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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
81,082
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33852
|
Discharge summary
|
report
|
Admission Date: [**2173-7-13**] Discharge Date: [**2173-7-17**]
Date of Birth: [**2127-8-16**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
end stage renal disease
Major Surgical or Invasive Procedure:
[**2173-7-13**] Living unrelated kidney transplant
History of Present Illness:
45-year-old gentleman with end-stage renal disease secondary to
multiple etiologies. He underwent nephrectomy at age 15 for
recurrent infections and
underwent a renal biopsy of his remaining kidney, which
demonstrated a secondary FSGS. He has over the last several
years progressed to end-stage renal disease and presented on
[**2173-7-13**] for living unrelated kidney transplant from his fiancee.
Past Medical History:
PMH: HTN, diabetes (formerly treated with insulin, currently on
oral agents)
PSH: left nephrectomy in [**2142**] and an AV fistula constructed in
[**2171**]
Social History:
ETOH is one to two times per week. No smoking, no IV drug use
or marijuana use.
Family History:
His mother died at age 54. His father is currently alive with
heart disease. He has three siblings, two of the three with
diabetes and two children that are aged 12 and 15 are currently
healthy.
Physical Exam:
Day of discharge:
AVSS
Gen NAD
CV RRR
Chest CTAB
Abd soft, nontender, nondistended; incision clean/dry/intact; JP
drain site with suture in place
Ext no edema; WWP
Pertinent Results:
[**2173-7-17**] 04:35AM BLOOD WBC-2.8* RBC-2.94* Hgb-8.4* Hct-26.4*
MCV-90 MCH-28.7 MCHC-31.9 RDW-17.9* Plt Ct-114*
[**2173-7-17**] 04:35AM BLOOD Glucose-202* UreaN-58* Creat-2.8* Na-139
K-4.8 Cl-108 HCO3-21* AnGap-15
[**2173-7-17**] 04:35AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
[**2173-7-17**] 04:35AM BLOOD tacroFK-4.9*
[**2173-7-16**] 05:10AM BLOOD tacroFK-4.0*
[**2173-7-15**] 05:30AM BLOOD tacroFK-2.1*
[**2173-7-14**] 05:00AM BLOOD tacroFK-4.4*
[**2173-7-13**] Renal transplant ultrasound: 1. Patent renal transplant
vasculature with appropriate waveforms. 2. No hydronephrosis.
Brief Hospital Course:
The patient presented for a living unrelated kidney trasnplant
on [**2173-7-13**]. In the perioperative period he was kept intubated
due to moderate intraoperative hypotension requiring pressors.
He was noted to have a metabolic acidosis at the time of surgery
and started on a bicarbonate drip and sent to the SICU,
intubated. Overnight his acidosis improved and his blood
pressure stabilized off pressors. Urine output was 300-500mL/hr
in the first 24 hours postop. He was extubated in the morning
of postop day #1 and transferred to the floor later that day.
On the floor his diet was advanced from clear liquids to regular
diet. His pain was well controlled with oral pain medications.
He was initialy given cc per cc repletion of his urine output
with IVF, then transitioned to 1/2 cc per cc repletion. The
repletion was then discontinued and his urine output remained
appropriate. He ambulated and moved his bowels without
difficulty. The foley catheter was removed. His creatinine
decreased from >10 preop to 2.8 on the day of discharge. He
tolerated his immunosuppresion regimen and antibiotic
prophylaxis. His blood sugars were elevated to the 200-400s
initially and he was treated with first an insulin drip, then
transitioned to SC insulin lantus and sliding scale. He
received med teaching and demonstrated understanding of his home
meds and self care. His JP drain output decreased and the JP
drain was removed on the day of discharge. At the time of
discharge he was ambulating, voiding and eating without
difficulty.
He is discharged to home on [**2173-7-17**] in good condition.
Medications on Admission:
AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
EPOETIN ALFA [PROCRIT] 20,000 unit/mL Solution - 40,000 units
every 2 weeks
SIMVASTATIN 20 mg Tablet - 1 Tablet(s) by mouth once a day
SITAGLIPTIN [JANUVIA] 25 mg Tablet - 1 Tablet(s) by mouth once
[**Last Name (un) 5490**]
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] - (Prescribed by
Other Provider) - 320 mg-12.5 mg Tablet - 1 Tablet(s) by mouth
once a day
CALCIUM CITRATE-VITAMIN D3 [CALCIUM CITRATE + D] 315 mg-200 unit
Tablet - 1 Tablet(s) by mouth once a day
OMEGA 3-VITAMIN E-FISH OIL - 1,100 mg-700 mg-15 unit Capsule -
2 Capsule(s) by mouth once a day
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
2. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
7. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
10. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours) for 2 doses: DOSE AS DIRECTED BY TRANSPLANT CENTER;
YOU WILL BE CONTACT[**Name (NI) **] BY PHONE WITH YOUR DOSE STARTING TONIGHT
[**2173-7-17**].
11. hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
12. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Disp:*qS 30 days* Refills:*2*
13. