neg [**6-23**]
hep A: done 01, 02
hep B: n/a
[**Last Name (un) 3907**]: advise
chol: ldl 113 in [**8-25**]
Social History:
lives with mother
good family support
quit tobbacco 1 week ago
former etoh and alcohol
Family History:
BrCa
lymphoma
Physical Exam:
Gen - A+Ox3, tachypneic,
T 101 BP 92/60 HR 90 RR 22 SO2 92% on 3L
HEENT: perrla, +scleral icterus. eomi.
NECK: no sig LAD. no JVD
CHEST: ronchi at L. base.
COR: rrr no m/r/g
ABD: soft ntnd. liver and spleen palpable
RECTAL: guaiac positive brown stool (per ID)
EXT: no c/c/e normal distal pulses
SKIN: chronic macular telangectatic angiomata ("spiders") over
upper R. chest, back and arm. +palmar erythema.
Neuro: no asterixis. CN II-XII intact. normal stength and
sensation x 4 ext.
Pertinent Results:
[**2148-4-3**] 03:50PM WBC-15.3*# RBC-2.34* HGB-8.7* HCT-25.9*
MCV-111* MCH-37.2* MCHC-33.6 RDW-15.4
[**2148-4-3**] 03:50PM PLT COUNT-74*
[**2148-4-3**] 03:50PM GLUCOSE-43* UREA N-18 CREAT-1.3* SODIUM-129*
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-20* ANION GAP-15
[**2148-4-3**] 03:50PM ALT(SGPT)-21 AST(SGOT)-49* LD(LDH)-182 ALK
PHOS-149* TOT BILI-5.5* DIR BILI-3.0* INDIR BIL-2.5
[**2148-4-3**] 03:50PM ALBUMIN-2.4* CALCIUM-7.9* PHOSPHATE-2.8
MAGNESIUM-1.4*
.
[**2148-4-3**] 1:39 pm SPUTUM Source: Expectorated.
FUNGAL CX ADDED [**2148-4-8**].. (SPECIMEN DISCARDED).
GRAM STAIN (Final [**2148-4-3**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2148-4-5**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.
MODERATE GROWTH.
BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.
FUNGAL CULTURE (Final [**2148-4-8**]):
TEST CANCELLED, PATIENT CREDITED.
SPECIMEN DISCARDED.
.
[**2148-4-11**] 3:30 pm BRONCHOALVEOLAR LAVAGE
HSV AND VZV DIRECT ANTIGEN TEST NOT AVAILABLE ON BRONCH
LAVAGE.
PLEASE REFER TO CULTURE RESULTS.
R/O CMV,VZV,HSV AND RESPIRATORY VIRUSES.
GRAM STAIN (Final [**2148-4-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2148-4-13**]): ~[**2142**]/ML
OROPHARYNGEAL FLORA.
ACID FAST SMEAR (Final [**2148-4-12**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
FUNGAL CULTURE (Pending):
POTASSIUM HYDROXIDE PREPARATION (Final [**2148-4-12**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
IMMUNOFLUORESCENT TEST FOR PNEUMOCYSTIS CARINII (Final
[**2148-4-12**]):
PNEUMOCYSTIS CARINII NOT SEEN.
Rapid Respiratory Viral Antigen Test (Final [**2148-4-12**]):
Respiratory viral antigens not detected.
CULTURE CONFIRMATION PENDING.
SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
RSV.
This kit is not FDA approved for direct detection of
parainfluenza
virus in specimens; interpret parainfluenza results with
caution.
VIRAL CULTURE (Pending):
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
.
CTA CHEST W&W/O C &RECONS [**2148-4-4**] 9:51 PM
IMPRESSION:
1. Complete dense consolidation of the left lower lobe, with
early left upper lobe consolidations as well.
2. No evidence of pulmonary embolism. We suggest close followup
with chest radiographs.
3. Small amount of ascites, with likely splenomegaly.
.
TTE ([**4-9**])
1. Left ventricular wall thickness, cavity size, and systolic
function are normal (LVEF>55%). Regional left ventricular wall
motion is normal.
2. Compared with the findings of the prior report (tape
unavailable for
review) of 1026/04, there has been no significant change
.
CTA CHEST W&W/O C &RECONS [**2148-4-10**] 2:49 PM
1) Apparent area of decreased density within a right upper lobe
anterior segmental branch, which most likely reflects streak
artifact from concentrated contrast within the superior vena
cava. If there is high clinical concern for pulmonary embolism,
V/Q scan can be performed for further evaluation.
2) Improved aeration of the left lower lobe as above. Increasing
multifocal ground glass opacities within the left upper lobe,
and to a lesser extent the right upper lobe. In an HIV-positive
patient, these findings are concerning for PCP pneumonia or
another atypical infection.
3) Splenomegaly.
Brief Hospital Course:
Ms. [**Known lastname 32477**] is a 37 year old female with a history HIV (CD4 177
and VL <50 on HAART [**3-26**]), HCV, HBV who presented with severe
dyspnea on exertion.
.
1) DYSPNEA - The patient presented to [**Hospital **] clinic with a physical
exam consistant with a pneumonia, including bronchial breath
sounds in the LLL. She was also hypoxic. CXR was remarkable
for a LLL pneumonia. She was started on levofloxacin for
presumed community acquired pneumonia. She was also maintained
on nebulizers. She continued to be hypoxic despite treatment
with levofloxacin. PO2 was 50. She was transferred to the ICU
and switched to Ceftriaxone and Azithromycin to cover resistant
pneumococci. In the ICU, the patient markedly improved with
hish flow O2. She was then transferred back to the floor.
Given her low CD4 count, she is at risk for other infections
such as fungal or PCP. [**Name10 (NameIs) 2772**], she is on dapsone prophylaxis,
and initial sputum negative for PCP. [**Name10 (NameIs) **] legionella negative.
She is PPD neg [**6-23**] and received pneumovax [**11-24**]. The patient
was ruled out for influenza with DFA this admission. Initial
sputum was positive for H. influenza. Given her continued
relatively high O2 requirement despite antibiotic therapy, a
repeat CTA was performed. This study showed increased
multifocal ground glass opacities within the LUL and RUL,
concerning for PCP. [**Name10 (NameIs) **] patient was empirically started on TMP
for treatment. The pulmonary service was consulted and a
bronchoscopy was performed with BAL. Several cultures were
sent, all of which negative so far, with several more results
pending at the time of discharge (including PCP [**Name Initial (PRE) 23426**]). She was
maintained on TMP/dapsone for PCP treatment and scheduled follow
up in the [**Hospital **] clinic the week after discharge. She was
discharged in stable condition with home oxygen therapy until
resolution of her pneumonia.
.
2) HIV - The patient was continued on her outpatient HAART and
dapsone therapy.
.
3) HEP B/C WITH CIRRHOSIS - The patient was continued on her
outpation dose of lasix, nadolol, and spirololactone. Her
diuretics were transiently held due to a slightly elevated
creatinine. These were restarted after resolution of this renal
insufficiency.
.
4) GERD - She was continued on zantac.
.
5) Depression - She was continued on zoloft.
.
6) Code status - Full Code
Medications on Admission:
ANTIVERT 12.5MG--One tablet by mouth three times a day as needed
for dizziness
ATAZANAVIR SULFATE 150MG--Two tabs by mouth daily
BENADRYL 25MG--Take two tablets at bedtime as needed for itching
CALCIUM 600/D 600MG-200--One tablet by mouth twice daily
DAPSONE 100MG--One tablet by mouth every day
DULCOLAX 5MG--One to tablets by mouth as needed for constipation
EPIVIR 300MG--One tablet by mouth every day
K-PHOS NEUTRAL 250MG--1-2 tabs by mouth four times a day
LASIX TABLETS 20MG--One tablet by mouth every other day
LORATADINE 10MG--One tablet by mouth every other day
NADOLOL 20MG--One by mouth every day
RITONAVIR 100MG--One tablet by mouth daily
SPIRONOLACTONE 50MG--One tablet by mouth every day
TENOFOVIR DISOPROXIL FUMARATE 300MG--One tablet by mouth every
day
WESTCORT 0.2%--Apply to affected area sparingly twice a day
ZANTAC 300MG--One tablet by mouth daily, take atleast 12 hours
apart from reyataz
ZOLOFT 100MG--Take one 1/2 tablets by mouth every morning per
psychiatry
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER if you experience
fever/chills, shortness of breath, or chest pain.
Followup Instructions:
1) [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD Where: LM [**Hospital Unit Name 4337**] DISEASE
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2148-4-18**] 1:30 PM
.
2) GI WEST,ROOM ONE GI ROOMS Where: GI ROOMS Date/Time:[**2148-5-21**]
9:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX)
ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2148-5-21**] 9:30
.
3) [**Name6 (MD) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 5628**]
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2148-5-22**] 11:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21117**] MD, [**MD Number(3) 21118**]
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|
4530, 4618
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,072
| 123,584
|
47055
|
Discharge summary
|
report
|
Admission Date: [**2160-6-15**] Discharge Date: [**2160-6-22**]
Service:
CHIEF COMPLAINT: "I've been feeling bad for the last few
days and since yesterday I have been nauseous and vomiting."
HISTORY OF PRESENT ILLNESS: The patient is a 77-year-old man
who presents with the above chief complaint and his past
medical history includes numerous medical problems including
non Q wave MI times two, status post CABG in [**2139**],
hypertension, insulin dependent diabetes mellitus,
hypercholesterolemia, history of TIAs, history of lower GI
bleed and diverticulosis. The patient was in his usual state
of health until approximately 4-5 weeks ago when his
degenerative joint disease and disc disease of his lumbar
spine began causing shooting right lower extremity pains. At
that time the patient was treated with steroid injections and
po Prednisone which caused an increase in his blood sugars.
For this increase in blood sugars he was started on Humalog
approximately 3-5 days ago as his sugars have been in the
300-400's on his previous regimen. Approximately one week
ago the patient began feeling bad and run down. The
patient's primary care doctor believed it was due to the high
blood sugars and started the Humalog 3-5 days ago. Yesterday
the patient reports the onset of nausea and vomiting after
eating. He tolerated lunch as his last meal and he has not
taken any po today. Also today he reports the onset of loose
stools times three. He denied any fevers, abdominal pain,
weight change or urinary symptoms. He does acknowledge night
sweats and chills at night over the last two days. He has a
chronic cough secondary to post nasal drip which is
unproductive of sputum. There is no erythema over the skin
where he injects his insulin. His exercise tolerance is
approximately one flight of stairs and he is limited by right
lower leg pain. He also denies any chest pain, shortness of
breath, palpitations or diaphoresis. He has no PND. The
patient finally came to the ER as he was not able to take
anything by mouth.
PAST MEDICAL HISTORY: 1) Insulin dependent diabetes
mellitus. 2) Hypertension, poorly controlled. 3) Chronic
renal insufficiency. 4) Status post non Q wave MI times two.
5) Status post CABG in [**2139**]. 6) Hypercholesterolemia. 7)
History of TIA. 8) Gout. 9) Lower GI bleed status post
polyp removal. 10) Diverticulosis. 11) Allergies and post
nasal drip.
MEDICATIONS: [**Doctor First Name **] 60 mg po q d, Lopressor 20 mg po q d,
Multivitamin, Doxazosin 4 mg q h.s., Lipitor 20 mg po q d,
Allopurinol 300 mg po q d, Ranitidine 150 mg po q h.s.,
Glyburide 10 mg po bid, Diovan 80 mg po q d, enteric coated
Aspirin 325 mg po q d, Quinine as needed, NPH 20-30 units q
a.m., 10-15 units q p.m., Humalog sliding scale started three
days ago.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] denies
any tobacco or alcohol use.
FAMILY HISTORY: Noncontributory.
ALLERGIES: Morphine makes him nauseous.
PHYSICAL EXAMINATION: Vital signs, temperature 99.5, heart
rate 83, blood pressure 170/125, respiratory rate 18, satting
100% on two liters nasal cannula. In general he is an
elderly man lying in bed in no acute distress. HEENT: He
has alopecia, pupils are equal, round and reactive to light
from 3 to 2 mm, sclera are anicteric. Mucus membranes are
moist. Neck supple, no jugulovenous distension, no
lymphadenopathy, no bruits. Cardiac exam, irregularly
irregular, S1 and S2 normal, no murmurs, gallops or rubs.
Lungs are clear to auscultation bilaterally. Abdomen, mild
tenderness to deep palpation of the left lower quadrant. He
is non distended, bowel sounds present and normal. Abdomen
is soft. GU, normal male genitalia, trace guaiac positive on
exam. Prostate without any nodules, regular and smooth.
Extremities, no clubbing, cyanosis or edema. Neuro, he is
alert and oriented times three, cranial nerves II through XII
normal. Reflexes 2+ bilaterally biceps and Achilles
strength, [**3-29**] upper extremities bilaterally, in the left
lower extremity is 4+/5 strength in his right big toe and
plantar and dorsiflexion of his foot. Gait and coordination
were not tested.
LABORATORY DATA: White count 14.6, differential with 84
neutrophils, 1 band, 10 lymphs, hematocrit 44.4, platelet
count 134,000, PT 11.7, PTT 21.4, INR 0.9. SMA 7, 137, 5.2
which was hemolyzed, 100, 21, 40, 1.4, glucose 297. Calcium
8.4, phosphorus 4.7, magnesium 2.1, AST 24, ALT 28, total
bilirubin 0.9, CK 54, troponin 0.3, alkaline phosphatase 59,
amylase 114, lipase 41, albumin 3.3, uric acid 4.3, TSH is
pending at this time. Chest x-ray showed no signs of
pulmonary edema and no infiltrate. EKG was irregularly
irregular at 92, axis -30, occasional P waves, looking like
flutter but there are also absent P waves. Intervals are
normal. There is a Q in 3 and F, no ST changes, poor R wave
progression. An echocardiogram from [**2160-4-25**] showed mild
left atrial dilatation, non obstructive focal septal
hypertrophy, depressed LV function 1+ aortic regurg, mild MR
[**First Name (Titles) **] [**Last Name (Titles) **] fraction could not be estimated at that time.
IMPRESSION: This is a 77-year-old man with multiple ongoing
medical problems who presents with generalized complaints of
the last week and a [**11-27**] day history of nausea and vomiting
and loose stool. He was found to be in new onset atrial
fibrillation in the ER. Physical exam was remarkable for the
atrial fibrillation with guaiac positive stool and mild left
lower quadrant tenderness. Labs revealed an increased white
blood cell count with left shift and low albumin. Chest
x-ray and EKG are normal and unchanged respectively.
PLAN:
Cardiac: The patient has known CAD. His Aspirin, beta
blocker, Lipitor and [**Last Name (un) **] will be continued. His hypertension
will be aggressively controlled. Although ischemia is
unlikely without any changes in EKG, CKs will be followed.
The patient is in new onset atrial fibrillation but Lopressor
will be increased to 50 mg [**Hospital1 **] for rate control. TSH is
pending after weighing the risks and benefits of Heparin.
Given the patient's trace guaiac positive stool, history of
lower GI bleed, the decision was made to start the patient on
Heparin as he had multiple risk factors for stroke elevating
him into a higher level of category including his past
history of TIAs.
Infectious Disease: He has an elevated white count with a
left shift. He has night sweats, chills times two days.
Cultures of urine, stool and blood will be sent. Blood
cultures will be obtained when the patient's fever curve is
greater than 101. No empiric antibiotics will be started at
this time.
Endocrine: The patient has poor glucose control. He will be
written for an insulin sliding scale while in the hospital
and fingersticks will be checked qid. His oral hypoglycemics
will be held for now.
GI: He is trace guaiac positive with left lower quadrant
tenderness and a history of diverticulosis. Diverticulitis
is certainly a possibility although given the benign
presentation of his abdomen on exam, it is unlikely.
However, we will continue to follow his abdominal exam. We
will guaiac all stools and we will follow hematocrit q d on
Heparin. The patient will be given antiemetics as needed to
control the nausea and vomiting.
Renal: The patient has a creatinine of 1.4 with an elevated
BUN to creatinine ratio. He is most likely dehydrated given
his nausea and vomiting and slightly prerenal and will be
hydrated.
Musculoskeletal and Neuro: He has decreased strength in his
right lower leg consistent with his past medical history of
DJD and disc disease of his lumbar spine. His pain will be
controlled with non Opioids as much as possible as Opioids
have given him bad reactions in the past. The patient was
admitted and this plan was pursued.
HOSPITAL COURSE: On hospital day #2 the patient had no
adverse events overnight. The stool samples and the TSH are
still pending. The patient is maintained on Heparin and the
plan will be to transition him to Coumadin, then to discharge
the patient and bring him back at 1-2 months for TEE and
cardioversion at that time after anticoagulation, as it is
unknown how long patient has been in atrial fibrillation.
Also on this admission the plan is to control his blood
sugars, hopefully the combined approach will lead to a
resolution of his nausea and vomiting and he can go home. On
hospital day #3 the patient complained of some right thigh
swelling. He was neurovascularly intact and this was thought
to be secondary to a muscle pull the patient experienced
approximately five days prior to admission. There was a
small hematoma. This is most likely exacerbated because of
the Heparin the patient has been on, but the team was not so
concerned about this. Also on the third hospital day the
patient became tachycardic and hypotensive with blood
pressure in the 60's/30's. The patient was somnolent at this
time. Exam was unchanged from prior. IV fluids were given
and EKG was done that was unchanged. The Heparin was
discontinued and an NG lavage was performed that showed dark
brown fluid in the stomach with occasional clots which were
Gastroccult positive. With the lavage, the red fluid did not
clear. A stat hematocrit came back at 26 which was down from
44 on admission, although this is partly due to rehydration,
this is significantly due to an upper GI bleed. The patient
was transferred to the CCU at that time and transfused two
units of packed red blood cells. The patient underwent
emergent EGD that showed clotted blood in the lower third of
the esophagus and multiple non bleeding diffuse erosions in
the lower third of the esophagus. The stomach was normal.
In the duodenum there were multiple acute crater ulcers in
the bulb and in the second part of the duodenum. Pigmented
material coating these ulcers suggested recent bleeding in
one of the ulcers. The patient was treated with proton pump
inhibitor [**Hospital1 **], discontinuation of all NSAIDS and
anticoagulation. Hematocrits were continually followed and
an H. pylori antibody was checked. The TSH level came back
as normal at this time. On the fourth hospital day the
patient was transferred back to the floor from the unit after
the EGD and the 2 units of packed cells when patient was
stabilized. On hospital day #5 the patient's main complaint
was his right thigh swelling leading to right thigh weakness
when he stood up. He denied anymore episodes of
lightheadedness, dizziness, chest pain, shortness of breath,
bright red blood per rectum, melena or vomiting of blood. At
this time his Aspirin was changed to 81 mg from 325 mg and
the patient was not on either Heparin or Coumadin. The
patient's hematocrit post transfusion rose to 31 and has
continued to rise since then. His creatinine and BUN bumped
transiently during the patient's hypovolemia episodes. They
are now trending down. The NPH and regular insulin sliding
scale is controlling the patient's blood sugars. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
consult was obtained because the patient is usually followed
in [**Last Name (un) **], to further optimize the patient's insulin regimen.
The plan is to treat the patient for one month with proton
pump inhibitors, to follow-up the results of the H. pylori,
treat that if positive and to allow the ulcers one month to
heal. The patient will return for a repeat upper endoscopy
in one month. At that time if the ulcers are healed,
anticoagulation will be pursued with the eventual goal of
performing a TEE and cardioversion either chemical or
electrical, once the patient has been on stable
anticoagulation for one month. Hospital day #6 the patient's
diet was advanced as tolerated. Physical therapy saw the
patient who agreed he was safe for discharge home. On
hospital day #7 the patient slowly was regaining his strength
in his right leg and mobility. He was starting to ask to go
home. On hospital day #8 he was discharged home. He will
follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1313**], Dr. [**Last Name (STitle) 19862**] from endocrine
and Dr. [**First Name (STitle) 1104**] from cardiology. All of those attendings are
aware of the [**Hospital 228**] hospital course. The patient's
Lopressor dose at the time of discharge is 37.5 mg po tid.
The H. pylori result came back positive. He will be treated
for H. pylori infection. He will follow-up with GI in [**2-29**]
weeks for repeat upper endoscopy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 31943**], M.D. [**MD Number(1) 31944**]
Dictated By:[**Last Name (NamePattern1) 8228**]
MEDQUIST36
D: [**2161-1-28**] 12:05
T: [**2161-1-28**] 14:07
JOB#: [**Job Number **]
|
[
"250.02",
"276.5",
"V45.81",
"532.40",
"427.31",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
2926, 2986
|
7899, 12864
|
3009, 7881
|
100, 202
|
231, 2051
|
2074, 2805
|
2822, 2909
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,884
| 162,917
|
32237
|
Discharge summary
|
report
|
Admission Date: [**2152-3-6**] Discharge Date: [**2152-3-11**]
Date of Birth: [**2067-1-31**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Aspirin
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
85 yo F with history of GI bleed, RLE DVT s/p IVC filter, heart
failure, multiple recent hospitalizations, presents with
tachypnea, dyspnea, and hypoxemia from extended care facility.
Per nursing notes, patient complaining of dyspnea and was found
to have pulse elevated to 114, RR elevated to 29, and O2Sat of
60% on RA. Nursing notes report diffuse wheezing. Patient
started on NRB.
.
Upon arrival to the ED vitals were: T 97.7, HR 93, BP 162/80, RR
28, O2Sat 96% 10L. Had a U/A in the ED that showed WBC and many
bacteria. Also with CXR showed RUL infiltrate. Received
ceftriaxone and levofloxacin. Also received olanzapine given
agitation. Had about 500 mL of UOP. Has a 20g IV in left arm.
Patient had a guaiac positive stool in ED. Vitals prior to
transfer to the MICU were: T 99.5, HR 95, BP 159/76, RR 24,
O2Sat 100% NRB.
.
Patient denies any dyspnea, fever, chills, dysuria, reports only
left calf pain, being hungry, and being cold.
Past Medical History:
* Coronary artery disease s/p MI ([**2132**]) with wall motion
abnormalities on ECHO in [**2149-3-1**], NSTEMI/CHF exacerbation at
[**Hospital1 882**] ([**7-/2151**])
* Congestive Heart Failure (EF45% in [**2149-3-1**]) felt due to
ichemia, with poor nutritional status and compensated
hypertension
* Moderate pulmonary artery systolic hypertension
* Mild-moderate tricuspid regurgiation
* Carotid stenosis (<40% stenosis within bilateral carotids,
right vertebral artery with no color flow on Doppler compatible
with occlusion, [**3-/2149**])
* Hypertension
* Hyperlipidemia
* Dementia (A&OX2 at [**Year (4 digits) 5348**])
* Chronic renal insufficiency, stage III
* Iron deficiency anemia with h/o heme positive stools
* Osteoporosis
* Anxiety
* GERD
* Constipation
* Macular degeneration
* s/p fall in [**2149-3-1**] with SAH, SDH, right temporal
intraparenchymal hemorrhage plus minimally displaced right
superior ramus fracture, left radial fracture
* h/o left hip fracture with replacement ([**2148**])
* h/p right hip fracture with repair [**12/2151**]
* h/o lower GI bleed
* h/o pneumonias including aspiration PNA ([**4-/2149**])
* h/o UTIs, Staph Aureus
* Left breast lumpectomy
Social History:
Denies tobacco/alcohol/illicit drugs. Retired teacher of Russian
and [**Doctor First Name 533**], resides at [**Hospital1 100**] Senior Life in [**Location (un) 2312**], Russian
unit since [**2148**]. Widowed, has two sons [**Name (NI) 2855**] and [**Name2 (NI) 59911**] [**Name (NI) 75363**]
who are actively involved in her care. She is able to use a
walker with assistance. She is incontinent of urine and stool.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 98.4, HR 91, BP 141/65, RR 17, O2Sat 97% by 40% Venturi
GEN: NAD, alert
HEENT: PERRL, no conjunctival pallor, oral mucosa slightly dry,
wearing face mask
NECK: Supple, no visible JVP elevation
PULM: Anterior exam with crackles and decreased breath sounds at
right axilla, no wheezing bilaterally
CARD: Tachycardic, nl S1, nl S2, no M/R/G
ABD: Soft, BS+, non-tender, non-distended
EXT: No lower extremity edema, left leg with tender calf
SKIN: Multiple scars and healed ulcers along BLE
NEURO: Oriented to self and "clinic", did not know date, is
alert and conversant, speaking Russian to her two sons
On Discharge:
O. Tc 96.2 BP 129/75 HR 80 RR 16 O2 100% RA
Gen: Unhappy to be in the hospital, NAD, Alert, improved
HEENT: MMM, sclera anicteric, EOMI, JVP not elevated
CV: RRR, no M/R/G.
Pulm: Diffuse light wheezing, shallow breaths
Abd: Flat, + BS, NT/ND.
Ext: warm and well perfused, no edema, r/dp/pt pulses 2+
bilaterally. Right lower extremity tender to any manipulation.
Skin: Right heel ulcer dressed with waffle boot.
Neuro: A & O*1
Psych: Not aware of place or time. strong in all extremities.
Pertinent Results:
Admission Labs:
[**2152-3-6**] 12:15PM BLOOD WBC-12.3*# RBC-3.59* Hgb-12.1 Hct-36.4
MCV-102* MCH-33.8* MCHC-33.3 RDW-15.6* Plt Ct-277
[**2152-3-6**] 12:15PM BLOOD Neuts-89.9* Lymphs-6.9* Monos-2.4 Eos-0.5
Baso-0.3
[**2152-3-6**] 12:15PM BLOOD Glucose-133* UreaN-29* Creat-1.0 Na-139
K-5.4* Cl-107 HCO3-20* AnGap-17
[**2152-3-6**] 12:28PM BLOOD Lactate-2.7* K-6.3*
Microbiology:
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.
[**2152-3-6**] 12:40PM URINE RBC-13* WBC-46* Bacteri-MANY Yeast-NONE
Epi-1 TransE-<1
[**2152-3-6**] 12:40PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-LG
CXR:
FINDINGS: Portable upright AP chest radiograph is obtained.
There is
pulmonary vascular congestion noted in the setting of low lung
volumes. There
is more confluent opacity in the right upper lobe which is
concerning for
pneumonia. Left mid lung linear density is likely an area of
atelectasis.
The heart appears grossly stable in size. The aorta is markedly
unfolded.
The imaged osseous structures appear diffusely demineralized.
IMPRESSION: Congestive heart failure with superimposed right
upper lobe
pneumonia.
[**2152-3-6**] 12:40PM URINE RBC-13* WBC-46* Bacteri-MANY Yeast-NONE
Epi-1 TransE-<1
[**2152-3-6**] 12:40PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-LG
Brief Hospital Course:
Mrs. [**Known lastname 75361**] is a 85 yo F with history of GI bleed, RLE DVT s/p
IVC filter, heart failure, multiple recent hospitalizations,
presents with tachypnea, dyspnea, and hypoxemia from extended
care facility.
#. Health Care Associated Pneumonia:
Patient presented with WBC count of 12.3, tachycardia up to 101,
and tachypnea to 28. She was also hypoxic initially and briefly
on a non-rebreather. She was admitted to the MICU overnight.
Vancomycin and cefepime were started and she stabilized quickly
with quick weaning to room air. No further issues occured and
she will complete a 6 day total course of antibiotics at her
rehab facility.
- F/U blood cultures final read, NGTD as of [**2152-3-11**].
# UTI: Positive for proteus. Treated with cefepime as already on
this for HCAP.
#. Hypoxemia: Initially presented hypoxic to 88% on 2 liters in
the ED and transiently placed on a Non-rebreather and observed
in the MICU overnight. She was quickly titrated to room air in
the MICU and did not require further oxygen requirement. This
was felt to be secondary to pneumonia and slight volume
overload. She did receive 20 IV lasix once with good effect.
#. Right heel ulcer: Patient with pressure ulcer and black
eschar of right heel and did not appear infected. Standard wound
care and waffle boots applied.
# ?worms in stool: Patient had a bowel movement and expelled
what appeared to be large white, gelatinous worms. This was sent
to the lab, and unfortunately it was unable to be identified. It
was reported as "no worms", however it is unclear what this
substance was. Encouraging that patient did not have an
eosinophilia. She was not treated empirically for parasites.
This should be monitored closely in the outpatient.
# Hematocrit drop: Patient's initial Hct was 36.4 and dropped to
26.3. It stabilized in the mid to high 20s with no signs of
active bleeding. She notably only received approximately 500 cc
NS in ED. She was guaiac positive in the ED, however further
guaiacs were negative. She was continued on her anti-acid
regimen and on day of discharge her Hct was stabe at 28.9.
# Dementia: Patient has [**Date Range 5348**] dementia. Initially, she was
oriented to person only, however with the treatment of her
infections, her mental status improved to [**Date Range 5348**]. She was
continued on her home regimen.
#. Hypertension: Given her infections, metoprolol was continued
and imdur was held. This should be readdressed in the outpatient
if patient becomes hypertensive, consider restarting this
medication as she was controlled on this prior.
#. CAD: Continue metoprolol and hold imdur as above. ASA held in
setting of recent GIB.
#. GERD and GI bleed history: Continue home pantoprazole and
sulcralfate
#. Chronic nausea: Ondansetron was given as needed.
#. Code Status: Full code
Medications on Admission:
1) Sucralfate 1 gram PO QID
2) Trazodone 50 mg PO HS
3) [**Date Range 10687**] 8.6 mg PO BID
4) Polyethylene glycol 17 gram PO DAILY
5) Megestrol 400 mg/10 mL PO BID
6) Bisacodyl 10 mg PO DAILY:PRN constipation
7) Acetaminophen 650 mg PO TID
8) Isosorbide mononitrate 15 mg PO DAILY
9) Metoprolol succinate 50 mg PO DAILY
10) Lorazepam 0.5 mg PO TID
11) Pantoprazole 40 mg PO Q12H
12) Ondansetron 4 mg Tablet PO Q8H standing
13) Prochlorperazine 25 mg Suppository Rectal Q12H:PRN nausea
14) Torsemide 20 mg PO DAILY
Discharge Medications:
1. [**Date Range **] 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a
day).
2. polyethylene glycol 3350 17 gram/dose Powder [**Date Range **]: One (1) PO
DAILY (Daily).
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. sucralfate 1 gram Tablet [**Date Range **]: One (1) Tablet PO QID (4 times
a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. ondansetron 4 mg Tablet, Rapid Dissolve [**Date Range **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
7. acetaminophen 650 mg/20.3 mL Solution [**Date Range **]: One (1) PO TID (3
times a day) as needed for pain.
8. lorazepam 0.5 mg Tablet [**Date Range **]: One (1) Tablet PO three times a
day as needed for anxiety/agitation.
9. trazodone 50 mg Tablet [**Date Range **]: One (1) Tablet PO HS (at bedtime)
as needed for sleep/agitation.
10. cefepime 1 gram Recon Soln [**Date Range **]: One (1) gram Intravenous
once a day for 1 days.
11. vancomycin 1,000 mg Recon Soln [**Date Range **]: One (1) gram Intravenous
once a day for 1 days.
12. acetaminophen 650 mg Suppository [**Date Range **]: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain.
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
[**Date Range **]: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
1. Health Care Associated Pneumonia
2. Urinary Tract infection
3. Toxic Metabolic Encephalopathy
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:
Mrs. [**Known lastname 75361**],
It was a pleasure taking care of you while you were admitted to
the [**Hospital1 69**]. On [**2152-3-6**] you
presented from [**Hospital1 100**] Senior Life confused and not responding in
a manner that is normal for you. In our Emergency Department
and X-Ray demonstrated a pneumonia and you were found to have an
infection in your urine. We treated you with IV antibiotics and
on [**2152-3-11**] you returned to your normal state of functioning and
we discharged you back to [**Hospital1 100**] Senior Life.
Please note that we will need you to complete your final dose of
IV Vancomycin and Cefepime at [**Hospital1 100**] Senior Life on [**2152-3-12**].
You should continue all of your medications with the following
important changes:
1. Vancomycin 1 g IV x one dose on Sunday [**2152-3-12**]
2. Cefepime 1 g IV x one dose on Sunday [**2152-3-12**]
3. HOLD Imdur 15 mg daily. This was held in the setting of her
infection. If blood pressure is elevated/stable, should consider
restarting.
Followup Instructions:
Please make an appointment to see your primary care physician,
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] at [**Telephone/Fax (1) 2634**] in 7 to 10 days.
|
[
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10488, 10553
|
5576, 8404
|
314, 321
|
10694, 10694
|
4184, 4184
|
11925, 12121
|
2956, 3038
|
8970, 10465
|
10574, 10673
|
8430, 8947
|
10872, 11902
|
3053, 3661
|
3675, 4165
|
255, 276
|
349, 1293
|
4200, 5553
|
10709, 10848
|
1315, 2506
|
2522, 2940
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,926
| 125,698
|
25404
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 63506**]
Admission Date: [**2164-7-22**]
Discharge Date: [**2164-8-9**]
Sex: M
Service: VSU
CHIEF COMPLAINT: Ischemic right leg.
HISTORY OF PRESENT ILLNESS: This is an 85 year-old gentleman
with known peripheral vascular disease who underwent a left
above knee amputation and presents now with acute right leg
pain which started yesterday afternoon. The pain has become
progressive and now the leg feels cold. The patient has no
motor or sensation in the foot. He was evaluated in the
emergency room here and vascular surgery was consulted. The
patient has a history of claudication of the right leg. No
history of ulceration. Occasional rest pain at night, not
specifically in the foot. He uses a wheelchair the majority
of the time for ambulation. He denies any other
constitutional symptoms. He now admitted for emergent
vascular surgery.
PAST MEDICAL HISTORY: Illnesses include hypertension,
history of cardiomyopathy with a history of alcohol abuse.
History of peripheral vascular disease.
PAST SURGICAL HISTORY: Left above knee amputation in [**2161**] at
the Veterans Administration Hospital.
ALLERGIES: The patient is allergic to penicillin which
causes anaphylaxis.
MEDICATIONS ON ADMISSION: Included metoprolol, gabapentin,
hydrochlorothiazide, Zantac, isosorbide, mirtazapine and
Colace.
SOCIAL HISTORY: The patient lives alone. He is self
sufficient and ambulates with a wheelchair. He has a 70 pack-
year history of smoking. He had heavy alcohol use up until 3
years ago.
PHYSICAL EXAMINATION: Vital signs: 98.9, 96, 198/86, 20.
General appearance is an alert black male in no acute
distress. Head, eyes, ears, nose and throat examination is
unremarkable. There is no jugular venous distension or
lymphadenopathy. Carotids are palpable without bruits. Lungs
are clear to auscultation bilaterally and the heart is
irregular-irregular rhythm without murmur. Abdominal
examination shows a well healed midline abdominal incision.
The rectal is guaiac negative. The pulse examination shows
radials are 2+ and palpable. Femoral on the left is 2+.
Femoral on the right is palpable with a Dopplerable popliteal
and dorsalis pedis and posterior tibialis on the right. There
are no pulses above the knee amputation on the left.
Neurological examination is nonfocal.
HOSPITAL COURSE: The patient was initially evaluated in the
emergency room. Patient was given morphine sulfate for pain
control, IV heparin with a 4400 unit bolus and 1,000 unit
infusion rate was begun. The patient's laboratories included
a CBC which was a white count of 14.5, hematocrit 35.7,
platelets 167,000. BUN 32, creatinine 1.6, potassium 3.9,
repleted. Magnesium 1.7, repleted. Electrocardiogram was
sinus rhythm at 75, no ischemic changes or acute changes. The
patient was on IV nitroglycerine for systolic hypertension.
He was transferred to the vascular intensive care unit for
continued monitoring and care after undergoing an
intraoperative arteriogram with a right common femoral artery
thrombectomy and a femoral-femoral bypass. Postoperatively he
did well. On postoperative day 1 there were no overnight
events. He was weaned off of his nitroglycerine. His systolic
blood pressure was 124. His postoperative hematocrit was
36.9, BUN 29, creatinine 1.5. His physical examination -
dressings were clean, dry and intact with a monophasic
profunda popliteal pulse and a palpable graft pulse. The leg
foot was warm to mid foot with a monophasic signal at the
ankle. The patient was continued on incentive spirometry. His
diet was advanced as tolerated. His fluids were HEP-locked.
Heparin was continued for a therapeutic range between 60 and
70. His serial PTTs were monitored. He was delined and
transferred to the regular nursing floor. The patient was
evaluated by physical therapy on postoperative day #2 that
they felt he was well below his baseline level and would
require rehabilitation upon discharge prior to be discharged
to home when medically stable. The patient's foot remained
ischemic.
A cardiology consult was requested. Dr. [**Last Name (STitle) **] evaluated the
patient and recommended an echocardiogram prior to surgery.
After reviewing the echocardiogram he felt that this is most
likely an acceptable risk but we should do our usual Swan
hemodynamic monitoring in the vascular intensive care unit
postoperatively. An echocardiogram was obtained which showed
the left atrium to be of normal size. The right atrium and
anterior atrial septum were normal with a normal right
atrium. Left ventricle wall thickness and cavity dimensions
were mild symmetric left ventricular hypertrophy with normal
cavity size and systolic function with ejection fraction
greater than 55%. It was a suboptimal technical quality of
the study and focal wall motion abnormality could not be
fully excluded. The patient underwent a stress in which he
responded appropriately to the Persantine. The nuclear
portions of the study essentially normal myocardial perfusion
in the setting of a subdiaphragmatic attenuated artifact,
normal left ventricular cavity size and function. This was
reviewed by Dr. [**Last Name (STitle) **] who felt that we could proceed with any
anticipated surgical intervention.
The patient underwent a diagnostic arteriogram on [**2164-7-27**] which demonstrated vascular insufficiency, repair
angiogram showed occlusions of the right superficial femoral
artery, left common femoral artery and anterior tibialis.
This arteriogram was done under a left brachial artery
approach secondary to his femoral-femoral bypass graft. The
patient tolerated the angiography and his BUN and creatinine
remained stable. The patient proceeded on [**2164-8-2**] to
surgery, underwent a right femoral to peroneal bypass graft
with reverse saphenous vein graft. He had a palpable graft
pulse at the end of the procedure. He was transferred
extubated and awake to the post anesthesia care unit in
stable condition. Immediately postoperatively he remained
hemodynamically stable and he was transferred to the VICU for
continued monitoring and care. An intraoperative
transesophageal echocardiography was done which showed left
ventricular systolic function is depressed globally (mild).
He had a complex friable atheroma in the descending thoracic
and upper abdominal aorta with questionable dissection. The
mitral valve flow propagation showed a velocity of 0.39
milliseconds. Cardiac output was 4.4 liters. Postoperative
day 1 from his right femoral peroneal bypass T-max was 101.8.
He continued to have a palpable graft pulse and a warm foot.
He required IV nitroglycerine drip for systolic blood
pressure control and his heparin was continued. He was
transfused 2 units of packed red blood cells
intraoperatively. His post transfusion hematocrit was 22.9.
His IV fluids were discontinued and he was transfused 2 more
units. His post transfusion hematocrit was 28.5. His
hematocrit at discharge was 35.0.
On postoperative day 2 he continued to remain febrile. Urine
culture, blood cultures and CTL was discontinued and the tip
was sent for culture. The cultures were no growth and
finalized. The chest x-ray obtained was without acute
pulmonary process. By postoperative day 2 the patient's
temperature returned to [**Location 213**]. His white count peaked at 20
from 17.9. It continued to show improvement. The patient's
diet was advanced and he was transferred to the regular
nursing floor and ambulation was encouraged. The patient
required a right knee immobilizer on the right leg secondary
to persistent knee flexure problems to maintain his leg in
anatomically neutral position for functioning. His Foley was
discontinued on postoperative day #3. He continued to be seen
by physical therapy. Rehabilitation screening was begun.
Anticipations for discharge was for [**2164-8-7**] but it
came to our attention that the patient did not have
insurance. This issue was investigated and found to be
incorrect as the patient did have insurance with the Veterans
Administration. Screening was continued and patient will be
transferred as soon as a bed is available.
The patient underwent on [**2164-8-8**] a CTA of the aortic
arch to femoral bifurcations by abdominal aortic protocol to
assess his abdominal and thoracic aorta for aneurysmal
changes. He was infused pre-angiogram with normal saline
solution and sodium bicarbonate 156 mg bolus and then at 55
cc per hour x6 hours. The results of the study were pending
at the time of dictation and we are awaiting evaluation by
occupational therapy to finalize patient's transfers.
DISCHARGE MEDICATIONS: Include isosorbide mononitrate 20 mg
b.i.d., coated acetaminophen 5/325 tablets 1 to 2 q 4 to 6
hours p.r.n. for pain, Protonix 40 mg q.d., metoprolol 25 mg
b.i.d., gabapentin 100 mg q 12 hours, amarine
hydrochlorothiazide 37.5/25 1 q.d., mirtazapine 30 mg tablet
at bedtime, acetaminophen 325 mg tablets 1 to 2 q 4 to 6
hours p.r.n. for pain, Colace 100 mg t.i.d., senna 8.6 tabs
b.i.d.
DISCHARGE DIAGNOSES:
1. Ischemic right foot and leg, status post intraoperative
arteriogram with femoral thrombectomy on the right and a
femoral-femoral bypass on [**2164-7-23**].
2. Status post diagnostic arteriogram via the left brachial
artery on [**2164-7-27**].
3. Status post a right femoral to peroneal bypass with non-
reverse saphenous vein graft on [**2164-8-2**].
4. History of peripheral vascular disease, status post left
above knee amputation.
5. Postoperative blood loss anemia, corrected.
6. Postoperative systolic hypertension, controlled.
7. History of hypertension.
8. History of alcohol abuse with questionable history of
cardiomyopathy.
9. History of penicillin allergy with anaphylaxis.
10. Postoperative constipation secondary to narcotics on
a bowel regimen.
INSTRUCTIONS: Patient will be discharged to extended care
facility. He should follow up with Dr. [**Last Name (STitle) **] in two
weeks time. He should call for an appointment at [**Telephone/Fax (1) 63507**]. At that time we will follow up with the patient
regarding the findings of the CTA study regarding his
thoracic and abdominal aorta.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2164-8-8**] 16:42:34
T: [**2164-8-8**] 17:51:21
Job#: [**Job Number 63508**]
|
[
"401.9",
"441.4",
"442.3",
"305.1",
"285.1",
"303.93",
"V49.76",
"425.4",
"564.00",
"440.22",
"444.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"88.72",
"39.29",
"99.04",
"88.47",
"88.48",
"88.42",
"38.68"
] |
icd9pcs
|
[
[
[]
]
] |
9010, 10417
|
8599, 8989
|
1248, 1347
|
2339, 8575
|
1061, 1221
|
1558, 2321
|
146, 167
|
196, 882
|
905, 1037
|
1364, 1535
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,121
| 127,925
|
32221
|
Discharge summary
|
report
|
Admission Date: [**2160-12-20**] Discharge Date: [**2161-1-1**]
Date of Birth: [**2115-3-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Pedestrian struck by auto
Major Surgical or Invasive Procedure:
[**2160-12-23**] Tracheostomy and open gastrostomy tube placement
History of Present Illness:
44 yo male pedestrian who was struck by auto, face hit
windshield, no reported LOC. He was taken to an area hospital
where he underwent emergency
cricothyrotomy for control of the airway due to facial swelling.
He was then prepared for transfer to [**Hospital1 18**] for further care
given his injuries.
Past Medical History:
CAD s/p MI
Bipolar
PVD
COPD
Hypercholesterolemia
s/p AICD placement
Family History:
Noncontributory
Pertinent Results:
[**2160-12-20**] 09:05PM GLUCOSE-188* UREA N-20 CREAT-0.8 SODIUM-140
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-27 ANION GAP-14
[**2160-12-20**] 09:05PM AMYLASE-46
[**2160-12-20**] 09:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-12-20**] 09:05PM WBC-21.2* RBC-4.46* HGB-14.4 HCT-41.0 MCV-92
MCH-32.2* MCHC-35.0 RDW-12.5
[**2160-12-20**] 09:05PM PLT COUNT-213
[**2160-12-20**] 09:05PM PT-14.7* PTT-24.8 INR(PT)-1.3*
[**2160-12-20**] 09:05PM FIBRINOGE-140*
[**2160-12-20**] CT SINUS/MANDIBLE/MAXILLOFACIA
IMPRESSION:
1. Bilateral Le Fort type II fractures.
2. Suggestion of low grade (Type I favored over type II) [**Male First Name (un) **]
complex fracture.
3. Comminuted nasal bone fracture.
[**2160-12-20**] CT HEAD W/O CONTRAST
IMPRESSION:
1. Bilateral LeFort type two fractures.
2. No evidence of intracranial hemorrhage.
Brief Hospital Course:
He was admitted to the Trauma Service. Plastic Surgery was
consulted for his facial fractures. On [**12-23**] he was taken to the
operating room for tracheostomy and [**Last Name (un) **] gastrostomy. He
underwent repair of his facial fractures on [**12-30**] without
complication. Postoperatively he was initially placed on
continuous tube feedings; they were eventually cycled. He was
later advanced to a full liquid diet and will be discharged to
home on a soft diet for 3 weeks until follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **].
Psychiatry was also consulted given his history of bipolar
disease and concerns for possible suicide attempt given reports
by his significant other of patient being depressed over his
health. Suicidality was ruled out; social work became closely
involved for emotional support. There were no behavioral issues
throughout his hospital stay.
His tracheostomy was eventually removed and there were no
problems with self management of his secretions. His gastrostomy
tube will remain in placed capped until follow up with Dr.
[**Last Name (STitle) **] (Trauma Surgery) in the next 1-2 weeks.
Medications on Admission:
Coreg 80'
Lisinopril 20'
Lipitor 80'
Plavix 75'
ASA 325'
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day).
Disp:*1350 ML(s)* Refills:*0*
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
5. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
10. Boost Plus Liquid Sig: One (1) Can PO three times a day.
Disp:*90 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Souhegan Nursing Association
Discharge Diagnosis:
s/p Pedestrian struck by auto
Facial fractures
Respiratory failure
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency room if you develop any fevers, chills,
increased facial pain or swelling, chest pain, shortness of
breath, abdominal pain, nausea, vomting, diarrhea and/or any
other symptoms that are concerning to you.
Adhere to a soft diet for the next 3 weeks because of your
facial fractures.
Followup Instructions:
Follow up in Plastic Surgery Clinic for your facial fractures in
the next 2-3 weeks, with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]; call [**Telephone/Fax (1) 5343**] for an
appointment.
Follow up with Dr. [**Last Name (STitle) **], Trauma Surgery, in [**1-15**] weeks, call
[**Telephone/Fax (1) 6429**] for an appointment.
Completed by:[**2161-1-1**]
|
[
"425.4",
"428.22",
"496",
"V45.02",
"920",
"E849.5",
"E814.7",
"428.0",
"802.4",
"V55.0",
"296.89",
"414.01",
"443.9",
"802.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.71",
"31.1",
"31.72",
"76.74",
"96.72",
"76.92",
"96.04",
"43.11",
"96.6",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
4146, 4205
|
1796, 2961
|
343, 411
|
4316, 4323
|
887, 1773
|
4677, 5060
|
851, 868
|
3068, 4123
|
4226, 4295
|
2987, 3045
|
4347, 4654
|
274, 305
|
439, 744
|
766, 835
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,213
| 189,888
|
1774
|
Discharge summary
|
report
|
Admission Date: [**2194-1-22**] Discharge Date: [**2194-1-28**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
[**2194-1-23**]: s/p open reduction internal fixation, left hip.
History of Present Illness:
[**Age over 90 **] year old female nursing home resident who fell at the nursing
home on [**2194-1-22**] resulting in a left hip fracture requiring
surgical fixation.
Past Medical History:
Alzheimer's dementia
Diabetes Mellitus type 2
Hypertension
Depression
Dyslipedemia
Osteoporosis
Multiple Falls
Anemia
Spinal stenosis
Degenerative joint disease
Gastritis
Hiatal hernia
Colonic diverticulosis
s/p TAH for uterine prolapse
Status post hip fracture
Social History:
Lives alone in independent living. No smoking, no alcohol,
Bookeeper, degree in [**2123**].
HCP: [**Name (NI) **] [**Name (NI) 2714**] [**Telephone/Fax (1) 10003**]
Family History:
both sisters with AD. Brother died of heart disease in his 50s.
+ Spinal stenosis
Physical Exam:
Physical examination on admission:
VITAL SIGNS: T = 98.4 BP= 143/58 HR= 92 SATS= 96%.
General: Elderly female, lying on bed. very lethargic.
HEENT: Normal cephalic atraumatic, pupils equal round reactive
to light accomodation, extra occular motions intact bilaterally.
Oral mucosa moist.
NECK: No lymphadenopathy, no jugular venous distention, no
bruit.
Cardiac: Regular rate and rhythm, no mumurs, no gallops, no
rubs.
RESP: Clear, no wheezes, no crackles, no rhonchi.
Abdomen: + Bowel sounds, soft, non-distended, non-tender, no
masses, no guarding or rebound tenderness.
Extremities: No edema, no cyanosis, no clubbing throughout.
-Left lower extremity: Skin intact, internally rotated and
shortened, pain with internal and external rotation.
Compartments soft and compressable, 2+ dorsal pedialis &
tibialis posterior pulses. Motor and sensory grossly intact.
-Right lower extremity: Skin intact. No deformity.
Compartments soft and compressable. 2+ dorsal pedialis &
tibialis posterior pulses. Motor and sensory grosssly intact.
-Left upper extremity: Skin intact. No deformity. Compartments
soft and compressable. 2+ radial & ulna pulses. Motor and
sensory grossly intact.
-Right upper extremity: Skin intact. No deformity.
Compartments soft and compressable. 2+ radial & ulna pulses.
Motor and sensory grossly intact.
SKIN : No rash, no ulceration, no erythema in decubiti.
Spine: No mid-line tenderness. No focal neurological deficits.
Pertinent Results:
[**2194-1-28**] 07:00AM BLOOD Hct-32.6*
[**2194-1-27**] 07:00AM BLOOD Hct-30.2*
[**2194-1-26**] 07:20AM BLOOD WBC-7.2 RBC-3.04* Hgb-8.9* Hct-26.7*
MCV-88 MCH-29.2 MCHC-33.2 RDW-15.7* Plt Ct-124*
[**2194-1-25**] 01:25PM BLOOD WBC-8.9 RBC-3.22* Hgb-9.2* Hct-26.8*
MCV-83 MCH-28.7 MCHC-34.5 RDW-15.5 Plt Ct-112*
[**2194-1-24**] 12:52PM BLOOD Hct-30.2*
[**2194-1-24**] 06:02AM BLOOD Hct-25.2*
[**2194-1-24**] 03:30AM BLOOD WBC-10.2 RBC-3.07* Hgb-8.8* Hct-25.7*
MCV-84 MCH-28.7 MCHC-34.3 RDW-15.3 Plt Ct-111*
[**2194-1-23**] 09:28PM BLOOD WBC-11.9* RBC-3.36* Hgb-9.7* Hct-28.4*
MCV-85 MCH-28.8 MCHC-34.1 RDW-15.3 Plt Ct-101*
[**2194-1-23**] 11:59AM BLOOD WBC-11.3*# RBC-4.08*# Hgb-11.3*#
Hct-34.6*# MCV-85 MCH-27.8 MCHC-32.8 RDW-14.9 Plt Ct-139*
[**2194-1-23**] 07:25AM BLOOD WBC-7.2 RBC-2.73*# Hgb-7.8*# Hct-23.8*#
MCV-87 MCH-28.5 MCHC-32.7 RDW-14.7 Plt Ct-149*
[**2194-1-22**] 04:50PM BLOOD WBC-5.9 RBC-3.83* Hgb-10.8* Hct-33.5*
MCV-87 MCH-28.2 MCHC-32.3 RDW-14.6 Plt Ct-156
[**2194-1-26**] 07:20AM BLOOD Plt Ct-124*
[**2194-1-25**] 01:25PM BLOOD Plt Ct-112*
[**2194-1-24**] 03:30AM BLOOD Plt Ct-111*
[**2194-1-23**] 09:28PM BLOOD Plt Ct-101*
[**2194-1-23**] 09:28PM BLOOD PT-12.6 PTT-21.8* INR(PT)-1.1
[**2194-1-23**] 01:31PM BLOOD PT-12.7 PTT-23.0 INR(PT)-1.1
[**2194-1-23**] 11:59AM BLOOD Plt Ct-139*
[**2194-1-28**] 07:00AM BLOOD K-3.9
[**2194-1-27**] 07:00AM BLOOD K-3.9
[**2194-1-26**] 07:20AM BLOOD Glucose-117* UreaN-19 Creat-0.8 Na-142
K-4.2 Cl-107 HCO3-27 AnGap-12
[**2194-1-25**] 01:25PM BLOOD Glucose-117* UreaN-17 Creat-0.8 Na-142
K-3.7 Cl-106 HCO3-26 AnGap-14
[**2194-1-23**] 09:28PM BLOOD Glucose-200* UreaN-15 Creat-0.8 Na-138
K-4.0 Cl-103 HCO3-29 AnGap-10
[**2194-1-23**] 11:59AM BLOOD Glucose-186* UreaN-13 Creat-0.8 Na-138
K-4.1 Cl-104 HCO3-27 AnGap-11
[**2194-1-22**] 04:50PM BLOOD Glucose-167* UreaN-18 Creat-0.9 Na-143
K-3.3 Cl-100 HCO3-28 AnGap-18
[**2194-1-24**] 03:30AM BLOOD CK(CPK)-109
[**2194-1-23**] 09:28PM BLOOD CK(CPK)-138
[**2194-1-23**] 04:36PM BLOOD CK(CPK)-141
[**2194-1-28**] 07:00AM BLOOD Phos-3.1 Mg-1.6
[**2194-1-27**] 07:00AM BLOOD Phos-3.0 Mg-1.6
[**2194-1-26**] 07:20AM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8
[**2194-1-24**] 03:30AM BLOOD Type-ART pO2-320* pCO2-53* pH-7.38
calTCO2-33* Base XS-5
[**2194-1-23**] 09:50PM BLOOD Type-ART pO2-266* pCO2-58* pH-7.35
calTCO2-33* Base XS-4
[**2194-1-23**] 06:51PM BLOOD Type-ART Temp-36.9 Rates-/14 FiO2-35
pO2-133* pCO2-57* pH-7.33* calTCO2-31* Base XS-2 Intubat-NOT
INTUBA Vent-CONTROLLED
[**2194-1-23**] 05:11PM BLOOD Type-ART Temp-36.9 PEEP-5 pO2-132*
pCO2-58* pH-7.31* calTCO2-31* Base XS-1 Intubat-NOT INTUBA
Comment-O2 DELIVER
[**2194-1-23**] 03:24PM BLOOD Type-ART Temp-36.1 FiO2-40 pO2-125*
pCO2-57* pH-7.32* calTCO2-31* Base XS-1 Intubat-NOT INTUBA
Comment-SIMPLE FAC
[**2194-1-24**] 03:30AM BLOOD O2 Sat-98
[**2194-1-23**] 09:50PM BLOOD O2 Sat-98
Brief Hospital Course:
Ms. [**Known lastname 2714**] is a [**Age over 90 **] year old nursing home patient who fell on
[**2194-1-22**] and was admitted to the Orthopedic service on [**2194-1-22**]
for a left hip fracture after being evaluated and treated with
closed reduction in the emergency room. She underwent open
reduction internal fixation of the left hip without complication
on [**2194-1-23**]. She was extubated in the recovery room. In the
early postop period, the patient was lethargic and developed
hypercapnea, with pCO2 of 57, requiring BiPAP. Her mental status
and O2 requirements improved while in the recovery room. She
was admitted to the surgical intensive care unit on the night of
surgery for close monitoring. She was transfused 2 units of
packed red blood cells for post operative blood loss anemia. She
improved overnight in the intensive care unit. On hospital day
one she was transferred out to the floor in stable condition.
On [**2194-1-24**] she was again transfused with 1 unit of packed red
blood cells due to acute blood loss anemia. On [**2194-1-26**] she was
again transfused with 1 unit of packed red blood cells due to
acute blood loss anemia.
She had adequate pain management and worked with physical
therapy while in the hospital.
The remainder of her hospital course was uneventful and Ms.
[**Known lastname 2714**] is being discharged to rehab. on 02/ ? /10 in stable
condition.
Medications on Admission:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
2. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Medications:
1. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous Q24H (every 24 hours) for 4 weeks.
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
3. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
17. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
21. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
22. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 4 weeks.
23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
24. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-14**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
1. Left hip fracture.
2. post-operative hypercapnea.
3. post operative blood loss anemia
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Wound Care:
-Keep Incision dry. Do not soak the incision in a bath or pool.
Activity:
-Continue to be full weight bearing on your left leg.
-You should not lift anything greater than 5 pounds.
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Physical Therapy:
full weight bearing as tolerated, left leg.
Treatment Frequency:
Discontinue staples 14 days from date of surgery.
Followup Instructions:
2 weeks in the [**Hospital **] clinic with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP.
Please call [**Telephone/Fax (1) 1228**] to make this appointment.
Completed by:[**2194-1-28**]
|
[
"820.21",
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"272.0",
"285.1",
"294.10",
"724.00",
"518.5",
"733.00",
"998.12",
"250.00",
"783.7",
"E849.7",
"311",
"293.0",
"V88.01",
"287.5",
"E885.9",
"331.0",
"V15.88",
"562.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.55"
] |
icd9pcs
|
[
[
[]
]
] |
9649, 9727
|
5455, 6860
|
271, 338
|
9859, 9859
|
2595, 5432
|
11495, 11706
|
1020, 1104
|
7581, 9626
|
9748, 9838
|
6886, 7558
|
10037, 10037
|
1119, 1140
|
11356, 11400
|
227, 233
|
10049, 11338
|
366, 534
|
1155, 2576
|
9873, 10013
|
11421, 11472
|
556, 821
|
837, 1004
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,486
| 136,145
|
14260
|
Discharge summary
|
report
|
Admission Date: [**2198-1-10**] Discharge Date: [**2198-1-18**]
Service: NEUROLOGY
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is an 83-year-old man, Russian-speaking, with a left
temporo-parietal glioblastoma multiforme, s/p resection in
[**2197-11-24**], chronic Left frontal SDH and bilateral DVT's recently
on Fragmin, and living in [**Hospital6 310**]
receiving daily brain XRT. He initially presented with right
arm weakness and non-fluent aphasia after an XRT treatment. He
was found to have extension of his SDH. The patient was in his
usual state of health on the day of admission when he received
XRT at [**Hospital1 69**]. The patient was in
an ambulance on the way back [**Hospital6 310**] when
he was noted to have right upper extremity weakness and
non-expressive aphasia. The patient was taken to [**Hospital 8**]
Hospital where head CT revealed acute on chronic SDH. The
patient was transferred to [**Hospital1 69**]
where repeat CT and MRI revealed a stable, unchanged acute on
chronic SDH. The patient was monitored by the neurosurgical team
in the Trauma ICU without intervention. Of note, the evening
prior to transfer, the patient developed significant agitation
requiring restraint.
ROS: No fevers, chills, nightsweats, abdominal complaints.
Past Medical History:
- Cerebral glioma. S/p resection in [**10/2197**]. Currently undergoing XRT/Temodar therapy (though
patient does not know he has cancer, and the family wishes not
to tell him that he has cancer)
- Atrial fibrillation (has been on anticoagulated prior to
glioma surgery, has been on Lovenox and Coumadin)
- RLE extremity DVT with PE in [**10/2197**], which led to workup
leading to dx of cerebral glioma. s/p IVC filter.
- Pyloric stenosis s/p resection 20 yrs ago.
- h/o TB 40 yrs ago, treated, s/p lung resection (unknown which
lobe)
- CRI
- Hypothyroidism
- Anemia
- Urinary retention
Social History:
He lives at [**Hospital6 310**] at present. He quit
smoking 40 years ago. He never used alcohol.
Family History:
His mother died of gastric cancer.
Physical Exam:
Vital Signs: Temperature is 98.4 F, heart rate is 108, blood
pressure is 124/80, repsiratory rate is 22, and oxygen
saturation is 99% in room air.
General: Elderly gentleman. NAD. Responsive to questions.
Integumentary: No lesions.
HEENT: Pupils constricted. Pink, moist oral mucosa without
lesions.
Cardiovascular: RRR, normal S1 and S2, and no M/R/G.
Pulmonary: Chest clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended. No masses or
organomegaly.
Extremities: 2+ edema bilateral
Neurological Examination: He was awake and alert, but not
oriented to place or time. He could communicate in Russian, and
his daughter translated for him. Cranial nerve examination:
His pupils were equal and reactive to light, 3 mm to 2 mm
bilaterally. Extraocular movements were full but there was
saccadic intrusion. Visual fields were full to threat
bilaterally. Funduscopic examination revealed sharp disks
margins bilaterally. His face was symmetric. His hearing was
grossly intact bilaterally. His tongue was midline. Palate
went up in the midline. Sternocleidomastoids and upper
trapezius were strong. Motor Examination: He did not have a
drift. His muscle strengths were [**6-2**] at all muscle groups. His
muscle tone was normal. His reflexes were 0-1 bilaterally. His
ankle jerks were absent. His toes were down going. Sensory
examination was intact to painful stimuli at all 4 extremities.
Coordination examination did not reveal gross dysmetria. He
could not walk.
Pertinent Results:
[**2198-1-10**] 06:15PM GLUCOSE-143* UREA N-27* CREAT-1.4* SODIUM-139
POTASSIUM-5.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
[**2198-1-10**] 06:15PM WBC-6.3 RBC-3.70* HGB-10.4* HCT-30.6* MCV-83
MCH-28.2 MCHC-34.0 RDW-16.6*
[**2198-1-10**] 06:15PM CALCIUM-9.5 PHOSPHATE-3.0 MAGNESIUM-2.4
[**2198-1-10**] 06:15PM PT-13.4* PTT-32.1 INR(PT)-1.2*
[**2198-1-10**] 09:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
Imaging:
OSH head CT (by report): Acute SDH
CT head ([**2198-1-10**]): 1. Increase in size of left subdural
hematoma compared to the prior study, with new fluid-fluid level
with areas of hyperdensities, worrisome for acute on chronic
subdural hematoma. 2. Slightly increased shift of midline
structures. 3. Increase in size of the post-glioma resection
cavity with increased mass effect, worrisome for recurrence of
the glioma. Further evaluation by MRI is
recommended. 4. High density in the subcutaneous tissue in the
neck.
MRA Brain ([**2198-1-11**]): Some increased mass effect in left
hemisphere when compared to the prior study associated with some
increased edema and/or recurrent neoplasm around the operative
site together with slight increase in the left- sided subdural
fluid collection.
MRA OF THE CIRCLE OF [**Location (un) **] AND ITS MAJOR TRIBUTARIES On the MIP
sequence, there is some question of reduced flow in the lower
basilar artery. There is no evidence of abnormal signal in this
area on the
axial T2-weighted MRI sequences and this is felt to represent
artifact. There is no definite evidence of flow abnormality.
CT head ([**2198-1-11**]): No evidence of enlargement of the subdural
hematoma since [**2198-1-10**]. The density appears more uniform than
on the prior study.
Echo ([**2197-12-13**]): 1. The left atrium is normal in size. The left
atrium is elongated. The right atrium is moderately dilated. 2.
Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
low normal (LVEF 50-55%). 3. Right ventricular chamber size is
normal. Right ventricular systolic function is hard to assess
given the limited views but appears depressed. 4.The aortic root
is mildly dilated. The aortic arch is mildly dilated. 5.The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. 6.The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen. 7.The
estimated pulmonary artery systolic pressure is normal. 8.There
is no pericardial effusion.
Brief Hospital Course:
A/P: This is an 83-year-old man, Russian-speaking, with a Left
temporo-parietal glioblastoma multiforme, s/p resection in
[**2197-11-24**], chronic Left frontal SDH and bilateral DVT's recently
on Fragmin, and living in [**Hospital 23645**] Rehabilitation Center
receiving daily brain XRT. He initially presented with right
arm weakness and non-fluent aphasia after an XRT session, and
was found to have extension of his SDH.
(1) Right Arm Weakness and Dysarthria: Possible etiologies
include acute on chronic SDH with mass effect, seizure, GBM
progression, toxic-metabolic or radiation encephalopathy. The
patient had some progression of his SDH on admission, though
none on repeat imaging. He appears to have increased mass
effects without clear recurrence of the GBM. The patient has no
clear toxic-metabolic causes. The patient had an EEG with
diffuse slowing though no seizure activity. The patient was
started on seizure prophylaxis with Dilantin and started on
dexamethasone for potentially radiation-induced subacute
encephalopathy. Over the course of the patient's
hospitalization, his symptoms improved, including resolved right
arm weakness and facial droop. The patient initially failed
speach and swallowing evaluations. With improvement in his
symptoms, the patient passed a video swallow with restrictions:
Pureed consistency, thin liquids, crush all pills and aspiration
precautions. Initially the patient's anticoagulation was held,
though this was restarted at a reduced dose days prior to
discharge without incident.
(2) Agitation Overnight: The patient had a few episodes of
disorientation, likely in part related to language barrier and
lack of a familiar face. It is also possible that this was due
to delirium or a component of encephalopathy. The patient was
without problems when his daughter was in the hospital.
(3) Glioblastoma Multiforme: Stable without clear signs of
recurrence. To further discuss management options with primary
neuro-oncologist. The patient completed his scheduled XRT
therapy while in the hospital. The temozolamide was discontinued
as this was intended only to be administered in the
peri-radiation period and the patient is not tolerating who
pills (and this medication cannot be crushed). He will follow-up
with Dr. [**Last Name (STitle) 724**] in 2 weeks. In the interim he will receive no
therapy. The progress at that time will determine further
therapy vs. hospice care.
(4) Atrial Fibrillation: Stable. The patient was continued on
home metoprolol for rate control. The patient was discharged on
prophylactic lovenox dose.
(5) DVT and PE: Large documented DVT with prior PE. He was s/p
IVC filter placement and was on Fragmin prior to admission.
Patient was discharged on prophylactic dose of Lovenox. He was
felt not to be a candidate for full anticoagulation.
(6) Urinary Tract Infection: He had 50 WBC's in his U/A. But he
was asymptomatic and afebrile. The patient received a 7 day
course of Ceftriaxone IV.
(7) CODE: Full code.
(8) Disposition: The patient was discharged back to [**Hospital1 42372**].
Medications on Admission:
Fragmin 8000units SQ [**Hospital1 **]
Colace 100mg TID
Lasix 40mg QD
Metoprolol XL 50mg QD
Multi-vit 1tab QD
Polyethylene Glycol 17gm QD
K-dur 20mEq QD
Prochlorperazine 10mg - give prior to chemo
Senna 2 PO QD
Tylenol prn
Lactulose 20gm PO QD prn
MOM prn
Discharge Medications:
1. Colace 150 mg/15 mL Liquid Sig: One (1) PO three times a
day.
Disp:*90 QS* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
4. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1) PO
once a day.
5. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
6. Senna 8.8 mg/5 mL Syrup Sig: [**1-30**] PO once a day.
Disp:*30 QS* Refills:*2*
7. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO every
6-8 hours as needed for nausea.
8. Lactulose 10 g/15 mL Solution Sig: [**1-30**] PO once a day as
needed for constipation.
9. Milk of Magnesia 800 mg/5 mL Suspension Sig: One (1) PO
every 6-8 hours as needed for heartburn.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
11. Phenytoin 100 mg/4 mL Suspension Sig: One (1) PO every
eight (8) hours.
Disp:*90 QS* Refills:*2*
12. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
once a day.
Disp:*30 Injections* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Subacute radiation-induced encephalopathy
Chronic and subacute subdural hematoma
Glioblastoma multiforme
Discharge Condition:
Stable, as evidenced by stable vital signs, laboratory data. he
was back to baseline neurologic function without apparent right
arm or facial weakness.
Discharge Instructions:
You were admitted with right arm weakness and facial weakness.
It is likely that this was due to bleeding within your skull. It
is also possible that this was related to seizure activity.
Another possibility is swelling within the brain. There were no
signs of re-occurrence of your brain tumor. Please take
Phenytoin (also called dilantin) 100mg every 8 hours to prevent
seizures. Also take dexamethasone 4mg once daily to reduce the
swelling within your brain. Reduce your lovenox injections to
once a day 30mg to limit the risk of bleeding and provide some
protection against clotting.
Take all medications as prescribed.
Follow-up with Dr. [**Last Name (STitle) 724**] for further management of this ongoing
problem.
Call your doctor or return to the hospital for any new or
worsening, nausea, vomiting, weakness or any other concerning
symptoms.
Followup Instructions:
Dr. [**Last Name (STitle) 724**], [**2197-2-5**] ([**Telephone/Fax (1) **]) 4:00PM
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**]
Date/Time:[**2198-3-14**] 2:30
|
[
"V58.61",
"E879.2",
"599.0",
"585.9",
"244.9",
"191.9",
"348.39",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
11110, 11189
|
6411, 9488
|
246, 253
|
11337, 11490
|
3743, 6388
|
12392, 12654
|
2170, 2206
|
9794, 11087
|
11210, 11316
|
9514, 9771
|
11514, 12369
|
2221, 3724
|
184, 208
|
281, 1427
|
1449, 2038
|
2054, 2154
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,917
| 159,755
|
5967
|
Discharge summary
|
report
|
Admission Date: [**2102-5-1**] Discharge Date: [**2102-5-9**]
Date of Birth: [**2055-7-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
CC:[**CC Contact Info 23516**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Briefly, this is a 46yo man with a h/o HCV, HTN, heavy EtOH
abuse, dilated alcoholic cardiomyopathy (EF 25%), and bilateral
cavitary pulmonary lesions who was BIBA after drinking a large
quantity of EtOH. He had recently been admitted to [**Hospital 7302**] for EtOH withdrawal on the evening of
[**2102-5-1**] but left AMA. He then called his girlfriend after
consuming a large amount of EtOH, who called the EMS. On
presentation, he c/o chest pain, chronic SOB and cough, was
found to be hypertensive to 260/166 with HR 110. In the ED he
was given ASA 325, SL NTG, and IV Nitro for 10 mins, thiamine,
folic acid, mvi, and ativan 2 mg. His EtOH level was 420. He was
seen by cardiology for ?ST elevations. A bedside echo was
limited but revealed likley mild global HK. He ruled out for an
MI with 3 negative sets of cardiac enzymes. He was admitted
initially to the floor but then sent to the MICU for symptoms
consistent with etoh withdrawal. He was continued on valium per
CIWA, restarted on his listed BP meds but his SBP then dropped
and so his lisinopril was decreased.
.
Pt is currently without complaints, says that he feels he is "on
the upswing" and "should be ready to go by the end of the week."
He is requesting transfer to a rehabilitation upon discharge
from [**Hospital1 18**].
Past Medical History:
Past Medical History:
- EtOH abuse
- h/o withdrawl seizures
- Alcoholic Dilated Cardiomyopathy (EF 25%)
- cocaine abuse (last use several wks ago)
- hypothyroidism
- h/o head and neck cancer s/p resection and radiation in [**2093**]
- bilateral cavitary lung lesions; bx demonstrated Aspergillous
fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**]
- h/o C. diff colitis
- h/o IVDA per OSH records (pt denies)
Social History:
Recently cut down to 5-6 cigs/day, prior to that he smoked 1 ppd
x30 years. Heavy EtOH use; drinks 1 shot of Vodka every 3 hours
(~1 pint per day). Sober x10 years, started drinking again 1.5
yrs ago. +Cocaine abuse; last use several wks ago. He denies
IVDA although history questionable. Sexually active with his
girlfriend. Reports negative HIV test 2 yrs ago.
Family History:
Mother - CAD. Sister - h/o CVA.
Physical Exam:
Physical Exam:
Vitals: T 97.0, BP 122/70, HR 93, RR 20, Sat 100% on RA flat at
rest
Gen: thin, disheveled man, lying flat in bed in NAD, talkative
Skin: warm and dry, no jaundice
HEENT: EOMI, no nystagmus, anicteric sclerae, dry MM
Neck: no JVD, no LAD
CV: distant heart sounds, no s3/s4, no m/r
Lungs: CTA, no w/r/r
Abd: thin, soft, nt, nd, no apparent ascites, no prominent
umbilical veins
Ext: decreased muscle bulk, FROM x 4, 2+ DP bilaterally
Neuro: alert, oriented to person, place and month with some
coaching on the month; talkative, but not pressured; CN 2-12
intact; some tongue fasciculations, no nystagmus, no hand
tremors; strength intact in all 4 extremities; decreased
sensation in stocking distribution bilaterally to ankles
Pertinent Results:
Admit labs:
Urine: pos bzds otherwise neg
Serum EtOH 420
Serum ASA, Acetmnphn, [**Last Name (LF) 2238**], [**First Name3 (LF) **], Tricyc Negative
.
U/A neg
145 107 10
--------------< 86
4.0 25 0.7
Ca: 8.9 Mg: 1.7 P: 3.9
ALT: 314 AP: 140 Tbili: 0.5 Alb: 4.1
AST: 571
[**Doctor First Name **]: 30 Lip: 65
CK: 144 MB: 4
Trop-T: <0.01
PT: 11.7 PTT: 26.4 INR: 1.0
.
12.4
5.9 >----< 341
37.4
N:41.3 L:50.2 M:5.4 E:2.2 Bas:0.9
.
trends:
dispo WBC 8.8 HCT 34 Plt 236
dispo lytes: no change
ALT [**Telephone/Fax (3) 23517**] - 224
AST [**Telephone/Fax (3) 23518**] - 243
Alk phos: remained around 100-140
TBili 1.7 - 1.1
CE neg x2
TSH 10
B12 698 folate 17
HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE HAV Ab-NEGATIVE
.
Radiology:
Admission CXR: nad
admission ekg: nsr no acute st t changes
.
Echo [**5-2**]: The study is limited by poor acoustic windows. The
left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Left ventricular wall motion is difficult to assess but
is probably globally mildly depressed. No aortic regurgitation
is seen. Mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. There is no pericardial effusion. If
clinically indicated, a repeat transthoracic study by a
son[**Name (NI) 930**] with possible contrast administration for
endocardial definition may be helpful.
Brief Hospital Course:
46 yo M with HCV, HTN, EtOH abuse, dilated alcoholic CMY (EF
25%), admitted with EtOH intox. Hosp course by problem:
.
# EtOH withdrawal: He has a known h/o EtOH withdrawel w
seizures. When he first arrived on the floor, he required very
high dosages of valium (up to 140 per day). Thus, he was
briefly transferred to the ICU for closer monitoring. He did
well in the ICU and was transferred back to the floor. There
his CIWA scale was initially in the 15-20 range and improved
with valium (up to 100 per day). The patient was seen by
psychiatry and we put him on a strict valium taper. He
tolerated this fairly well over the course of several days. He
did have anxiety as below which likely lengthened the valium
taper. We had the patient evaluated by case management as well
as social work and psych placement services to assess for
outpatient withdrawal/recovery services. However, quite
abruptly, the patient decided he needed to make an appointment
on [**5-9**]. We would not prescribe a [**Month/Day (4) **] upon discharge but
instead wrote for a short course of seroquel. He was aware of
the fact that we might have had placement for him within a few
days but refused such an investigation.
.
# Hypothyroid: patient reported good compliance with synthroid
as an outpatient (although did not take any other meds). His
TSH was high so we increased the synthroid. We recommend
followup TSH in [**3-7**] weeks.
.
# HTN: likely combination of withdrawal and noncompliance with
home regimen. we restarted his home meds and he did well.
However, on [**5-5**], he had assymptomatic hypotension with systolic
in the 80s which responded to IVF. We decreased his lisinopril
with good effect.
.
# CV:
a) Coronaries: no known CAD; ruled out for MI by enzymes;
continued ASA 81 mg daily for ppx. While in the ICU, he did
have a brief episode of chest pain which was not accompanied by
EKG changes or any elevation in enzymes.
b) Dilated CMY (EF 25%): appears euvolemic to slightly dry.
- cont outpt lasix and spironalactone doses, watched fluid
status and followed renal function. Did well.
- cont outpt digoxin for inotropy
.
# Transaminitis: likely from HCV plus etoh toxicity. LFT's at
baseline per report. Pt unlikely to be a candidate for treatment
with interferon given significant psychiatric and behavioral
comordities
- counselled about the importance of abstaining from any further
etoh
- hep B serologies as above
.
# Anxiety: multiple life stressors, including girlfriend out of
town and apparent movie deal involving patient and his family
- social work assisted with his care. psychiatry also saw
patient and helped with the valium taper. We were however
reluctant to prescribe benzos upon dispo which is why we used
many resources to search for a detox center, which he refused.
- pt had an appt with a psychiatrist as an outpatient on [**5-29**]
per his report; We contact[**Name (NI) **] the facility prior to discharge and
were unable to move the appointment to a closer date.
.
# FEN. Low Na, heart healthy diet
.
# PPX. SC heparin, PPI, bowel regimen
.
# Code: Full
Medications on Admission:
1. Carvedilol 6.25 mg [**Hospital1 **]
2. Digoxin 0.125 mg daily
3. Folic acid 1 mg daily
4. Klonopin 1 mg [**Hospital1 **]
5. Lisinopril 30 mg daily
6. Mvi 1 tab daily
7. Spironolactone 25mg daily
8. Synthroid 50 mcg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Quetiapine 25 mg Tablet Sig: 1-2 Tablets PO TID (3 times a
day) as needed for anxiety for 2 weeks.
Disp:*60 Tablet(s)* Refills:*0*
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- etoh withdrawal
- alcoholic dilated cardiomyopathy
- cocaine abuse
- hypothyroid (synthroid increased on admit. needs followup TSH
in 1 month)
Secondary:
- HTN
- hx of cavitary lesions
Discharge Condition:
okay
Discharge Instructions:
You were admitted with alcohol withdrawal. You were in the ICU
briefly because you required heavy amounts of benzodiazepines.
Psychiatry service saw you and we treated you with a valium
taper. Your agitation improved. On [**5-9**] you were anxious to
leave. We tried to set you up with a detox center but you
refused. We will not give you a prescription for valium but
will treat your anxiety with seroquel.
.
Please return to the ED if you experience any chest pain,
agitation, seizure, fever, chills, abdominal pain, shortness of
breath.
.
Please take all of your medications as instructed. Please
followup with your PCP and psychiatrist. Please have your
thyroid hormone checked in one month.
Followup Instructions:
Please followup with your PCP within the next 1-2 weeks. This
is very important. Contact them at [**Telephone/Fax (1) 23519**].
.
Please followup with your psychiatrist as scheduled on [**5-29**].
I was unable to move this appointment up.
|
[
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"244.9",
"305.60",
"425.5",
"303.01",
"291.81",
"070.32",
"V15.81",
"518.89",
"305.1",
"401.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
9230, 9236
|
4757, 7858
|
344, 351
|
9477, 9484
|
3333, 4734
|
10235, 10480
|
2523, 2556
|
8133, 9207
|
9257, 9456
|
7884, 8110
|
9508, 10212
|
2586, 3314
|
274, 306
|
379, 1675
|
1719, 2127
|
2143, 2507
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,921
| 110,237
|
15929
|
Discharge summary
|
report
|
Admission Date: [**2193-4-18**] Discharge Date: [**2193-4-24**]
Date of Birth: [**2126-1-13**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
CHF
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
67 year old patient transferred from [**Hospital 25368**] [**Hospital 107**] Hospital,
well known to Dr.[**Name (NI) 3536**] heart failure service, hx of dilated
cardiomyopathy with an LVEF less than 10% and bioprosthetic
mitral valve replacement for severe MR, admitted to OSH on
[**2193-4-6**] with acidemia, SOB, hypotension, requiring intubation 3
days after admission. She was treated for CHF with IV lasix and
Milrinone. Transferred to step down floor on [**2193-4-14**] where she
went into respiratory distress, stridorous breath sounds (no
arrythmia). Required reintubation. Initially thought this was
due to heart failure but CVP was 2. Placed back on IV milrinone
and extubated two days later (on [**2193-4-16**]). Currently with sats
98-100% on 2 liters. Getting treated with antibiotics for UTI
and ? infiltrate on initial CXR. Also with stage I decubutis
ulcer on buttocks covered with duoderm.
.
Prior to transfer vitals were HR 70-90's AF with paced beats,
PVC's, BP 80/40-110/60, sats 98-100% on 2 liters, RR 20,
afebrile.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis, black stools or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. She does note some
swelling of her ankles. Also notes left pointer finger DIP pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
cannot assess dyspnea on exertion as pt has been bed-bound in
hospital, denies paroxysmal nocturnal dyspnea, palpitations,
syncope or presyncope. As above, ROS + for mild orthopnea, ankle
edema.
Past Medical History:
-Valvular heart disease s/p bioprosthetic MVR and ASD repair in
[**2188**]
-Dilated CM with an LVEF < 10% (secondary to rheumatic heart dx)
-S/p BiV ICD
-Type 2 DM
-HTN
-Hyperlipidemia
-CRI
-GERD
-PAF
-S/p TAH
-sleep apnea
Social History:
Lives with her husband, has 2 adult children. Used to work as a
nurse's aid, now retired. She is a pastor. Never smoked, denies
etoh, denies illicit drugs. Originally from [**Male First Name (un) 1056**].
Family History:
There is no known family history of premature coronary artery
disease or sudden death. Sister had uterine cancer. Mother with
DM died of "[**Last Name **] problem."
Physical Exam:
Vitals - T , HR 70, BP 91/67, RR 20, O2 99% 2L NC
General - awake, alert, NAD
HEENT - PERRL, EOMI, OP clear
Neck - no carotid bruit b/l, no LAD, JVP at approx 10cm
CVS - Palpation of the heart revealed the PMI to be located in
the 5th intercostal space, mid clavicular line. There were no
thrills, lifts or palpable S3 or S4. The heart sounds revealed a
normal S1 and the S2 was normal. There were no rubs, murmurs,
clicks or gallops.
Lungs - The were no chest wall deformities, scoliosis or
kyphosis. The respirations were not labored and there were no
use of accessory muscles. The lungs were clear to ascultation
bilaterally with normal breath sounds and no adventitial sounds
or rubs.
Abd - The abdominal aorta was not enlarged by palpation. There
was no hepatosplenomegaly or tenderness. The abdomen was soft
nontender and nondistended. The extremities had no pallor,
cyanosis, clubbing or edema. There were no abdominal, femoral or
carotid bruits.
Skin - Inspection and/or palpation of skin and subcutaneous
tissue showed Stage I decubitus ulcer on buttocks, otherwise no
stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
TELEMETRY demonstrated: NSR at 70 bpm.
.
2D-ECHOCARDIOGRAM performed on [**2192-11-1**] demonstrated:
Conclusions:
The left atrium is markedly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is severely
dilated. There is severe global left ventricular hypokinesis.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Moderate (2+) aortic regurgitation is
seen. A bioprosthetic mitral valve prosthesis is present. The
mitral prosthesis appears well seated, with normal leaflet/disc
motion and transvalvular gradients. Moderate [2+] tricuspid
regurgitation is seen. The tricuspid regurgitation jet is
eccentric and may be underestimated. The estimated pulmonary
artery systolic pressure is normal. Significant pulmonic
regurgitation is seen. The end-diastolic pulmonic regurgitation
velocity is increased suggesting pulmonary artery diastolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2192-3-12**],
there is more tricuspid regurgitation. Otherwise, the findings
are similar.
.
CARDIAC CATH performed on [**2192-11-1**] demonstrated:
COMMENTS:
1. Right heart catheterization revealed severe elevation of left
sided filling pressures with low cardiac index (wedge 34. CI
1.87). The right sided filing pressures were severely elevated
with RA of 13mmHg. There was pulmonary hypertension to 58/27.
With infusion of 1mcg/kg/min of nitroprusside the wedge fell to
19 with cardiac index up to 2.16. The PVR fell from 123 to 85.
The systemic blood pressure fell slightly from 107/57 to 89/50.
Dobutamine and milrinone were not used.
2. Patient transferred to CCU for tailored therapy.
FINAL DIAGNOSIS:
1. Severe low output heart failure with elevated filling
pressures responsive to vasodilator.
.
HEMODYNAMICS: SEE Above
.
LABORATORY DATA:
[**2193-4-17**]:
wbc 7.9, hct 33.1, plt 212, K 3.9, bun 51, creat 1.8, BNP 844,
INR 1.6
.
OSH microbiology data:
[**2193-4-8**] Sputum cx - oropharyngeal flora
[**2193-4-15**] Blood cx - NGTD
[**2193-4-15**] Sputum cx - gram stain negative
[**2193-4-15**] Urine cx - + enterococcus, [**Last Name (un) 36**] to ampicillin,
nitrofurantoin, vancomycin, resistant to levofloxacin.
.
Reports:
CXR upon admit to OSH: CHF, ? infiltrate
.
CXR on admission [**2193-4-18**]: Stable cardiomegaly, left base
atelectasis, no PTX, small left pleural effusion.
.
Cardiac cath [**2193-4-19**]: The right sided filling pressures were
mildly elevated. The left sided filling pressures were severely
elevated. There was moderate pulmonary hypertension. The
cardiac index was reduced.
.
TEE [**2193-4-19**]: Severe nearly static spontaneous echo contrast is
seen in the left atrial appendage and there is probable thyombus
formation. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No spontaneous echo contrast or thrombus is
seen in the body of the right atrium or the right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity is severely dilated.
Overall left ventricular systolic function is severely
depressed. There is right ventricular free wall is hypokinetic.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The prosthetic mitral
leaflets appear normal. The motion of the mitral valve
prosthetic leaflets appears normal. The transmitral gradient is
normal for this prosthesis (although gradient difficult to judge
in setting of low output state). Physiologic mitral
regurgitation is seen (within normal limits). There is no
pericardial effusion.
Brief Hospital Course:
Pt is a 67 yo woman with history of severe dilated
cardiomyopathy (EF 10%), bioprosthetic mitral valve replacement,
HTN, hyperlipidemia, DM2, who initially presented to OSH w/ SOB,
acidemia, hypotension, found to have likely heart failure
exacerbation, UTI, and ?pna, transferred here for further w/u
and management per Dr. [**First Name (STitle) 437**]. Hospital course by problem:
.
1) Cardiac:
A. Pump: Pt w/ h/o severe dilated cardiomyopathy, EF 10%, h/o
recurrent exacerbations, now w/ apparent re-exacerbation. She
was initially treated on milrinone, aldactone, coreg, digoxin.
She underwent right heart cath to assess hemodynamics. Finding
on right heart cath (on milrinone): RA 7, RV 59/9, PA 59/22,
wedge 30/39, co/ci 3.3/1.9, SVR 1770, PVR 121. In the CCU, when
milrinone was turned off, there was a significant reduction in
the CO (approx 4 to 2). Therefore, milrinone was restarted.
However, patient improved considerably so that milrinone was
discontinued again. We were able to start a low dose captopril
and titrate up. She tolerated this very well and we changed her
to lisinopril prior to discharge. Her symptoms markedly
improved and she was reportedly back to her baseline. PT saw
her prior to discharge and did not recommend home PT.
*** As an outpatient, please be aware that patient has systolic
BPs in the high 80s-low 100s. This is normal for her, given her
low EF and substantial heart failure. Her cardiac meds should
not be held if her BP is in this range, per d/w Dr. [**First Name (STitle) 437**] ***
.
B. Rhythm: Pt w/ h/o AF, s/p PM and ICD. She was treated with
coreg, dig, amiodarone. The initial plan was to DCCV, however,
a pre-cardioversion TEE showed [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**], therefore,
amiodarone was stopped, she was started on a heparin GTT and the
plan was for the pt. to return in 6 weeks to repeat a TEE and
consider cardioversion at that time. In the interim she is to be
anti-coagulated. We started lovenox and coumadin. Patient and
her family underwent lovenox teaching and she will remain on it
[**Hospital1 **] until INR therapeutic. She has f/u with her PCP in two days
for an INR check. She will need outpatient followup for a TEE
and possible cardioversion after approx 6 weeks of adequate
anticoagulation.
C. Cor: No h/o CAD. Continued cardiac management as above.
.
2) UTI: Enterococcus in urine, resistant to levofloxacin,
sensitive to ampicillin.
She was treated with 7d course of amox prior to discharge.
.
3) ?Pneumonia: Per report ?infiltrate on CXR at OSH. No
indication of pna on CXR at [**Hospital1 18**]. We did not treat
.
4) Stage I Decub Ulcer: Wound care assisted with management of
wounds.
.
5) GERD: continued protonix
.
6) FEN: Low salt, diabetic diet, monitored and repleted lytes
PRN.
.
7) Access: R subclavian placed at OSH [**2193-4-17**]. RH catheter
placed at BIMDC. This was discontinued prior to discharge.
.
8) Code: Full
.
.
Medications on Admission:
Mag oxide
Unasyn 2 IV q 12
Aldactone 25mg daily
Amiodarone 400mg daily
Digoxin .125mg daily
Coreg 3.125 [**Hospital1 **]
Asa 81
Protonix 40mg IV
Coumadin has been on hold
Milrinone 5cc/hour (.28mcg/kg/min)
Heparin at 780u/hour.
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*14 Tablet(s)* Refills:*0*
8. LAB WORK
Please have your INR checked on [**4-26**] at your PCP's office. You
can discontinue your lovenox injections when your INR is between
[**12-29**]
9. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous twice a day for 7 days.
Disp:*14 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location 45673**]VNA & Hospice
Discharge Diagnosis:
Primary Diagnosis:
-Severe dilated cardiomyopathy with CHF exacerbation
-Atrial fibrillation with thrombus noted in LA on recent echo
-Stage I decub ulcer treated with wound care
-GERD
.
Secondary Diagnosis:
-valvular heart disease s/p bioprosthetic MVR and ASD repair in
[**2188**]
-s/p BiV ICD
-DMII
-HTN
-Hyperlipidemia
-CRI
-sleep apnea
Discharge Condition:
Afebrile. Hemodynamically stable. Ambulating. Tolerating PO.
Discharge Instructions:
You were admitted for further treatment of your heart failure.
We treated you with medications to imporve your heart function.
You also had a urinary tract infection which we treated.
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding or any other concerning symptoms.
.
Please take all your medications as directed. Notably:
1. Please take lovenox injections twice daily until your
coumadin level becomes between [**12-29**]. This may take up to [**4-1**]
days.
2. We started lisinopril 10mg daily
3. We started metoprolol 12.5mg [**Hospital1 **]
4. We restarted your coumadin at 5mg per day. please adjust
per your PCPs recommendations.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 ml
.
Please keep you follow up appointments as below.
Followup Instructions:
Please follow up with your primary care doctor
(ABDELKADER,KHALED M. [**Telephone/Fax (3) 45678**]) on Friday
[**2193-4-26**] at 10:45am to have your INR checked and to have a
followup appt.
.
Please also follow up with:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2193-6-12**]
9:30
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2193-6-12**] 10:00
.
You will also need an appointment with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] and
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. They can be reached at ([**Telephone/Fax (1) 13786**]. Please
followup with them within 2 weeks. You are tentatively
scheduled for an appt on [**5-7**] at 2:30pm
|
[
"416.8",
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"599.0",
"530.81",
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"427.31",
"780.57",
"V45.02"
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icd9cm
|
[
[
[]
]
] |
[
"89.64",
"89.49",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
12207, 12271
|
7885, 8241
|
280, 305
|
12657, 12720
|
3992, 5761
|
13691, 14546
|
2547, 2713
|
11138, 12184
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12292, 12292
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12744, 13668
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237, 242
|
8269, 10859
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333, 2061
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12501, 12636
|
12311, 12480
|
2083, 2309
|
2325, 2531
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,364
| 129,723
|
15254
|
Discharge summary
|
report
|
Admission Date: [**2102-4-17**] Discharge Date: [**2102-5-12**]
Date of Birth: [**2058-5-21**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a 43 year old man
with diabetes mellitus times twenty years, end stage renal
disease on dialysis times two months, with right permacath
present, who presents with fevers to 103.7 times two days,
positive chills, positive nausea and vomiting, decreased p.o.
intake times two days, also mild watery diarrhea with cough
and mild shortness of breath. Of note, the patient had left
foot debridement surgery for osteomyelitis on the left second
digit per podiatry. He had good granulation tissue of the
site. He was getting Oxacillin two grams q4hours until
[**2102-3-10**]. In the Emergency Department, temperature was
102.2, pulse 90, blood pressure 113/59, respiratory rate 20,
oxygen saturation 100% in room air. The patient had culture
of the Hickman at dialysis but before dialysis had decreased
blood pressure to 90/40 with his pulse increasing to 115 and
then 160s with supraventricular tachycardia. The patient
received Adenosine in the Emergency Department with no effect
and he was then cardioverted successfully. His heart rate
went to 116. He received Vancomycin and Gentamicin in the
Emergency Department and two liters of normal saline.
PAST MEDICAL HISTORY:
1. Diabetes mellitus type 2.
2. End stage renal disease times two months with permacath
and left arm fistula.
3. Hypertension.
4. Hypercholesterolemia.
5. Cataracts.
6. Retinopathy.
7. Chronic anemia.
8. Bicuspid aortic valve.
PAST SURGICAL HISTORY:
1. Left arm fistula on [**8-31**].
2. Status post cholecystectomy.
3. Left shoulder surgery times two.
4. Eye surgery.
ALLERGIES: Duricef causes rash.
SOCIAL HISTORY: The patient is on disability and lives with
daughter. [**Name (NI) **] alcohol or tobacco use.
MEDICATIONS ON ADMISSION: (From discharge note from
[**2102-2-7**]).
1. Lipitor 10 mg once daily.
2. Topamax 150 mg once daily.
3. Doxazosin 2 mg q.h.s.
4. Percocet p.r.n.
5. Calcitriol.
6. Lopressor 100 mg three times a day.
7. [**Doctor First Name **] 60 mg once daily.
8. Oxacillin two grams q4hours.
9. PhosLo 667 mg three times a day.
10. TUMS 500 four times a day.
11. Lisinopril 30 mg p.o. once daily.
12. Ativan 0.5 mg p.o. p.r.n.
PHYSICAL EXAMINATION: Pulse 111, blood pressure 92/47,
respiratory rate 23, oxygen saturation 100% on four liters
nasal cannula. In general, the patient is an ill appearing
white male in no acute distress. The pupils are equal,
round, and reactive to light and accommodation. Extraocular
movements are intact. The oropharynx is clear. Mucous
membranes are dry. Jugular venous distention is flat. The
lungs are clear to auscultation anteriorly. The heart is
regular rate and rhythm, S1 and S2, II/VI systolic murmur at
the left upper sternal border. The abdomen reveals mild
diffuse tenderness, positive bowel sounds, nondistended.
Extremities revealed trace edema. Neurologically, the
patient is alert and oriented times three.
LABORATORY DATA: White blood cell count 13.6, hematocrit
40.0, platelets clumped, 83% neutrophils, 15% bands, 1%
lymphocytes, 1% monocytes. Sodium 130, potassium 4.3,
chloride 92, bicarbonate 17, blood urea nitrogen 69,
creatinine 10.2, glucose 194.
Chest x-ray showed no pneumonia. Echocardiogram from
[**2102-2-14**], showed moderate left ventricular hypertrophy,
bicuspid aortic valve, no mitral regurgitation, no tricuspid
regurgitation, no vegetation. Electrocardiogram after
cardioversion revealed normal sinus rhythm at 150 beats per
minute.
HOSPITAL COURSE:
1. Cardiovascular - The patient was admitted to the
Intensive Care Unit following his supraventricular
tachycardia. The patient remained stable following
conversion. He was started back on his Lopressor for rate
control. He was then transferred to the floor. On the
floor, he remained stable, however, he remained persistently
tachycardic. This was felt to be due to his underlying
infection, however, his beta blocker was titrated up. The
patient was started back on his ace inhibitor and started
back on his statin. Upon discharge, the patient was taking
Aspirin, Atenolol 100 mg once daily, Lisinopril 30 mg once
daily, Lipitor 10 mg once daily.
2. Infectious disease - The patient was initially started on
Vancomycin and Gentamicin for possible Methicillin resistant
Staphylococcus aureus endocarditis. The patient's blood
cultures came back coagulase positive Staphylococcus from his
dialysis catheter. His dialysis catheter was removed. The
patient's cultures came back MSSA. His Vancomycin and
Gentamicin were discontinued. The patient was switched over
to Oxacillin. The patient started complaining of pleuritic
chest pain along with pain in his back and left
sternoclavicular region. The patient had chest CT done which
showed numerous nodules, one of which was cavitating
suggestive of pulmonary emboli. The patient had an upper
extremity ultrasound done to evaluate for possible source of
septic emboli. This was negative. The patient also had a
transesophageal echocardiogram done to evaluate for
endocarditis. The patient's transesophageal echocardiogram
showed that the right valves were clean. On the left, mitral
valve was thickened, and a small minimally mobile strand was
seen on the left atrial side at the base of the anterior
leaflet without associated mitral regurgitation at that site.
Differential for the strand included fibrinous strand versus
small vegetation. Aortic valve was moderately thickened but
no discrete masses or vegetation were seen on the aortic
valve. Due to the possibility of vegetation, it was decided
that the patient would be treated for six week course of
intravenous antibiotics. As the patient was complaining of
pain in his back and supraclavicular joint region, a bone
scan was ordered. Bone scan showed no signs of osteomyelitis
or abscess. The patient had persistent swelling at the time
of the sternoclavicular region. CT surgery was consulted and
attempts were made to aspirate possible abscess. No pocket
was found on aspiration, however, was sent and grew out MSSA.
It is likely that this represents a small abscess. Status
post procedure, the pain improved in the sternoclavicular
region. The patient defervesced. His blood cultures grew
MSSA until [**2102-4-24**], following surveillance cultures were all
negative. The patient's liver function tests began rising
several days after starting on Oxacillin and it was felt that
it was due to the Oxacillin. His Oxacillin was discontinued
and the patient was started on Cefazolin. The patient
tolerated the Cefazolin and will be dosed with two grams of
Cefazolin following hemodialysis. The patient had low grade
fevers and persistent nausea and vomiting. In an attempt to
evaluate for possible abdominal abscess, ultrasound was
performed. Ultrasound revealed splenomegaly but no other
obvious foci. Splenomegaly likely reflects his infective
endocarditis. The patient had abdominal CT done which showed
no obvious abscess. A repeat chest CT was done and showed
decrease in size of his pulmonary nodules. It is presumed
that these septic emboli were thrown when the dialysis
catheter was pulled. The patient received over two weeks of
intravenous antibiotics while hospitalized and will receive
another four weeks duration of intravenous antibiotics.
3. Hearing loss - During hospital course, the patient
developed acute hearing loss. This was preceded with right
sided tinnitus followed by hearing loss along with nausea,
vomiting on standing. The patient denied having sensation of
vertigo. ENT was consulted and an audiogram was performed
which confirmed right sided sensineural hearing loss. The
patient was started on Prednisone 60 mg once daily for seven
days. The patient had repeat audiology examination six days
later which still showed hearing loss in the right ear. The
patient did say that his balance improved after starting
Prednisone. The patient will be discharged on Prednisone
taper and will follow-up with ENT, Dr. [**First Name (STitle) **], in one week.
He was also scheduled for a neurology appointment to evaluate
his hearing loss as suggested by ENT. Etiology of his
hearing loss is unknown. It was felt possibly related to the
Gentamicin, however, the patient had been off Gentamicin for
one and one half weeks prior to the acute onset hearing loss.
4. Gastrointestinal - The patient had nausea and vomiting.
Initially, this was in the setting of rising liver function
tests. His liver function tests went down after switching
from Oxacillin. The nausea and vomiting improved but then
returned. It was noted that his pancreatic enzymes were
rising. His Topamax was discontinued and the patient's
pancreatic enzymes fell. The patient persisted to have nausea
and vomiting but this was in the setting of sitting up. It
was felt due to his inner ear pathology. The patient was
started on Meclizine with improvement in the nausea and
vomiting. The patient on discharge was still having problems
with emesis on sitting up, however, was able to tolerate
adequate p.o.
5. Renal disease - The patient's hemodialysis catheter was
pulled, however, his AV fistula was felt to be mature enough
for use. The patient continued to have dialysis three times
a week. His phosphate was found to be rising. His phosphate
binders were increased. The patient will be discharged with
follow-up with hemodialysis three times a week, Monday,
Wednesday and Friday.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with follow-up with dialysis three
times a week.
DISCHARGE DIAGNOSES:
1. MSSA bacteremia being treated for six weeks for possible
endocarditis.
2. Right sensineural hearing loss.
3. Positional nausea and vomiting from inner ear process.
4. End stage renal disease on hemodialysis.
5. Hypertension.
6. Hypercholesterolemia.
7. Lower back pain.
MEDICATIONS ON DISCHARGE:
1. Nephrocaps one tablet once daily.
2. Enteric Coated Aspirin 325 mg once daily.
3. Colace 100 mg twice a day.
4. Flomax 0.4 mg once daily.
5. Atenolol 100 mg once daily.
6. PhosLo three tablets with meals three times a day.
7. Sevelamer three tablets three times a day with meals.
8. Lisinopril 30 mg once daily.
9. Dilaudid 2 mg q6hours p.r.n.
10. Prednisone taper as instructed by ENT. The taper is to
finish on [**2102-5-19**].
11. M.S. Contin 30 mg twice a day.
12. Lipitor 10 mg once daily.
13. Meclizine 12.5 mg three times a day.
14. Ibuprofen 600 mg q6hours p.r.n.
15. Compazine 10 mg q6hours p.r.n.
FOLLOW-UP: The patient is to follow-up with Dr. [**First Name (STitle) **] on
[**2102-5-19**], for repeat evaluation and audiometry. He is also
to follow-up with Dr. [**Last Name (STitle) **] of neurology on [**2102-5-30**].
He is to call [**Telephone/Fax (1) 44362**] to update registration
information. He is to continue on outpatient hemodialysis as
before. He is to follow-up with primary care physician in
one week. He will need his liver function tests checked
every week while on Cefazolin. The patient is to have his
Cefazolin dose two grams at dialysis.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 23326**]
MEDQUIST36
D: [**2102-5-16**] 18:23
T: [**2102-5-16**] 18:45
JOB#: [**Job Number 44363**]
|
[
"V09.0",
"276.1",
"424.90",
"403.91",
"427.31",
"038.11",
"996.62",
"250.40",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"81.91",
"42.23",
"38.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9728, 10009
|
10035, 11478
|
1920, 2343
|
3655, 9596
|
1621, 1779
|
2366, 3638
|
170, 1340
|
1362, 1598
|
1796, 1893
|
9621, 9707
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,549
| 183,210
|
17642
|
Discharge summary
|
report
|
Admission Date: [**2169-5-30**] Discharge Date: [**2169-6-2**]
Date of Birth: [**2104-2-1**] Sex: M
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old
gentleman transferred from an outside hospital with small
intraparenchymal hemorrhages, dens fracture and facial
fracture. The patient fell from a ladder greater than 10' on
[**2169-5-30**] but felt okay and went home. The following day, he
was having neck pain and became confused and presented to an
outside hospital with these symptoms and was transferred to
[**Hospital3 **].
PAST MEDICAL HISTORY: 1) High blood pressure, 2) Gout, 3)
Alcohol abuse with history of DT's.
MEDICATIONS: Only taking atenolol at home.
ALLERGIES: Morphine--patient gets GI upset.
PHYSICAL EXAM: Alert and oriented x 3, in no apparent
distress. Pupils equally round and reactive to light.
Extraocular muscles intact. Right eye ecchymotic, swollen.
Lids with subconjunctival hemorrhage. Neck initially with
C-collar. Cardiac - regular rate and rhythm. Respiratory -
coarse breath sounds bilaterally, mild diffuse tenderness on
the right side. Abdominal exam - soft, nontender,
nondistended. Extremities - no lower extremity edema and no
gross deformities. Neurologic - cranial nerves II through
XII grossly intact, [**6-5**] muscles, motor strength distally,
distal senses intact.
LABORATORY: Initially, the hematocrit was 35. Tox screen
was negative. The patient had a head CT that showed some
right frontal contusion, small subarachnoid hemorrhage with
no epidural hemorrhage. Facial CT showed right orbital
fracture, frontal and maxilla fracture through sphenoid.
C-spine - the CT showed a type 2 dens fracture, rib fracture
of 1 and 2, without any cord intrusion. The patient also
complained of right upper extremity pain, but films of the
shoulders, humerus, elbow and forearm were negative. Pelvic
x-rays showed no fracture or dislocation. TL-spine showed an
old anterolisthesis of L5 on S1 and significant DJD.
Neurosurgery was consulted and followed neuro exam. Repeat
head CT did not show any interval changes. Ophthalmology was
consulted for his right eye ecchymoses, as well as orbital
fractures. They did not see any signs of extraocular muscle
entrapment or proptosis or diplopia, and stated that there
was no need for surgical repair, and his globe was intact.
They recommended Artificial Tears prn and follow-up with
ophthalmology in [**3-7**] weeks.
Plastics was also consulted and felt that there was no
operative management required for his facial fractures.
Plastics will follow as outpatient.
Orthopedics and spine were consulted regarding his type 2
dens fracture which is stable. Halo was not placed because
with his body type it would have been difficult to properly
place a halo on the patient. The patient also was put on a
hard collar. They recommended hard collar for 3 months and
follow-up with Dr. [**Last Name (STitle) 363**] on an outpatient basis.
HOSPITAL COURSE: The patient had been hemodynamically
stable. Labs were stable.
DISPOSITION: The patient is being discharged in good
condition.
DISCHARGE MEDICATIONS: 1) atenolol, 2) PRN percocet.
Physical therapy was also consulted and they noted that he
has good potential to return to prior level of functionality
as pain improves, and would recommend continuing rehab to
optimize his potential to return to baseline. The patient
will be discharged to a rehab facility pending acceptance by
an outside facility. The patient discharged in good
condition.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 49124**]
MEDQUIST36
D: [**2169-6-1**] 15:50
T: [**2169-6-2**] 11:22
JOB#: [**Job Number 49125**]
|
[
"E884.9",
"801.21",
"807.03",
"805.02",
"802.8",
"921.0",
"372.72",
"800.21",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3171, 3843
|
3016, 3147
|
789, 2998
|
174, 586
|
609, 773
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,749
| 112,178
|
36695
|
Discharge summary
|
report
|
Admission Date: [**2129-9-23**] Discharge Date: [**2129-10-3**]
Date of Birth: [**2052-5-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
left arm pain, nausea
Major Surgical or Invasive Procedure:
[**2129-9-28**] s/p Coronary artery bypass grafting x4:
Left internal mammary artery graft to left anterior
descending, reverse vein graft to the first marginal, second
marginal and third marginal branches of the circumflex
History of Present Illness:
77 year old male presented to outside hospital with left arm,
axilla, and flank pain, additionally diaphoresis and nausea. He
was transferred to [**Hospital1 18**] for cardiac evaluation
Past Medical History:
coronary artery disease
s/p PCI [**2119**] (2 stents to OM1)
gout
hypertension
hypercholesterolemia
osteoarthritis
skin cancer
Social History:
Occupation: retired from trucking business
Lives with: wife
[**Name (NI) 1139**]: denies
ETOH: denies
Family History:
brothers with CAD, s/p CABG
Physical Exam:
Pulse: 67 Resp: 16 O2 sat: 98% RA
B/P Right: 157/81 Left:
Height: Weight: 94.9kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
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 x
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits
Pertinent Results:
[**2129-10-3**] 06:25AM BLOOD Hct-26.1*
[**2129-10-1**] 06:55AM BLOOD WBC-14.3* RBC-2.53* Hgb-8.6* Hct-25.0*
MCV-99* MCH-34.1* MCHC-34.5 RDW-13.3 Plt Ct-159
[**2129-9-24**] 04:40AM BLOOD WBC-10.7 RBC-3.74* Hgb-12.5* Hct-36.3*
MCV-97 MCH-33.4* MCHC-34.4 RDW-13.5 Plt Ct-187
[**2129-10-1**] 06:55AM BLOOD Plt Ct-159
[**2129-9-24**] 01:43AM BLOOD Plt Ct-189
[**2129-9-24**] 04:40AM BLOOD PT-12.1 PTT-25.2 INR(PT)-1.0
[**2129-10-3**] 06:25AM BLOOD UreaN-23* Creat-1.0 K-4.8
[**2129-9-24**] 01:43AM BLOOD Glucose-197* UreaN-16 Creat-0.9 Na-136
K-4.3 Cl-103 HCO3-23 AnGap-14
[**2129-9-26**] 05:59AM BLOOD ALT-14 AST-15 LD(LDH)-155 AlkPhos-76
TotBili-0.7
[**2129-9-24**] 04:40AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2129-9-26**] 05:59AM BLOOD %HbA1c-7.7*
PA AND LATERAL CHEST ON [**2129-10-1**] AT 15:39
INDICATION: CABG.
COMPARISON: [**2129-9-30**].
FINDINGS: Basilar atelectasis is seen bilaterally with a right
effusion. The
latter appears a little more prominent than the prior study.
There is a
patchy opacity in the left lower lobe, which could be
atelectasis or
pneumonia. Clinical correlation is needed. No definite
pneumothorax is seen.
Cardiomegaly is stable and the pulmonary vascular markings are
within normal
limits.
IMPRESSION:
Slight increase in right pleural fluid. Somewhat improved
aeration of the
previously seen retrocardiac density, but pneumonia cannot be
ruled out.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SAT [**2129-10-1**] 9:17 PM
Cardiology Report ECG Study Date of [**2129-9-28**] 8:48:06 PM
Sinus rhythm. Prior inferior myocardial infarction. Incomplete
right
bundle-branch block. Since the previous tracing of [**2129-9-27**]
incomplete right
bundle-branch block pattern is now present.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 192 110 382/438 47 -42 66
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 82989**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82990**]
(Complete) Done [**2129-9-28**] at 3:02:23 PM 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: [**2052-5-8**]
Age (years): 77 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for CABG
ICD-9 Codes: 427.89, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2129-9-28**] at 15:02 Interpret MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Name Initial (MD) **] [**Name8 (MD) 4901**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Suboptimal
Tape #: 2009AW4-: Machine: AW2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - LVOT diam: 2.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the LA/LAA or the RA/RAA. Good (>20 cm/s) LAA
ejection velocity. All four pulmonary veins identified and enter
the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Top normal/borderline dilated LV cavity
size. Mild-moderate regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Normal ascending
aorta diameter. Focal calcifications in ascending aorta. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. The patient appears to be in sinus rhythm. Frequent
ventricular premature beats. Results were personally reviewed
with the MD caring for the patient.
Conclusions
PRE BYPASS The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. The left ventricular cavity size is top
normal/borderline dilated. There is mild to moderate regional
left ventricular systolic dysfunction with severe inferior and
inferolateral hypokinesis/akinesis and mild global hypokinesis
of the remaining myocardial segments. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. 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. Mild (1+) mitral regurgitation is seen. Dr.
[**Last Name (STitle) **] was notified in person of the results in the operating
room at the time of the study.
POST BYPASS The patient is receiving epinephrine by infusion.
There is normal right ventricular systolic function. The left
ventricle displays continued severe inferior and inferolateral
wall hypokinesis/akinesis but all other segments now show
improved and near normal function. Left ventricular ejection
fraction is in the 45% range. Valvular function is unchanged and
the thoracic aorta appears intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2129-9-28**] 16:25
Brief Hospital Course:
Transferred from outside hospital for cardiac evaluation, he was
ruled out for myocardial infarction, troponin < 0.01, and
underwent cardiac catherization [**2129-9-23**] which revealed coronary
artery disease. He was referred for surgical evaluation. He
underwent preoperative work up and on [**2129-9-28**] was brought to the
operating room and underwent coronary artery bypass graft
surgery. See operative report for details. He received
vancomycin for perioperative antibiotics as he was in the
hospital preoperatively. He was transferred to the intensive
care unit for hemodynamic management. In the first twenty four
hours he was weaned from sedation, awoke neurologically intact,
and was extubated without complications. On post operative day
one he was started on beta blockers and diuretics, and
transferred to the post operative floor for the remainder of his
care. Physical therapy worked with him on strength and
mobility. He had issues with back pain that was limiting
activity, his medications were adjusted with good response and
improved mobility. He was ready for discharge home with services
on post operative day five.
Medications on Admission:
Plavix 75 mg daily
Zocor 80 mg daily
Allopurinol 300 md daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
4. Zocor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*65 Tablet(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p cabg
Hypertension
hyperlipidemia
osteoarthritis
skin cancer
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 82991**] in 1 week [**Telephone/Fax (1) 65735**]
Dr. [**Last Name (STitle) **] in [**3-15**] weeks
Wound check appointment as instructed by [**Hospital Ward Name **] 6 nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2129-10-3**]
|
[
"272.0",
"724.8",
"V45.82",
"790.29",
"274.9",
"403.90",
"585.9",
"V10.83",
"272.4",
"715.90",
"414.01",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.53",
"88.56",
"99.20",
"36.15",
"36.13",
"00.40",
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icd9pcs
|
[
[
[]
]
] |
10665, 10714
|
8289, 9438
|
342, 568
|
10847, 10854
|
1762, 8266
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11393, 11764
|
1071, 1101
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9550, 10642
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10735, 10826
|
9464, 9527
|
10878, 11370
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1116, 1743
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281, 304
|
596, 785
|
807, 936
|
952, 1055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,532
| 158,305
|
15388+15419
|
Discharge summary
|
report+report
|
Admission Date: [**2179-11-1**] Discharge Date: [**2179-11-7**]
Date of Birth: [**2112-9-29**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
male who has not seen a physician for [**Name Initial (PRE) **] long time. Since
about nine months ago, the patient has been experiencing
dyspnea with exertion and symptoms of reflux associated with
eating. The patient finally saw a physician. [**Name10 (NameIs) **]
consequently underwent a stress test on [**2179-10-5**].
At the time, he exercised 4.5 min on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol and
achieved more than 100% of his age predicted heart rate. He
did not experience any chest pain during the stress test.
The electrocardiogram at the time revealed [**Street Address(2) 44678**]
depressions. The echocardiogram showed a moderate apical
ischemia with an ejection fraction of 54% and mild apical
hypokinesis.
Given the findings, the patient was referred for a cardiac
catheterization. The patient denied any symptoms of
claudication, orthopnea, edema, paroxysmal nocturnal dyspnea,
or light-headedness. The patient underwent cardiac
catheterization on [**2179-10-18**], which showed two-vessel
and ramus intermedius coronary artery disease. Specifically,
the proximal left anterior descending had an 80% ostial
lesion and was totally occluded in its mid segment. The left
circumflex was diffusely disease proximally. The obtuse
marginal I had a proximal 70% stenosis. The ramus
intermedius had a 90% ostial lesion. The dominant RCA system
had mild luminal irregularities throughout its course and a
discreet 70% stenosis distally. The estimated left
ventricular ejection fraction was 57%. The patient was
consequently referred to Cardiac Surgery for further
evaluation.
PAST MEDICAL HISTORY: 1. Hiatal hernia. 2.
Gastroesophageal reflux disease.
PAST SURGICAL HISTORY: None.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS: Enteric Coated Aspirin 325 mg p.o. q.d.,
Lopressor 25 mg p.o. b.i.d., Protonix 40 mg p.o. q.d.
LABORATORY DATA: On admission hematocrit was 28.4, white
blood cell count 8.0, platelet count 396; INR 1.0; urinalysis
negative; sodium 139, creatinine 0.7, BUN 16, glucose 106,
potassium 3.5; AST 33, ALT 32, amylase 28.
Electrocardiogram showed sinus rhythm with a heart rate of 68
with Q-waves in leads III and AVF.
PHYSICAL EXAMINATION: Vital signs: The patient was
afebrile. Heart rate 68, blood pressure 116/70, respirations
20, 98% on room air. General: The patient was a
well-appearing male in no apparent distress. HEENT: Within
normal limits. No jugular venous distention. No bruits.
Respiratory: Clear to auscultation bilaterally.
Cardiovascular: Regular, rate and rhythm. Normal S1 and S2.
No murmurs, rubs, or gallops. Abdomen: Soft, nontender,
nondistended. Bowel sounds positive. Extremities: Warm and
well perfused. No edema or clubbing. Neurological: Alert
and oriented times three. Cranial nerves III-XII grossly
intact. Pulses: Upper and lower extremity pulses present
bilaterally.
Preoperative chest x-ray done on [**2179-10-18**], showed no
acute cardiopulmonary abnormalities.
HOSPITAL COURSE: Given the findings of two-vessel coronary
artery disease and the disease in the ramus intermedius, and
given the symptoms of unstable angina, the recommendation was
to undergo a bypass surgery. On [**2179-11-1**], the
patient underwent coronary artery bypass grafting times four
(LIMA to LAD, SVG to PDA, SVG to ramus intermedius, SVG to
obtuse marginal). The patient tolerated the procedure well.
There were no complications. Please see the full operative
report for details.
The patient was transferred to the Intensive Care Unit in
fair condition. The patient remained intubated; however, he
was extubated on postoperative day #0 without any
complications. On on postoperative day #1, the patient was
alert and oriented and was responding to commands. He was
making an adequate amount of urine. His chest tube was
draining a moderate amount of fluid. He was maintained on
inotropic support for low systolic blood pressure. His lungs
were clear to auscultation. The patient remained in sinus
rhythm. He remained afebrile with stable heart rate and
blood pressure. Chest tubes were removed.
The patient was transferred to the regular floor in stable
condition. Physical Therapy was consulted who followed the
patient during his hospitalization. Their recommendation was
to discharge the patient to home when ready clinically. A
beta-blocker was started. Pacing wires were removed on
postoperative day #3.
On on postoperative day #4, the patient experienced an
episode of atrial fibrillation. The patient was treated with
intravenous Lopressor. The patient converted spontaneously
to sinus rhythm the same day. He experienced palpitations,
but otherwise remained asymptomatic during the atrial
fibrillation episode. The patient was started on oral
Amiodarone and was also given an intravenous load. In
addition, his stool was noted to be guaiac positive, although
there was no frank blood. Of note, the patient was
maintained on Aspirin.
The patient remained in sinus rhythm for at least 48 hours
prior to discharge. He was ambulating without difficulty.
His oxygen saturation was adequate. His incision was clean,
dry, and intact. The patient was discharged to home on
[**2179-11-7**].
CONDITION ON DISCHARGE: Good.
DISPOSITION: Home.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease status post coronary artery
bypass grafting times four.
2. Atrial fibrillation.
3. Guaiac positive stool.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2179-11-8**] 19:18
T: [**2179-11-8**] 17:26
JOB#: [**Job Number 44679**]
Admission Date: [**2179-11-1**] Discharge Date: [**2179-11-7**]
Date of Birth: [**2112-9-29**] Sex: M
Service:
ADDENDUM:
MEDICATIONS ON DISCHARGE:
1. Lopressor 50 mg p.o. twice a day.
2. Protonix 40 mg p.o. once daily.
3. Aspirin 325 mg p.o. once daily.
4. Amiodarone 400 mg p.o. twice a day times one week
followed by 400 mg p.o. once daily times three months.
5. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
6. Ibuprofen 400 mg p.o. q6hours p.r.n. pain.
7. Lasix 20 mg p.o. twice a day times seven days.
8. Potassium Chloride 20 meq p.o. twice a day times seven
days.
9. Colace 100 mg p.o. twice a day.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with his surgeon, Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **], of cardiac surgery in approximately four weeks.
2. The patient is to follow-up with his cardiologist, Dr.
[**Last Name (STitle) **], in approximately three weeks.
3. The patient is to follow-up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17996**], in approximately one week.
4. The patient was instructed to follow-up on his guaiac
positive stools with his primary care physician. [**Name10 (NameIs) **] patient
was also instructed to have his pulse checked daily for any
signs of irregular heart rhythm.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2179-11-8**] 19:21
T: [**2179-11-8**] 17:39
JOB#: [**Job Number 44728**]
|
[
"553.3",
"411.1",
"427.31",
"794.31",
"530.81",
"792.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5534, 6081
|
6107, 6586
|
3243, 5460
|
6610, 7541
|
1944, 2420
|
2443, 3225
|
177, 1840
|
1863, 1920
|
5485, 5513
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,639
| 187,697
|
26788
|
Discharge summary
|
report
|
Admission Date: [**2112-10-12**] Discharge Date: [**2112-10-16**]
Date of Birth: [**2048-10-3**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11892**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 53899**] is a 64 year old female with large anterolateral
STEMI requiring IABP in late [**2112-9-7**] s/p LAD bare metal
stent who presented with chest pain and shortness of breath on
[**2112-10-11**]. The shortness of breath started about 40 minutes
before the chest pain while she was making dinner. She described
substernal chest pain and tightness that was acute in onset and
felt similar to her prior MI, but not as severe. It did not
radiate to her arm or jaw, and was not associated with nausea or
diaphoresis. On the way to the hospital she took 3 of her
husband's sublingual nitroglycerine tabs which provided minimal
relief of the chest pain.
.
On arrival to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], initial vital signs were: T:98.6
HR:90 BP:83/51 RR:20 O2sat:97% RA. She was given oxygen and 3L
normal saline but BP responded only transiently to each bolus.
She was eventually transferred to [**Hospital1 18**] ED to rule out MI.
.
In the [**Hospital1 18**] ED, initial vital signs were: T:97.3 P:80 B:92/53
(on 10 dopa) R:16 O2sat:97% RA. She had new TWIs in V2-V4
(similar to when she had an NSTEMI in [**2108**]). Her chest x-ray was
clear, she had no LE edema, and was not hypoxic. She was given
potassium chloride 60 mEq SR and dopamine 400mg. Cardiac enzymes
were negative. Cardiology did not think this was a cardiac
issue, so she was admitted to the MICU for management of
hypotension.
.
Past Medical History:
1. Coronary artery disease, NSTEMI [**2108**], STEMI [**9-/2112**] s/p BMS
to LAD
2. Migraine headaches
3. Chronic lower back pain
4. 100 lb weight loss: pt has undergone extensive w/u including
colonoscopy, GYN exam, HIV test, cardiac w/u, stool studies,
celiac studies negative. Also had abd CT negative, Chest CT
demonstrated LUL nodule which was monitered. Had recent scan
that demonstrated increase in size of LUL nodule from 3mm->7mm,
PET scan in [**12-11**] negative - scheduled to have repeat Chest CT
this month.
5. Depression
Social History:
Patient is married, lives with husband. Family stress due to
death of her son from heroin overdose. Also has daughter w/
current substance abuse problems. [**Name (NI) **] a 60 pack year history and
currently smokes about one pack per day, but has plans to quit.
Family History:
Mother had CHF, died from [**Name (NI) 11964**] at age 80. Father died from
lung cancer.
Physical Exam:
MICU:
Vitals: T: 97.2 BP:84/43 P:79 R: 16 O2: 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**2-13**] holosystolic
murmur best heard over mitral area.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2112-10-11**] 11:52PM BLOOD WBC-13.4* RBC-3.74* Hgb-12.5 Hct-37.5
MCV-100* MCH-33.5* MCHC-33.5 RDW-14.3 Plt Ct-345 Neuts-85.4*
Lymphs-9.7* Monos-2.6 Eos-1.8 Baso-0.5
[**2112-10-11**] 11:52PM BLOOD PT-12.1 PTT-29.6 INR(PT)-1.0
[**2112-10-11**] 11:52PM BLOOD Glucose-83 UreaN-24* Creat-0.9 Na-140
K-2.8* Cl-105 HCO3-21* AnGap-17 Calcium-7.9* Phos-3.2 Mg-2.0
[**2112-10-11**] 11:52PM BLOOD CK-MB-3 cTropnT-<0.01
[**2112-10-12**] 05:15AM BLOOD CK-MB-4 cTropnT-<0.01
[**2112-10-12**] 12:29PM BLOOD CK-MB-3 cTropnT-<0.01
[**2112-10-12**] 01:47AM BLOOD D-Dimer-298
[**2112-10-11**] 11:52PM BLOOD TSH-0.79
[**2112-10-11**] 11:52PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2112-10-12**] 04:36AM BLOOD Type-ART pO2-48* pCO2-43 pH-7.38
calTCO2-26 Base XS-0
[**2112-10-12**] 02:40PM BLOOD Lactate-1.1
[**2112-10-14**] 03:01AM BLOOD VitB12-387
.
Studies:
[**2112-10-12**] ECG: Sinus rhythm with a late cycle atrial premature
beat. Q-T interval prolongation. Anterior myocardial infarction.
Low voltage throughout. Since the previous tracing precordial
voltage has decreased. T wave abnormalites and Q-T interval
prolongation persist. Clinical correlation is suggested.
.
[**2112-10-12**] ECHO: No pericardial effusion or tamponade. Regional LV
systolic dysfunction consistent with prior LAD infarction. Left
ventricle ejection fraction: 25% to 30%.
.
[**2112-10-11**] CHEST (PORTABLE AP) Approved: No acute intrathoracic
abnormality.
.
[**2112-10-11**] ECG: Sinus rhythm with atrial premature beats. Low limb
lead voltage.Late R wave progression. Q-T interval prolongation
with marked precordial ST-T wave abnormalities. Since the
previous tracing of [**2112-9-9**] there is new Q-T interval
prolongation with prominent precordial T wave inversions.
Consider infarction or metabolic derangements. Clinical
correlation is suggested. The precordial Q waves were present on
the previous tracing of [**2112-9-9**].
.
Micro:
[**2112-10-12**] Urinalysis: negative
.
[**2112-10-12**] MRSA screen: No MRSA isolated
.
[**2112-10-12**] Blood Culture: Pending, no growth to date
.
Discharge Labs:
[**2112-10-16**] 06:26AM BLOOD WBC-6.4 RBC-3.52* Hgb-11.6* Hct-34.5*
MCV-98 MCH-33.1* MCHC-33.8 RDW-14.4 Plt Ct-306
[**2112-10-16**] 06:26AM BLOOD Glucose-82 UreaN-9 Creat-0.6 Na-142 K-3.9
Cl-106 HCO3-31 AnGap-9
[**2112-10-16**] 06:26AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.8 Mg-2.3
Brief Hospital Course:
Mrs. [**Known lastname 53899**] is a 64 year old female s/p anteriolateral STEMI
with BMS to LAD who required IABP in cath lab, who presented on
[**2112-10-11**] with chest pain and shortness of breath. Hypotension
on presentation required MICU stay with peripheral dopamine.
.
# Hypotension: She was hypotensive to the 70s systolic on
arrival to [**Hospital3 **], which was likely due to a recently
started beta-blocker in the setting of her systolic heart
failure and possible volume depletion from decreased PO intake
leading up to admission. She was given a total 3.5 L normal
saline in [**Hospital1 **] and [**Hospital1 18**], and was started on peripheral
dopamine in the [**Hospital1 18**] MICU. Her lisinopril, furosemide, and
metoprolol were all held. No infectious etiology was
identified. There was no evidence of adrenal insufficiency with
cortisol stimulation testing. Bedside echo showed no interval
worsening of EF. Interestingly, the MICU team noted that her
pressure with invasive montitoring via a-line was consistently
[**10-21**] points higher than with a peripheral cuff. Her blood
pressure stabilized to the 90s systolic without dopamine and she
was transferred to the floor. Her metoprolol was restarted
before leaving the MICU, but was discontinued again on the floor
because her SBPs were intermittently in the high 80s-90s.
Whether or not to re-start her BBlocker and ACEi should be
discussed at her cardiology follow up in a few days. Given
recent weight loss, there was concern that poor nutritional
status was resulting in a decreased oncotic pressure in the
vasculature, but albumin was 3.7. On discharge, she was
hemodynamically stable without orthostasis and denied any
symptoms of feelings of lightheadedness or feeling unsteady.
.
# Chest pain: She had substernal chest pain and tightness that
was acute in onset and felt similar to her prior MI. The pain
was mildly relieved by 3 of her husband's expired sublingual
nitroglycerine tabs. On arrival to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], she was given
oxygen which improved her symptoms. She had new T-wave
inversions in V2-V4 on her initial ECG. Negative cardiac enzymes
x 3. Her chest pain resolved without further intervention and
had no complaints of chest pain throughout her admission. She
has a follow up formal ECHO scheduled later this week at [**Hospital1 **].
.
# CAD - NSTEMI in [**2108**] and STEMI in 09/[**2112**]. We continued her
home aspirin and statin. She had not been taking furosemide or
HCTZ since STEMI in 09/[**2112**]. On arrival lisinopril and
metoprolol were held. After her blood pressure stabilized in the
MICU, she was re-started on metoprolol, but her BPs were
intermittently in the 80s, so metoprolol was discontinued again.
She has scheduled follow up with her cardiologist as above.
.
# Acute kidney injury: Her baseline creatinine is 0.4-0.5, but
was up to 1.1 on arrival likely from volume depletion. Her
creatinine trended down to 0.5 following fluid resusitation.
.
# Depression: She has a history of depression with suicide
attempts. We continued her home buproprion, fluoxitine, and
quetiapine. Mood was stable throughout hospital course.
.
# Chronic pain: Continue home gabapentin and oxycodone for her
chronic back pain.
.
# Smoking history: Has a 60 pack year history and currently
smokes approximately 1 pack per day. Did not have interest in a
nicotine patch. Has plans to quit smoking. This should be
addressed at cardiology and PCP follow up.
Medications on Admission:
1. Lisinopril 2.5 mg PO daily
2. Simvastatin (Zocor) 80 mg PO daily
3. Aspirin 325 mg PO daily
4. Clopidogrel (Plavix) 75 mg PO daily
5. Fluoxetine (Prozac) 60 mg PO daily
6. Bupropion HCl (Wellbutrin) 100 mg PO BID
7. Topiramate (Topamax) 100 mg PO BID
8. Cyclobenzaprine (Flexeril) 10 mg PO daily, PRN
9. Oxycodone-Acetaminophen (Percocet) 5-325 mg 1-2 tabs PO TID
10. Quetiapine (Seroquel) 25 mg 1-2 tabs PO QHS
11. Gabapentin (Neurontin) 400 mg PO BID
12. Modafinil (Provigil) 100 mg PO BID
13. Ranitidine HCl (Zantac) 150 mg PO BID
14. Metoprolol (Toprol) 12.5 mg PO daily
15. Premarin 0.3 mg tabs
Discharge Medications:
1. bupropion HCl 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. quetiapine 25 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime)
as needed for insomnia.
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
8. fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
9. Topamax 100 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
10. Premarin 0.3 mg Tablet Sig: One (1) Tablet PO once a day.
11. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain.
12. modafinil 100 mg Tablet Sig: One (1) Tablet PO twice a day.
13. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Hypotension
.
Secondary:
Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 53899**],
.
It was a pleasure taking care of you here at [**Hospital1 18**]. You were
initially admitted to the medical intensive care unit (ICU) for
management of low blood pressure. You got IV fluids and a
medicine to help increase your blood pressure. We did not find
any evidence of an infection causing low blood pressure. We
checked to make sure you did not have another heart attack. We
are concerned that part of the reson your pressure was low was
that you have not been eating and drinking enough at home.
Please do your best to eat three meals a day when you go home.
.
We have made the following changes to your medications:
- Please STOP taking metoprolol XL 12.5 mg daily. Please STOP
taking lisinopril 2.5 mg daily. Your cardiologist may re-start
these medicines when you see him.
- Continue to STOP taking furosemide (Lasix) and HCTZ.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please keep the appointment with your cardiologist and for an
echocardiogram on Thursday at [**Hospital3 **].
.
Please call your primary care doctor's office on Tuesday at
[**Telephone/Fax (1) 4475**] for an appointment this week or early next week.
[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DO 12-BDU
|
[
"E941.3",
"276.50",
"V45.82",
"584.9",
"428.22",
"410.02",
"458.29",
"276.8",
"348.30",
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icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
11007, 11013
|
5827, 9340
|
350, 356
|
11114, 11114
|
3405, 3405
|
12253, 12641
|
2704, 2795
|
9994, 10984
|
11034, 11093
|
9366, 9971
|
11265, 11895
|
5520, 5804
|
2810, 3386
|
11924, 12230
|
279, 312
|
384, 1847
|
3419, 5504
|
11129, 11241
|
1869, 2406
|
2422, 2688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,911
| 188,361
|
3898
|
Discharge summary
|
report
|
Admission Date: [**2122-8-1**] Discharge Date: [**2122-8-12**]
Date of Birth: [**2055-10-31**] Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
endotracheal intubation, central venous catheter placement,
arterial line placement.
History of Present Illness:
66yoM with a complicated medical history including CAD s/p CABG,
VF arrest s/p pacer/ICD, CHF (EF 25%), diabetes, OSA presenting
for altered mental status.
Per patient's daughter and wife, the patient had been
complaining of fatigue and weakness for the past several days to
week. He had also reportedly been constantly coughing and
gasping for air in his sleep, and his daughter noted increased
swelling of his face and legs recently. His Torsemide had been
increased from 100 mg qAM, 50 mg q afternoon to 100 mg [**Hospital1 **] on
[**7-28**] by his PCPfor these symptoms. Of note, he had been having
difficulty with his CPAP at home recently. Per family, the
patient has not had headaches, altered mental status, neck
stiffness, chest pain, shortness of breath, abdominal pain,
diarrhea, or fevers. He did reportedly complain of chills the
night prior to presentation. This morning, the patient's wife
was concerned that the patient had altered mental status and
called EMS.
Per EMS report, the patient was found laying in bed moaning and
grunting. He was reportedly confused and non-verbal but
responded to his name. FSBS was 61, and he was given 2 tubes of
glucose paste with repeat FSBS 65 and reported to be "somewhat
verbal" subsequently. EMS found the patient to be hypoxic with
labored respirations and he was placed on a non-rebreather. He
was also found to be febrile to 102. Per report, his pupils
were fixed and dilated.
.
In the ED, initial VS were: 102.7 113 117/58 20 88%RA, 100%
Non-Rebreather. Unresponsive, open eyes to sternal rub, but not
responsive to questions. Satting low-mid 90's on NRB, increased
work of breathing and so was intubated for concern for tiring.
He received etomidate 20 mg, rocuronium 100 mg. After
intubation, he was bradycardic to 47 with BP 79/56 -> 65/37. He
was given 0.5mg atropine HR improved to 122, hypotension
persistent so he was given a total of 5L NS. A RIJ was placed
and levophed was started. CVP was 27. He was hypoglycemic and
was given an amp d50 -> fsbs 136.
CXR revealed right sided fluid overload and suggestive of
probable underlying PNA. Given Piperacillin-Tazob, Linezolid
(because of vancomycin allergy) and 1gm tylenol PR for T102.8.
Most recent vitals: 82 121/66 22 98% 22 Vt: 450 PEEP: 5 50%.
.
Of note, he saw Dr. [**Last Name (STitle) **] in pulmonary clinic for worsening
restrictive disease and while not mentioned in HPI, his A/P
mentions he had signs and symptoms concerning for Lower
respiratory tract infection. Weight recently in the 190s when
dry weight is reportedly in the 170s. Has been having
progressively worsening Dyspnea over the last week according to
clinic notes and his torsemide was increased to 100mg PO BID.
.
On arrival to the MICU the pt is intubated on the ventilator.
Past Medical History:
1. Severe CAD s/p 4vCABG [**2107**]
2. V-Fib arrest 4-days post-CABG s/p pacemaker/ICD [**2107**]
- Generator change and pocket revision in [**2120-1-14**] to right
side of chest secondary to pain
3. Ischemic cardiomypoathy / systolic CHF, EF 25%
4. Peripheral vascular disease s/p bilateral femoral-popliteal
bypass
5. multiple lower extremity catheterizations
6. Diabetes Type II - followed at [**Last Name (un) **]
7. Obstructive sleep apnea
8. Gout
9. Asthma
10. Mild sigmoid colonic thickening on recent CT-Abd/Plv,
colonoscopy showing sessile polyps, biopsy will have to happen
off [**Last Name (un) 4532**]
11. Esophagitis, gastritis, peptic ulcer disease
12. Afib/flutter s/p TTE cardioversion [**1-/2121**], ablation.
Social History:
Unable to obtain at time of arrival, but on past admissions:
-Tobacco history: quit [**2107**], prior 70 pack year history
-ETOH: quit [**2107**], prior heavy use
-Illicit drugs: denies any history
Married, lives at home with wife. [**Name (NI) 3003**] to his admission to
rehab he lived at home with his wife. [**Name (NI) **] walks with a cane. He
does not drink or smoke.
Family History:
Unable to obtain at time of arrival, but on past admissions:
There is no family history of premature coronary artery disease
or sudden death. Mother with kidney problems. Father died of
unknown causes. + h/o stomach cancer. Diabetes is prevalent
throughout the family.
Physical Exam:
Vitals: T: 99.3 BP: 136/67 P: 82 R: 17 O2: 100% on CMV
at TV 440, RR 22, PEEP 5, 100% FIO2 -> 50% FIO2
General: Unresponsive to commands, non-interactive. Intubated
and sedated.
HEENT: Pupils equal, round, reactive to light, sclera anicteric,
intubated
CV: Regular rate and rhythm, normal S1/S2, GII holosystolic
murmer at LSB, GII holosystolic murmer at apex, no rubs or
gallops, (+) parasternal heave, PMI non-displaced
Lungs: Breath sounds equal bilaterally anteriorly, decreased BS
at bases b/l, no wheezes or rhonchi
Abdomen: Soft, non-tender, moderately distended, (+) bowel
sounds
GU: Foley in place
Ext: Warm, well perfused, equal [**Name (NI) 17394**] PT pulses b/l, 2+
pitting edema to thighs b/l, (+) erythema of anterior shins b/l
consistent with stasis dermatitis without induration or calor
Pertinent Results:
[**2122-8-1**] 06:30AM BLOOD WBC-11.5*# RBC-4.13* Hgb-9.5* Hct-31.2*
MCV-76* MCH-23.0* MCHC-30.4* RDW-20.8* Plt Ct-289
[**2122-8-5**] 02:16PM BLOOD WBC-6.2 RBC-3.47* Hgb-8.0* Hct-26.4*
MCV-76* MCH-23.2* MCHC-30.4* RDW-20.1* Plt Ct-131*
[**2122-8-8**] 12:43AM BLOOD WBC-10.6 RBC-3.73* Hgb-8.6* Hct-28.2*
MCV-76* MCH-23.0* MCHC-30.4* RDW-20.8* Plt Ct-167
[**2122-8-10**] 04:02AM BLOOD WBC-12.1* RBC-3.20* Hgb-7.2* Hct-23.7*
MCV-74* MCH-22.5* MCHC-30.3* RDW-20.7* Plt Ct-153
[**2122-8-11**] 06:08AM BLOOD WBC-13.0* RBC-3.30* Hgb-7.7* Hct-23.7*
MCV-72* MCH-23.5* MCHC-32.7 RDW-21.4* Plt Ct-273#
[**2122-8-12**] 03:30AM BLOOD WBC-16.9* RBC-3.20* Hgb-7.4* Hct-22.8*
MCV-71* MCH-23.1* MCHC-32.4 RDW-21.6* Plt Ct-319
[**2122-8-1**] 06:30AM BLOOD Neuts-82.8* Bands-0 Lymphs-6.5* Monos-5.3
Eos-4.9* Baso-0.5
[**2122-8-7**] 02:38AM BLOOD Neuts-71* Bands-1 Lymphs-8* Monos-6
Eos-14* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2122-8-10**] 04:02AM BLOOD Neuts-80.3* Lymphs-5.9* Monos-4.9
Eos-8.5* Baso-0.4
[**2122-8-12**] 03:30AM BLOOD Neuts-92.5* Lymphs-4.0* Monos-2.9 Eos-0.4
Baso-0.2
[**2122-8-12**] 03:30AM BLOOD PT-14.0* PTT-27.9 INR(PT)-1.2*
[**2122-8-9**] 03:59PM BLOOD ESR-114*
[**2122-8-9**] 05:47PM BLOOD Fibrino-817*
[**2122-8-12**] 03:30AM BLOOD Glucose-283* UreaN-99* Creat-3.1* Na-132*
K-4.1 Cl-93* HCO3-25 AnGap-18
[**2122-8-12**] 03:30AM BLOOD Calcium-8.3* Phos-6.1* Mg-3.0*
[**2122-8-6**] 02:13PM BLOOD TSH-1.5
[**2122-8-9**] 03:59PM BLOOD ANCA-NEGATIVE B
[**2122-8-9**] 03:59PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2122-8-9**] 03:59PM BLOOD RheuFac-39* CRP-248.8*
[**2122-8-1**] 06:30AM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
C-SPINE
FINDINGS: There is no acute fracture or malalignment, and the
normal cervical lordosis is maintained. The patient is intubated
and an enteric tube has been placed, limiting the evaluation of
prevertebral soft tissue abnormality. Again seen is
uncovertebral and endplate spondylosis with bilateral neural
foraminal narrowing, mild at C5-6 and moderate at C6-7,
unchanged from prior exam. There is also ventral spinal canal
narrowing at these respective levels, but no cord effacement is
identified.
Bilateral carotid arterial calcifications are noted. A right
side central
venous line and left-sided cardiac pacemaker lead are present.
The right
mastoid and the sphenoid air cells contain aerosolized
secretions which are likely secondary to recent endotracheal
intubation and supine positioning.
IMPRESSION:
1. No fracture or acute alignment abnormality.
2. Bilateral neural foraminal and mild ventral canal narrowing
at C5-6 and
C6-7, unchanged since the [**2-/2121**] study.
CT HEAD (Repeat)
FINDINGS: There is no intracranial hemorrhage. The [**Doctor Last Name 352**]-white
matter
differentiation is preserved. There is no edema or mass effect.
The
ventricles and sulci are unchanged in size. Again small lacunar
infarcts are seen in the left subinsular white matter. The
visualized paranasal sinuses demonstrate mild mucosal thickening
of the sphenoid sinuses. The mastoid air cells appear clear as
do the remaining paranasal sinuses; however, assessment of these
structures is limited due to motion artifact.
IMPRESSION: No intracranial hemorrhage or CT evidence for acute
CVA; MR is
more sensitive in detecting acute CVA.
Brief Hospital Course:
66 yo man with Severe systolic CHF (EF 20%) and restrictive
pulmonary disease, Pulmonary HTN [**12-17**] CHF who presents with
altered mental status, fevers, respiratory distress and
hypotension.
.
#. Hypoxia/respiratory distress: Upon initial presentation the
patient had increasing peripheral edema, orthopnea, and weight
gain over the past week, and clinically appeared hypervolemic,
consistent with an acute on chronic CHF exacerbation. The
initial strategy was to diuresis the patient to euvolemia, with
respect to pressure management. He was empirically covered for
HCAP. The patient was broadly cultured, but no growth at the
time of discharge. The patient was continued on conservative
management until the 22nd, when the patient was extubated in the
morning, without incident.
.
After extubation, the patient maintained good pulmonary
function, presented to have increased secretions. He is required
frequent suctioning, hourly. A scopolamine patch was tried
initially, but had minimal effect, and it was discontinued for
concerned about affecting mental status.
.
#. NSTEMI: Based on initial laboratory values, the patient
ruled in for a non-ST segment elevation myocardial infarction
with Trop 0.78, CK-MB 26, MBI 10.5, CK 247. His
electrocardiogram showed mild ST segment depression in certain
areas, was not initially concerning for coronary artery
occlusion. Patient was met medically managed, and troponins were
followed clinical resolution. There were no dynamic ST segment
changes on electrocardiogram throughout his stay in the medical
intensive care unit. Echocardiography was performed during his
initial medical intensive care unit stay, which showed an
ejection fraction of 25-30%, 2+ mitral regurgitation, trace
tricuspid regurgitation, and diffuse hypokinesis globally. There
were no additional complications of his myocardial infarction
during his intensive care unit stay. The patient will be
discharged on [**Last Name (LF) 4532**], [**First Name3 (LF) **], and metoprolol.
.
#. Hypotension and Fever: In the beginning of his course, the
patient was initially hypotensive, requiring pressors. These
were eventually weaned down, in the face of ongoing diuresis.
The patient eventually maintained normal blood pressures. The
patient however started to develop fevers, spreading
intermittently above 100??????. The patient initially had a central
venous line, which was discontinued. The patient was repeatedly
cultured for infection, but no sources were found. The ongoing
fever, and the setting of joint pain, skin rashes, prompted the
differential diagnosis to expand to include vasculitis (see
below). The patient has a history of gout, and event though a
joint aspirate demosntrated no crystals, given the clinic
presentation the patient was started on a Solu-Medrol [**Doctor Last Name 2949**]
(see below). The pain was controlled with Tylenol, and Dilaudid,
to good effect.
.
#. Altered Mental Status: Initially the patient was found to
have a fingerstick of 61, but was resuscitated with IV dextrose.
After which time the patient was intubated for his infection,
and was sedated medically. After extubation however, the patient
had prolonged altered mental status. EEG was first performed on
[**8-6**], which showed widespread metabolic disturbances,
nonspecific findings. Repeat CT of the head performed which
showed no acute intracranial pathology. MRI was unable to be
performed due to an implantable cardiac defibrillator. In the
emergency department the patient had a negative serum tox
screen, and a negative urine drug screen. The patient had no
initial signs of focal infection based on physical exam or
laboratory findings to explain his altered mental status.
.
Evolving throughout his medical care unit stay, the patient
remained encephalopathic, making moaning sounds, and was not
interactive with his environment. Patient seem to be in mild
painful distress at times, exacerbated by movement and certain
joints. A repeat EEG was performed, but was not lateralizing or
revealing. The working diagnosis for his altered mental status
was toxic metabolic insult due to prolonged hypoglycemic.
Throughout his stay here in the medical intensive care unit the
patient was monitored for further bouts of hypoglycemia, and
hypotension. The neurology service was consulted, and only
specifically recommended IV mineral and vitamin replacement.
.
#. Purpura Skin lesion: Throughout the [**Hospital 228**] medical
intensive care unit stay, he developed maculopapular rashes on
his upper extremities, concerning for septic emboli or
vasculitis. Dermatology was consulted, and a bedside biopsy was
performed. In addition we sent for vasculitis workup laboratory
tests. The results of the vasculitis workup showed no evidence
for vasculitis. The skin biopsy demonstrated hemorrhage without
imflammatory components. The biopsy site should be covered with
vaseline and bandaid, changed daily. The patient should follow
up with dermatology as to when to take out the sutures.
.
#. Gout: Colchicine was held given elevated Cr. The patient's
home dose of allopurinol was continued. The patient will be
discharged on Solumedrol 10 IV daily, until the patient can take
PO. At which time, the patient should be started on Prednisone
7.5mg daily, until his creatinine returns to below 1.8. At that
time, prednisone should be discontinued, and the patient should
be started on colchicine 0.6mg PO every other day.
.
#. Diabetes: The patient was found to be hypoglycemic to 61 on
initial evaluation by EMS, and remained persistently
hypoglycemic despite 2 tubes of glucose until 1 amp D50 was
given in the ED. After this initial episode, there were no
further episodes of hypoglycemia. The patient was placed on
insulin sliding scale to good effect (see attached medication
list). His home dose of insulin glargine was continued at 30mg
[**Hospital1 **]. Consider increasing the glargine dose while on solumedrol
(see above), if the patient remains hyperglycemic.
.
#. Renal Failure: The patient has had a variable baseline Cr
1.6-1.8 within the past year but most recent Cr in late [**Month (only) 216**]
and early [**Month (only) **] were 2.0-2.1. His Cr was currently
uptrending to 3.1 secondary to poor forward flow in the setting
of his current CHF exacerbation. Nephrotoxic medications were
held. He should follow up with primary care provider regarding
his changed in kidney function.
.
#. CAD: s/p CABG [**2107**]. Management of NSTEMI as above
.
#. Ischemic cardiomypoathy: Systolic CHF, EF 25%. Held
Lisinopril in the setting of hypotension in the ED and elevated
Cr.
.
#. Asthma: home inhalers/neublizers were continued.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg 2 puffs QID
ALLOPURINOL - 300 mg Daily
ATORVASTATIN [LIPITOR] - 40 mg Daily
COLCHICINE [COLCRYS] - 0.6 mg Tablet - 1 Tablet(s) by mouth
every
other day
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 inhalation po twice daily
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 60 units sc
once a day am
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - 20 Units
before
breakfast and 20 Units before dinner
LISINOPRIL - 5 mg Daily
METOPROLOL SUCCINATE - 50 mg Daily
PANTOPRAZOLE - 40 mg Daily
PREDNISONE - (Not Taking as Prescribed: pt currently not
taking,
PCP [**Name Initial (PRE) 12309**]) - 2.5 mg Tablet - 1 Tablet(s) by mouth daily
PREGABALIN [LYRICA] - 75 mg [**Hospital1 **]
SILDENAFIL [REVATIO] - 20 mg TID
TORSEMIDE - 100 mg Tablet [**Hospital1 **].
ACETAMINOPHEN - (OTC) - Dosage uncertain
ASPIRIN - 81 mg Q72H
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. beclomethasone dipropionate 80 mcg/Actuation Aerosol [**Hospital1 **]: One
(1) Inhalation [**Hospital1 **] (2 times a day).
5. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for sob, wheezing .
9. olanzapine 5 mg Tablet, Rapid Dissolve [**Last Name (STitle) **]: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed for agitation.
10. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
11. allopurinol 300 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
12. acetaminophen 650 mg/20.3 mL Solution [**Last Name (STitle) **]: One (1) PO Q6H
(every 6 hours) as needed for pain, fever.
13. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
14. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
15. linezolid 100 mg/5 mL Suspension for Reconstitution [**Last Name (STitle) **]: One
(1) PO Q12H (every 12 hours) for 3 doses: PLEASE GIVE FIRST
DOSE AT 0001 ON [**2122-8-13**].
16. dextrose 50% in water (D50W) Syringe [**Date Range **]: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
17. hydromorphone (PF) 1 mg/mL Syringe [**Date Range **]: One (1) Injection
Q4H (every 4 hours) as needed for pain.
18. thiamine HCl 100 mg/mL Solution [**Date Range **]: One (1) Injection
DAILY (Daily).
19. aztreonam in dextrose(iso-osm) 1 gram/50 mL Piggyback [**Date Range **]:
One (1) Intravenous Q12H (every 12 hours) for 3 doses: PLEASE
GIVE FIRST DOSE AT 8PM ON [**2122-8-12**].
20. methylprednisolone sodium succ 40 mg Recon Soln [**Date Range **]: 0.25
Recon Soln Injection ONCE (Once): PLEASE CONTINUE UNTIL TAKING
PO, THEN SWITCH TO PREDNISONE 7.5MG PO DAILY (SEE OTHER ORDER).
21. INSULIN SLIDING SCALE
PLEAE SEE ATTACHED INSULIN SLIDING SCALE
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
gout
acute toxic metabolic brain injury like secondary to anoxia
diabetes
Ischemic cardiomyopathy
Asthma
non-ST elevation myocardial infarction
acute on chronic kidney injury
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname **], You were admitted to [**Hospital1 1170**] for altered mental status. We found that you had low
blood sugar which contributed to your brain injury. We also
found that you had a heart attack, which we treated with
medications. We also found that you might have had pneumonia
which we are treating with antibotics. We also found that you
likely had a gout flair, which we are treating with steroids.
You will be taken to [**Hospital 100**] Rehab for more treatment.
Medication Changes:
continue the following medication only
Atorvastatin 80mg PO/NG daily
albuterol neb soln q6hr prn wheezing
allopurinol 300mg PO/NG daily
acetaminophen 325mg-100mg PO/NG p6hr prn fever, do not exceed 4
grams per 24 hours
Aztreonam 1000mg IV q12 for 2 more days
clopidogrel 75mg PO/NG Daily
Dextrose 50% 12.5gm IV prn hypoglycemia
Docusate Sodium (liquid) 100mg PO/NG [**Hospital1 **], hold for loose stool
Glucagon 1mg IM q15min PRN hypoglycemia
Heparin 5000 units SC TID
Dilaudid 0.25 IV q4hr prn pain
Insulin Sliding Scale (please see attached)
Lansoprazole Oral Disintegrating Tab 30mg PO/NG Daily
Linezolid 600mg PO/NG Q12 for 2 more days
Metoprolol Tartrate 12.5mg PO/NG [**Hospital1 **]
MethylPrednisolone Sodium Succ 10mg IV daily, until can take by
PO (NOT NG) then switch to Prednisone 7.5mg PO daily, until
creatinine returns to below 1.8, then switch to colchicine 0.6
mg Tablet ever other day.
Olanzapine(Disintegrating Tablet) 2.5mg PO BID prn agitation
Qvar *NF* (beclomethasone dipropionate) 80 mcg/Actuation
Inhalation [**Hospital1 **]
Senna 1 tab PO/NG [**Hospital1 **]; hold for loose stools
Thiamine 100mg IV daily, can switch to PO if taking PO
Followup Instructions:
You should make a follow appointment with your primary care
provider [**Name Initial (PRE) 176**] 1 week of leaving [**Hospital 100**] Rehab.
Department: ENDO SUITES
When: FRIDAY [**2122-8-21**] at 11:00 AM
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2122-8-21**] at 11:00 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2122-9-9**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9864**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
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"518.81",
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"250.00",
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"276.0",
"518.89",
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"348.1",
"285.9",
"584.9",
"414.00"
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
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"96.72",
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] |
icd9pcs
|
[
[
[]
]
] |
19029, 19095
|
8840, 11766
|
300, 386
|
19314, 19314
|
5490, 8817
|
21152, 22257
|
4369, 4641
|
16453, 19006
|
19116, 19293
|
15542, 16430
|
19450, 19945
|
4656, 5471
|
19965, 21129
|
239, 262
|
414, 3206
|
19329, 19426
|
3228, 3957
|
3973, 4353
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,504
| 191,100
|
4965
|
Discharge summary
|
report
|
Admission Date: [**2120-8-6**] Discharge Date: [**2120-8-15**]
Date of Birth: [**2046-6-15**] Sex: M
Service: MEDICINE
Allergies:
Pneumovax 23 / Allopurinol / Hydralazine
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
transferred from OSH with abdominal pain
Major Surgical or Invasive Procedure:
ERCP with stent; cholecystostomy; Hemodialysis
History of Present Illness:
The pt is a 74M with hx of CAD s/p cabg in [**2105**], DM, gout, CKD
who presented to [**Location (un) 5871**] yesterday with RUQ pain and noted to
have T=100.4 with wbc of 13K (17K today), elevated ast/alt/alk
phos. U/s w/ gallstones. Noted to have elevated troponins
although EKG unrevealing. Was given cefoxitin and iv hep. Is
pain free this am. He denies any chest pain or shortness of
breath beyond his baseline. He has baseline DOE, PND, orthopnea,
EF is 40% in [**2115**]. He was transferred for ERCP and placement of
biliary stent.
On arrival, his VS were stable and he was comfortable. He denied
chest pain, SOB beyond his basline, fevers, chills. All other
review of systems was negative.
Past Medical History:
CAD s/p CABG [**2095**], redo CAB G [**2105**]
s/p AAA repair
IDDM
CKD
gout
chronic systolic CHF
h/o GIB
Social History:
Retired managment consultant. Has 5 children. Nonsmoker, quit
over 20 years ago. No alcohol use.
Family History:
NC
Physical Exam:
Appearance: NAD
Vitals: T: 97.9 BP: 115/71 HR: 88 RR: 18 O2: 90% RA
Eyes: EOMI, PERRL, conjunctiva clear, noninjected, anicteric, no
exudate
ENT: Dry
Neck: No JVD, no carotid bruits
Cardiovascular: RRR, nl S1/S2, no m/r/g
Respiratory: CTA bilaterally, comfortable, no wheezing, mild
bibasilar crackles
Gastrointestinal: soft, RUQ tenderness, non-distended, no
hepatosplenomegaly, normal bowel sounds
Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint
swelling, no edema in the bilateral extremities
Neurological: Alert and oriented x3, fluent speech
Integument: warm, no rash, no ulcer
Psychiatric: appropriate, pleasant
Pertinent Results:
[**2120-8-6**] 06:04PM GLUCOSE-156* UREA N-68* CREAT-5.1*#
SODIUM-137 POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-23 ANION GAP-21*
[**2120-8-6**] 06:04PM ALT(SGPT)-125* AST(SGOT)-141* LD(LDH)-298*
CK(CPK)-1051* ALK PHOS-466* AMYLASE-53 TOT BILI-5.6*
[**2120-8-6**] 06:04PM LIPASE-25
[**2120-8-6**] 06:04PM ALBUMIN-3.2* CALCIUM-8.0* PHOSPHATE-6.6*#
MAGNESIUM-2.2
[**2120-8-6**] 06:04PM TRIGLYCER-115
[**2120-8-6**] 06:04PM WBC-18.4*# RBC-3.73* HGB-10.9* HCT-33.7*
MCV-91 MCH-29.1 MCHC-32.2 RDW-14.2
[**2120-8-6**] 06:04PM PT-17.5* INR(PT)-1.6*
[**2120-8-7**]
[**2120-8-8**]
[**2120-8-9**]
[**2120-8-10**]
[**2120-8-11**]:
138 104 81 117 AGap=16
------------------<
4.2 22 4.0
Ca: 8.1 Mg: 2.2 P: 4.7
CK: 73 MB: 4 Trop-T: 2.10
cbc 7.5/30.7 /360
PT: 15.3 PTT: 31.3 INR: 1.4
LFts:
ALT: 33 (44) Alkphos 272 (286) Tbili: 2.0 (2.2) Alb: none this
am (2.6) AST: 23 (38) LDH: 191 (197) [**Doctor First Name **]: 82 (88) Lip: 86 (97)
.
CXR ([**2120-8-10**]): LLL effusion
.
ECHO: EF 40% LVH, LAD, mild MR, no new WMA
.
ECG: sinus rhythm, RBBB with ST depressions in V2-V4 and
terminal deflection in qrs but not significantly changed from
prior tracings
.
RUQ U U/s- percholecystic fluid, [**Name (NI) **] [**Name2 (NI) **] sign,
stones in gallbladder
.
Fe panel: Fe-14 calTIBC: 155 Ferritn: 1431 TRF: 119
UA- positive (17WBC, 800+ RBCs, pos leuk est)
Urine and blood cultures negative.
.
CT:
HISTORY: Cholangitis, status post ERCP with stent placement.
TECHNIQUE/FINDINGS: Initial MDCT axial images through the
abdomen were
obtained for guidance for this patient's drainage. The lung
bases demonstrate bilateral dependent atelectases and small
pleural effusions. The heart is enlarged. There is no
pericardial effusion. The liver and spleen appear within normal
limits. The gallbladder is markedly distended with gallstones. A
biliary stent is seen. Pericholecystic fluid and soft tissue
stranding is noted. The right kidney is atrophic. There is a
2.3-cm hypodense nodule in the lower pole of the right kidney.
In addition, a 1.7-cm hypodense nodule is seen in the lower pole
of the left kidney, not fully characterized in this non-
contrast study. The patient is status post CABG.
After explanation of the risks and benefits of the procedure,
informed consent was obtained from the patient's wife. The
patient was placed in supine position. The right upper quadrant
was prepped and draped in a standard sterile fashion. 1%
lidocaine was used for topical anesthesia.
An 8 French pigtail catheter was advanced into the gallbladder.
The patient tolerated the procedure well. There were no
immediate complications.
IMPRESSION: Successful placement of an 8 French percutaneous
cholecystostomy catheter.
Hypotrophic right kidney and bilateral renal hypodense lesions,
not fully
characterized on this non- contrast study. Further evaluation
with MRI could be performed when feasible.
Brief Hospital Course:
74M w/ CAD s/p CABGx2, DM, gout, [**Hospital 2091**] transferred from OSH with
cholangitis and gallstones with positive troponins in the
setting of ARF/CKD.
.
For his cholecystitis with ascending cholangitis: Pt was
admitted from OSH after an extensive negative GI workup for RUQ
pain on Unasyn, admitted after clearance of NSTEMI, for ERCP
emergently. Exploratory ECRP demonstrated gross pus in the
stomach and spilling from the papilla, and a biliary stent was
placed. Zosyn was started pre-procedure and continued
post-procedure for a 7 day course (8/12/008-8/19/08). A
cholecystomy tube was placed percutaneously, and elective
cholecystectomy was deferred by general surgery until the near
future. LFTs trended down throughout his ICU stay. Amylase and
lipase rose transiently suggestive of post ERCP pancreatitis but
trended downwards by POD2. He will have a percutaneous
cholecystomy tube remain in place until he is seen in Surgery
Clinic for consideration of cholecystectomy.
.
Acute on chronic renal failure: He presented in prerenal ARF
with Cr ~6, with likely component of oliguric ATN [**1-27**] CHF with
kidney hypoperfusion. He displayed indications for HD including
acidemia, hyperkalemia, and uremic encephalopathy. Nephrology
was consulted regarding need for HD and placed a hemodialysis
catheter for hemodialysis. He received dialysis on [**2120-8-10**].
After hemodialysis, pt's UOP picked up to 40-150 cc/hr, with Cr
recovering to 2.2 by discharge. He received dialysis on [**2120-8-12**]
for volume overload and 2L were taken off. His AceI,
colchicine, statin, lasix were held due to renal failure. His
ACE inhibitor was restarted. He will need to restart the Lasix
at his rehabilitation facility.
.
Mental status change: related to uremic encephalopathy given
renal failure but there was also convern for bacteremia possible
related to biliary sepsis. Blood cx were negative. Urine cx were
positive (already covered with zosyn). NH3 levels from OSH (51)
were normal at 10 by ICU day7. Pt. returned to baseline mental
status on day 7.
.
NSTEMI: likely [**1-27**] to demand ischemia in the setting of
infection and ARF/CKD, as opposed to NSTEMI. Troponins were
elevated from OSH on heparin gtt, peaking at trop 2.19 on ICU
day 6 ([**2120-8-12**]). ECG showed sinus rhythm, RBBB with ST
depressions in V2-V4 and terminal deflection in qrs but not
significantly changed from prior tracings. ECHO showed EF 40%
which is unchanged from prior, mild-moderate systolic
dysfunction, symmetric LVH, and mild MR. Pt was started on Asa
and metoprolol, and restarted on an ACE inhibitor. Pt was
recommended to have outpatient MIBI by cardiology.
.
Restrictive lung disease/COPD: OBstructive disease [**1-27**] COPD with
superimposed Chest wall dysfunction [**1-27**] obesity and
deconditioning and restarted on home atrovent and encouraged to
use incentive spirometry.
.
Bilateral pleural opacities in LLL, RLL: Thought to be [**1-27**] fluid
overload, atelectasis. His lasix was held given his renal
status, so he was dialyzed on [**8-12**] to try to improve fluid
status, also OOB to chair.
.
DM: He was continued on insulin sliding scale. His pioglitazone
was held. He will need reinitation of glargine insulin when he
is eating well.
.
Gout: Patient has a history of gout, and had pain in his joints
secondary to gout. This was treated with narcotics, including
oxycodone and Tylenol #3.
.
Anemia: normocytic Hct 30 down from baseline of 37-40, likely
related to CKD, Fe deficiency given hx of GIB with possible
malnutrition. He was transfused one unit of pRBC. His stool was
guaiac negative. His hematocrit remained stable for the rest of
his hospital stay.
.
PVD: Hx of TIA, PVD, and carotid stenosis b/l. continue Asa.
.
CHF: ECHO from [**2115**] shows EF 50%, with inferior basal
hypokinesis and the ECHO obtained in the ICU did not show
interval development of wall mortion abnormalities. Lasix was
held while he was in ARF.
Medications on Admission:
Meds at home:
atenolol 25mg qd
lipitor 10mg qd
colchicine 0.6mg qd
nexium 20mg qd
Lasix 20mg [**Hospital1 **]
glyburide 10mg qd
Lantus 35U qhs
atrovent inhaler q6h prn
Imdur 120mg qd
NTG prn
ASA 81mg qd
On transfer, on the above plus (or in place of where indicated):
Tylenol #3 1 tab [**Hospital1 **]
Protonix 20mg qd instead of Nexium
plyethylene glycol 17gm qd
ASA 325mg qd instead of 81mg qd
prazosin 5mg qd
Lantus 20 Units qhs instead of 35 Units
heparin gtt
Plavix 75mg qd
Unasyn 3g IV q12h
atenolol 25mg [**Hospital1 **] instead of daily
morphine 4mg IV q2h prn
Zofran 4mg IV q6h prn
HISS
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
2. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Prazosin 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for pain.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
9. Insulin Lispro 100 unit/mL Solution Sig: Per sliding scale
Per scale Subcutaneous ASDIR (AS DIRECTED).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
15. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
1. Acute on chronic renal failure
2. Acute cholecystitis
3. NSTEMI
4. Chronic systolic heart failure
5. Diabetes mellitus
Discharge Condition:
Stable
Discharge Instructions:
If you develop worsening shortness of breath, nausea, vomiting,
fevers, chills, or confusion, call your primary care doctor or
go to the emergency room.
Followup Instructions:
1. Please follow up with the nurse practitioner in Dr.[**Name (NI) 6001**]
office. Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2120-8-27**] 10:00
2. Please follow up with the kidney doctors. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
[**Name (STitle) **] Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2120-9-5**] 3:00
3. Please follow up with your podiatrist. Provider: [**Name10 (NameIs) 5445**] [**Name Initial (NameIs) **].
[**Doctor Last Name 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2120-10-2**] 11:40
You will need to have an ERCP performed again around [**10-6**].
Please call Dr.[**Name (NI) 12202**] office at [**Telephone/Fax (1) 1983**] to make an
appointment.
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41,260
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40013
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Discharge summary
|
report
|
Admission Date: [**2165-12-5**] Discharge Date: [**2166-1-11**]
Date of Birth: [**2126-10-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
respiratory failure
Major Surgical or Invasive Procedure:
intubation
central line placement (RIJ)
arterial line placement
bronchoscopy
History of Present Illness:
39 y/o with morbid obese without recent medical care presents
with SOB. History obtained via records and his friend. The
patients landlord entered his appartment today in order to evict
him and found him lying on the floor. He stated at that time
that he had been unable to move for 2 days [**3-19**] his back pain and
was not eating or drinking. The patient had been working as a
chef until 3 weeks ago but had been fired. He has been depressed
recently and gained approximately 100 pounds over the last 3
months.
He was taken to St [**Hospital1 88007**] hospital in [**Hospital1 189**]. There he was
somulent. He was given vanco and ctx for cellulitis as well as
DuoNebs and albuterol. A d-dimer was elevated (D dimer 5.04,
range <0.52). BNP 325. He was sating in the 70s on room air, and
improved to 90s on NRB. He was transfered to [**Hospital1 18**].
In the ED, initial vs were: T 98.7 P 100 BP 160/130 R 24 O2 sat
95% on NRB. Patient was given 1 gm vancomycin and 3L NS. ABG
showed severe hypercarbia and hypoxia. He was noted to appear
diffusely erythematous (even prior to vanco). CXR showed
cardiomegaly and CHF. He was intubed using a fiberoptic scope
and propofol was started. VS prior to transfer were 104/57, 84,
17, 89% on AC with 100% FIO2.
On the floor, we was intubated and sedated on arrival with sats
in the mid 80s. 1 PIV was lost in transfer of the patient.
Review of systems:
(+) Per HPI. Lower back pain leaving him unable to move for days
at a time. Conjuctivitis x 1 week.
otherwise negative
Past Medical History:
Has not been to the doctor since high school.
Depression
Chronic lower back pain
Conjunctivitis
Social History:
recently lost job as chef; evicted today. No tobacco; 6-12 beers
per day; no drugs.
- Tobacco: no
- Alcohol: 6-12 beers per day
- Illicits: no
Family History:
estranged; none
Physical Exam:
Vitals: T: 96.3 BP: 126/81 P: 84 R: 12 O2: 87% on AC
550/14/100%/15
General: intubated and sedated
HEENT: Sclera injected, eyelids crusted, MMM
Neck: supple, JVP un able to be interpreted
Lungs: diminised BS but Clear to auscultation bilaterally, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: cold ext, cynatoic on arrival. 1+ pulses, no clubbing,
cyanosis. 1+ BL edema to sacrum
Pertinent Results:
I. Labs
A. Admission:
[**2165-12-5**] 06:30PM BLOOD WBC-6.7 RBC-6.04 Hgb-18.2* Hct-58.1*
MCV-96 MCH-30.1 MCHC-31.3 RDW-17.9* Plt Ct-149*
[**2165-12-5**] 06:30PM BLOOD Neuts-70.0 Lymphs-16.9* Monos-9.0 Eos-1.2
Baso-3.0*
[**2165-12-5**] 06:30PM BLOOD PT-21.0* PTT-39.0* INR(PT)-2.0*
[**2165-12-5**] 06:30PM BLOOD Glucose-96 UreaN-10 Creat-1.0 Na-141
K-3.6 Cl-91* HCO3-38* AnGap-16
[**2165-12-5**] 06:30PM BLOOD ALT-23 AST-40 LD(LDH)-435* CK(CPK)-113
AlkPhos-68 TotBili-9.6* DirBili-4.6* IndBili-5.0
[**2165-12-5**] 06:30PM BLOOD Lipase-45
[**2165-12-5**] 06:30PM BLOOD proBNP-3421*
[**2165-12-6**] 01:10AM BLOOD Albumin-3.0* Calcium-8.4 Phos-5.1* Mg-1.9
[**2165-12-6**] 05:07AM BLOOD Hapto-<5*
[**2165-12-9**] 03:16AM BLOOD calTIBC-309 TRF-238
[**2165-12-17**] 02:40AM BLOOD Triglyc-246*
[**2165-12-11**] 02:03AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2165-12-12**] 12:29AM BLOOD Vanco-27.6*
[**2165-12-5**] 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2165-12-11**] 02:03AM BLOOD HCV Ab-NEGATIVE
[**2165-12-5**] 08:19PM BLOOD Type-ART O2 Flow-6 pO2-84* pCO2-132*
pH-7.12* calTCO2-46* Base XS-8 Intubat-NOT INTUBA
Vent-SPONTANEOU Comment-NASAL [**Last Name (un) 154**]
[**2165-12-5**] 06:40PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.017
[**2165-12-5**] 06:40PM URINE Blood-MOD Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-8* pH-5.0 Leuks-TR
[**2165-12-5**] 06:40PM URINE RBC-[**7-25**]* WBC-6* Bacteri-OCC Yeast-NONE
Epi-0-2
[**2165-12-5**] 06:40PM URINE CastHy-[**1-4**]*
[**2165-12-5**] 06:40PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CXR (Portable AP) [**2165-12-5**]:
FINDINGS: Consistent with the given history, an endotracheal
tube has been
introduced. The distal tip is situated approximately 5.1 cm from
the carina. Please note the positioning is markedly limited and
the lung bases are excluded. There are diffuse interstitial and
alveolar opacities and marked widening of pneumomediastinum. The
cardiac silhouette is not included.
IMPRESSION: Markedly limited study as above. Signs of heart
failure again
noted. Endotracheal tube in satisfactory position.
TTE [**2165-12-6**]:
The left atrium is moderately dilated. The right atrium is
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 with depressed free wall contractility. The aortic valve
is not well seen. No aortic stenosis and no aortic regurgitation
is seen. The mitral valve leaflets are structurally normal. No
mitral regurgitation is seen (suboptimal technical quality).
There is mild pulmonary artery systolic hypertension. There is a
very small pericardial effusion.
IMPRESSION: Suboptimal image quality. Right ventricular cavity
enlargement with free wall hypokinesis suggestive of a primary
pulmonary process or primary right ventricular cardiomyopathy.
Pulmonary artery systolic hypertension. Preserved global left
ventricular systolic function.
Lower extremity US [**2165-12-6**]:
IMPRESSION: Deep vein thrombosis seen in the posterior tibial
veins of the right calf. No additional thrombus seen in either
leg.
RUQ ultrasound [**2165-12-11**]:
1. Extremely limited study; there is suggestion of a nodular
liver parenchyma which could correlate with chronic liver
disease, but evaluation is markedly limited.
2. Slightly distended gallbladder with no evidence of
gallstones.
3. Splenomegaly.
CTA Chest [**2165-12-23**]:
1. Significant image noise due to body mass index, allowing for
this limitation, there is no evidence of a first to third order
pulmonary embolism.
2. Multifocal lower lobe pneumonia.
3. Moderately severe pulmonary arterial enlargement suggesting
pulmonary
hypertension.
4. Global moderate cardiomegaly.
Brief Hospital Course:
# Hypoxic and hypercarbic resp failure: Likely multifactorial,
combination of obesity hypoventilation syndrome, fluid overload.
Patient was found down at home, intubated on admission and
admitted to the ICU. TTE showed EF of 55%, right ventricular
cavity enlargment with free wall hypokinesis suggestive of a
primary pulmonary process or primary right ventricular
cardiomyopathy. Pulmonary artery systolic pressure was elevated
at 36. He was started on aggressive diuresis for CHF
exacerbation with lasix drip and chlorothiazide which was later
changed to metolozone. His ICU length of stay fluid balance was
negative 30 liters. He was ruled out for MI as source of CHF
with cardiac enzymes x 3. PE was also considered on
differential for respiratory failure. Lower extremity US showed
right posterior tibial DVT; PE was suspected but on admission
pt's size did not accomodate CTA machine. In addition, giving
ongoing hypoxemia, a bubble study was performed to rule out
shunt, but was poor in quality. He was started empirically on
heparin gtt which was eventually discontinued when pt began
having bloody secretions. After aggressive diuresis, he was
able to undergo CTA that showed no PE in a large vessel but
could not rule out PE in smaller vessels due to body habitus.
Bronchoscopy was performed to investigate bloody secretions that
showed likely suction tube induced trauma but no actively
bleeding vessels. He was extubated on on [**2165-12-19**] and tolerated
well. Sleep apnea was suspected given body habitus and
desaturations to 80s during sleep. He was started on bipap; he
tolerated the settings well and follow up with an outpatient
sleep study was advised. Interval Lower Extremity [**Last Name (un) 7737**] was
obtained which showed persistent bilateral calf vein DVT.
Heparin gtt was re-started on [**12-29**] and the patient was bridged
to coumadin. He is discharged on Coumadin 10 mg daily and will
need continued anticoagulation for at least three months for
DVTs. Outpatient Primary Care and anti-coagulation follow-up was
arranged.
# Right-sided heart failure
Course with diuresis as above. Unknown precipitant although had
gained about ~ 50 kg over past 3 months.
Admission weight of ~ 200 kg with discharge weight of ~ 155 kg.
He was discharged on furosemide 20 mg PO BID and lisinopril 5 mg
PO daily.
# Bilateral lower extremity DVTs
As per above. Immobility favored as precipitant. Patient
dischanrged on coumadin 10 mg PO daily. Recommended duration is
3 - 6 months of therapy. Will need INR followed closely.
# Chronic hypoxemia with pulmonary hypertension
On admission, polycythemia and elevated HCO3 suggesting chronic
hypoxia thought to be secondary to OSA given habitus. Sleep was
consulted and observed that CPAP did not appear effective for
his likely sleep apnea and obesity hypoventilation syndrome.
BiPAP actually seemed to worsen his breathing leading to
induction of apneas. He will be referred for an outpatient sleep
study for exact determination of his BiPAP/ Auto SV pressures
which will further need augmentation with nocturnal O2. He was
continued on BiPAP during hospitalization. In addition on an
outpatient basis, alternative etiologies of pulmonary
hypertension including chronic thromboembolic disease, portal
pulmonary hypertension, and hepatopulmonary syndrome should be
explored.
# Pneumonia: Pt developed fever during MICU course; WBC peaked
at 11.2. CXR was concering for PNA and he was started on
empiric tx with levofloxacin, vancomycin and cefepime initially
for VAP. He completed a 6 day course of antibiotics and WBC was
within normal range and he did not have further febrile
episodes.
# Hoarseness: Patient had hoarseness after extubation. Likely
trauma from intubation as difficult airway. Advise ENT
evaluation on outpatient basis if does not resolve within next 2
weeks.
# Abnormal liver function tests: Patient with possible history
alcohol abuse. Found to have elevated T. bili, transaminitis and
elevated INR 1.7 on admission with nadir to 1.3. RUQ ultrasound
was performed that was limited due to body habitus but was
suggestive of nodular liver parenchyma concerning for chronic
liver disease, slightly distended gallbladder with no evidence
of gallstones and splenomegaly. Hepatitis panel for A, B, and C
negative. Abnormal liver functions thought to be due to liver
congestion +/- alcohol. He should follow up with liver clinic as
outpatient.
# Tinea Pedis and Onychomycosis: treated with topical
anti-fungal. Systemic therapy for onychomycosis is currently
avoided in the setting of abnormal liver functions. He is
discharge with topical 2% miconazole cream. He will need further
outpatient evaluation.
# Obesity
Patient morbidly obese with 100-lb weight gain in over past 3
months with unknown etiology. Suggest outpatient consideration
of secondary causes of obesity such as testing for
hypothyroidism and [**Location (un) 3484**] syndrome.
# Depression: Prior to this admission Mr. [**Known lastname **] seems to have
undegone multiple social stressors including the loss of his job
(worked as a chef) and housing and was finally found down at
home with evidence of squalor and neglect. He has no family and
little social support and did not have health insurance or prior
healthcare. He has history of alcohol use but the degree to
which this played a role in his pre-hospital course remains
unclear. [**Name2 (NI) **] admitted to prior depression but denied any current
or past SI/SA/HI and has never sought psychiatric care. During
this admission he was noted to have flat affect and was
difficult to engage in conversation regarding his psycho-social
issues. Inpatient psychiatric consult was not indicated as he
did not have any acutely concerning psychiatric issues and
denied current depression. He was followed by social work and
case managment and was enrolled in Freecare and an application
has been filed for MassHealth/disability. Primary care follow-up
at [**Hospital 189**] Community Health Center was arranged. The medical team
and social work have also been in touch with the patient's
friend Mr. [**Name13 (STitle) 88008**] who will be taking the patient into his home
following discharge. Out-patient follow-up with social work and
mental-health is advised.
In addition, secondary causes of depression should be considered
such as hypothyroidism and [**Location (un) 3484**] syndrome given gained ~ 50
kg over past 3 months. Thyroid tests deferred in setting of
acute illness.
Fax Discharge Summary to:
Primary Care Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 189**] Community Health Center
585-[**Hospital1 88009**], [**Numeric Identifier 41087**]
tel: [**Telephone/Fax (1) 30953**]
fax: [**Telephone/Fax (1) 87883**]
Medications on Admission:
none
Discharge Medications:
1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
3. warfarin 2.5 mg Tablet Sig: Four (4) Tablet PO once a day:
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Facility:
[**Hospital3 **]
Discharge Diagnosis:
PRIMARY:
1. Respiratory Failure
2. Obesity Hypoventilation Syndrome
3. Morbid Obesity
4. obstructive sleep apnea
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:
You were admitted for respiratory distress. You required
intubation. You were found to have heart failure and were
treated with diuretic medication which removed a significant
amount of fluid. You also developed a lung infection which
resolved with antibiotics.
.
You were found to have blood clots in both your legs and will
need continued treatment with blood thinning medication.
.
Please weigh yourself every morning and call your physician if
your weight goes up more than 3 lbs. You should also restrict
yourself to no more than 2 liters of fluid every day.
.
You have difficulty breathing when you sleep. You need to wear
mask at night to help you breath. You have an appointment with a
sleep doctor to help set this up.
.
You had some elevation in your liver enzymes while you were
here. You should have your liver tests followed to make sure
this resolves.
.
Loosing weight and abstaining for alcohol will be very important
for your future health.
.
You will need to continue to take the following medications:
.
- Warfarin 2.5 mg Tablet. Take FOUR Tablets Once Daily at 4 PM.
The dosage of this medication will be further adjusted by your
treating physician.
[**Name Initial (NameIs) **] furosemide 20 mg Tablet, Take one tablet twice daily
- lisinopril 5mg tablet, take 1 tablet once daily.
Followup Instructions:
Primary Care Provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 766**], [**1-13**] at 3:30PM
[**Hospital 189**] Community Health Center
585-[**Hospital1 88009**], [**Numeric Identifier 41087**]
tel: [**Telephone/Fax (1) 30953**], [**Numeric Identifier 88010**], [**Numeric Identifier 88011**]
Department: MEDICAL SPECIALTIES/SLEEP PULMONARY
When: THURSDAY [**2166-1-23**] at 10:30 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: [**Hospital Ward Name **] [**2166-2-17**] at 11:50 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"782.4",
"278.01",
"V85.44",
"429.3",
"305.01",
"584.9",
"416.8",
"724.2",
"790.7",
"372.30",
"453.42",
"286.9",
"518.81",
"110.1",
"311",
"997.31",
"278.03",
"276.8",
"428.0",
"110.4",
"599.0",
"682.6",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"38.93",
"33.23",
"38.97",
"38.91",
"96.56"
] |
icd9pcs
|
[
[
[]
]
] |
14032, 14066
|
6864, 13666
|
334, 413
|
14223, 14223
|
2883, 6841
|
15732, 16725
|
2260, 2277
|
13721, 14009
|
14087, 14202
|
13692, 13698
|
14403, 15709
|
2292, 2864
|
1842, 1963
|
275, 296
|
441, 1823
|
14238, 14379
|
1985, 2083
|
2099, 2244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,628
| 184,148
|
28158
|
Discharge summary
|
report
|
Admission Date: [**2180-11-16**] Discharge Date: [**2180-11-21**]
Date of Birth: [**2144-12-2**] Sex: M
Service: MEDICINE
Allergies:
Nsaids / Vancomycin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Low back pain with radiculopathy.
Concern of GHB withdrawal.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
35-year-old man with history of depression and polysubstance
abuse (remote history of intravenous drug use, crystal meth and
GHB) who presented to the emergency room with chief complaint of
low back pain with radiculopathy on the night of [**11-15**]. He was
also reporting incontinence of the bowel and bladder. Per the ED
report, his low back pain developed on Friday with associated
tingling down the left leg and into the left foot. Patient
stated that he was incontinent of bowel and bladder one time on
Saturday. The pain he described as sharp and constant.
His initial ED vitals were T 98.7, HR 105, BP 150/98, RR 18,
satting 100% on RA. Exam was notable for normal rectal tone. EKG
showed sinus tachycardia with QTc of 410. Labs showed a normal
CBC; white count was 8.3 with 4% bands, 59% polys; hematocrit
and platelets were at baseline. Electrolytes were normal, with
normal kidney function. UA showed trace ketones. Toxicology
screen was positive for benzodiazepines. Given his complaint of
low back pain with incontinence, the patient underwent L-spine
radiography followed by L-spine MRI. The latter showed mild
posterior disc bulge at L4-L5 with mild spinal canal and
bilateral neural foraminal narrowing. The cord was normal. The
patient was at this time getting prepared for discharge when he
was noted to be tachycardic to the 110s.
Further history at this time revealed that he had used GHB 2
days prior. Given concern of GHB withdrawal, he was started on
Diazepam, receiving in total 100 mg intravenous Valium
throughout the course of the night. He also received 3 mg of
Dilaudid. Toxicology service was consulted for assistance with
management of GHB withdrawal: they recommended high doses of
Valium as needed for withdrawal symptoms, serial CK measurements
and aggressive hydration, and admission to the ICU for close
hemodynamic monitoring. Vitals at time of admission were HR 124,
BP 167/90, RR 20, satting 97% RA. He was in four-point
restraints for agitation. For access the patient has 1
peripheral IV.
Of note, patient has been admitted for GHB detox previously,
with most recent admission being in [**2179-8-26**]. During that
admission, the patient was treated with Valium per CIWA scale,
receiving regular doses for sweatiness, tremor, and agitation.
He was seen by both toxicology and psychiatry services during
that admission, and ultimately he was discharged on a tapering
dose of Valium for withdrawal symptoms.
ROS: Difficult to obtain due to patient agitation and poor
cooperation. Patient complaining of "pain all over,"
particularly in the ankles (where he has restraints). Otherwise
he is without focal complaints.
Past Medical History:
# HIV
# Depression
# Polysubstance abuse - crystal method and gammahydroxybutyrate
# Spondylolithesis - diagnosed at age 19, chronic sciatica
# History of MRSA lung abscess diagnosed in [**2173**]
# Asthma
Social History:
Patient lives alone in [**Location (un) 686**]. Not currently working. Notes
in the medical record document a history of GHB abuse, and
patient has a history of positive toxicology screens for
amphetamines and benzodiazepines.
Family History:
Both parents have a history of alcoholism.
Physical Exam:
On Admission:
General: thin and muscular young man, moving all four
extremities in bed, appears uncomfortable and agitated, in four
point restraints. No respiratory distress.
Vitals: BP 189/76, HR 130, RR 19, oxygen saturation 97% on RA.
HEENT: non-icteric sclera, dry mucus membranes.
Neck: supple.
Heart: regular rate and rhythm, tachycardic.
Lungs: exam limited by patient agitation; no focal wheezes or
decrease in breath sounds over the anterior fields.
Abdomen: soft, non-tender.
Extremities: non-edematous, warm and well-perfused.
Pertinent Results:
Tox screens:
[**2180-11-16**] 09:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
Urine tox 1: [**2180-11-15**] 03:45PM BLOOD ASA-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Urine tox 2: [**2180-11-16**] 02:40AM URINE bnzodzpn-POS barbitrt-NEG
opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG
.
[**2180-11-15**] 04:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2180-11-15**] 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-6.5 LEUK-NEG
[**2180-11-15**] 03:45PM GLUCOSE-113* UREA N-13 CREAT-0.6 SODIUM-138
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16
[**2180-11-15**] 03:45PM estGFR-Using this
[**2180-11-15**] 03:45PM ALT(SGPT)-42* AST(SGOT)-27 LD(LDH)-323*
CK(CPK)-127 ALK PHOS-89 TOT BILI-1.3
[**2180-11-15**] 03:45PM LIPASE-28
[**2180-11-15**] 03:45PM CK-MB-5 cTropnT-<0.01
[**2180-11-15**] 03:45PM ALBUMIN-3.6
[**2180-11-15**] 03:45PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2180-11-15**] 03:45PM WBC-8.3 RBC-4.74 HGB-14.0 HCT-41.3 MCV-87
MCH-29.5 MCHC-33.8 RDW-15.0
[**2180-11-15**] 03:45PM NEUTS-59 BANDS-4 LYMPHS-23 MONOS-6 EOS-3
BASOS-0 ATYPS-5* METAS-0 MYELOS-0
[**2180-11-15**] 03:45PM PLT SMR-NORMAL PLT COUNT-359
[**2180-11-15**] 03:45PM PT-12.3 PTT-24.0 INR(PT)-1.0
.
MRI L spine [**11-16**]:
1. No evidence of cord compression.
2. Moderate to severe multilevel degenerative change. Grade 1
anterolisthesis of L5 upon S1 with bilateral pars defects and
moderate-to-severe bilateral L5-S1 and right L4-L5 neural
foraminal narrowing as above.
CXR [**11-16**]:
No acute cardiopulmonary disease
EKG: [**11-16**]: sinus tachycardia.
.
Discharge labs:
[**2180-11-20**] 09:40AM BLOOD WBC-8.0 RBC-4.09* Hgb-11.9* Hct-35.9*
MCV-88 MCH-29.0 MCHC-33.1 RDW-14.5 Plt Ct-342
[**2180-11-20**] 09:40AM BLOOD Glucose-74 UreaN-12 Creat-0.7 Na-138
K-4.0 Cl-103 HCO3-31 AnGap-8
Brief Hospital Course:
A 35-year-old man with history of polysubstance abuse who
presented to the emergency room with low back pain, found to be
tachycardic and hypertensive, now admitted to the ICU for close
monitoring given concern of gamma-hydroxybutyrate withdrawal.
.
# GHB withdrawal: He was admitted with tachycardia and
hypertension, that developed in the ED. Presumed secondary to
GHB withdrawal. Tox screen on admission negative, but second
positive for for benzos. Per toxicology recs was treated with
standing IV Phenobarbital 30mg TID and PRN Valium per CIWA scale
> 10. Initial waxing/[**Doctor Last Name 688**] mental status that resolved by
transfer out of ICU. Phenobarb was d/c'd, per Psych recs,
decreased standing valium dosing to 15mg q8 and continue valium
taper to 10mg. He was treated with a valium taper after benzo
load to treat GHB withdrawal, with improvement.
.
# Acute severe encephalopathy: In the setting of GHB withdrawal
and benzodiazepine treatment, he had severe agitation, requiring
restraints and haldol.
# Low-back pain: complained of lower back pain with radiation to
left buttock and along posterior aspect of LLE to the foot. Had
positive left SLR on exam w/o motor or sensory deficit. MRI
showed mild posterior disc bulge at L4-L5, with mild spinal
canal and bilateral neural foraminal narrowing without evidence
of epidural abscess or cord compression. Nabumetone was started
with good effect. In addition, he was started on tizanadine,
standing tylenol and lidocaine patches. He was referred to the
pain clinic for possible injection if his symptoms persist.
Narcotics were not prescribed.
.
# recent diarrheal illness: Continued flagyl for 10 day course.
.
# GHB abuse: He was seen by social work and his PCP [**Name Initial (PRE) 21150**].
He gradually developed some small insight into his illness. He
was referred to the Triangle program at [**Hospital1 1680**], although
transportation as well as motivation and insight may prevent
enrollment.
.
# Insomnia:
As he has been using the GHB as a sleep aid (and possibly for
anxiolysis), he will discuss further treatment of insomnia with
his PCP.
.
# HIV:
He has continued night sweats, both prior to admission, and
while in the hospital, without other localizing symptoms.
.
Key follow up:
He will follow up with his PCP tomorrow and the pain clinic next
week.
Outstanding tests:
None
Medications on Admission:
truvada once daily
reyataz 300 mg once daily
norvir 100 mg once daily
valium 5 mg PO Q12H (for known issues with GHB)
azithro 500 mg x 5days for sinusitis
flagyl 500 mg Q8H since [**11-10**] for diarrheal illness (outpt C.
diff pending)
flovent 110 mcg [**Hospital1 **]
albuterol MDI PRN
Discharge Medications:
1. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
2. atazanavir 300 mg Capsule Sig: One (1) Capsule PO once a day.
3. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Adderall 10 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for inattention.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
7. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
8. nabumetone 500 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
9. tizanidine 4 mg Tablet Sig: One (1) Tablet PO three times a
day for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
10. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 10
days.
Disp:*10 Adhesive Patch, Medicated(s)* Refills:*0*
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Acute back pain
GHB withdrawal
HIV
Insomnia
Chronic night sweats.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with back pain, and then started to become
agitated in the emergency room. We treated you in the ICU for
GHB withdrawal, and you slowly improved. You were treated with
valium for your GHB withdrawal. Your back pain improved with
tylenol, nabumetone, lidocaine patches and a muscle relaxant,
tizanadine. I also set up an appointment for you to see the
pain clinic if your back pain is still bothering you next week
for possible injection. Follow up as scheduled tomorrow with
Dr. [**Last Name (STitle) 6420**].
.
MEDICATION CHANGES:
Start LIDOCAINE patches to your back 12 hours on, 12 off
Start NABUMETONE 500 mg three times daily - this is related to
NSAIDs, so if your asthma gets worse, stop it.
Start TYLENOL 1000 mg (2 extrastrength) three times daily
Start ZANAFLEX 4 mg three times daily.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R.
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Street Address(2) **], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
Appt: [**11-22**] at 1:30 pm
.
Department: SPINE CENTER
When: TUESDAY [**2180-11-28**] at 10:15 AM
With: [**Name6 (MD) 1089**] [**Name8 (MD) 1090**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"311",
"V08",
"305.1",
"968.4",
"348.39",
"724.2",
"788.30",
"787.91",
"292.0",
"338.29",
"304.11",
"780.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.65"
] |
icd9pcs
|
[
[
[]
]
] |
10014, 10020
|
6128, 8391
|
344, 350
|
10129, 10129
|
4151, 5875
|
11123, 11706
|
3531, 3576
|
8837, 9991
|
10041, 10108
|
8524, 8814
|
10279, 10814
|
5891, 6105
|
3591, 3591
|
8402, 8498
|
10834, 11100
|
243, 306
|
378, 3040
|
3606, 4132
|
10144, 10255
|
3062, 3270
|
3286, 3515
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,580
| 155,575
|
45085
|
Discharge summary
|
report
|
Admission Date: [**2111-7-21**] Discharge Date: [**2111-7-23**]
Service:
ADMISSION DIAGNOSIS: Admission diagnosis is hypoxia and
pneumonia.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
male with a history of tuberculosis status post numerous
pneumothorax therapies many years ago, who presented to his
cardiologist on the morning of admission for routine followup
and was noted to be markedly dyspneic. He was noted here to
have a PO2 of 87% on room air. The patient was suffering
from rigors in the Emergency Department, although his
temperature was only 99.3 orally and axially. The patient
continued to have oxygen saturations in the high 80s to low
90s on 100% nonrebreather and was then placed on CPAP with
marked improvement in his clinical state, and a PO2 improving
to 97%. The patient did continue to be tachypneic to the
middle 30s. Levofloxacin and Flagyl were started, and blood
cultures were sent.
REVIEW OF SYSTEMS: On review of systems on admission the
patient states that he had not felt well for approximately
three to four days prior to admission with an increasing
cough that was yellow/green along with wheezing and new
shortness of breath on the morning of admission. He denies
any sick contacts and has had Pneumovax and influenza
vaccines.
PAST MEDICAL HISTORY:
1. Left lung tuberculosis contracted in a concentration
camp during World War II, and status post pneumothorax
therapy for it. No medical therapy for tuberculosis.
2. Hypercholesterolemia.
3. Hypertension.
4. Coronary artery disease, status post myocardial
infarction and coronary artery bypass graft in [**2096**].
5. Peripheral vascular disease.
6. Thyroid cancer, status post resection in [**2110**].
7. Diverticulosis.
8. Prostate atypia.
9. Status post right middle cerebral artery with left
hemiparesis that has improved markedly status post t-PA
treatment.
10. Carotid stenosis.
MEDICATIONS ON ADMISSION: Flomax 0.4 mg p.o. q.h.s.,
Axid 150 mg p.o. b.i.d., Lopressor 12.5 mg p.o. q.d.,
Synthroid 200 mcg p.o. q.d., Norvasc 5 mg p.o. q.d.,
Coumadin 5 mg p.o. q.d., Lipitor 20 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Lives with wife in [**Name (NI) 1268**]. Was a
[**Doctor Last Name **] in a temple, is now retired and was in a Nazi
concentration camp during World War II.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs were
temperature of 99.3, blood pressure 168/88, pulse 116, oxygen
saturation 97% on BiPAP at 100% FIO2; was 87% on room air.
In general, alert, oriented, and aware times three. On CPAP,
appeared tachypneic but comfortable. HEENT revealed moist
mucous membranes. Neck had no jugular venous distention. A
well-healed scar. No lymphadenopathy. Positive for right
carotid bruit. Pulmonary with good inspiratory effort on
CPAP, diffuse rhonchi on the right side, fine expiratory
wheezes, and prolonged expiratory phase, markedly decreased
breath sounds on the left. Cardiovascular had a regular rate
and rhythm, S1 was normal, S2 was loud, and a 1/6 systolic
ejection murmur at the apex. Abdomen was soft, nontender,
and nondistended. Normal active bowel sounds. Extremities
revealed +3 pitting edema in bilateral lower extremities,
with small superficial ulcer on left pretibial surface. Skin
was warm and dry, improved facial complexion.
Neurologically, slight left hand drop (old per records).
LABORATORY ON ADMISSION: Arterial blood gas on 100%
nonrebreather showed a pH of 7.42, PCO2 of 37, PO2 of 128.
White blood cell count 12.3, hemoglobin 12.6,
hematocrit 40.1, platelets 243. Sodium 142, potassium 4.2,
chloride 102, bicarbonate 23, BUN 23, creatinine 1.4
(baseline is 1 to 1.5), glucose 113. Neutrophils 79,
lymphocytes 15, monocytes 4, eosinophils 1.5.
RADIOLOGY/IMAGING: Chest x-ray showed a collapsed left upper
lobe with pleural thickening and calcifications. The right
lung was clear. No changes from previous studies.
Electrocardiogram showed sinus tachycardia at 106 beats per
minute, normal axis. No ST-T wave changes.
HOSPITAL COURSE:
1. PULMONARY: The patient was hypoxic on room air on
initial presentation. Did not improve on 100% nonrebreather
but showed good response to BiPAP. Arterial blood gas showed
a large A to A gradient most likely secondary to large
atelectasis on the left that was chronic. CO2 and
bicarbonate were okay. The patient spent one day in the
Medical Intensive Care Unit and then was transferred to the
floor as he was slowly weaned off various levels of
supplemental oxygen.
When he was transferred to the floor he was maintained on 3
liters nasal cannula with an oxygen saturation of 97%, and on
the day of discharge was found to have an oxygen saturation
of 97% on room air and an ambulatory oxygen saturation (after
walking 700 feet) of 96%. He was continued on levofloxacin
for community-acquired pneumonia coverage as well as Flagyl
for the possibility of aspiration pneumonia. He was then
discharged on this levofloxacin/Flagyl regimen and sent home
to finish a 14-day course. He was provided with albuterol
and Atrovent nebulizers to help open his airways and moisten
and mobilize secretions.
2. CARDIOVASCULAR: The patient has a history of angina,
myocardial infarction, and coronary artery bypass graft in
[**2099**]. The patient did not have any cardiovascular symptoms
throughout the course of his stay. There was no evidence for
congestive heart failure to account for his respiratory
distress, and he was continued on his antihypertensive
medications.
3. RENAL: The patient has a baseline chronic renal
insufficiency most likely secondary to hypertensive
nephropathy. He was followed with serial BUN and creatinine
levels that remained stable throughout the course of his
stay.
4. INFECTIOUS DISEASE: The patient had rigors but no
fevers on presentation. The source appeared to be pulmonary
by history, but no clear infiltrate was shown on chest x-ray.
The patient was started, and remained on, a course of
levofloxacin and Flagyl to be finished as an outpatient. His
sputum cultures grew back organisms representing many
morphologies, and blood cultures had no growth at the time of
discharge.
5. GASTROINTESTINAL: The patient remained asymptomatic and
was maintained on PPI throughout the course of his stay.
6. HEMATOLOGY: The patient is currently anticoagulated
because of his right internal carotid artery stenosis. His
INR remained stable, and his baseline dose of Coumadin was
continued.
7. ENDOCRINE: Status post thyroidectomy for cancer. He
was continued on his baseline Synthroid dose.
8. NUTRITION: The patient has a history of swallowing
difficulties status post cerebrovascular accident. We
obtained a swallowing study for him that was negative for any
aspiration risk.
9. NEUROLOGY: The patient had a stable examination, status
post a right middle cerebral artery infarct. The patient
with a known 80% to 90% right internal carotid artery
stenosis and is considered a poor candidate for angioplasty,
and also the patient has refused surgery in the past.
10. GENITOURINARY: The patient remained on Flomax for
benign prostatic hypertrophy, and no evidence of obstruction
throughout the course of his stay.
11. PROPHYLAXIS: The patient was maintained on subcutaneous
heparin for deep venous thrombosis prophylaxis, PPI, and
aspiration precautions prior to the swallowing study that
cleared him.
DISCHARGE DIAGNOSES: Pneumonia.
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 500 mg p.o. q.d. (to finish out a 14-day
course)
2. Flagyl 500 mg p.o. t.i.d. (to finish out a 14-day
course).
3. Flomax 0.4 mg p.o. q.h.s.
4. Axid 150 mg p.o. b.i.d.
5. Lopressor 12.5 mg p.o. q.d.
6. Synthroid 200 mcg p.o. q.d.
7. Norvasc 5 mg p.o. q.d.
8. Coumadin 5 mg p.o. q.d.
9. Lipitor 20 mg p.o. q.d.
DISCHARGE INSTRUCTIONS: Follow up with primary care
physician.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 4385**]
MEDQUIST36
D: [**2111-7-25**] 16:54
T: [**2111-7-25**] 05:34
JOB#: [**Job Number 21388**]
cc:[**Telephone/Fax (1) 96366**]
|
[
"V45.81",
"486",
"414.01",
"V58.61",
"582.9",
"403.90",
"433.10",
"272.0",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
2369, 2408
|
7504, 7516
|
7542, 7878
|
1954, 2176
|
4111, 7482
|
7903, 8228
|
104, 151
|
962, 1297
|
180, 941
|
3467, 4092
|
1320, 1927
|
2193, 2352
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,432
| 111,523
|
26856
|
Discharge summary
|
report
|
Admission Date: [**2182-11-28**] Discharge Date: [**2182-11-29**]
Date of Birth: [**2106-3-26**] Sex: M
Service: MEDICINE
Allergies:
Captopril / Codeine
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
s/p carotid stent placement
Major Surgical or Invasive Procedure:
Carotid Stent Placement by Dr. [**Last Name (STitle) 33746**] [**2182-11-28**]
History of Present Illness:
76yo M PMHx COPD, CAD s/p s/p PCI RCA [**2165**], s/p unsuccessful PCI
of the RCA and OM [**2174**], s/p left renal artery stenting, recently
found to have critical 80-90% stenosis in the [**Country **] on carotid
artery duplex, now s/p stenting. Several weeks prior to
presentation pt found to have Hollenhorst plaque of R eye on
routine ophthalmology visit, subsequently found to have above
carotid finding. Patient was asymptomatic at that time w only
complaint being possible increased blurriness of R eye on top of
chronic glaucoma symptoms (legally blind).
.
On day of admission, patient underwent [**Country **] stenting without
known complication, was hemodynamically stable and was admitted
to CCU for further monitoring.
.
On review of symptoms, patient reports chronic bilateral LE
numbness, chronic visual deficits [**2-13**] glaucoma, and unchanged
chronic DOE [**2-13**] COPD.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
- PERCUTANEOUS CORONARY INTERVENTIONS: RCA PCI [**2165**]; failed PCI
of RCA and LCx [**2174**].
- [**Country **] Stenosis 80%, now s/p stenting
- CAD, s/p MI, s/p PCI
3. OTHER PAST MEDICAL HISTORY:
- COPD (not on home O2)
- Chronic Pain Syndrome
- s/p Left renal artery stenting
- Chronic Back Pain
- Lumbar Disc Disease [**2-13**] Osteoporosis
- Abdominal Aortic Aneurysm
- Pulmonary Nodule
- Peptic Ulcer Disease
- Glaucoma
- s/p hemorrhoidectomy
- s/p L inguinal hernia repair
- s/p appendectomy
- s/p Tonsillectomy
Social History:
Lives at home with wife in [**Name (NI) 86**], has 3 adult children. Uses a
cane for ambulation. Current smoker, >120pack-years, rare EtOH,
denies illicits
Family History:
Mother died of gastric cancer at age 83 years of age. Father
died of alcoholism at age 55.
Physical Exam:
ADMISSION PHYSICAL EXAM:
.
VS: Normal and stable
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of *** cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM:
.
VS: Normal and stable
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of *** cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN's III-XII intact, 5/5 strength in all 4 extremities,
no gross sensory deficits, 2+ reflexes throughout.
PULSES
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
.
[**2182-11-28**] 03:14PM BLOOD WBC-7.4 RBC-4.32* Hgb-13.5* Hct-39.0*
MCV-90 MCH-31.2 MCHC-34.5 RDW-12.7 Plt Ct-182
[**2182-11-28**] 03:14PM BLOOD Neuts-60.8 Lymphs-32.1 Monos-4.4 Eos-2.2
Baso-0.5
[**2182-11-28**] 03:14PM BLOOD PT-12.4 PTT-33.0 INR(PT)-1.0
[**2182-11-28**] 03:14PM BLOOD Glucose-107* UreaN-23* Creat-1.3* Na-137
K-4.2 Cl-103 HCO3-23 AnGap-15
[**2182-11-28**] 03:14PM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
.
PERTINENT LABS:
.
[**2182-11-28**] 03:14PM BLOOD CK-MB-2
[**2182-11-29**] 03:22AM BLOOD CK-MB-3
.
DISCHARGE LABS:
.
[**2182-11-29**] 03:22AM BLOOD WBC-8.3 RBC-4.24* Hgb-13.1* Hct-38.6*
MCV-91 MCH-30.9 MCHC-34.0 RDW-12.2 Plt Ct-196
[**2182-11-29**] 03:22AM BLOOD Plt Ct-196
[**2182-11-29**] 03:22AM BLOOD Glucose-115* UreaN-22* Creat-1.3* Na-139
K-4.1 Cl-103 HCO3-25 AnGap-15
[**2182-11-29**] 03:22AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.0
.
MICRO/PATH:
MRSA Screen [**11-28**]: Negative
.
IMAGING/STUDIES:
.
C.CATH [**11-28**]:
FINAL DIAGNOSIS:
1. Aortic arch angiography showed type 2 arch with moderate
calcification.
2. No significant disease in the right and left common carotids
or
subclavian arteries.
3. Right carotid angiography showed 90% ulcerated and eccentric
stenosis
in the proximal right internal carotid artery sparing the
ostium. Kink
in the vessel distal to the stenosis. Rest of the [**Country **] is widely
patent
supplying both ACA and MCA.
4. Left CCA and ICA are widely patent.
5. The aforementioned 90% [**Country **] stenosis was successfully treated
with
PTA and stenting with a 8.0 x 30 mm Xact stent. The procedure
was
performed using distal protection ([**Doctor Last Name 4726**] embolic protection
device).
.
Complete Carotid Series [**11-28**]:
IMPRESSION: There is no evidence of significant carotid artery
stenosis
bilaterally.
Brief Hospital Course:
76yo PMHx CAD, HTN, HLD, recently found to have critical [**Country **]
stenosis now s/p [**Country **] today without complication, admitted for
post-procedure monitoring.
.
ACTIVE DIAGNOSES:
.
#Right Internal Carotid Artery Stent Placement: Mr. [**Known lastname 66096**]
presented with 80-90% stenosis of [**Country **], and underwent
catheterization with stenting without known complications. There
was, however, question of kinking of distal end of stent which
led the team to obtain a carotid duplex study which was normal.
He was started on a nitro drip to maintain his systolic
pressures in the 100-130 mmHg range but never actually required
the medication. He was found to be completely neurologically
intact with baseline poor vision related to his glaucoma and was
discharge on his home aspirin and plavix with follow-up
appointments arranged.
.
# Coronary Artery Disease: His home atenolol and isosorbide were
held given concerns for his blood pressure in the post-stent
period with follow-up established with his outpatient
cardiologist for re-initiation of those medications. He was
continued on his home ASA, Plavix, and ezetimibe-simvastatin. He
had CK-MB negative x 2 during this admission.
.
CHRONIC DIAGNOSES:
.
# COPD: Stable. He was continued on his albuterol nebs and home
advair.
.
# Glaucoma: Stable with very poor baseline vision. He was
continued on his home eye drops.
.
# Osteoporosis: Stable. Continued on his home calcitonin,
calcium, and vitamin D3.
.
# Chronic Pain: Stable. Continued on his home percocet.
.
# BPH: Stable. We attempted to hold his tamsulosin given concern
for hypotension but he had significant symptoms and robust blood
pressures so this medications was continued.
.
TRANSITIONAL ISSUES:
#He was discharged with close follow-up
Medications on Admission:
- Albuterol Sulfate nebs q6-8hrs
- Atenolol 100mg daily
- Bimatoprost 0.03 % 1 drop qhs
- Brimonidine 0.2 % 1 drop [**Hospital1 **]
- Calcitonin
- Plavix 75 mg daily
- Ezetimibe-Simvastatin 10 mg-10 mg qHS
- Advair 500 mcg-50 mcg [**Hospital1 **]
- Isosorbide Dinitrate 40mg TID
- SLNTG prn
- Percocet 5mg-325mg 1-2 tabs q4hrs prn
- Tamsulosin 0.4 mg Capsule qhs
- ASA 325mg daily
- Calcium / Vitamin D
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for shortness of breath or wheezing.
2. Lumigan 0.03 % Drops Sig: One (1) Ophthalmic QHS (once a day
(at bedtime)).
3. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q12H
(every 12 hours).
4. calcitonin (salmon) 200 unit/actuation Spray, Non-Aerosol
Sig: One (1) Nasal DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. ezetimibe-simvastatin 10-10 mg Tablet Sig: One (1) Tablet PO
once a day.
7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
9. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
10. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Calcium 500 + D Oral
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Carotid Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 66096**]--
.
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for carotid stenting--a
procedure to help open up one of the arteries that supplies your
brain with blood. You were monitored after your procedure and
are now ready for discharge.
.
During your hospitalization, the following changes were made to
your medications:
- Held atenolol
- Held isosorbide dinitrate
.
Please talk to your cardiologist Dr. [**Last Name (STitle) 33746**] before you restart
either of these medications. Please make sure to continue
taking your aspirin and plavix every day.
.
See below for the follow-up you have scheduled with Dr. [**Last Name (STitle) 66097**]
and Dr. [**Last Name (STitle) 2257**].
Followup Instructions:
1) Dr. [**Last Name (STitle) 33746**] @ [**Location (un) **] Cardiology, [**2182-12-24**] @ 09:30am,
[**Telephone/Fax (1) 2258**]
2) Dr. [**Last Name (STitle) 2257**] @ [**Location (un) **] Cardiology, [**2182-1-15**] @ 10:30am
Completed by:[**2182-12-1**]
|
[
"V45.82",
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"441.4",
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"338.4",
"433.10",
"492.8",
"369.4",
"600.00",
"518.89",
"414.01",
"365.9",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"88.41",
"88.42",
"00.61",
"00.63",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
9178, 9184
|
5889, 6063
|
309, 390
|
9253, 9253
|
4071, 4071
|
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|
2135, 2227
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|
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|
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|
7627, 7668
|
242, 271
|
418, 1312
|
4087, 4508
|
9268, 9412
|
4524, 4606
|
1623, 1945
|
6081, 7606
|
1334, 1402
|
1961, 2119
|
3116, 4052
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,697
| 127,264
|
48258
|
Discharge summary
|
report
|
Admission Date: [**2159-10-10**] Discharge Date: [**2159-10-15**]
Date of Birth: [**2085-10-31**] Sex: M
Service: Acove
CHIEF COMPLAINT: Status post fall and [**Hospital Unit Name 153**] call out.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 73 year old
male with hypertension, diabetes mellitus, coronary artery
disease, small vessel cerebrovascular accident in [**2159-4-18**],
admitted to the [**Hospital Unit Name 153**] no [**2159-10-10**] after falling at
home. The patient had been in his usual state of good health
until [**10-10**] in AM. He had been watching television and
talking with his family. In addition he also checked his
fingerstick blood glucose which was 195 that morning. He
walked in the restroom with the aid of his walker, and a few
minutes layer, his daughter heard a fall, and found him
slumped on the toilet, with his pants on and his zipper up.
Emergency medical services was called, and intubation was
attempted on the patient. In the [**Hospital6 649**] the patient was moving all extremities and
moaning. He was then intubated for a question secondary to
decreased respiratory rate, agitation/combativeness?.
Electrocardiogram was with lateral ST depression. He was
evaluated by Cardiology, and they recommended ruling out
myocardial infarction. A computerized tomography scan of the
head was done for the patient because of his fall, which was
negative. In addition, the patient was also evaluated by
Neurology, who felt that the episode was unlikely to
represent cerebrovascular accident or seizure. He was
admitted to the [**Hospital Unit Name 153**] and further worked up with
electroencephalogram and echocardiogram. After extubation,
the patient was transferred to the floor in good condition.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes mellitus Type 2 (hemoglobin A1c is 8.7%).
3. Coronary artery disease - mLAD 80% in [**2158-3-19**]; left
ventriculography ejection fraction 46% in [**2158-3-19**], mild
to moderate systolic and diastolic dysfunction.
4. Small vessel cerebrovascular accident in [**2159-4-18**].
5. Depression.
6. Head injury in [**2126**] with two seizures post injury.
7. Gastroesophageal reflux disease.
SOCIAL HISTORY: 30 Pack year smoking history (age 20 through
50), denies drugs. He is married with six children, former
heavy ethanol abuser. He is a retired forklift driver for 48
hours in [**Location 27256**].
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. Glyburide 7.5 q. AM, 2.5 q. PM
2. Aspirin
3. Protonic 40 mg p.o. q.d.
4. Zoloft 50 mg p.o. q.d.
5. Multivitamin
6. Imodium
7. Nitroglycerin sublingual
8. Diovan
9. Questionable Imdur
10. Lactaid
TRANSFER VITAL SIGNS: Blood pressure 183/56, heartrate 59,
respiratory rate 16. Oxygen saturation was 100% on room air.
PHYSICAL EXAMINATION ON TRANSFER: In general, a middle-aged
appearing (looks younger than 73) sitting in chair, pleasant,
very poor historian, laughs in appropriately. Head, eyes,
ears, nose and throat, mucous membranes slightly dry,
oropharynx pink, edentulous (no upper or lower teeth),
extraocular motions intact. Conjunctiva anicteric.
Cardiovascular, regular rate and rhythm, questionable I/VI
systolic ejection murmur at the apex, left lower sternal
border. Chest, bilaterally clear to auscultation, good
inspiratory effort, no crackles, no wheezing. Abdomen, soft,
nontender, nondistended, positive bowel sounds, no guarding.
Extremities, warm, no edema, not cyanotic.
LABORATORY DATA: Laboratory data on transfer equals white
count of 4.0, hematocrit 29.4, platelets 89,000, sodium 141,
potassium 3.8, chloride 109, bicarbonate 23, BUN 29,
creatinine 1.0, glucose 6.7, creatinine kinase 763 (increased
from [**10-11**] at 585), MB fraction 10, index 1.3%, calcium
8.9, phosphorus 3.6, magnesium 2.0, cholesterol 168,
triglycerides 84, HDL 56, LDL 95. Blood:
Aspirin/ethanol/Tylenol/benzodiazepines/barbiturates/PCA
negative; urine: EDC/barbiturates/opiates/cocaine/Tylenol/
Methadone negative. Lactate 2.6.
Radiologic data: Computerized tomography scan of the head
without contrast on [**10-10**] revealed no hemorrhage but
positive for old infarcts, bilateral frontal encephalomalacia
and subcortical infarct in the left corona radiata.
Trauma series on [**2159-10-10**] - No trauma in the
chest/pelvis. Cervical spine, trauma [**2159-10-11**], no
trauma. Magnetic resonance angiography of head/neck in [**2159-6-18**] - Mild atherosclerotic changes at the [**Country **], bilateral
atherosclerotics of the vertebrals with highgrade stenosis in
the left vertebra in the mid cervical region, posterior
circulation irregularity with diffuse narrowing of the
basilar arteries (greater than 50% stenosis in proximal and
distal basal artery). Carotids [**2159-7-19**] - Left ICA with
60% stenoses, right RCA 40 to 59% stenoses.
Cardiology - Echocardiogram on [**2159-10-12**], left
ventricular ejection fraction 55 to 60%, mild symmetric left
ventricular hypertrophy, cavity size is in the top
normal/borderline dilated, left ventricular resting wall
motion abnormalities: 1. Basal inferoseptal hypokinesis, 2.
Basal inferior hypokinesis. Right ventricle is normal in
size, normal in thickness and function. There is moderate 2+
mitral regurgitation. Compared to a previous echocardiogram
in [**2157-12-19**] there are new wall motion abnormalities and
a mitral regurgitation has increased from trace to 2+.
Neurology - Electroencephalogram on [**2159-10-11**], this is
an abnormal electroencephalogram with slow background with
superimposed slow transients, suggesting moderate
encephalopathy of toxic/metabolic/or anoxic etiology.
Hematology - Bone marrow biopsy in [**2158-10-19**] -
Normocellular bone marrow for age with trilinear
hematopoiesis.
HOSPITAL COURSE: Our impression is that this is a 73 year
old male with a mechanical fall versus syncope, versus
seizure, versus head bleed with no known trauma or witnessed
episode for his fall. Body systems as dealt with in the
hospital include
1. Neurology - The Neurology Service evaluated the patient
and he had an electroencephalogram. Given his negative
computerized tomography scan of head, there was likely no
bleeding intracranially. His electroencephalogram revealed
nonspecific abnormalities, and they were nondiagnostic of a
seizure disorder. Neurology was asked regarding starting the
patient on antiseizure medications for prophylaxis, and a
recommendation is to not treat this as it is unlikely a
seizure. In addition the question whether the
vertebral/decreased blood flow contributed to a possible
syncopal episode. There was moderate stenoses, but likely
not significant enough to cause such an episode.
2. Cardiology - The patient had a positive troponin leak,
but negative CKMB fraction. His electrocardiogram changes
were consistent with strain/demand ischemia. The patient was
placed on Telemetry to rule out any possible arrhythmias
which may have contributed to the patient's falling. No
arrhythmias were detected on Telemetry. A repeat
echocardiogram was obtained, which showed new wall motion
abnormalities and increased mitral regurgitation since [**2157**].
This was discussed with Cardiology and the recommendation was
that the patient have an outpatient stress test. Throughout
this admission, the patient denied any chest pain and any
shortness of breath. His hypertension was elevated while in
the hospital and his blood pressure was up to the 180s
systolic. His Lopressor was increased in the [**Hospital Unit Name 153**] from 25
b.i.d. to 37.5 b.i.d. In addition when he was on the floor
his blood pressure continued to be elevated and his Lopressor
was further increased to 50 mg p.o. b.i.d. In addition his
Valsartan was restarted. His primary care physician should
monitor and follow his blood pressure, and adjust the dose as
needed. There was no evidence for myocardial infarction and
his elevated troponins were attributed to the troponin leak
secondary to strain/demand ischemia.
3. Mobility - This was likely a mechanical fall, leading to
his loss of consciousness. The patient was placed on strict
fall precautions including bed rails up, bed alarm on, the
patient only ambulating only with the assistance of RN or
physical therapy. The patient appeared unsteady on his feet,
and has a baseline gait abnormality which was present even
before his admission to the hospital. Physical therapy
consult was placed for the patient for evaluation and
recommendations regarding his fall risk/safety of the
patient/as well as possible need for rehabilitation.
Physical therapy evaluation revealed physical therapy
impression that this patient presents with impairment
associated with reduction for loss of balance and falls. The
patient was unsteady on his feet and presents with
fluctuating mental and physical capacities. Given the
patient's fluctuating state, physical therapy thought that
the patient would benefit from [**Hospital 5735**] rehabilitation.
This patient has the good potential to return to the present
line of function given his state of functioning right now as
well as family support. However, the patient is not safe to
return to home at this time secondary to fluctuating mental
status as well as a history of falls. Regarding his muscle
strength, the patient had pretty good muscle strength with
either [**2-20**] or [**4-22**] muscle strength. His sensation was intact
to light touch. Regarding balance, the patient had a slight
loss of balance, perhaps preservations using hip strategies
for correction. His gait included a shuffle gait with
decreased step length and decreased heel strike and positive
right foot lag and positive right Charcot foot. Physical
therapy as well as nursing communicated with the patient
regarding his clinical status as well as plan for
rehabilitation. Both the patient and family agreed to
rehabilitation.
4. Endocrine - The patient has diabetes mellitus. He was
placed on a regular insulin sliding scale with fingersticks
and blood glucose q.i.d. His home medications of Glipizide
7.5 q. AM, and 2.5 q. PM were held while the patient had
decreased eating as well as fluctuations in appetite. Now
that the patient has been eating better and eating regular,
regular insulin sliding scale will be continued and his home
dose of Glipizide should be restarted. Given his last
hemoglobin A1c was 8.7%, the patient had pretty good control
of his diabetes over the past few months, however, this
should be followed up as an outpatient and checked
periodically.
5. Hematology - The patient has pancytopenia with white
count of 4, hematocrit 29.4, platelets 89,000. However, this
is a known diagnosis, a bone marrow biopsy performed in
[**2158-10-19**] revealed normocellular trilineage. This was
thought to be secondary to his hypersplenism (increased
spleen size).
DISCHARGE STATUS: The patient is to be sent to the [**First Name4 (NamePattern1) 1188**]
[**Last Name (NamePattern1) **] for a [**Hospital 5735**] rehabilitation. On the day of
discharge the patient was afebrile, hemodynamically stable,
sating well on room oxygen. He was ambulating well without
assistance, however, an aide/family member/nurse was always
present when the patient ambulated because he is still a fall
precaution risk.
CONDITION ON DISCHARGE: On the day of discharge the
patient's discharge condition is good.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o. b.i.d., hold for heartrate less than
60
2. Colace 100 mg p.o. b.i.d.
3. Tylenol 325 to 650 mg p.o./p.r. q. 6 hours prn headache
4. Protonix 40 mg p.o. q.d.
5. Zoloft 50 mg p.o. q.d.
6. Aspirin EC 325 mg p.o. q.d.
7. Heparin 5000 units subcutaneously q. 12 hours-this is
only while the patient is not ambulating, if the patient is
ambulating, this medicine should be discontinued.
8. Regular insulin sliding scale with fingerstick blood
glucoses t.i.d.
9. Valsartan 160 mg p.o. q.d.
10. Glyburide 7.5 mg p.o. q. AM, 2.5 mg p.o. q. PM
DISCHARGE DIAGNOSIS:
1. Mechanical fall
2. Hypertension
3. Diabetes mellitus
4. Coronary artery disease
5. Depression
6. Gastroesophageal reflux disease
7. Status post small vessel cerebrovascular accident
FOLLOW UP APPOINTMENT: The patient should follow up with his
primary care physician in one month. The patient has been
scheduled for an outpatient stress test in the Cardiology
Clinic, on Tuesday [**10-23**], 2:30 PM. Phone should the
patient not be able to make it or need to change the date,
[**Telephone/Fax (1) 128**].
DISPOSITION: The patient is to be discharged to [**Hospital 5735**]
rehabilitation at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. The patient should follow
up with his primary care physician in one month. The patient
should pursue his cardiology workup on [**10-23**], 2:30 PM
for outpatient cardiac stress test.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Last Name (NamePattern1) 101679**]
MEDQUIST36
D: [**2159-10-15**] 13:56
T: [**2159-10-15**] 14:09
JOB#: [**Job Number 27620**]
|
[
"719.70",
"424.0",
"E885.9",
"401.9",
"250.00",
"284.8",
"780.2",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11466, 12033
|
12054, 13200
|
5832, 11350
|
2503, 5814
|
159, 220
|
249, 1783
|
1805, 2228
|
2245, 2482
|
11375, 11443
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,395
| 108,653
|
54225
|
Discharge summary
|
report
|
Admission Date: [**2193-7-3**] [**Month/Day/Year **] Date: [**2193-7-7**]
Service: MEDICINE
Allergies:
Aleve / Ace Inhibitors / Florinef
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Nausea/vomitting
Major Surgical or Invasive Procedure:
ERCP [**2193-7-5**] with stent placement
History of Present Illness:
[**Age over 90 **]yo M PMHx lymphoma p/w N/V x several hours. Patient reports
that shortly after eating dinner on day of admission, he
developed acute onset nausea and vomitting. He had 3 episodes
of NB/NB emesis. Patient denied
.
Found by ems rigoring. no cp, sob, abd pain, flank pain. fever
to 100.2 at home.
Of note, patient reports eating a hamburger for dinner and is
concerned that it may have been undercooked; no one else eating
the dinner got sick; patient denies any other sick contacts,
recent travel.
.
In the ED, initial vital signs were 100.4 (oral) 104.0 (rectal)
123 137/80 18 95%RA. Labs were significant for WBC 3.1, Hct 28,
Platelet 54, Cr 1.6, ALT/AST 168/226, AP456, Tbili 1.2, lactate
2.7 (repeat lactate 3.2). CXR was unremarkable. Patient was
given IV vanco/cefepime. Vital signs prior to transfer were
113/49 102 23 97.
.
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:
- recurrent malignant melanoma (including local recurrences),
last [**2191**] that was pT1b
- [**Doctor Last Name **] 3+3 prostate adenocarcinoma (diagnosed [**2183**]) followed
by surveillance with Dr. [**Last Name (STitle) **] [**Last Name (STitle) 79**]
- benign prostatic hypertrophy
- cholecystectomy
- chronic intestinal pneumatosis
- Type 2 DM
- HTN
- asthma
- hyperlipidemia
- GERD
- Subarachnoid Hemorrhage
- Orthostatic Hypotension
- Anemia attributed to MDS
- Thrombocytopenia
- Acute renal failure
Social History:
Retired 11 years ago after working as a travel [**Doctor Last Name 360**]
for 50+ years; also worked conducting a band. Lives at home with
his 78yo wife. Smoked 6-7 years as a young adult, none since.
Denies etoh, illicits
Family History:
NC
Physical Exam:
ADMISSION
Vitals: T: 99.8 rectal BP: 97/42 P: 88 R: 18 O2: 97%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: markedly distended and tympanic to percussion;
non-tender, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
[**Doctor Last Name 894**]
Pertinent Results:
Admission Labs: [**2193-7-2**] 10:30PM
WBC-3.1* RBC-3.02* Hgb-9.6* Hct-28.0* MCV-93 Plt Ct-54*
Glucose-145* UreaN-66* Creat-1.7* Na-140 K-6.0* Cl-107 HCO3-25
AnGap-14
ALT-172* AST-271* AlkPhos-540* TotBili-1.4
Lactate-2.7*
TTE:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The aortic valve is not well seen. The mitral valve
leaflets are mildly thickened. No mitral regurgitation is seen.
There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: poor technical quality due to patient's body
habitus. Left ventricular function is probably normal, a focal
wall motion abnormality cannot be fully excluded. The right
ventricle is not well seen. No pathologic valvular abnormality
seen. Pulmonary artery systolic pressure could not be
determined.
Compared with the prior study dated [**2193-1-11**] (images reviewed),
image quality is worse.
CT Abd/Pelvis:
1. Opacities at the lung bases, right greater than left,
concerning for
aspiration pneumonia as seen on the recent chest x-ray.
2. No evidence of bowel obstruction. Persistent mild gaseous
distention of
the colon which tapers to normal caliber at the sigmoid colon.
3. Mild central intrahepatic biliary dilation and inflammatory
changes
surrounding the common bile duct, unchanged since [**2192-10-5**]. Again, this is likely related to sequela of chronic
cholangitis with no evidence of an active process.
RUQ U/S :
This is a very limited study due to overlying gas, showing mild
central common hepatic duct dilatation. The etiology for this is
not apparent and most of the common duct cannot be imaged
successfully. This could be further evaluated with MRCP or ERCP
if clinically appropriate.
ERCP [**7-5**]:
Impression: A plastic stent placed in the biliary duct was found
in the major papilla. The stent appeared occluded without
noticeable drainage - this was successfully removed. Upon
removal, extensive sludge and debris extruded from the biliary
orifice. Three stones and debris ranging in size from 5 mm to 10
mm that were causing partial obstruction were seen at the common
bile duct. The CBD was dilated to 12 mm. Given recent MI and low
platelets, decision was made not to proceed with sphincterotomy.
A 7cm by 10FR biliary stent was placed successfully. Good
drainage of bile was noted from the stent after placement.
Microbiology: [**Month/Year (2) **] cultures no growth to date at the time of
[**Month/Year (2) **].
[**Month/Year (2) **] Labs: [**2193-7-7**] 05:26AM
WBC-2.2* RBC-2.71* Hgb-8.4* Hct-25.6* MCV-95 Plt Ct-36*
Glucose-121* UreaN-43* Creat-1.5* Na-140 K-4.3 Cl-110* HCO3-22
AnGap-12
ALT-52* AST-27 LD(LDH)-238 AlkPhos-305* Amylase-21 TotBili-1.6*
Brief Hospital Course:
HOSPITAL COURSE
[**Age over 90 **]yo M PMHx CLL, recent SAH, a/w fever, vomitting, elevated
LFTs, thought to have infection of biliary source, course
complicated by NSTEMI.
Active Diagnoses:
# Fever: Patient was admitted with fever, rigors, labs
significant for transaminitis and elevated alk phos suggesting
billiary source; u/s abd demonstrated mild CBD dilatation, CT
abd demonstrated intrahepatic biliary dilation and inflammatory
changes surrounding the common bile duct, without significant
change from prior imaging performed at time of recent CBD
stenting. Review of records demonstrated prior ERCP performed
[**9-/2193**] at which time biliary stent was placed w recommendation
for removal in 2 months, however this was never done. ERCP was
performed which showed sludge and debris from biliary orifice
upon removal of an occluded stent. Stones were found to be
obstructing the CBD and there was biliary dilation. No
spincterotomy was performed in the setting of recent NSTEMI and
low platelets. Patient remained afebrile on Unasyn, and was
transitioned to Augmentin on [**2193-7-6**]. He is being discharged
with a prescription for ten additional days of antibiotics.
# NSTEMI: Pt reported a brief episode of chest pain on admission
accompanied by non-specific ST depressions that resolved w/o
intervention, followed by troponins peaking at 1.17 before
trending downward. He was seen in consultation by cardiology who
felt this was an NSTEMI. Aspirin was started, along with a
beta-blocker. He remained chest pain free on the general
medicine service and in the ICU. He will need to be seen in
follow-up for a [**Date Range **] pressure check and consideration of
further risk stratification.
#Myelodysplasia: Oncology (Dr.[**Last Name (STitle) **] and Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4587**])
following. Neulasta and Epo held while patient hospitalized. He
was transfused 2u pRBC's and 1u platelets on [**2193-7-4**] in
anticipation of his ERCP. He developed a dry cough and 1-2L
oxygen requirement following his second unit of pRBC's, and was
given one dose of Lasix 5mg IV overnight and 20mg IV the morning
of [**2193-7-5**] with resolution of his respiratory symptoms. He will
resume his outpatient Neulasta and Epo schedule, with his next
nursing visit scheduled for [**7-11**].
#DM: Patient had intermittent episodes of hypoglycemia while in
the ICU. His home insulin was held and the patient was placed on
D51/2NS while NPO. As his diet was advanced his sugars improved,
and his home NPH 70/30 was re-started at 7u rather than his
prior dose of 15u. He was instructed to check his finger sticks
at home and follow-up with his PCP to have his insulin increased
as needed.
#GERD: Continued omeprazole
#Glaucoma: Continued timolol and bimatoprost
#BPH: Continued finasteride
TRANSITIONAL ISSUES
- Patient needs Repeat ERCP in 2 months for stent removal and
stone extraction. The [**Hospital **] [**Hospital **] will call him to schedule that
appointment.
- Follow-up final results of [**Hospital **] cultures
- Check [**Hospital **] pressure on Toprol 50mg (new medication for
patient)
- Uptitrate NPH as needed
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. timolol maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
3. bimatoprost 0.03 % Drops Sig: One (1) Ophthalmic daily ().
4. magnesium oxide 140mg Sig: Two (2) twice a day.
5. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Insulin NPH 70/30 Sig: 15 units qAM.
[**Hospital1 **] Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
[**Hospital **] Diagnosis:
Cholangitis
NSTEMI (damage to your heart)
Pancytopenia (low [**Hospital **] counts)
[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
[**Hospital **] Instructions:
You were admitted to the hospital with fevers that were thought
to be due to an infection of your biliary system. You were given
IV antibiotics and underwent an ERCP during which your previous
stent was removed and a new stent was placed. You will need to
follow-up with the ERCP team in eight weeks to have that stent
removed; their office will call you to schedule that
appointment.
In the setting of your fever and infection you had evidence of
damage to your heart. For this reason you were started on a new
medication called Toprol. You will need to follow-up closely
with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] to have your [**Last Name (Titles) **]
pressure checked while on this medication.
While in the hospital you received transfusions of [**Last Name (Titles) **] and
platelets; you were not given Neulasta or Epo. You should resume
your usual schedule when you are discharged, and will receive
your next doses on [**7-11**]. You will follow-up with
Dr.[**First Name (STitle) 4587**] again on [**7-25**].
While in the hospital you were not able to eat for several days.
In this setting, your [**Month (only) **] sugars dropped down very low, and
your home insulin was stopped. When you started eating again
your [**Month (only) **] sugars began to improve and your insulin was
re-started at a lower dose (7 units instead of the 15 units you
normally take at home). You should check your [**Month (only) **] sugars at
home and follow-up with your PCP so that they can help you
increase your insulin dose back up to an appropriate level as
your appetite improves.
Followup Instructions:
Please call to schedule an appointment with your primary care
doctor within 3 to 5 days of [**Month (only) **], and keep the following
previously scheduled appointments:
Department: NEUROSURGERY
When: THURSDAY [**2193-7-11**] at 10:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-7-11**] at 11:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-7-25**] at 2:30 PM
With: DR. [**First Name4 (NamePattern1) 4912**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"185",
"600.00",
"200.10",
"585.9",
"272.4",
"038.9",
"410.71",
"995.91",
"403.90",
"576.1",
"530.81",
"V10.82",
"250.02",
"574.51",
"V49.86",
"493.90",
"284.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"97.05"
] |
icd9pcs
|
[
[
[]
]
] |
5921, 6095
|
268, 310
|
3070, 3070
|
11535, 12621
|
2451, 2455
|
9119, 9553
|
2470, 3051
|
1212, 1660
|
212, 230
|
9583, 9781
|
338, 1193
|
3086, 5898
|
9796, 11512
|
6113, 9093
|
1682, 2193
|
2209, 2435
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,688
| 199,743
|
34136
|
Discharge summary
|
report
|
Admission Date: [**2117-6-26**] Discharge Date: [**2117-6-28**]
Date of Birth: [**2058-8-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
NG lavage
History of Present Illness:
58 yo M with a history of substance abuse admitted from [**Hospital1 **]
detox center with hematemesis and concern for high doses of
acetaminophen.
.
The patient states that for 3 days he has consumed 30 pills of
vicodin. The medication was prescribed for chronic back pain and
the patient describes escalating use over a prolonged period of
time. For at least 5 days the patient reports described
appetite, poor sleep and general lethargy with poor PO intake.
He notes 3 days of abdominal pain and emesis. On the second day
of emesis he began to notice red, dark blood within his emesis.
He also notes 1 day of loose stool without bloody or black
stools.
.
Original back injury started [**2111-5-13**] when he was working as a
furniture mover. His pain is largely in the right thigh with
numbness in the left foot, and left side of lower back. Pain is
constant, rates now [**5-22**] in bed in comfortable position. Has
had several falls related to foot numbness. Other medications
that were helpful were lidocaine patches. Uses TENS unit at
night. Heat and cold are not effective. He had back surgery
which failed, has also had several injections. Seen at the pain
clinic in [**Hospital1 1559**] MA which helped him wean off several
medications including gabapentin, baclofen. Has taken oxycodone
for pain but he did not like the way he felt with this.
.
The patient reports that he went to detox in [**Location (un) **] ([**Hospital1 **])
the evening prior to admission. At the facility, orthostatics
revealed supine 92 159/82, seated 103 142/83, standing 113
124/101. He had hematemesis and was referred the hospital. At an
outside hospital approximately 12 hours prior to admission to
[**Hospital1 **] he was found to have an acetaminophen level of 90. He was
transferred to [**Hospital1 18**].
.
In our ED, he had observed 2-300cc of hematemesis with stable
Hct at 40. NG lavage revealed clots with frank blood initially
that cleared significantly after 600cc. He was hemodynamically
stable with normal LFT's. The case was discussed with the GI
fellow. The patient was admitted to the ICU for endoscopy for
evaluation of hematemesis. CIWA score was 10 at that time. He
was given morphine for withdrawal.
.
On presentation to the [**Hospital1 18**] ED, 99.8 88 154/90 16 97% RA. Pulse
was 100 lying supine, 112 standing. Orthostatic bp was not done.
He received 3L NS as well as 8mg Zofran, pantoprazole 40mg IV,
morphine 2mg IV, phenergan 12.5mg IV. .
ROS: Denies fevers, chills, headache, blurry vision, chest pain,
shortness of breath, dysuria, rashes, arthralgias or any other
concerning symptoms.
Past Medical History:
left-sided L5-S1 disk herniation impinging upon the left S1
nerve root.
Alcohol abuse (sober x 16 years)
Depression
Remote history of gastric ulcer
cyst removal on right upper back
right shoulder surgery
Left L5-S1 microdiskectomy with nerve root decompression [**11-14**]
NEBH
Medial meniscal tear in the right knee as per MRI s/p cortisone
injections
Social History:
As above, ongoing narcotic abuse. Denies alcohol use. Smokes
1ppd tobacco x30 years. Lives alone with nephew in upstairs
apartment. Close with sister [**Name (NI) **].
Family History:
FH: Non-contributory.
Physical Exam:
Gen: Mildly uncomfortable appearing. NAD.
HEENT: No palpable cervical or clavicular lymphadenopathy.
CV: Tachycardic. Regular rhythm. Normal S1 and S2. No M/R/g.
Pulm: Basilar crackles in the right lung base. Otherwise clear
to auscultation.
Abd: Mild diffuse tenderness worst in the RUQ. Normoactive bowel
sounds.
Ext: No edema.
Neuro: A&Ox3.
Pertinent Results:
Admission labs:
===============
[**2117-6-26**] 02:08AM WBC-14.8* RBC-4.07* HGB-14.1 HCT-40.4 MCV-99*
MCH-34.5* MCHC-34.8 RDW-15.2
[**2117-6-26**] 02:08AM NEUTS-91.8* BANDS-0 LYMPHS-6.1* MONOS-1.7*
EOS-0.2 BASOS-0.2
[**2117-6-26**] 02:08AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2117-6-26**] 02:08AM PLT SMR-HIGH PLT COUNT-577*
[**2117-6-26**] 02:08AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2117-6-26**] 02:08AM OSMOLAL-273*
[**2117-6-26**] 02:08AM GLUCOSE-115* UREA N-15 CREAT-1.0 SODIUM-130*
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-21* ANION GAP-19
[**2117-6-26**] 02:08AM ALT(SGPT)-19 AST(SGOT)-16 ALK PHOS-58 TOT
BILI-0.4
[**2117-6-26**] 02:08AM CALCIUM-9.7 PHOSPHATE-2.4* MAGNESIUM-1.9
[**2117-6-26**] 02:08AM LIPASE-17
[**2117-6-26**] 02:08AM GLUCOSE-115* UREA N-15 CREAT-1.0 SODIUM-130*
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-21* ANION GAP-19
[**2117-6-26**] 02:50AM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-<1
[**2117-6-26**] 02:50AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2117-6-26**] 02:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2117-6-26**] 02:50AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-POS mthdone-NEG
[**2117-6-26**] 02:50AM URINE OSMOLAL-623
[**2117-6-26**] 02:50AM URINE HOURS-RANDOM CREAT-113 SODIUM-LESS THAN
[**2117-6-26**] 03:36AM PT-13.8* PTT-33.1 INR(PT)-1.2*
[**2117-6-26**] 09:41AM HCT-32.6*
[**2117-6-26**] 05:00PM HCT-29.5*
[**2117-6-26**] 10:08PM HCT-29.5*
Imaging:
========
ABD Xray [**6-26**] FINDINGS: Supine and upright abdominal radiographs
are reviewed without comparison. There is no sign of free
intraperitoneal air. No dilated loops of bowel are seen. Foci of
gas are seen within non-distended left colon, and in the rectum.
There is a mild amount of stool noted in the left colon.
Visualized osseous structures are normal.
IMPRESSION: No sign of free intraperitoneal air.
Chest Xray [**6-26**] FINDINGS: Portable upright chest radiograph is
reviewed without comparison. Cardiomediastinal contours are
unremarkable. Pulmonary vascularity is normal. Lungs are clear.
There is no pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
A/P: 58 yo M with a history of substance abuse admitted from
rehab with vicodin overdose complicated by hematemesis.
.
# Acetaminophen overdose: At the OSH ED the pt was found to have
a acetaminophen level of 90. He has minimal signs of liver
injury currently with normal LFT's and minimally elevated INR.
Based upon report of last vicodin use 12 hours ago and level of
0 on admission was felt likely not at risk of liver injury.
However, reported history of last use is not well-defined and
the patient did have an initial level at the OSH that put him at
risk for liver injury so he was given a full course of
N-cetylcysteine.
Repeat LFTs and synthetic function stable.
.
# Hematemesis. Resolved spontaneously, hct remained stable with
no need for transfusion. EGD showed non bleeding ulcers in
esophagus, stomach, and duodenum. Biopsied, results pending and
pt has follow up for results and repeat EGD with Dr. [**First Name (STitle) **]
[**Name (STitle) 2473**] of GI at [**Hospital1 18**]. Prescribed [**Hospital1 **] PPI.
.
# Substance abuse. Tox screen positive for opiates and
amphetamines on admission. The patient had symptoms of narcotic
withdrawal and was started on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] scale with methadone. No
evidence of active withdrawal. A social work consult was
obtained and the patient has expressed interest in further
outpatient treatment, however, he told the social worker that he
will discuss further with PCP. [**Name10 (NameIs) **] no longer is interested inpt
detox. On dc he will take only 2 vicodin per day, and will see
his PCP in one week.
Medications on Admission:
Vicodin
Paroxetine 20mg Daily
Discharge Medications:
1. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical PRN DAILY ().
Disp:*1 box* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days.
Discharge Disposition:
Home
Discharge Diagnosis:
peptic ulcer
esophageal ulcer
Discharge Condition:
stable
Discharge Instructions:
You have multiple ulcers in your stomache, esophagus, and
intestine. Call your PCP or go to ER if you have vomit with
bleeding or if you have red or black stool.
1. If tolerate clears then advance diet slowly.
2. No ibuprophen (advil, motrin, etc) and aspirin
3. Follow up in clinic with Dr. [**Last Name (STitle) 78696**] (GI specialist) for
results of the biopsy and cytology results, which are evaluating
for infection or cancer.
4. Repeat endoscopy in [**4-18**] weeks (Dr. [**Last Name (STitle) 78696**] can help organize
when you see him)
You should take the vicodin no more than twice per day, and try
to wean down to once per day.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] 9:30am on [**8-4**]. This appt was
made for you and case discussed with Dr. [**Known firstname 1169**] (Dr. [**Last Name (STitle) 78697**] is
away until Monday)
GastroenterologyProvider: [**Name6 (MD) 8758**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2117-8-3**] 2:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2117-6-28**]
|
[
"722.10",
"E849.9",
"E980.0",
"305.03",
"292.0",
"305.1",
"304.71",
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"531.40",
"965.4",
"311",
"530.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16"
] |
icd9pcs
|
[
[
[]
]
] |
8553, 8559
|
6360, 7982
|
333, 344
|
8633, 8642
|
3975, 3975
|
9332, 9845
|
3571, 3595
|
8063, 8530
|
8580, 8612
|
8008, 8040
|
8666, 9309
|
3610, 3956
|
276, 295
|
372, 2991
|
3991, 6337
|
3013, 3368
|
3384, 3555
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,354
| 150,186
|
38486+38487
|
Discharge summary
|
report+report
|
Admission Date: [**2150-6-15**] Discharge Date: [**2150-6-26**]
Date of Birth: [**2125-11-15**] Sex: M
Service: NEUROLOGY
Allergies:
Tegretol
Attending:[**First Name3 (LF) 11291**]
Chief Complaint:
Increasing Seizure Frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 2427**] is a 24 year-old man with a past medical history
including developmental delay and epilepsy who presents with an
increase in seizure frequency despite a recent up-titration in
anti-epileptic drugs.
.
Mr. [**Known lastname 2427**] was reportedly diagnosed with seizure disorder by
the age of three and is thought to have symptomatic generalized
epilepsy. Notes describe approximately five seizure subtypes
characterized by: 1) staring episodes lasting seconds; 2) the
tonic extension of arms following deep inspiration; 3)
head/upper
extremity loss of tone following deep inspiration; 4)
(secondarily) generalized tonic clonic seizures; 5) jerking of
upper extremities. Previously tried, and discontinued,
anti-epileptic drugs include dilantin (frequent urination and
dazed eyes), valproate (worsening seizures, malodorous bowel
movements, excessive urination, glazed eyes), Tegretol (rash),
and Ativan (excessive muscle weakness).
.
He moved to a group home in [**10-29**], at which time he was able to
walk (despite ataxia) and feed himself. He is non-verbal at
baseline and, at best, able to follow simple requests. However,
records document a general decline in function in the six months
prior to admisison. He can no longer feed himself and requires
full assistance with activities of daily living. In this
setting, he has developed an increase in seizure frequency (now
as many as five seizures daily) and status requiring admission
on
two occasions. During the last admisison ([**5-2**]) at [**Hospital1 2025**],
telemetry was thought to be consistent with [**Location (un) 849**]-Gastaut
Syndrome (frequent multi-focal and generalized epileptic
discharges, often as semi-rhythmic 2 Hz runs). To address the
syndrome, topamax was increased (to 250 mg po bid) and vimpat
(peak of 150 mg po tid) was added. There is no known history of
recent head trauma. He is on augmentin for a presumed sinus
infection.
Past Medical History:
- seizure disorder - since age of 3
- mental retardation
- ataxic diplegia
- acne
- myopia
- atopic dermatitis
- hypothyroidism
- chronic congestion
- frequent aspiration pna
- GERD
- static encephalopathy
- quadriparesis
Social History:
The patient has lived at [**Hospital3 19386**] Group Home since [**2147**]. The
patient's parents are his legal guardians and they live in [**State 4260**].
Family History:
The patient's mother is 48 [**Name2 (NI) **] and healthy and the father is
54 [**Name2 (NI) **] and also healthy. The patient has two brothers
in their 20s, both healthy. There is family history of DM on
both
sides of family, thyroid disorder.
Physical Exam:
AT ADMISSON:
PHYSICAL EXAMINATION:
Vitals: T: 97 P: 66 R: 12 BP: 98/62 SaO2: 100% RA
General: Awake, NAD. Non-verbal.
HEENT: Long face (right aspect seems smaller than left), pointed
ears, atruamatic, no scleral icterus noted.
Neck: Supple.
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: Lungs clear to auscultation bilaterally.
Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused. Flexion at wrists.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Alert.
Cranial Nerves:
* I: Olfaction not evaluated.
* II: PERRL 5 to 4mm and brisk. Gaze conjugate.
* III, IV, VI: Tracks nearly fully in horizontal and vertical
directions.
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: No facial droop, right ptosis (previously documented).
* VIII: Hearing difficult to assess
Motor:
* Tone: Increased in upper extremities bilaterally.
* Adventitious Movements: No tremor or asterixis noted.
Strength:
* Left Upper Extremity: moves spontaneously at least versus
gravity
* Right Upper Extremity: moves spontaneously at least versus
gravity
* Left Lower Extremity: moves spontaneously at least versus
gravity
* Right Lower Extremity: moves spontaneously at least versus
gravity
Reflexes:
* Left: 2+ throughout Biceps, Bracheoradialis, 3+ Patella
* Right: 2+ thoughout Biceps, Bracheoradialis, 3+ Patella
* Babinski: flexor bilaterally
Sensation:
* Light Touch: intact bilaterally in lower extremities, upper
extremities, trunk, face
Coordination
* seems to reach with relative accuracy.
Pertinent Results:
Admission Labs:
.
WBC-5.5 RBC-5.33 HGB-14.5 HCT-43.3 MCV-81* PLT-235
GLUCOSE-102* UREA N-14 CREAT-0.8 SODIUM-144 POTASSIUM-3.7
CHLORIDE-112* TOTAL CO2-23 ANION GAP-13
ALT(SGPT)-20 AST(SGOT)-16 LD(LDH)-137 ALK PHOS-77 TOT BILI-0.3
ALBUMIN-4.1 CALCIUM-8.6 PHOSPHATE-2.3* MAGNESIUM-2.1
.
Discharge Labs:
.
TO BE FILLED IN
.
EEG ([**Date range (1) 33873**]): per daily note
With frequent generalized slow spike and slow wave
discharges and at times, focal left temporal epileptiform
discharges.
.
EEG ([**Date range (1) 33874**]):
IMPRESSION: This telemetry captured three pushbutton
activations. They
did not show clear electrographic seizure activity, and there
was no
definite seizure activity on video, either. Nevertheless, there
were
many runs of irregular generalized slow sharp and wave activity
at about
1 Hz, if without clinical changes. There were also some other
paroxysmal rhythmic changes in the EEG that suggested seizures
though
they did not seem to have a clinical effect.
.
EEG ([**Date range (1) 17057**]):
IMPRESSION: This is an abnormal video EEG study due to multiple
electrographic seizures as described above in Pushbutton and
Seizure
Detection files. This telemetry captured one pushbutton
activation.
Note is also made of interictal frequent generalized spike and
slow wave
discharges as well as a mixed theta/delta background activity.
.
EEG ([**Date range (1) 62333**]): per daily note
Overnight, he had decreased frequency of seizures. He had about
6 clinical tonic seizures, but briefer than prior seizures,
without clusters and without progression to face and arm clonus.
.
EEG ([**Date range (1) 5833**]): per daily note
Overnight, he had decreased frequency of seizures. He had about
4 tonic seizures. However, this morning, the sitter reports 4
very brief seizures in a span of 20 minutes. otherwise, he is
more awake and alert today.
.
EEG ([**Date range (1) 18468**]): per daily note
Over the last 24 hours, he did not have any prolonged tonic
seizures on his EEG. Group home observer saw no seizures this
morning. The telemetry from overnight showed very brief events
lasting less than 5 seconds and on video, the patient had no
overt symptoms. Background activity showed diffuse slowing with
generalized and multifocal spikes (mostly left temporal) and
slow
spike and wave discharges.
.
EEG ([**6-21**] -[**6-22**]): per daily note
Over the last 24 hours, he had 2 slightly tonic seizures on his
EEG. Group home observer noted a cluster of 4 typical staring
seizures this morning for which he was given Ativan. The
telemetry from overnight showed very brief events lasting less
than 5 seconds and on video, the patient had no overt symptoms.
Background activity showed diffuse slowing with generalized and
multifocal spikes (mostly left temporal) and slow spike and wave
discharges. Overall, he has had a decrease in the frequency of
seizures.
.
EEG ([**2150-6-24**]);
IMPRESSION: This is an abnormal video EEG study due to multiple
tonic
seizures lasting approximately 40 seconds in duration
characterized by
slight back arching, a deep inspiration followed by decreased
respiration, and eye lid and bifacial myoclonus. This telemetry
captured 20 pushbutton activations. Compared to the prior 24
hours,
this EEG is worse due to increased seizure frequency.
.
IMAGING
.
Chest X-ray ([**2150-6-15**]):
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
.
Lateral aspect of the right chest is excluded from the
examination. The other
pleural surfaces are normal.
.
Triangular opacity at the base of the left lung should be
considered pneumonia
until proved otherwise, alternatively atelectasis or pulmonary
infarct. The
remainder of the imaged lungs is clear and there is no
appreciable pleural
effusion. Heart size is normal and there is no evidence of
central
adenopathy.
.
Chest X-ray ([**2150-6-16**]):
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. The pre-described triangular retrocardiac opacity is
unchanged in
size and severity. As noted in the previous report, this opacity
has to be
considered as pneumonia unless proven otherwise.
.
No other focal parenchymal opacities. Borderline size of the
cardiac
silhouette. No pulmonary edema. No pleural effusions.
.
Chest x-ray ([**2150-6-20**]):
FINDINGS:
There is S-shaped scoliosis of the thoracolumbar spine. There is
mild
atelectasis at the left lung base. Heart is top normal in size.
Remainder of
the lungs appear clear.
Brief Hospital Course:
Mr. [**Known lastname 2427**] is a 24 year-old man with a past medical history
including developmental delay and epilepsy who presented for a
scheduled long-term monitoring admission with an increase in
seizure frequency despite a recent up-titration in
anti-epileptic drugs. He was admitted to the general neurology
service from [**2150-6-15**] to [**2150-6-26**] for characterization of events by
electroencephalogram (EEG) and optimization of the
anti-epileptic drug regimen.
.
NEURO:
At the time of the admission, EEG leads were placed. The
initial phase of EEG telemetry revealed slow spike and wave
activity and focal temporal lobe epileptiform discharges.
Several medication changes were made in the first few days of
monitoring. The keppra dose was decreased, and a topamax wean
was initiated. In addition, vimpat was tapered and ultimately
discontinued. Banzel was initiated and up-titrated. Patient
continued to have frequent seizure activity both clinically and
electrographically. On the several days prior to transfer,
[**Known firstname **] would have clusters of [**3-26**] brief episodes of staring and
tonic stiffening lasting seconds at a time, usually clustering
over a 30 minute period. He was given ativan 1 mg for clusters
of 4 or more seizures in a one hour period. Prior to discharge
the possibility of dietary changes to help decrease seizure
frequency was discussed. While a ketogenic diet may be
considered in the future, for now we had recommended an attempt
at [**First Name8 (NamePattern2) **] [**Doctor Last Name 1729**] diet as a first step to evaluate for tolerability
and efficacy.
.
PULM:
Video EEG demonstrated periods of apenea associated with
seizures and independently. Accordingly, continuous oxygen
saturation monitoring was initiated and supplemental oxygen was
provided. Despite supplemental oxygen, periods of desaturation
as low as the 40s - and more frequently to the 60-70 range - was
noted. A sleep study was performed as an inpatient. [**Known firstname **] had
5 obstructive apneas, 20 central apneas, 18 hypopneas with
desaturation of 4% and an Apnea Hypopnea Index of 7.8 (mild
sleep apnea by AHI criteria). On sleep study he had rare
desaturations below 80. It was suspected that his major
pathology was obstructive but central sleep apneas may have also
been playing a role. He was tolerating 2 L/min nasal cannula
while sleeping at night and this is to be continued upon
discharge.
.
ID
In the course of the admission, a chest x-ray raised the
possibility of a pneumonia. However, because the patient was
afebrile with no evidence of a leukocytosis, the choice was made
to monitor him clinically rather than prescribe antibiotics.
Follow-up chest x-rays revealed the resolution of the
abnormality.
Medications on Admission:
- phenobarbitol 150mg daily
- Topamax 250mg [**Hospital1 **]
- Keppra 2000mg [**Hospital1 **]
- Clonipin 0.25mg at 8AM and noon, 0.5mg at 8PM
- Vimpat 150mg TID
- levothyroxine 100 mcg daily
- doxycycline 100mg [**Hospital1 **]
- albuterol neb 3ml [**Hospital1 **]
- calcium 600mg [**Hospital1 **]
- vitamin D 800units daily
- loratidine 10mg daily
- diazepam 20mg PR prn
- diastat acudial 15mg PO prn
- Delsym PRN cough
- Loratadine 10mg QAM
- Vimpat 150mg TID
- Vitamin D QAM
- Acidophilus with meals
- Augmentin 875mg [**Hospital1 **] D4/10
.
ALL:
- Tegretol (rash)
- Bee stings, mosquitos
Discharge Medications:
1. Rufinamide 400 mg Tablet Sig: Three (3) Tablet PO twice a
day.
Disp:*180 Tablet(s)* Refills:*2*
2. Home Oxygen
Home Oxygen. Please administer 2 liters per minute via nasal
cannula each night during sleep.
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonazepam 0.5 mg Tablet Sig: 0.5 ([**1-24**]) Tablet PO three times
a day.
5. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
6. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
7. Phenobarbital 100 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
8. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation [**Hospital1 **] (2 times a day).
11. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
12. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. Diastat AcuDial 12.5-15-17.5-20 mg Kit Sig: One (1) Rectal
once a day as needed for seizure.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Developmental Delay
Intractable Epilepsy
[**Location (un) 849**] Gastaut Syndrome
Sleep apnea
Discharge Condition:
Drowsy but arousable to voice. Nonverbal. Moves all
extremities spontaneously and antigravity.
Discharge Instructions:
You were admitted with increasing seizure frequency and for
changes in your anti-epileptic medications while undergoing
continuous EEG monitoring. Changes to your medications are as
follows;
Topamax was decreased from 250 mg [**Hospital1 **] to 100 mg [**Hospital1 **]
Keppra was decreased from [**2140**] mg [**Hospital1 **] to 1500 mg [**Hospital1 **]
Vimpat was stopped. (You had been taking 150 mg tid)
Clonopin will be decreased to 0.25 mg tid
Rufinamide was started and dose is 1200 mg [**Hospital1 **] at time of
discharge.
Continuous oxygen at 2L/min via nasal cannula during sleep was
started.
Followup Instructions:
Please follow up with your PCP as well as your neurologist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**4-28**] weeks. You can schedule an appointment at
[**Telephone/Fax (1) 3294**].
Admission Date: [**2150-6-27**] Discharge Date: [**2150-7-13**]
Date of Birth: [**2125-11-15**] Sex: M
Service: NEUROLOGY
Allergies:
Tegretol / Phenytoin
Attending:[**First Name3 (LF) 11291**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
Endotracheal Intubation
History of Present Illness:
24 yo M with hx developmental delay and [**Location (un) 849**] Gastaut
Syndrome, sleep apnea, recently discharged from epilepsy service
earlier today after admission [**Date range (1) 85637**]/10 for increased seizure
frequency and AED changes, returning with increasing seizures.
As per recent admission note;
Mr. [**Known lastname 2427**] was reportedly diagnosed with seizure disorder by
the age of three and is thought to have symptomatic generalized
epilepsy. Notes describe approximately five seizure subtypes
characterized by: 1) staring episodes lasting seconds; 2) the
tonic extension of arms following deep inspiration; 3)
head/upper extremity loss of tone following deep inspiration; 4)
(secondarily) generalized tonic clonic seizures; 5) jerking of
upper extremities. Previously tried, and discontinued,
anti-epileptic drugs include dilantin (frequent urination and
dazed eyes), valproate (worsening seizures, malodorous bowel
movements, excessive urination, glazed eyes), Tegretol (rash),
and Ativan (excessive muscle weakness).
.
He moved to a group home in [**10-29**], at which time he was able to
walk (despite ataxia) and feed himself. He is non-verbal at
baseline and, at best, able to follow simple requests. However,
records document a general decline in function in the six months
prior to admisison. He can no longer feed himself and requires
full assistance with activities of daily living. In this
setting, he has developed an increase in seizure frequency (now
as many as five seizures daily) and status requiring admission
on two occasions. During the last admisison ([**5-2**]) at [**Hospital1 2025**],
telemetry was thought to be consistent with [**Location (un) 849**]-Gastaut
Syndrome (frequent multi-focal and generalized epileptic
discharges, often as semi-rhythmic 2 Hz runs). To address the
syndrome, topamax was increased (to 250 mg po bid) and vimpat
(peak of 150 mg po tid) was added. There is no known history of
recent head trauma.
.
During his recent admission, his topiramate was decreased from
250 mg [**Hospital1 **] to 100 mg [**Hospital1 **], keppra decreased from [**2140**] mg [**Hospital1 **] to
1500 mg [**Hospital1 **], and vimpat was stopped. Rufinamide was started,
and
currently at 1200 mg [**Hospital1 **] and phenobarbital and clonazepam were
continued at his prior doses. He continued to have daily
clusters of brief clinical seizures, lasting seconds at a time,
consisting of eyelid fluttering and upper extremity jerking.
.
Shortly after discharge today, he had two seizures on his way to
his group home consisting of face twitching and right > left arm
jerking, lasting over twenty seconds each. He continued to have
more seizures upon arriving home and was given 15 mg diastat.
He
continued to seizure and was taken to [**Hospital3 **] Hospital where he
received 2 mg diazepam x2. En route to [**Hospital1 18**] ED he had further
seizures and since arriving he has been seizing every 2-3
minutes. He has received multiple doses of ativan and diazepam
but has not yet received his scheduled evening medications.
.
While in the ED he continued to have frequent seizures despite
benzodiazepines and was maintained on a non-rebreather. He was
initially saturating in the 90s consistently but began to
desaturate in association with his seizures into the 70s and was
having increased respiratory secretions. CXR was suggestive of
possible aspiration and is currently being closely monitored for
respiratory status.
.
Past Medical History:
- seizure disorder - since age of 3
- mental retardation
- ataxic diplegia
- acne
- myopia
- atopic dermatitis
- hypothyroidism
- chronic congestion
- frequent aspiration pna
- GERD
- static encephalopathy
- quadriparesis
Social History:
The patient has lived at [**Hospital3 19386**] Group Home since [**2147**]. The
patient's parents are his legal guardians and they live in [**State 4260**].
Family History:
The patient's mother is 48 [**Name2 (NI) **] and healthy and the father is
54 [**Name2 (NI) **] and also healthy. The patient has two brothers
in their 20s, both healthy. There is family history of DM on
both
sides of family, thyroid disorder.
Physical Exam:
VS; T 97 P 89 BP 103/54 RR 20 92% on NRB
General: Intermittently seizing during examination. Non-verbal,
unresponsive to noxious stimuli.
HEENT: Long face (right aspect seems smaller than left), pointed
ears, atruamatic, no scleral icterus noted.
Neck: Supple.
Cardiac: Regular rate, normal S1 and S2.
Pulmonary: Coarse lung sounds b/l (anteriorly)
Abdomen: soft, nt, nd
Extremities: Warm, well-perfused. Flexion at wrists.
Neurology;
MS; Intermittently seizing with eyelid fluttering, bilateral arm
shaking, lasting 20-30 seconds at a time. In between,
nonverbal,
does not interact with examiner.
CN; PERRL 4mm-->2mm, does not track. Face symmetric.
Motor; arms flexed at elbows and wrists, legs extended. Normal
tone. Occasional spontaneous movement of all extremities.
Sensory; withdraws to noxious in all extremities
Reflexes; 1+ throughout
Coordination; unable to assess
Gait; unable to assess
Pertinent Results:
[**2150-6-30**] 01:53AM BLOOD WBC-7.3 RBC-4.29* Hgb-11.3* Hct-34.3*
MCV-80* MCH-26.3* MCHC-32.9 RDW-12.7 Plt Ct-221
[**2150-6-29**] 02:42AM BLOOD WBC-10.5 RBC-4.44* Hgb-11.8* Hct-35.5*
MCV-80* MCH-26.6* MCHC-33.4 RDW-12.6 Plt Ct-199
[**2150-6-28**] 01:56AM BLOOD WBC-12.4* RBC-4.56* Hgb-12.3* Hct-37.3*
MCV-82 MCH-27.0 MCHC-33.0 RDW-12.7 Plt Ct-201
[**2150-6-27**] 02:29PM BLOOD WBC-9.4 RBC-4.44* Hgb-11.8* Hct-35.9*
MCV-81* MCH-26.5* MCHC-32.8 RDW-12.7 Plt Ct-231
[**2150-6-27**] 11:54AM BLOOD WBC-7.8 RBC-4.24*# Hgb-11.7*# Hct-34.5*#
MCV-82 MCH-27.5 MCHC-33.8 RDW-12.7 Plt Ct-173
[**2150-6-26**] 11:30PM BLOOD WBC-8.3 RBC-5.67 Hgb-15.3 Hct-45.9
MCV-81* MCH-26.9* MCHC-33.3 RDW-13.1 Plt Ct-309
[**2150-6-26**] 04:25AM BLOOD WBC-10.0 RBC-5.55 Hgb-14.7 Hct-44.6
MCV-80* MCH-26.4* MCHC-32.9 RDW-12.7 Plt Ct-284
[**2150-6-26**] 11:30PM BLOOD Neuts-62.9 Lymphs-28.6 Monos-6.1 Eos-2.0
Baso-0.4
[**2150-6-30**] 01:53AM BLOOD Plt Ct-221
[**2150-6-29**] 02:42AM BLOOD Plt Ct-199
[**2150-6-28**] 01:56AM BLOOD Plt Ct-201
[**2150-6-27**] 02:29PM BLOOD Plt Ct-231
[**2150-6-26**] 11:30PM BLOOD Plt Ct-309
[**2150-6-26**] 11:30PM BLOOD PT-13.3 PTT-30.9 INR(PT)-1.1
[**2150-6-30**] 08:14AM BLOOD Glucose-94 UreaN-2* Creat-0.7 Na-142
K-3.9 Cl-112* HCO3-23 AnGap-11
[**2150-6-30**] 01:53AM BLOOD Glucose-104* UreaN-2* Creat-0.6 Na-142
K-3.8 Cl-112* HCO3-22 AnGap-12
[**2150-6-29**] 05:40PM BLOOD Glucose-111* UreaN-2* Creat-0.6 Na-139
K-3.7 Cl-109* HCO3-22 AnGap-12
[**2150-6-29**] 04:30PM BLOOD Glucose-106* UreaN-3* Creat-0.6 Na-136
K-5.4* Cl-108 HCO3-21* AnGap-12
[**2150-6-29**] 02:42AM BLOOD Glucose-120* UreaN-4* Creat-0.7 Na-137
K-3.4 Cl-107 HCO3-21* AnGap-12
[**2150-6-28**] 01:56AM BLOOD Glucose-95 UreaN-6 Creat-0.8 Na-141 K-3.8
Cl-109* HCO3-21* AnGap-15
[**2150-6-27**] 02:29PM BLOOD Glucose-96 UreaN-8 Creat-0.7 Na-141 K-3.3
Cl-108 HCO3-22 AnGap-14
[**2150-6-27**] 11:54AM BLOOD Glucose-78 UreaN-8 Creat-0.6 Na-144
K-2.9* Cl-117* HCO3-20* AnGap-10
[**2150-6-26**] 11:30PM BLOOD Glucose-77 UreaN-12 Creat-1.1 Na-133
K-8.1* Cl-101 HCO3-22 AnGap-18
[**2150-6-30**] 08:14AM BLOOD Calcium-7.6* Phos-2.3* Mg-2.1
[**2150-6-30**] 01:53AM BLOOD Calcium-7.2* Phos-2.4* Mg-2.3
[**2150-6-29**] 05:40PM BLOOD Calcium-7.3* Phos-2.0* Mg-2.4
[**2150-6-29**] 04:30PM BLOOD Calcium-7.1* Phos-2.3* Mg-5.1*
[**2150-6-28**] 01:56AM BLOOD Calcium-7.4* Phos-1.5* Mg-2.8*
[**2150-6-27**] 02:29PM BLOOD Phos-2.7 Mg-1.2*
[**2150-6-27**] 11:54AM BLOOD Albumin-2.8* Calcium-5.8* Phos-2.1*
Mg-1.0*
[**2150-6-26**] 04:25AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
[**2150-6-26**] 04:25AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
[**2150-6-29**] 06:00AM BLOOD Vanco-7.2*
[**2150-6-28**] 03:17PM BLOOD Phenyto-15.4
[**2150-6-26**] 11:30PM BLOOD Phenoba-36.7
[**2150-6-26**] 11:30PM BLOOD LtGrnHD-HOLD
[**2150-6-26**] 11:30PM BLOOD GreenHd-HOLD
[**2150-6-29**] 05:16AM BLOOD Type-ART Temp-37.8 Rates-/17 PEEP-5
pO2-175* pCO2-35 pH-7.40 calTCO2-22 Base XS--1 Intubat-INTUBATED
Vent-SPONTANEOU
[**2150-6-27**] 01:05AM BLOOD K-3.5
[**2150-6-27**] 12:27AM BLOOD K-6.5*
[**2150-6-27**] 09:10AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2150-6-27**] 09:10AM URINE RBC-14* WBC-1 Bacteri-FEW Yeast-NONE
Epi-0
[**2150-6-27**] 01:13PM OTHER BODY FLUID Polys-95* Lymphs-0 Monos-0
Macro-5*
EEG [**2150-6-27**]
IMPRESSION: This 24-hour video EEG telemetry captured many
clinical and
electrographic seizures lasting about 30 seconds, each
characterized by
an electrodecremental pattern followed by rhythmic high
amplitude sharp
alpha frequency activity with a widespread distribution tapering
off to
rhythmic sharp theta activity in the right hemisphere,
particularly in
the right temporal region. Clinically, these events were
characterized
by bilateral rhythmic trembling of the upper extremities.
Interictally,
multifocal epileptiform discharges were seen. The background was
usually of mixed frequencies and disorganized, suggestive of an
encephalopathy, although abundant beta activity was seen at
other times,
which could be an effect of benzodiazepine medications.
EEG [**2150-6-28**]
IMPRESSION: This 24-hour video EEG telemetry captured three
clinical
and electrographic seizures. All of these were characterized by
bifrontal high amplitude rhythmic sharp alpha frequency activity
lasting
for about 30 seconds followed by more persistent rhythmic sharp
activity
in the right hemisphere but more polymorphic delta frequency
slowing in
the left hemisphere. Clinically, these were characterized by
rhythmic
trembling of the bilateral upper extremities sometimes followed
by some
more pronounced bilateral upper extremity clonic movements.
Interictally, bifrontal epileptiform discharges were seen. The
background was slow and disorganized throughout much of the
day's
recording, suggestive of an encephalopathy, and rhythmic runs of
frontal
delta activity were seen intermittently lasting up to 10 seconds
at a
time. Overall, compared to the prior day's recording, there was
a
significant reduction in the number of clinical and
electrographic
seizures with only three seen on this day's recording.
EEG [**2150-6-29**]
IMPRESSION: This 24-hour video EEG telemetry captured four
electrographic seizures, each lasting 30 seconds or more, that
had no
apparent clinical correlate. These were characterized by two per
second
bilateral widespread high voltage sharp activity with a
bifrontal
predominance. On many other occasions, briefer bursts of
similar epileptiform activity were seen and bursts of rapid beta
frequency high amplitude sharp bifrontal activity were also
seen.
Isolated multifocal epileptiform discharges were also seen. The
background was mostly slow and disorganized throughout the
recording,
suggestive of an encephalopathy, and runs of intermittent
frontal delta
slowing and focal left hemisphere slowing were seen. Compared to
the
prior day's recording, the number of electrographic seizures
remained
about the same, although they were subclinical on this day's
recording
without associated upper extremity trembling as had been seen on
the
previous day. The shorter bursts of interictal epileptiform
activity
were also more prominent on today's recording
EEG [**2150-6-30**]
IMPRESSION: This 24-hour video EEG telemetry captured no
pushbutton
activations. However, frequent electrographic seizures were seen
characterized by bifrontal sharp waves recurring at a two per
second
frequency and many of these lasted longer than 30 seconds. These
do not
appear to have clinical correlate on video. Shorter bursts of
interictal epileptiform activity of a similar appearance were
also
frequently seen as were bursts lasting several seconds of high
amplitude
alpha frequency sharp activity in the bifrontal regions. The
background
was slow and disorganized throughout the recording suggestive of
an
encephalopathy. Overall, compared to the prior day's recording,
this
day's tracing showed more epileptiform activity with more
frequent and
more prolonged electrographic seizures.
EEG [**2150-7-1**]
IMPRESSION: This 24-hour video EEG telemetry captured two types
of
epileptiform activity both with a bifrontal predominance and
both
manifest as runs of activity that lasted up to 10 or 20 seconds
typically without associated clinical accompaniment. Only
rarely, if
ever, did these runs of epileptiform activity last longer than
30
seconds on this day's recording. The background was slow and
disorganized throughout the recording suggestive of an
encephalopathy.
Compared to the prior day's recording, this day's recording was
improved. Although frequent bursts and runs of bifrontal
epileptiform
activity were still seen, they were less prolonged than on prior
days,
with almost no periods of epileptiform activity exceeding 30
seconds at
a time.
EEG [**2150-7-2**]
IMPRESSION: This is an abnormal video EEG study due to
electrographic
seizures characterized by low voltage rhythmic beta activity for
five to
ten seconds' duration. The interictal EEG is notable for a slow
background consistent with a mild to moderate encephalopathy as
well as
generalized spike and slow wave discharges with bifrontal
predominance
at times and, at other times, more monomorphic generalized delta
activity in brief runs. This telemetry captured nine pushbutton
activations for various facial grimacing and mouth movements
that did
not have a clear electrographic correlate. Compared to the prior
24
hours, this EEG is relatively unchanged in terms of frequency of
subclinical electrographic seizures.
EEG [**2150-7-3**]
IMPRESSION: This is an abnormal video EEG study due to a slow
background consistent with a moderate encephalopathy.
Additionally,
there are electrographic findings as detailed above in Seizure
Detection
programs without obvious clinical correlate on video that likely
represent electrographic seizures. This study captured 25
pushbutton
activations for various behaviors including hand wringing,
clapping,
groaning, facial movements that did not have an obvious
electrographic
correlate. This telemetry is unchanged compared to prior 24
hours.
EEG [**2150-7-4**]
IMPRESSION: This is an abnormal video EEG study due to slowing
of the
background rhythm consistent with a moderate encephalopathy.
Brief
electrographic seizures are described above in Seizure Detection
programs; however, no seizures of >30 seconds or one minute
duration
were seen in this study. Compared to the prior 24 hours, this
EEG is
unchanged. This telemetry captured six pushbutton activations
for
various behaviors including vocalization as well as grimacing
that did
not have an electrographic correlate.
EEG [**2150-7-5**]
IMPRESSION: This is an abnormal video EEG study due to brief
electrographic seizures, as mentioned above. Please note that
there is
an increase in duration of the low voltage fast activity up to
15
seconds in duration. This telemetry captured eight pushbutton
activations for various hand wringing movements that did not
have an
electrographic correlate. Compared to the prior 24 hours, this
EEG is
slightly worse in that the runs of low voltage fast activity are
of
slightly duration.
EEG [**2150-7-6**]
IMPRESSION: This is an abnormal extended routine recording for
electrographic seizures lasting up to 25 seconds, rhythmic sharp
activity seen independently in the right and left temporal
areas,
interictal bursts of spikes and polyspikes in a generalized
distribution, bursts of rhythmic delta slowing and a suppressed
background. These abnormalities suggest moderate encephalopathy
as well
as increased irritability which is generalized and multifocal.
CT head
IMPRESSION: No acute intracranial hemorrhage or fracture. Small
amount of
soft tissue swelling in the left parietal scalp- correlate
clinically.
Consider MR if necessary for assessment of parenchymal changes.
CXR [**2150-7-8**]
FINDINGS: As compared to the previous radiograph, the
pre-existing bilateral areas of focal parenchymal opacities are
unchanged. In addition, a subtle opacity has newly occurred in
the right upper lobe. No other parenchymal changes. No evidence
of pleural effusion. Normal size of the cardiac silhouette. No
evidence of pulmonary edema.
Brief Hospital Course:
Mr. [**Known lastname 2427**] was admitted to neurology ICU service for
evaluation and treatment of increasing frequency of seizures. He
underwent continuous video EEG montioring throughout most of his
hospital course.
Neuro
The most likely cause of increasing seizure frequency was noted
to be pneumonia. He was noted to have pneumonia while in the
hospital during last admission. Initially he was having near
continuous seizure activity and was given loading doses of
dilantin, keppra as well as phenobarbital for control of
seizures. the development of pneumonia coupled with tapered off
doses of seizure medications during last admission , probabaly
constituted for increased seizure frequency. He was closely
followed by epilepsy team and rufinamide was increased to 1600
[**Hospital1 **], keppra to [**2140**] [**Hospital1 **], and topiramate was increased to its
dose prior to recent taper (250 mg [**Hospital1 **]). He was started on
standing diazepam 5 mg q6 h IV for seizure control. Ativan prn
1-2m mg IV was on call for any prolonged or frequent seizures.
The EEG monitering showed improvement in the frequency of
seizures, from nearly 20 or so in 24 hrs to [**3-26**] in 24 hrs, and
from clinical seizures to subclinical seizures. He had good
seizure control with addition of dilantin, but after persistent
fevers and rash presumed to be caused by this [**Doctor Last Name 360**] (as
described below), dilantin was tapered off, receiving his last
dose 6/12. He had occasional brief clusters of [**4-27**] events of
head turning and stiffening, lasting seconds at a time, usually
no more than [**1-24**] clusters per day, and occasionally received
ativan 1 mg after clusters in addition to his standing
medications.
Pulm/ID
He was noted to have large right lower lobe pneumonia presumed
to be secondary to aspiration. The cultures were sent and he was
started on broad spectrum cover for nosocomial bacteria with
vancomycin, zosyn and cipro. Infectious disease inputs were
taken. After sputum grew E Coli - sensitive to zosyn, the other
2 antibiotics were stopped. He showed clinical improvement in
regards to WBC, he remained afebrile and becmae more awake and
alert. he was extubated and completed a seven-day course of
zosyn. He had worsening fevers, up to 104.6 without
leukocytosis or left shift. He also developed a faint
maculopapular rash on his extremities, sparing his palms and
soles. A suspicion of drug-related fever and rash were raised
and the patient's dilantin and zosyn were discontinued. Within
48 hours his fever curve had normalized, and suspicion was that
the reaction was most likely secondary to the dilantin. He has
been saturating well on room air but it is recommended he use 2L
O2 via nasal cannula at night for sleep apnea as started during
his last admission.
Medications on Admission:
Medications;
1. Rufinamide 400 mg Tablet Sig: Three (3) Tablet PO twice a
day.
Disp:*180 Tablet(s)* Refills:*2*
2. Home Oxygen
Home Oxygen. Please administer 2 liters per minute via nasal
cannula each night during sleep.
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Clonazepam 0.5 mg Tablet Sig: 0.5 ([**1-24**]) Tablet PO three times
a day.
5. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
6. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
7. Phenobarbital 100 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
8. Topiramate 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
9. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation [**Hospital1 **] (2 times a day).
11. Vitamin D 400 unit Tablet Sig: Two (2) Tablet PO once a day.
12. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. Diastat AcuDial 12.5-15-17.5-20 mg Kit Sig: One (1) Rectal
once a day as needed for seizure.
Discharge Medications:
1. Rufinamide 400 mg Tablet Sig: Four (4) Tablet PO twice a day.
Disp:*240 Tablet(s)* Refills:*2*
2. Levothyroxine 50 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Phenobarbital 100 mg Tablet Sig: 1.5 Tablets PO QPM (once a
day (in the evening)).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB.
6. Topiramate 100 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
Disp:*150 Tablet(s)* Refills:*2*
7. Calcium 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
twice a day.
8. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
9. Keppra 1,000 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
10. Home Oxygen
Please administer 2 liters per minute via nasal cannula each
night during sleep for sleep apnea.
11. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
12. Diastat AcuDial 12.5-15-17.5-20 mg Kit Sig: One (1) kit
Rectal once a day as needed for seizure: as directed for
prolonged seizure or cluster of seizures.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Epilepsy
Discharge Condition:
Awake, non-verbal, does not follow commands. Increased tone
throughout but moves all extremities antigravity.
Discharge Instructions:
You were admitted with increasing seizures. Your keppra,
rufinamide, and topamax were increased, and your clonopin was
replaced by valium. You were found to have an aspiration
pneumonia and required intubation. You completed a seven-day
course of antibiotics for your infection. After this, you
continued to have fevers which were thought to be related to
phenytoin, which have resolved after this medication was
discontinued.
Changes in seizure medications;
-Keppra increased to [**2140**] mg twice daily
-Rufinamide increased to 1600 mg twice daily
-Topiramate increased to 250 mg twice daily
-Clonazepam was discontinued
-Valium was started at 5 mg four times daily
Followup Instructions:
Please follow up with your neurologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**1-24**]
months. Her office can be reached at ([**Telephone/Fax (1) 35413**].
|
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icd9cm
|
[
[
[]
]
] |
[
"96.72",
"33.23",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,645
| 187,423
|
31155
|
Discharge summary
|
report
|
Admission Date: [**2119-7-1**] Discharge Date: [**2119-7-4**]
Date of Birth: [**2049-4-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
arterial line, terminal extubation
History of Present Illness:
70M with DOE, hypotension, stridor, goiter, multiple lung
nodules transferred from [**Hospital6 1597**] intubated to the
SICU team for potential tracheal stent placement [**2119-7-2**]. The pt
presented to OSH (initially N-W then MtAH) with increasing DOE
over the past few days. Per his daughter, he had been in his
USOH until 2 weeks prior to admission when he developed urinary
frequency went to N-W where he had a ?UTI had cystoscopy and
turp and sent home with a foley cath in place. On [**6-26**] he began
having weakness and required a wheelchair to go to bathroom
(baseline walks with cane). On Wednesday he had a fever to
99.6F, began having SOB and complained of pain in his ribs. He
presented to N-W ED the next morning.
.
He was evaluate at N-W and sent to MtAH MICU for admission.
Evaluation yielded WBC 34.2, HCT 26.6. CT chest revealed large
anterior/sup mediastinal mass (new compared to Chest CT in
[**2-/2119**]) multiple lung nodules. Hospital course at MtAH included
mass biopsy on [**6-30**], R PICC placed on [**6-30**], intubation [**7-1**] just
prior to transfer. He also had LENIS (-), V/Q scan indeterminate
and was on hep gtt for presumed pulmonary embolism.
.
He was transferred to [**Hospital1 18**] for potential tracheal stent
placement on [**2119-7-1**]. He was hypotensive requiring pressors
overnight. He was transferred to MICU service on [**2119-7-2**].
Past Medical History:
HTN
BPH s/p TURP (2 weeks ago)
CVA (10 yrs ago) with residual left sided weakness arm > leg
.
Social History:
Social History: Originally from [**Country 11150**], immigrated to [**Country 6607**] 9
years ago and then to US 2-3 years ago (when he had his thyroid
biopsied). Patient is married with children in the area. Smoking
hx, but quit 10 years ago.
.
Family History:
Family History: Parents died a while ago without known
diagnosis. Patient is youngest of 3 siblings the other 2 are
well. His children are all well.
Physical Exam:
VS: 100.3F HR88 BP 92/56 vented
Vent settings: CPAP PS 15x10 Tv 500-700's rr 20-30, FiO 35%
HEENT: EMOI, PERRL, NG tube in place,
Neck: Firm thyroid bilaterally
Chest: Firm mass palpable midway between nipple and sternum on
the right side, Lungs clear to ascultation anteriorly
Cardiac: RRR no m/r/g
Abd: hypoactive bowel sounds
Ext: moves right arm, feet bilaterally
Neuro: Alert, follows commands, answers yes/no questions, moves
right arm and legs bilaterally.
Pertinent Results:
[**2119-7-1**] 11:31PM PO2-89 PCO2-25* PH-7.42 TOTAL CO2-17* BASE
XS--5
[**2119-7-1**] 11:31PM GLUCOSE-102
[**2119-7-1**] 11:31PM O2 SAT-97
[**2119-7-1**] 11:26PM URINE COLOR-PINK APPEAR-Cloudy SP [**Last Name (un) 155**]-1.010
[**2119-7-1**] 11:26PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2119-7-1**] 11:26PM URINE RBC->1000* WBC-25* BACTERIA-NONE
YEAST-MOD EPI-<1
[**2119-7-1**] 10:34PM GLUCOSE-98 UREA N-23* CREAT-1.1 SODIUM-142
POTASSIUM-3.9 CHLORIDE-113* TOTAL CO2-17* ANION GAP-16
[**2119-7-1**] 10:34PM estGFR-Using this
[**2119-7-1**] 10:34PM CALCIUM-8.9 PHOSPHATE-2.7 MAGNESIUM-2.0
[**2119-7-1**] 10:34PM TSH-4.8*
[**2119-7-1**] 10:34PM WBC-43.2* RBC-3.73* HGB-10.0* HCT-30.6*
MCV-82 MCH-26.8* MCHC-32.7 RDW-17.0*
[**2119-7-1**] 10:34PM NEUTS-85* BANDS-7* LYMPHS-3* MONOS-1* EOS-1
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2119-7-1**] 10:34PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
BURR-OCCASIONAL
[**2119-7-1**] 10:34PM PLT SMR-NORMAL PLT COUNT-429
[**2119-7-1**] 10:34PM PT-14.5* PTT-28.9 INR(PT)-1.3*
Brief Hospital Course:
.
(1) Respiratory failure - Patient with respiratory distress at
OSH with increased work of breathing. Intubation showed deviated
trachea secondary to mediastinal mass. Remained intubated on
pressure support until expiration.
.
(2) Mediastinal mass - Pathology from [**Hospital3 **] suggested
non-small-cell adenocarcinoma, with primary likely from lung.
Other considerations included thyroid and thymic origin.
Heme-onc and Rad-onc were consulted, felt that no interventions
could be offered given the nature and extent of disease.
.
(3) Pulmonary nodules - Appeared to have increased in size based
on imaging reports compared to CXR here. Likely metastases from
primary carcinoma.
.
(4) Hypotension - Pt was given NS boluses to keep volume
resuscitated, but also required vasopressors (neo and levophed).
.
(5) Urology/Renal - Pt was s/p dilation of urethral contracture,
but hematuria unlikely to be [**1-27**] to urologic procedure. Renal
expressed concern for glomerular process, considering findings
of spiculated blood cells in urine.
.
(6) SBO - Pt found to have abdominal mass on CT compressing
distal small intestine, so NG tube was placed.
.
(7) End of life care - After discussion with pt's family, pt was
made comfort measures only on the morning of [**2119-7-4**].
.
Medications on Admission:
Meds on Transfer:
vanco 1g [**Hospital1 **]
levoflox 750 qd
Neo 1.5
Discharge Medications:
none - expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Adenocarcinoma, primary likely non-small-cell from lung.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
|
[
"240.9",
"038.9",
"785.52",
"162.8",
"599.7",
"459.2",
"518.81",
"585.6",
"995.92",
"276.2",
"403.91",
"197.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.07",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5483, 5492
|
4039, 5324
|
332, 368
|
5592, 5602
|
2837, 4016
|
5659, 5670
|
2202, 2337
|
5443, 5460
|
5513, 5571
|
5350, 5350
|
5626, 5636
|
2352, 2818
|
273, 294
|
396, 1788
|
1810, 1906
|
1938, 2169
|
5368, 5420
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,674
| 105,869
|
2294+55368
|
Discharge summary
|
report+addendum
|
Admission Date: [**2197-11-13**] Discharge Date: [**2197-11-27**]
Date of Birth: [**2143-11-7**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Shellfish / Fish Product Derivatives / Barium
Sulfate / Iodine
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Lumbar pain
Major Surgical or Invasive Procedure:
anterior lumbar fusion L5-S1 [**2197-11-13**]. posterior lumbar fusion
L5-S1 [**2197-11-14**]
History of Present Illness:
Pt has a history of chronic lumbar pain and radiculopathy
Past Medical History:
RA--on chronic prednisone and arava
osteoporosis
spinal stenosis s/p laminectomy and decomp of C6-C7
recent pyelo/ horshoe kidney
ulcerative keratitis from RA
reactive airway disease
RLL nodules (seen [**2197-3-29**])
chronic anemia-Fe deficiency
reactive airway disease
Social History:
Denies EtOH, tobacco, illicits
Family History:
NC
Physical Exam:
A+OX 3 NAD. Afebrile. generalized weakness secondary to chronic
illness.
Pertinent Results:
[**2197-11-13**] 11:00AM GLUCOSE-194* UREA N-22* CREAT-1.1 SODIUM-139
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-24 ANION GAP-18
[**2197-11-13**] 11:00AM HCT-29.4*
Brief Hospital Course:
Pt had surgery [**0-**] post op course uneventful.
Medications on Admission:
. Albuterol Sulfate 0.083 % Solution Sig: [**1-15**] Inhalation Q6H
(every 6 hours) as needed for wheezing.
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-15**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for wheezing.
7. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Sig: One (1) PO twice a day: hold
if HR < 60.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
15. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO qd ().
. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week:
verify dose with Patient
. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO qd ().
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Albuterol Sulfate 0.083 % Solution Sig: [**1-15**] Inhalation Q6H
(every 6 hours) as needed for wheezing.
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-15**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for wheezing.
7. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Sig: One (1) PO twice a day:
hold if HR < 60.
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
14. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
15. Leflunomide 10 mg Tablet Sig: Two (2) Tablet PO qd ().
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for breakthrough pain.
17. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
18. Dolasetron Mesylate 25 mg IV Q8H:PRN n/v
19. FOSAMAX 70 mg Tablet Sig: One (1) Tablet PO once a week:
verify dose with Patient.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Degenerative disc disease.
Discharge Condition:
good
Discharge Instructions:
keep incisions clean and dry X 2.
Physical Therapy:
no lifting > 15 lbs. no bending/twisting
Treatments Frequency:
keep incision clean and dry
Accuchecks twice a day
Followup Instructions:
10 days with Dr [**Last Name (STitle) 363**] [**Telephone/Fax (1) 3573**]
Completed by:[**2197-11-16**] Name: [**Known lastname 1737**],[**Known firstname 1738**] Unit No: [**Numeric Identifier 1739**]
Admission Date: [**2197-11-13**] Discharge Date: [**2197-11-27**]
Date of Birth: [**2143-11-7**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Shellfish / Fish Product Derivatives / Barium
Sulfate / Iodine
Attending:[**First Name3 (LF) 1740**]
Addendum:
Pt developed acute renal failure requiring an ICU transfer
[**Date range (1) 1741**].
Major Surgical or Invasive Procedure:
anterior lumbar fusion L5-S1 [**2197-11-13**]. posterior lumbar fusion
L5-S1 [**2197-11-14**]
Past Medical History:
RA--on chronic prednisone and arava
osteoporosis
spinal stenosis s/p laminectomy and decomp of C6-C7
recent pyelo/ horshoe kidney
ulcerative keratitis from RA
reactive airway disease
RLL nodules (seen [**2197-3-29**])
chronic anemia-Fe deficiency
reactive airway disease
Social History:
Denies EtOH, tobacco, illicits
Family History:
NC
Pertinent Results:
[**2197-11-27**] 03:11AM BLOOD WBC-8.5 RBC-2.90* Hgb-7.9* Hct-24.2*
MCV-83 MCH-27.3 MCHC-32.7 RDW-15.9* Plt Ct-365
[**2197-11-24**] 08:11AM BLOOD WBC-9.6 RBC-2.94* Hgb-8.1* Hct-24.4*
MCV-83 MCH-27.7 MCHC-33.5 RDW-16.1* Plt Ct-388
[**2197-11-27**] 03:11AM BLOOD Plt Ct-365
[**2197-11-27**] 03:11AM BLOOD PT-12.8 INR(PT)-1.1
[**2197-11-27**] 03:11AM BLOOD Glucose-166* UreaN-98* Creat-4.0*# Na-139
K-5.2* Cl-107 HCO3-20* AnGap-17
[**2197-11-22**] 03:04AM BLOOD Glucose-128* UreaN-114* Creat-7.8* Na-141
K-5.2* Cl-103 HCO3-19* AnGap-24*
[**2197-11-17**] 03:49PM BLOOD Glucose-185* UreaN-22* Creat-4.0*# Na-136
K-4.5 Cl-103 HCO3-20* AnGap-18
[**2197-11-27**] 03:11AM BLOOD Calcium-8.5 Phos-4.6* Mg-1.6
Brief Hospital Course:
pt transferred to ICU 11/4-119 secondary to acute renal failure.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Albuterol Sulfate 0.083 % Solution Sig: [**1-15**] Inhalation Q6H
(every 6 hours) as needed for wheezing.
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-15**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day) as needed for wheezing.
5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Oxycodone 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
7. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO DAILY (Daily).
8. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): until ambulating regularly.
13. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
15. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
18. Valium 2 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed.
19. Hydrocortisone 20 mg Tablet Sig: Four (4) Tablet PO every
eight (8) hours: titrate per pcp.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
Discharge Diagnosis:
Degenerative disc disease. Acute renal failure.
Discharge Condition:
good
Discharge Instructions:
keep incisions clean and dry X 2.
Physical Therapy:
no lifting > 15 lbs. no bending/twisting
Treatments Frequency:
keep incision clean and dry
Followup Instructions:
10 days with Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 1742**]. 10 days with PCP Monitor
pt's creatinine/BUN levels QOD
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1743**] MD [**MD Number(1) 1744**]
Completed by:[**2197-11-27**]
|
[
"560.1",
"738.4",
"753.3",
"584.9",
"714.0",
"722.10",
"997.4",
"997.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"84.52",
"80.51",
"84.51",
"03.90",
"81.62",
"77.89",
"38.93",
"81.06",
"81.08",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
8802, 8872
|
6715, 6781
|
5513, 5609
|
8964, 8971
|
5993, 6692
|
9162, 9450
|
5969, 5974
|
6804, 8779
|
8893, 8943
|
1275, 2706
|
8995, 9029
|
918, 992
|
9047, 9088
|
9110, 9139
|
304, 317
|
479, 538
|
5631, 5904
|
5920, 5953
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,948
| 164,096
|
53065
|
Discharge summary
|
report
|
Admission Date: [**2195-2-23**] Discharge Date: [**2195-2-26**]
Date of Birth: [**2117-2-10**] Sex: M
Service: MEDICINE
Allergies:
Procainamide / Niacin
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78yoM cml hx, chf, ckd, presents with fever and cough. Pt
reports about 3 weeks of "not feeling well," associated with a
mild cough, runny nose, both of which worsened over past day. He
had sputum w/ his cough. Pt reports fevers at home, but no
temperatures were taken. Pt's cough worsened over past days,
with ongoing malaise and fatigue, and today had shaking chills,
became pale, and confused (per wife) prompting arrival in [**Name (NI) **].
In [**Hospital1 18**] ED, T 102.5, T 98.6 after tylenol, hr 90s, 120/70
triage with lower BP of 105/60 after transport to core, given
total 3L ivf, with BPs persistently in 90s. Pt was given
Ceftriaxone 1g IVx1, and Azithromycin 500mg po x1. Admitted to
[**Hospital Unit Name 153**] for closer monitoring of hemodynamics, possible pending
sepsis. 2pIVs.
.
[**Hospital Unit Name **] notable for nl lactate, no leukocytosis, INR 3.6 (on
coumadin for past cva), Cr 2.1 up from baseline 1.6. CXR bil
lower lobe infiltrates.
.
ROS: Pt noticed vibrations in his chest at the area of his
defibrillator, vomit x1 after taking gleevac pill. Denies
melana/hematochezia/hematuria/dysuria.
.
Past Medical History:
-chronic myelogenous leukemia on Gleevec
-s/p ICD implantation [**10-29**], h/o VT, EF 25% (echo [**3-31**])
-CKD - baseline Cr 1.1
-CAD, h/o IMI late [**2155**]'s, cath [**2183**] - RCA 90% proximal, totally
occ distally, akinetic inferoposterior segment, EF 25-30%
([**3-31**])
-Bilateral hearing aides
-Lumbar disc disease
-Depression
-[**2177**] CVA d/t LV thrombus - no residual deficits
-CHF, TTE [**3-31**] - LVEF 25%, severe global LV hypokinesis, 4+ MR,
3+
TR, mild pulmonary hypertension
Social History:
Lives with wife. Quit smoking 25 yrs ago, smoked 1 ppd x 20-25
years. ETOH 1 glass wine/day. No IVDU. Worked in construction,
worked only part-time after CVA in [**2178**], now retired. Was in the
military.
Family History:
(-) FHx CAD
no leukemia/lymphoma
Physical Exam:
T=97.9 BP=102/50 HR=78 RR=14 O2= 99%
PHYSICAL EXAM
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=7cm
LUNGS: bilateral rales L>R and expiratory wheezes
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: confused, mental slowing. Appropriate. CN 2-12 grossly
intact.
BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Lactate:1.7
Trop-T: 0.05 CK: 118 MB: 4
.
136 101 37 AGap=11
--------------< 130
4.6 29 2.1
.
101
9.6
6.7 >-----< 186
27.6
N:86.2 L:9.2 M:3.8 E:0.3 Bas:0.4
.
PT: 34.4 PTT: 32.9 INR: 3.6
.
Brief Hospital Course:
Mr. [**Known lastname 29436**] is a 78 year old man with a history of Chronic
Myelogenous Leukemia, Congestive Heart Failure and Chronic
Kidney Disease who presented with fever and cough, was then
found to have relative hypotension despite IVF resuscitation,
and was admitted to the medical ICU for possible sepsis and
hemodynamic monitoring.
.
Hospital course by problem:
.
#. [**Name (NI) **] Pt has had fevers, confusion and has bilateral
infiltrates on chest xray. He was treated with ceftriaxone and
azithromycin in ED. The likely etiology of the pt's chest xray
findings is bacterial, but with a history of CML the pt may be
immunocompromised and at risk for fungal infection. Blood
cultures, galactomannan and glucan were sent and were
unremarkable.
Initially in the ICU the pt was continued on ceftriaxone 2g QD
and azithro 500mg QD which was later changed to cefpodoxime and
azithro on discharge.
.
#. [**Name (NI) **] The pt's hypotension was likely secondary to
infection and improved with intravenous fluids and temporary
discontinuation of the pt's home metoprolol and [**Name (NI) **].
.
#. Altered mental status- On admission the pt was alert and
oriented to person, place and time but had cognitive slowing and
poor recall. This was attributed to delirium secondary to the
pt's infection. The patient's delirium cleared during his
admission.
.
#. CHF- On admission the pt appeared euvolemic, and given his
hypotension the pt's home lasix dose was held. This was
restarted on discharge.
.
#. CKD- On admission the pt's creatinine had increased to 2.1
from a baseline of 1.6. This was likely due to prerenal azotemia
in the setting of increased insensible losses due to infection
and decreased oral intake. The pt's creatinine improved after
receiving approximately 3L IVF in the ED.
.
#. Left ventricle thrombus- On admission the pt was
supratherapeutic on coumadin with an INR of 3.6. Coumadin was
held in the ICU. The patient's INR was stable at 2.0 on
discharge after reinitiation of coumadin for several days. He
was briefly on a heparin ggt due to concern that he may become
subtherapeutic (which he did very briefly to INR of 1.9).
-Patient discharged on coumadin 4 mg po qd x3 days with VNA to
provide home INR checks to ensure that patient remains
therapeutic.
.
Epistaxis/Bloody Sputum) The patient had epistaxis and very
bloody sputum for which he was monitored. This improved over
the course of his hospitalization.
.
Anemia) In the setting of the patient's bloody sputum and
epsitaxis his hct went down to 23 and he was transfused 1 unit
PRBC.
Medications on Admission:
1.Aspirin 81 qd
2.Metoprolol Succinate 50 qd
3.Lasix 40 mg qd
4.Calcium Carbonate 500 mg qd
5.Ferrous Sulfate 325 mg qd
6.Ranitidine HCl 150 qd
7.Pravastatin 40mg [**Hospital1 **]
8.Docusate Sodium 100 [**Hospital1 **]
9.Venlafaxine 75 mg qd
Discharge Medications:
1. Gleevec 400 mg Tablet Sig: One (1) Tablet PO once a day.
2. Furosemide 40 mg Tablet Sig: One (1) 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. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Ocuvite 150-30-6-150 mg-unit-mg-mg Capsule Sig: One (1)
Capsule PO once a day.
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily): or take per prior
home regimen.
10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: Take 4 mg po qd for three days and then can revert to prior
coumadin dosing schedule.
11. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO twice a day.
12. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO every other day.
14. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO three times
a day: take per prior home regimen.
15. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
16. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Delirium
Epsistaxis, Bloody Sputum
Anemia
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Patient to return to the ED if he is coughing up large amounts
of blood, develops difficulty breathing, has chest pain, high
fevers, light-headedness, confusion, significant weakness or
lethagy, red blood in his stool.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2195-4-20**]
9:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2195-6-4**]
8:00
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2195-6-4**] 9:20
Patient to schedule f/u with his PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Telephone/Fax (1) 608**].
|
[
"585.9",
"424.2",
"458.9",
"V45.02",
"411.81",
"584.9",
"285.9",
"784.7",
"311",
"486",
"414.01",
"293.0",
"412",
"428.22",
"428.0",
"V12.54",
"205.10"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7674, 7680
|
3261, 3606
|
288, 294
|
7776, 7796
|
3019, 3238
|
8063, 8638
|
2212, 2246
|
6133, 7651
|
7701, 7755
|
5866, 6110
|
7820, 8040
|
2262, 3000
|
243, 250
|
3634, 5839
|
322, 1450
|
1472, 1971
|
1987, 2196
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,244
| 135,273
|
45147
|
Discharge summary
|
report
|
Admission Date: [**2187-5-17**] Discharge Date: [**2187-5-23**]
Service: MEDICINE
Allergies:
Ipratropium
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
R IJ CVL placement [**5-17**]
History of Present Illness:
[**Age over 90 **]yo demented NH resident with CHF (EF 15%), CRI (Cr 1.0-1.3),
CAD s/p stents, DM who presents with labored breathing,
hypotension, diaphorisis, and confusion, suspected to have
urosepsis.
.
Pt was in USOH at [**Hospital3 2558**]. Noon fingerstick 327 and he
received 8 units regular insulin. At approximately 2:15 PM he
was noted to be poorly responsive, diaphoretic, and with labored
breathing. His systolic BP was 70, HR >110, he had a loose BM.
02 sat on RA was 80% increased to 92% with 2L NC. He is a full
code and family requests evaluation so PCP sent him to ED.
.
Of note, pt was recently admitted from [**3-2**] to [**3-22**] with
unresponsiveness and fever. He required intubation in the ED due
to thick secretions versus mucus plugging. He was empirically
treated with vancomycin and zosyn for PNA. Extubated on [**3-7**],
but required regular airway suctioning. On the floor, he
deveolped new PNA (aspiration vs HAP). Abx were changed to
ceftazidime, flagyl
and IV vancomycin was continued. The patient defervesced and
his leukocytosis resolved. During his stay, he also had coag neg
staph TLC infection. He was followed by ID and it was decided to
cover him broadly with Vanc, Ceftax, Flagyl for 14 day course
which he completed on [**2186-3-29**].
.
His course was c/b by NSTEMI on admission that was managed
conservatively. Heparin gtt stopped due to GIB, Hct remained
stable at 25. Also AF/RVR responsive to IV BB, and ARF on
chronic, improved with IVF. Furthermore, CHF exacerbation with
EF of [**11-21**]% (previously 20% in 9/[**2186**]). Found to have thrombi
on the echo that decreased in size on repeat echo. Not a
candidate for anticoagulation given GIB. On the floor, again
acute resp distress. BNP of over [**Numeric Identifier 389**]. He was aggressively
diuresed and discharged on 100 PO lasix daily.
improved.
.
In the ED, his VS were T104, 106, 95/63, 36, 99%NRB.
Unresponsive on exam. An EKG showed old STD I, aVL. CXR was
unremarkable. Head CT without acute change. WBC up with left
shift. Lactate 2.2 -> 3.8. UA positive. Hypotensive to .80s/50s.
Received total of 1L IVF. Code sepsis was called. R IJ was
placed after two attempts. Vanc, Zosyn, Flagyl given and
admitted to ICU.
.
On arrival, pt was still unresponsive, satting well on NRB.
Past Medical History:
1. CRI- baseline creatinine 1.0 -1.3
2. CAD- h/o AMI [**2175**] s/p PTCA to proximal LAD
3. CHF- TTE [**2187**] with EF 15%
4. HTN
5. Dementia - mostly nonverbal, baseline is pleasant, alert and
confused (chronic microvascular infarcts)
6. Osteoporosis
7. Type 2 diabetes mellitus
8. Mild oropharyngela dysphagia --> thin liquids, pureed solids
9. h/o vasovagal syncope in setting of infections
10. h/o AV blocks and bundle branch blocks in setting of
infections
11. h/o multiple PNAs
12. acute cholecystitis s/p perc cholecystostomy tube placement
[**9-13**]
Social History:
Lives in nursing home, apparently has two caregivers who are
very involved Heavy tobacco use in past, but quit ~20 years ago,
no EtOH.
Daughter: [**First Name8 (NamePattern2) 96492**] [**Last Name (NamePattern1) 3228**] ([**Telephone/Fax (1) 96493**]
Family History:
NC
Physical Exam:
Vitals- T 96.4, BP 92/59, HR 67, RR 23, O2sat 99% NRB
General- elderly man lying in bed, nonresponsive
HEENT- NCAT, PERRL, EOMI, sclerae anicteric, very dry mucous
membranes
Neck- No significant JVP, no neck stiffness
Pulm- CTAB anteriorly
CV- RR, nl S1, S2, no obvious murmur appreciated
Abd- sparse BS, NT, ND, soft
Extrem- no LE edema, DP pulses 1+ bilaterally, feet cool
Neuro- nonresponsive to shouting, sternal rub or painful
stimuli, mild b/l UE rigidity, DTRs 0-1+ throughout, toes
downgoing
Pertinent Results:
On admission notable for positive UA, WBC of 18 with left shift.
Lactate of 2.2 ->3.8. Hct of 22 (on repeat 40 and 43). INR of
1.4.
.
Stool: C diff positive, stool culture otherwise negative
UCX [**5-17**]: pseudomonas, resistant to zosyn, sensitive to
meropenem
Bcx: negative
.
EKG- ST at 109, LAD, IVCD, old STD I,aVL
.
Head CT in ED: Age-related changes, stable from the prior
examination. No CT evidence for acute intracranial process.
.
CXR in ED: No evidence of pneumonia or CHF.
.
Cardiac Echo [**2187-3-19**]: EF 15-20%. Dilated, severely hypokinetic
left ventricle with a left ventricular thrombus. Compared with
the prior study (images reviewed) of [**2187-3-5**], the previously
seen apical thrombus is not seen (although the apex is not well
visualized). The previously seen inferior apical thrombus now
measures 1.0 x 1.6cm (previously measured as 1.5cm x 1.7cm). The
pulmonary artery systolic pressure is slightly higher on the
current study.
R PICC placed under ultrasound guidance on [**5-22**].
Brief Hospital Course:
Hospital course by problem:
1. Sepsis -UTI and Cdiff colitis: Patient was hypotensive and
unresponsive at rehab. Found to have urosepsis with Pseudomonas
growing from urine and severe C difficile colitis. BB and lasix
were held when patient was initially hypotensive. He responded
to 15 litres total of Ringers lactate boluses. He was initially
on IV vancomycin/Pip-Tazo, and then IV metronidazole and PO
Vancomycin were added on for severe C. difficile colitis. IV
Vancomycin was discontinued on [**5-20**] due to lack of Gram positive
culture data. His Piperacillin-Tazobactam was changed to
meropenem on [**2187-5-21**] when his UTI pseudomonas returned as
resistant to Zosyn but sensitive to meropenem, and he will need
to complete a 2-week course for urosepsis wiht last day on
[**2187-6-3**]. He will then need to complete an additional 2-weeks
of Oral Vancomycin 250mg PO q6 hours and oral metronidazole
500mg PO q8 hours up until 2 weeks after the completion of the
meropenem (last day [**2187-6-17**]). Patient's blood pressure
normalized with fluid boluses and furosemide and metoprolol were
resumed after this. PICC line was placed under fluoroscopy for
antibiotic administration.
2. Respiratory distress: In setting of sepsis and poor EF. CXR
clear. O2 sats remained stable on 3L NC. He received prn
nebulizers. Furosemide was resumed after achieving adequate
fluid resuscitation. He is currently on furosemide 100mg po
qday.
3. AMS: Reportedly A&Ox2 at baseline, improved with treatment
of sepsis. Head CT was wnl. TSH, B12, folate were wnl.
Hypernatremia was improved. Patient became responsive and gives
one word ansewrs to questions.
4. ARF: Resolved with IVF. Baseline creatinine 1.2-1.4. Cr of
2.0 on admission, improved back to baseline after aggressive IV
fluids consistent with prerenal etiology.
5. CAD: History of stents. EKG without acute changes. Recent
NSTEMI during last admission in setting of GI bleed on heparin
gtt. In ED, trop 0.03, then 0.07, then 0.09 in MICU, thus not
significantly elevated despite ARF. He was continued on ASA. BB
was initially held in setting of sepsis and restarted due to
recurrent ventricular ectopy on telemetry. He was started on a
dose of 6.25mg po bid, which is lower than his admission dose of
12.5mg po bid, and this will need to be uptitrated as tolerated
as outpatient. We also held his captopril during his stay due
to borderline blood pressure. This should be restarted and
titrated as an outpatient as his blood pressure improves.
6. Acute on chronic systolic CHF: EF of 15%. Recent CHF
exacerbation. On 100 Lasix PO daily on discharge from last
hospitalization, at rehab down to 30 daily. Lasix and BB were
held initially and were restarted due to positive fluid balance
after resuscitation.
7. Anemia: Hct baseline 25. In ED, Hct first 22, then 40-43
after initial resuscitation, eventually down to ~30 with IV
fluids.
8. Diabetes mellitus: Patient was transiently on Insulin drip
in the setting of sepsis. His tube feeds was resumed and his
regimen was adjusted with sliding scale and glargine 30 units at
breakfast. This will need to be further titrated as outpatient,
as his admission dose was insulin glargine 6 units qam and 35
units qhs.
9. Dementia: His memantine and donepezil were continued
throughout his stay.
10. Nutrition: Tube feeds were continued with free-water
boluses for hypernatremia.
11. Prophylaxis: Patient received pantoprazole and heparin
subcutaneously while in house.
12. Access: Right-internal jugular triple lumen catheter was
initially inserted then changed to a PICC line. PICC line will
need to be pulled after completion of Flagyl course.
13. Code status: FULL CODE, confirmed with Health-care proxy
14. Communication: - Wife [**Telephone/Fax (1) 96491**]
- Daughter (HCP) [**Name (NI) 96492**] [**Name (NI) 3228**] ([**Telephone/Fax (1) 96493**]
- Caregivers: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17**] and [**First Name9 (NamePattern2) 96494**] [**Doctor Last Name **] of Generations NH - 617
[**Telephone/Fax (1) **]
The patient was stable on the day of discharge and is discharged
back to [**Hospital3 2558**].
Medications on Admission:
1. Albuterol Q4H (every 4 hours).
2. Albuterol Q2H prn
3. Polyvinyl Alcohol-Povidone Ophthalmic PRN (as needed).
4. Heparin sc TID
5. Docusate Sodium PO BID prn
6. Atorvastatin 80 mg daily
7. Metoprolol 12.5 mg [**Hospital1 **]
8. Captopril 6.25 mg tid
9. Aspirin 325 mg daily
10. Donepezil 5 mg qHS
11. Memantine 5 mg PO BID
12. Citalopram 10 mg daily
13. Calcium Carbonate 500 mg PO QID
14. Cholecalciferol (Vitamin D3) 400 unit daily
15. Senna [**Hospital1 **] prn
16. Lansoprazole 30 mg daily
17. MVI daily
18. Acetaminophen q6h prn
19. Ferrous Sulfate 300 mg daily
20. Furosemide 30 mg daily (100 mg at discharge in [**3-16**])
21. RISS
22. Lantus 6U qAM and 35U qHS
23. Bisacodyl 5 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
2. Albuterol 90 mcg/Actuation Aerosol [**Date Range **]: One (1) Inhalation
every four (4) hours as needed.
3. Artificial Tears Drops [**Date Range **]: One (1) Ophthalmic twice a
day as needed for eye irritation.
4. Heparin (Porcine) 5,000 unit/mL Solution [**Date Range **]: One (1)
Injection TID (3 times a day): Continue while on antibiotics.
5. Acetaminophen 325 mg Tablet [**Date Range **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Atorvastatin 80 mg Tablet [**Date Range **]: One (1) Tablet PO once a day.
7. Metoprolol Tartrate 25 mg Tablet [**Date Range **]: [**2-7**] Tablet PO twice a
day: Hold for systolic blood pressure < 90 or heart rate less
than 50.
8. Donepezil 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO at bedtime.
9. Memantine 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO twice a day.
10. Citalopram 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
11. Calcium Carbonate 500 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO
four times a day: Please separate from all other medications by
1 hour.
12. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (2) **]: One (1)
Tablet PO once a day.
13. Senna 8.6 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO twice a day as
needed for constipation: Hold for diarrhea. Capsule(s)
14. Docusate Sodium 100 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO twice a
day as needed for constipation: Hold for diarrhea.
15. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. Multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
17. Iron 325 mg (65 mg Iron) Capsule, Sustained Release [**Last Name (STitle) **]: One
(1) Capsule, Sustained Release PO once a day.
18. Furosemide 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
19. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Twenty Four (24)
Units Subcutaneous at bedtime.
20. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: Per sliding
scale Injection QACHS.
21. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
22. Vancomycin 250 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours) for 4 weeks: To complete regimen 2 weeks after
meropenem finishes, last day [**2187-6-17**].
23. Meropenem 500 mg Recon Soln [**Year (4 digits) **]: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 2 weeks: To complete 2 week
course with last day on [**2187-6-3**].
24. Metronidazole 500 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO three
times a day for 4 weeks: To complete course 2 weeks after
meropenem finishes, last day [**2187-6-17**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnoses
Septic shock
Acute renal failure
Complicated urinary tract infection with urosepsis
C. difficile colitis
Hypernatremia
Dehydration
Secondary diagnoses:
Diabetes mellitus
Hypertension
Coronary artery disease
Dementia
Discharge Condition:
Stable, tolerating tube feeds.
Discharge Instructions:
You were admitted with septic shock from urine infection and C.
difficile colitis. You were started on antibiotics for this and
will need to complete a 2 week course (meropenem) for the urine
infection and a total of 4 weeks (PO vancomycin and IV flagyl)
for the C. difficile colitis. You received intravenous fluids
for low-blood pressure and your blood pressure medications were
changed from the ones that you came in on. Please follow-up
with your primary care physician for further adjustment of your
blood pressure medications as appropriate. Please contact your
physician or return to the emergency room if you notice fevers,
lightheadedness, or any other concerning symptoms.
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks.
Completed by:[**2187-5-23**]
|
[
"486",
"285.9",
"250.00",
"428.0",
"041.7",
"403.90",
"414.01",
"038.9",
"428.23",
"995.92",
"294.8",
"008.45",
"599.0",
"V45.82",
"276.0",
"585.9",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
12911, 12981
|
5030, 5030
|
231, 262
|
13260, 13293
|
3993, 5007
|
14028, 14150
|
3452, 3457
|
9963, 12888
|
13002, 13152
|
9241, 9940
|
13317, 14005
|
3472, 3974
|
13173, 13239
|
180, 193
|
5059, 9215
|
290, 2585
|
2607, 3168
|
3184, 3436
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,802
| 109,016
|
17469
|
Discharge summary
|
report
|
Admission Date: [**2190-8-2**] Discharge Date: [**2190-8-3**]
Date of Birth: [**2149-10-9**] Sex: F
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
Bronchoscopy with metal stent removal
History of Present Illness:
40 year old woman with h/o central airway amyloid with tracheal
narrowing at several levels s/p left main stem stenting in the
past complicated by stent narrowing and stent break up now comes
to the micu for observation.
She has been treated for asthma since college for shortness
of breath with no relief. She was later found to have tracheal
stenosis. She underwent tracheal stenting with 2 bare metal
stents to her mid trachea and left main stem in [**2188-6-9**]. She
had mesh stent placed in [**2189-4-9**]. She had radiation done in
[**2189-9-9**]. She has been on steroids intermittingly in [**2189**].
She had repeat bronchoscopy in [**2190-6-16**] demonstrating presence of
metal wall tracheal stent with evidence of tracheal deformity
and narrowing because of the stent. The Right main bronchus had
evidence of metal debris, probably from
the stent at the medial aspect of the right main bronchus. Rigid
bronchoscopy was attempted on [**2190-6-17**] and dilatation of the left
upper lobe was attempted by a
4 mm balloon, but the balloon could not be passed because of the
severe stenosis in the left upper lobe.
Patient then underwent elective tracheostomy at UNC-CH 11 days
ago complicated by yellow secretions and ?wound infection. She
has been on Keflex since that time.
She came today to the [**Hospital1 18**] where she underwent rigid
bronchoscoy. The tracheal stent was removed. She then had
balloon dilation of left main stem bronchus performed. She was
then sent to the PACU for observasation. She did well in the
PACU except for scant bloody secretions. She will be admitted to
the MICU for observations and repeat bronchoscoy in the AM. She
currently has no complaints. No chest pain, shortness of breath,
fevers, chills.
Past Medical History:
Central Airway Amyloid: see HPI for details
S/p Tracheostomy: 11 days ago
Social History:
Lives in [**Doctor First Name 5256**]. Works for department of health Diabetes
program. Lives with her husband and two children. No h/o ETOH,
smoking, drug use.
Family History:
Father with [**Name2 (NI) 2320**]
Physical Exam:
GEN: sitting in bed in NAD
HEENT: trach in place with trace amount of blood in secretions.
trach mask in place. NO cervical LAD
COR: RRR No M/R/G
LUNGS: CTA bilaterally
ABD: soft, NT, ND, +BS
EXT: No LE edema
NEURO: Alert and oriented x 3
SKIN: no rashes
Pertinent Results:
CXR [**8-2**]: left hemidiaphragm elevation. Volume loss. ?LUL
collapse. two bare metal stents still in place.
CXR [**8-3**]: interval improvement in Left lung ventilation, stent
still in place in L mainstem bronchus.
Brief Hospital Course:
40 year old woman with central airway amyloidosis s/p tracheal
stent removal.
1) Central airway amyloid: has complicated history and is s/p
radiation and multiple stents to her trachea. She is also on
prednisone with mild improvment in symptoms. She continues to
suffer from tracheal stenosis and granulation tissue. This may
have been exacerbated by the broken metal stent that was removed
today.
- admit to MICU for observation on trach mask
- no events overnight
- cxr in AM demonstrated much improved L lung ventilation
2) trach site infection: patient on extended course of keflex
prior to admission, with no obvious infection now.
- continue keflex per outpatient regimen for seven days
3) FEN: regular diet today. NPO after MN for repeat bronch in AM
4) PPX: out of bed with assist
5) Code: full
6) Access: PIV
7) Communication: husband is proxy. [**Name (NI) **] is in N.C.
8) Dispo: d/c to home today
9) Follow-up with interventional pulm on Monday [**2190-8-9**] for
rigid bronch.
Medications on Admission:
Prednisone 40 mg po qd
Nexium 40 mg po qd
Keflex 500 q6h
Discharge Medications:
Prednisone 40mg po qd
Nexium 40mg po qd
Keflex 500 q6h
Discharge Disposition:
Home
Discharge Diagnosis:
Central airway amyloid
Discharge Condition:
Good, stable
Discharge Instructions:
Return to hospital on Monday for repeat rigid bronchoscopy.
Return to hospital for difficulty breathing or coughing up
blood. Please call your physician if you have any questions
about your symptoms.
Followup Instructions:
Return to [**Hospital1 69**] on Monday [**2190-8-9**]
for rigid bronchoscopy by Interventional Pulmonary.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
|
[
"786.3",
"517.8",
"V55.0",
"277.3",
"519.1",
"996.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.91",
"98.15",
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
4176, 4182
|
2995, 3990
|
318, 357
|
4248, 4262
|
2752, 2972
|
4511, 4710
|
2427, 2462
|
4097, 4153
|
4203, 4227
|
4016, 4074
|
4286, 4488
|
2477, 2733
|
268, 280
|
385, 2136
|
2158, 2233
|
2249, 2411
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,826
| 126,716
|
47040
|
Discharge summary
|
report
|
Admission Date: [**2182-3-9**] Discharge Date: [**2182-3-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
Thoracentesis
History of Present Illness:
88 year old female with history of Stage IV right sided breast
cancer (no chemo d/t poor functional status) and CVA with chief
complaint of lethargy. Pt was sent to [**Hospital1 18**] ED from [**Hospital 15332**], where, [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], the pt was found to be
bradycardic to 40's, and unobtainable BP on the day of
admission. The pt was picked up by a BLS ambulance and atropine
was not given. Per pt's family since a week prior to admission
the pt has been more listless, less interactive and more
lethargic on visits. They note that recently she has had
difficulty with swallowing at [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]. At [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **],
the pt was currently being treated for aspiration pneumonia with
levaquin and flagyl since [**2182-3-6**].
.
In the ED, initial vs were: P 100 BP 60's systolic, 100% NRB. Pt
received Vanc, Zosyn and rectal tylenol and norepinephrine was
started for hypotension. Lactate was noted to be in the 5's. A
CVL was placed in the ED. 3L NS was given. Exam notable for L
sided weakness which is residual from old CVA. CXR showed
evidence of left effusion, infectious versus malignant. Pt was
admitted to the MICU for presumed sepsis.
Past Medical History:
s/p basal ganglia CVA in [**5-14**]
L.carotid stenosis 60% MRI/MRA in [**4-12**]
valvular heart disease
Hypertension
Osteoarthritis
peripheral vascular disease
depression
LBBB at least since [**4-12**]
Prolonged QTc
Social History:
Denies tobacco, alcohol, drugs. Lived in [**Location 74419**], [**State 4260**] with
son and daughter-in-law. Moved to [**Location (un) 86**] [**9-13**] to be with
daughter and receive further rehab care.
[**0-0-**], work phone number, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (daughter)
Family History:
Diabetes, hypertension, heart disease
Physical Exam:
Vitals: T: 95.6 BP: 108/59 P: 89 R: 24 O2: 100% 3L NC
General: Alert, oriented, no acute distress; reports that she
feels "lazy."
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Right rhonchi, left minimal breath sounds, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox2 (to [**Hospital1 18**], [**Holiday **], name, not oriented to year).
Speech slow.
CN II-XII intact, Strength 4/5 in RUE, less in LUE
Pertinent Results:
CXR ([**2182-3-9**])
FINDINGS: There has been interval development of a massive left
pleural
effusion. There is only a small component of the left upper lung
demonstrating aeration. There is resultant mass effect with
rightward
deviation of the mediastinum. Although cardiac silhouette size
is impossible to assess given the presence of a massive left
effusion, it is presumed relatively stable in size. The right
lung is grossly clear free of any focal consolidation. The
extreme right costophrenic angle has been excluded from view,
but no large effusion is seen on the right. There is no
pneumothorax. The underlying osseous structures again reveal
relatively stable marked degenerative change.
IMPRESSION: Interval development of a massive left pleural
effusion with
resultant mass effect on the mediastinum. Correlate clinically.
.
[**2182-3-9**] 10:10PM BLOOD WBC-14.3*# RBC-5.27 Hgb-13.3 Hct-41.8
MCV-79* MCH-25.2* MCHC-31.8 RDW-14.7 Plt Ct-511*#
[**2182-3-9**] 10:10PM BLOOD PT-15.4* PTT-26.4 INR(PT)-1.4*
[**2182-3-9**] 10:10PM BLOOD Glucose-117* UreaN-39* Creat-1.9* Na-138
K-4.8 Cl-98 HCO3-19* AnGap-26*
[**2182-3-10**] 05:55AM BLOOD ALT-6 AST-31 LD(LDH)-339* AlkPhos-99
TotBili-0.8
[**2182-3-9**] 10:10PM BLOOD Calcium-9.3 Phos-6.1*# Mg-2.4
[**2182-3-9**] 10:19PM BLOOD Lactate-5.9*
[**2182-3-9**] 10:19PM BLOOD Lactate-5.9*
[**2182-3-10**] 06:21AM BLOOD Lactate-1.3
Brief Hospital Course:
# Sepsis: Patient with hypotension and tachycardia with
leukocytosis and elevated lactate level. The source was thought
to be pulmonary infection given large effusion. She was fluid
hydrated to CVP 8-12 and started on norepinephrine to MAP >65.
She was started on vancomcycin and zosyn. She was initially on a
non-rebreather but weaned down to nasal cannula. Blood cultures
were no growth to date at time of call out of ICU. She was
weaned off pressors on hospital day 2. Her antibiotics were
changed to unasyn on day 3 given her clinical improvement. She
will need to complete a 10 day course, to finish [**2182-3-18**].
.
# Pleural effusion: She was found to have a large left sided
pleural effusion, which was though to be either of malignant or
pneumonic etiology. She had a recent chest fiml that showed left
consolidation with effusion so she was started on broad spectrum
antibiotics. However, she also had a recent PET scan with
mediastinal LN involvement malignancy was also considered. She
underwent a diagnostic and therapeutic thoracentesis that
demonstrated exudative physiology. Initial results were not
consistent with infection with culture and cytology was negative
for malignant cells. Effusion subsequently reaccumulated.
Repeat thoracentesis showed a similarly exudative physiology.
She remained stable on 2L NC O2 and was thus discharged with
plans to follow up with the interventional pulmonologist in 2
weeks. At that time the cytology from the second fluid sample
will be followed up.
.
# Acute renal failure: She was found to have an elevated
creatinine, which was thought to be due to either reduced renal
perfusion in the setting of hypotension, possibly ATN. Her ACE
inhibitor and diuretics were held. Her medications were renally
dosed. Her renal function improved to baseline with fluid
hydration.
.
# Anion-gap acidosis: Pt initially had an anion gap of 21, with
a delta-delta of [**10-11**] which suggests a metabolic alkalosis as
well. The anion gap acidosis likely due to lactic acidosis and
uremia. The acidosis and her anion gap closed with normalization
of her lactate with fluid resuscitation.
.
# Hypertension: Her anti-hypertensives were held in the setting
of hypotension. The amlodipine and lisinopril were restarted.
Her HCTZ will be restarted on discharge.
.
# H/o CVA: She was continued on her home statin.
.
.
Medications on Admission:
AMLODIPINE 5 mg once a day
CARBIDOPA-LEVODOPA - 25 mg-100 mg Tablet - 1.5 Tablet(s) by
mouth
four times a day
CLOPIDOGREL [PLAVIX] - 75 mg daily
HYDROCHLOROTHIAZIDE - 25 mg daily
LISINOPRIL - 20 mg DAILY
POLYETHYLENE GLYCOL 3350 [MIRALAX]
SIMVASTATIN 10 mg at bedtime
ACETAMINOPHEN
BISACODYL 10 mg Suppository
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] 30 ml by mouth daily as
needed for constipation
SODIUM PHOSPHATES [FLEET ENEMA] rectally daily as needed for
constipation 2 hours post dulcolax
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
primary: pneumonia
secondary: hypertension
Discharge Condition:
A&O x 2, requires 2L O2 by nasal cannula, not ambulatory
Discharge Instructions:
You came to the hospital because of fevers. You were found to
have a pneumonia. This was likely due to aspiration of food
into your lungs. You were treated with antibiotics. You will
need to continue IV antibiotics until [**3-18**].
Followup Instructions:
We scheduled a follow-up [**Month/Year (2) 648**] with the interventional
pulmonologist who removed the fluid from your lung.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2182-6-24**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4286**], 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
Name: [**Last Name (LF) 251**],[**First Name3 (LF) **] G.
Location: [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **]
Address: 545A CENTRE ST, [**Location (un) **],[**Numeric Identifier 6809**]
Phone: [**Telephone/Fax (1) 608**]
.
We also made an [**Telephone/Fax (1) 648**] with your primary care provider:
[**Name10 (NameIs) **] date: Friday [**2182-3-15**]
At that time you will be seen at [**First Name4 (NamePattern1) 4233**] [**Last Name (NamePattern1) **] by your Nurse
Practitioner [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 14034**]. Your doctors office [**Name5 (PTitle) **] [**Name5 (PTitle) 19301**]
notified regarding your discharge.
Completed by:[**2182-3-15**]
|
[
"311",
"584.9",
"038.9",
"507.0",
"174.9",
"196.3",
"276.2",
"197.0",
"438.20",
"443.9",
"995.92",
"511.9",
"276.3",
"401.9",
"196.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
7322, 7395
|
4415, 6779
|
269, 284
|
7484, 7543
|
3011, 4392
|
7828, 8999
|
2245, 2284
|
7416, 7463
|
6805, 7299
|
7567, 7805
|
2299, 2992
|
221, 231
|
312, 1659
|
1681, 1898
|
1914, 2229
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,200
| 147,685
|
38145
|
Discharge summary
|
report
|
Admission Date: [**2113-8-16**] Discharge Date: [**2113-8-18**]
Date of Birth: [**2061-5-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
altered mental status, distended abdomen, jaundice
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53-year-old man with histoyr of HCC with IVC thrombus receiving
CyberKnife, hep C, presents with worsening ascites and jaundice.
Patient presented to radiation oncology [**2113-8-16**] for another
scheduled CyberKnife treatment but was found to have worsening
abdominal distention, confusion, and was referred to the ED. Of
note, his CT-PET on [**2113-8-9**] showed completely obstructing IVC
thrombus.
.
In the ED, T 97.4, BP 123/74, HR 106, RR 21, 95%2L. He was found
to have AMS with asterixis and jaundice. INR was 12.9, tbili
9.2. He received 2 units of FFP, hydromorphine 4 mg PO x 1, and
was admitted to OMED.
.
On review of systems, patient is unable to answer many questions
due to his altered mental status.
Past Medical History:
ONCOLOGIC HISTORY:
Hepatocellular carcinoma:
- presented to [**Hospital3 417**] Hospital on [**2113-7-3**] with
fatigue, new-onset ascites and lower extremity edema. During his
hospitalization, CT identified as 7.8 cm mass in the right liver
extending into the IVC. His AFP was elevated at 49,833.
Thrombus
invading the IVC appeared to be both tumor and bland thrombus.
His portal vein was patent.
- [**2113-8-14**]: CyberKnife started
.
OTHER MEDICAL HISTORY:
1. Status post left femur fracture, [**2089**].
2. Hepatitis C.
3. History of orchitis.
4. History of nephrolithiasis.
5. Status post left knee replacement in [**2111**].
6. Osteoarthritis.
7. History of L2 vertebral fracture.
Social History:
(from OMR) The patient is married and lives with his wife. [**Name (NI) **]
does not have children. He is currently unemployed but
previously worked as a restaurant manager. Tobacco: One pack
per day for 30 years. Alcohol: History of abuse, now
occasional use. Illicits: History of IV drug use, last use 10
years prior.
Family History:
(from OMR) The patient's maternal aunt died of lung cancer. She
was a smoker. His mother died at 54 years of a brain aneurysm.
His father is alive at 75 years. He has four brothers without
health concerns.
Physical Exam:
T 96.4, BP 124/80, HR 107, RR 24, 94%RA
Gen: middle-aged man lying in bed watching TV, responding to
questions but unable to recall much history, oriented to name,
hospital (but "[**Hospital3 2576**]"), US president, not date
Neuro: positive asterixis
HEENT: EOMI, sclerae icteric
Neck: supple
Lungs: CTAB
CV: slightly tachycardic, normal S1/S2, no murmur
Abd: very distended, tense, mildly and diffusely tender, no
rebound tenderness, no guarding, bowel sounds present
Ext: 3+ edema bilaterally to sacrum
Pertinent Results:
[**2113-8-16**] 01:10PM WBC-10.4 RBC-5.00 HGB-13.7* HCT-40.9 MCV-82
MCH-27.5 MCHC-33.6 RDW-17.9*
[**2113-8-16**] 01:10PM PLT COUNT-301
[**2113-8-16**] 01:10PM PT-102.8* PTT-59.5* INR(PT)-12.9*
[**2113-8-16**] 01:10PM GLUCOSE-91 UREA N-12 CREAT-0.8 SODIUM-128*
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-17* ANION GAP-18
[**2113-8-16**] 01:10PM ALT(SGPT)-189* AST(SGOT)-292* ALK PHOS-200*
TOT BILI-9.2*
[**2113-8-16**] 01:10PM CALCIUM-8.4 PHOSPHATE-3.0 MAGNESIUM-2.1
Brief Hospital Course:
53-year-old man with histoyr of HCC with IVC thrombus receiving
CyberKnife, hep C, presents with worsening abdominal distention
and confusion. He was found to have altered mental status.
likely from ascites and known complete IVC occlusion. No fever,
no leukocytosis, no significant abdominal pain. Abdominal
distention is causing dyspnea. Of note, his CT-PET on [**2113-8-9**]
showed completely obstructing IVC thrombus. He was transferred
to ICU due to ongoing shortness of breath and desaturations on
the oncology medical floor to mid-80s. Prior to admission,
patient was supposed to have cyberknife procedure, however given
current clinical status, the procedure was cancelled. According
to radiation oncologists, treatment options had been exhausted.
Family meeting with oncology, ICU team, radiation oncology and
family was conducted and goals of care were discuss. Decision
was made to make patient DNR/DNI and to be sent home with
hospice.
Medications on Admission:
fentanyl patch 25 mcg/72hr
furosemide 40 mg PO daily
hydromorphone 4 mg PO q4h prn pain
lorazepam 0.5 mg q8hr prn anxiety
prochlorperazine prn
spironolactone 50 mg daily
Discharge Medications:
1. Hospice
[**Month (only) 116**] screen and admit to Hospice
2. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
every four (4) hours as needed for pain or shortness of breath.
Disp:*30 mL* Refills:*0*
3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
Disp:*10 Tablet(s)* Refills:*0*
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every
eight (8) hours as needed for confusion: Titrate to 3 bowel
movements per day.
Disp:*1200 ML(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice
Discharge Diagnosis:
1. Hepatocellular Carcinoma
2. IVC thrombus
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:
You were admitted to the hospital from your schedule radiation
oncology appointment due to low blood pressure. Once you were
admitted, you had some difficulties breathing. You were
transferred to the Intensive Care Unit for closer monitoring.
You had an ultrasound which showed no change in your tumors.
After discussion with your oncologist, radiation oncology and
your family, you are going home with hospice.
Followup Instructions:
None
Completed by:[**2113-8-21**]
|
[
"V66.7",
"571.5",
"453.2",
"276.1",
"V70.7",
"789.59",
"570",
"715.90",
"155.0",
"429.89",
"070.54",
"452",
"572.3",
"V43.65"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5465, 5523
|
3444, 4394
|
365, 372
|
5611, 5611
|
2949, 3421
|
6229, 6265
|
2199, 2408
|
4614, 5442
|
5544, 5590
|
4420, 4591
|
5791, 6206
|
2423, 2930
|
275, 327
|
400, 1119
|
5626, 5767
|
1141, 1838
|
1854, 2183
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,935
| 171,152
|
47469
|
Discharge summary
|
report
|
Admission Date: [**2157-1-27**] Discharge Date: [**2157-2-4**]
Service: MEDICINE/[**Company 191**]
CHIEF COMPLAINT: Gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: The patient is an 81 year-old
man with a history of severe coronary artery disease status
post three coronary artery bypass graft surgeries (the last
of which was in [**2153**]) and peptic ulcer disease status post a
Billroth I surgery approximately 50 years ago who presented
to the [**Hospital1 69**] Emergency
Department with a gastrointestinal bleed. He states that he
was in his usual state of health until six hours prior to
admission at which time he began experiencing black tarry
stools that occurred a total of four times. He states he has
had intermittent chest pain, dyspnea and finger paresthesias.
He called his primary care physician who referred the patient
to the Emergency Department. In the Emergency Department the
patient had an nasogastric lavage that demonstrated coffee
ground emesis that cleared after 250 cc. The patient's blood
pressure transiently dropped to a systolic of 80, this
pressure increased to 105 after a liter of normal saline. At
the time of transfer to the Intensive Care Unit, the patient
was without complaints.
PAST MEDICAL HISTORY:
1. Severe coronary artery disease status post three coronary
artery bypass graft surgeries the last of which was in [**2153**].
The patient's cardiologist is at the [**Hospital6 15291**]. His telephone number is [**Telephone/Fax (1) 100395**], beeper
#[**Numeric Identifier **].
2. Hypertension.
3. Peptic ulcer disease status post Billroth I in
approximately [**2106**].
4. Appendectomy.
5. Cholecystectomy.
6. Pacemaker placement.
7. Diverticulosis.
8. Irritable bowel syndrome.
9. Colonic polyps.
ALLERGIES: Amoxicillin causes a rash.
MEDICATIONS ON ADMISSION:
1. Isosorbide dinitrate 30 mg po q.i.d.
2. Rofecoxib.
3. Lorazepam.
4. Clopidogrel 75 mg po q day.
5. Propanolol 10 mg po four or five times a day.
6. Aspirin 81 mg po q day.
7. Amlodipine 2.5 to 5 mg po q day.
8. Fibercon.
9. Furosemide.
SOCIAL HISTORY: The patient has a remote tobacco history,
but he quit smoking approximately 30 years ago. He denies
any history of alcohol or illicit drug abuse. He is a former
hairdresser. He lives in [**Location 86**] with his wife.
FAMILY HISTORY: The patient's mother died at age 42 of
stomach cancer.
PHYSICAL EXAMINATION: The patient's temperature was 97.1.
Heart rate 65. Blood pressure 104/45. Respiratory rate 18.
Oxygen saturation 98% on room air. This is a pleasant man in
no acute distress. He has conjunctival pallor. Mucous
membranes are moist. Oropharynx is clear. His heart is a
regular rate and rhythm. There are normal S1 and S2 heart
sounds. There is a 2 out of 6 holosystolic murmur heard
throughout the precordium. His lungs are clear to
auscultation bilaterally. His abdomen was soft, nontender,
nondistended, and there are normoactive bowel sounds. He has
2+ dorsalis pedis pulses bilaterally and there is no
peripheral edema. Neurologically cranial nerves II through
XII are intact. He has normal finger nose finger testing,
sensation to light touch is intact and he has 5 out of 5
muscular strength in all extremities diffusely. Rectal
examination demonstrates guaiac positive, black tarry stool.
INITIAL LABORATORY EVALUATION: White blood cell count of
7.7, hematocrit 27.3, platelet count 158,000. PT 13.5, PTT
26.9, INR 1.2. Serum chemistries demonstrate sodium 137,
potassium 5.2, chloride 106, bicarbonate 26, BUN 71,
creatinine 1.6, glucose 107. His CK is 77 and his troponin
is less then 0.01.
Initial chest radiograph demonstrated no acute
cardiopulmonary abnormalities. Initial electrocardiogram
demonstrated normal sinus rhythm at 65 beats per minute,
normal axis, increased PR interval consistent with first
degree AV block, inferior Q waves, lateral Q waves and
inferolateral T wave inversions. There was no old
electrocardiogram available for comparison.
HOSPITAL COURSE: 1. Gastrointestinal bleeding: The patient
underwent three esophagogastroduodenoscopies this
hospitalization. These procedures were done on the 19th,
22nd, and [**2-2**]. Each procedure demonstrated slow
oozing of blood from the prior anastomotic site of the
patient's remote Billroth 2 surgical procedure. During the
first two esophagogastroduodenoscopies the most predominant
areas of oozing were treated with epinephrine and local
cautery. Because the patient's hematocrit continued to drop
following these procedures, during his third
esophagogastroduodenoscopy the anastomotic site was treated
with Argon plasma coagulation. Throughout the course of his
hospitalization the patient was transfused 7 units of packed
red blood cells and one unit of platelets for his falling
hematocrit. By the time of discharge his hematocrit was
stable at 36 for approximately 24 hours. The patient was
therefore deemed medically stable for discharge to home with
plans for a repeat hematocrit check on [**2157-2-7**].
Of note, because the patient's bleeding source was believed
to be his prior anastomotic site, surgical consultation was
obtained on the day prior to discharge for evaluation of any
possible surgical options that may resolve the patient's
bleeding. The surgical staff felt that continued medical
management was the first appropriate treatment for the
patient's ongoing oozing. This treatment initially
recommended by the Gastroenterology Service includes
Sucralfate 1 gram po q.i.d. and supplemental iron therapy.
In addition, the patient was naturally advised to stop taking
Rofecoxib. In addition, both his aspirin and his Clopidogrel
were held throughout his hospitalization. Neither of these
medications were restarted at the time of discharge and
further consideration to restarting these medications should
be made in conjunction with the patient and his primary care
physician following his discharge from the hospital. He was
also continued on a proton pump inhibitor throughout his
hospitalization. This medication will be continued on
discharge.
2. Coronary artery disease: The patient had several
episodes of chest pain throughout the beginnings of this
hospitalization. Throughout this time he had repeated
electrocardiograms, none of which demonstrated any changes
from his admission electrocardiogram. In addition, the
patient was ruled out for myocardial infarction by cardiac
enzymes on multiple occasions. Although his Propanolol was
initially held around the time of his acute gastrointestinal
bleeding on admission this medication was subsequently
restarted and titrated to both heart rate and blood pressure.
In addition, he was continued on his oral and topical
nitrates for treatment of his angina. As noted above his
antiplatelet agents including aspirin and Clopidogrel were
held throughout his hospitalization due to his ongoing
gastrointestinal bleeding. The patient was instructed to
follow up with his primary care physician and [**Name9 (PRE) 100396**]
regarding ongoing management of his coronary artery disease.
Given that he has already received at least coronary artery
bypass grafts, however, the patient is likely not a candidate
for repeat cardiac intervention, but will likely be medically
managed indefinitely.
3. Hypertension: As noted above, the patient's Propanolol
was titrated to blood pressure throughout the
hospitalization. In addition, his Losartan and Amlodipine
were held throughout the hospitalization. At the time of
discharge his Losartan was restarted, but his Amlodipine was
not. Further management of the patient's antihypertensive
regimen should be made in conjunction with the patient and
his primary care physician following discharge.
4. Anxiety: The patient was continued on his baseline
Lorazepam dose.
DISCHARGE PLACEMENT: Home.
DISCHARGE CONDITION: The patient's hematocrit had been
stable at 24 hours by the time of discharge. He is
tolerating a full diet and ambulating without assistance.
DISCHARGE DIAGNOSES:
1. Bleeding peptic ulcer.
2. Acute blood loss anemia.
3. Native vessel coronary artery disease.
4. Hypertension.
5. Low back pain.
DISCHARGE MEDICATIONS:
1. Isosorbide dinitrate 40 mg po t.i.d.
2. Propanolol 20 mg po q.i.d.
3. Lorazepam 2 to 4 mg po q.h.s. anxiety.
4. Nitropaste [**4-13**] of an inch transdermally b.i.d.
5. Sucralfate 1 gram po q.i.d.
6. Ferrous sulfate 325 mg po q.d. with [**Location (un) 2452**] juice.
7. Pantoprazole 40 mg po q.d.
8. Ezetimibe 10 mg po q.h.s.
9. Fibercon 1300 mg po q.d.
10. Sublingual nitroglycerin 0.4 mg prn chest pain.
11. Refresh tears 0.5%.
12. Cyanocobalamin 1000 micrograms po q day.
13. Losartan 25 mg po q.d.
The patient was instructed to go to the laboratory of his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2-7**] to
have a hematocrit checked. The patient's primary care
physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] was contact[**Name (NI) **] on the day of the
patient's discharge. Dr. [**First Name (STitle) **] will follow up on the
result of the hematocrit check. In addition, the patient was
instructed to arrange for a follow up with his primary care
physician during the week following his discharge from the
hospital. Further consideration or adjustment of the
patient's medication regimen should be made at that time.
The patient was also scheduled for a colonoscopy with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**] on [**2157-2-25**]. The patient was
provided with further details regarding this procedure by the
Gastroenterology Service prior to his discharge from the
hospital. The patient was advised to return to the Emergency
Department in the event of shortness of breath,
lightheadedness, chest pain, or recurrent blood in the stool.
He was advised to stop taking Rofecoxib, Clopedigril and
aspirin. All of the above was discussed.
[**First Name8 (NamePattern2) **] [**Doctor First Name **], M.D. [**MD Number(1) 19814**]
Dictated By:[**Doctor Last Name 25381**]
MEDQUIST36
D: [**2157-2-4**] 03:38
T: [**2157-2-9**] 07:17
JOB#: [**Job Number 100397**]
|
[
"V45.81",
"V12.72",
"V45.01",
"458.9",
"414.01",
"533.40",
"401.9",
"285.1",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.41",
"99.29"
] |
icd9pcs
|
[
[
[]
]
] |
7888, 8033
|
2348, 2404
|
8054, 8191
|
8214, 10284
|
1842, 2091
|
4034, 7866
|
2427, 4016
|
127, 152
|
181, 1243
|
1265, 1816
|
2108, 2331
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,734
| 177,714
|
7079
|
Discharge summary
|
report
|
Admission Date: [**2119-12-14**] Discharge Date: [**2119-12-19**]
Date of Birth: [**2055-5-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tetanus Toxoid,Adsorbed
Attending:[**Known firstname 922**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2119-12-14**] Coronary artery bypass grafting x3 with left internal
mammary artery to left anterior descending coronary artery;
reversed saphenous vein single graft from the aorta to the first
obtuse marginal coronary artery; reverse saphenous vein single
graft from the aorta to the distal right coronary artery.
Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
64 year old male with failed kidney allograft referred for
cardiac catheterization as part of evaluation for kidney
transplant. His cardiac catheterization revealed severe three
vessel disease.
Past Medical History:
Hypertension
Polycystic kidney disease/End-stage renal disease with Kidney
Allograft failure and Hemodialysis MWF -> Right Subclavian
tunneled catheter and a non-matured left arm AV fistula
Gout
Anemia
Incarcerated Hernia as an infant (Surgically repaired)
Skin cancer s/p excision on back
Social History:
He is married to [**Doctor First Name 2013**], with 2 adult children who live locally.
He works in a sales position in own company. He denies any
alcohol, drug use or smoking.
Family History:
Mother and son with PKD.
Physical Exam:
Pulse:77 Resp:16 O2 sat: 95%RA
B/P Right: 119/72 Left: NO BP
Height: 5'7" Weight:200 lbs
General: WDWN in NAD
Skin: Dry, warm and intact. Right forearm is warm to palpation
with mild erythema. It is tender to touch. Right radial
ecchymosis at puncture site from cath. Left wrist AV fistula
with
minimal thrill.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign.
Neck: Supple [X] Full ROM [X] No JVD
Chest: Lungs clear bilaterally [X]
Heart: RRR, Nl S1-S2, No M/R/G
Abdomen: Obese, Soft [X] non-distended [X] non-tender [X] bowel
sounds + [X] RLQ renal transplant incision well healed. No
hepatosplenomegaly.
Extremities: Warm [X], well-perfused [X] Trace->1+ Edema (B)
Varicosities: None noted on standing. Some minor superficial
varicosities noted which don't seem to be related to GSV system.
Neuro: Grossly intact, MAE, Strength 5/5
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 1+ Left: +Thrill
Carotid Bruit: Right: + Bruit Left: Question very faint bruit
Pertinent Results:
[**2119-12-18**] 05:05AM BLOOD Hct-29.0*
[**2119-12-17**] 08:00AM BLOOD WBC-4.8 RBC-3.06* Hgb-8.8* Hct-27.8*
MCV-91 MCH-28.6 MCHC-31.5 RDW-16.6* Plt Ct-174
[**2119-12-14**] 11:55AM BLOOD WBC-5.6 RBC-3.39*# Hgb-9.8*# Hct-31.1*
MCV-92 MCH-29.1 MCHC-31.7 RDW-16.1* Plt Ct-125*
[**2119-12-18**] 05:05AM BLOOD PT-17.3* INR(PT)-1.6*
[**2119-12-17**] 08:00AM BLOOD Plt Ct-174
[**2119-12-14**] 11:55AM BLOOD Plt Ct-125*
[**2119-12-14**] 11:55AM BLOOD PT-16.0* PTT-29.7 INR(PT)-1.4*
[**2119-12-14**] 11:55AM BLOOD Fibrino-501*
[**2119-12-18**] 05:05AM BLOOD UreaN-37* Creat-6.3*# K-4.5
[**2119-12-17**] 05:22AM BLOOD Glucose-112* UreaN-41* Creat-7.4*# Na-141
K-4.7 Cl-102 HCO3-27 AnGap-17
[**2119-12-14**] 01:32PM BLOOD UreaN-34* Creat-6.8*# Cl-110* HCO3-24
[**2119-12-17**] 05:22AM BLOOD Calcium-8.8 Phos-5.5*# Mg-2.6
[**Known lastname 26413**], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 26414**] (Complete)
Done [**2119-12-14**] at 11:54:38 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**Known firstname 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2055-5-5**]
Age (years): 64 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Coronary artery disease. Left
ventricular function. Mitral valve disease. Right ventricular
function. Valvular heart disease.
ICD-9 Codes: 424.1, 424.0
Test Information
Date/Time: [**2119-12-14**] at 11:54 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**],
MD
Test Type: TEE (Complete)
3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.2 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.4 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Normal LV
cavity size. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (3). No AS. Mild (1+) AR. Eccentric AR
jet.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild
thickening of mitral valve chordae. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic 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 TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Conclusions
PRE-BYPASS: The left atrium is normal in size. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The aortic regurgitation jet is
eccentric. The mitral valve leaflets are moderately thickened.
Trivial mitral regurgitation is seen. There is no pericardial
effusion.
POST CPB:
1. Preserved [**Hospital1 **]-ventricular systolic function.
2. No change in vemvular structure or function
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2119-12-14**] 12:26
Brief Hospital Course:
He was admitted same day surgery and underwent coronary artery
bypass graft surgery. Please see operative report for further
details. He was transferred to the intensive care unit for post
operative management. In the first twenty four hours he was
weaned from sedation, awoke neurologically intact and was
extubated without complications. On post operative day one he
was transferred to the floor for the remainder of his care.
Renal was consulted for renal disease and dialysis. Physical
therapy worked with him on strength and mobility. He was ready
for discharge home on post operative day five with plan for
dialysis [**2119-12-21**] at outpatient dialysis.
Medications on Admission:
Amlodipine 5mg po BID
Calcium Acetate 667mg cap 4 capsules po TID
Cincalcet 30mg po daily (Tx secondary hyperparathyroidism in
CKD)
Colchicine 0.6mg po daily
Furosemide 80mg po BID
Leflunomide 20mg po BID
Metoprolol Tartrate 75mg po BID
**Warfarin 5mg po daily - stopped last week for cath (This was
to
maintain patency of HD Catheter)
Phoslo 463mg tab, 3 tablets po TID
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Leflunomide 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*360 Capsule(s)* Refills:*0*
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a week
: monday and thrusday .
Disp:*10 Tablet(s)* Refills:*0*
11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: dose
changes based on INR - please have checked at HD [**12-21**] for
further dosing .
Disp:*60 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*0*
13. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6011**] Care
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x 3
Hypertension
Polycystic kidney disease
Kidney Allograft failure
Hemodialysis MWF -> Right Subclavian tunneled catheter and a
non-matured left arm AV fistula - on coumadin for tunnel line
Gout
Anemia
Incarcerated Hernia as an infant (Surgically repaired)
Skin cancer s/p excision on back
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol prn
Discharge Instructions:
Please wash daily (no shower due to tunnel line per renal)
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:
Please call to schedule appointments
Surgeon Dr.[**Last Name (STitle) 914**] - tuesday [**1-23**] at 1:30pm [**Telephone/Fax (1) 170**]
Primary Care Dr. [**Last Name (STitle) **] in [**12-30**] weeks
Cardiologist Dr. [**Last Name (STitle) **] in [**12-30**] weeks
Nephrology Dr [**Last Name (STitle) 17315**] ([**Telephone/Fax (1) 26415**]
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
PT/INR for coumadin dosing to be done with dialysis and further
lab draws and dosing done at dialysis (Dr [**Last Name (STitle) 17315**] nephrologist)
Completed by:[**2119-12-19**]
|
[
"338.18",
"996.81",
"285.9",
"414.01",
"285.21",
"E878.0",
"276.7",
"V10.83",
"V58.61",
"V45.11",
"403.91",
"274.9",
"753.12",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"39.95",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
10137, 10193
|
7511, 8183
|
302, 671
|
10585, 10680
|
2553, 6318
|
11259, 11897
|
1416, 1442
|
8604, 10114
|
10214, 10564
|
8209, 8581
|
10704, 11236
|
6357, 7198
|
1457, 2534
|
250, 264
|
699, 894
|
916, 1207
|
1223, 1400
|
7208, 7488
|
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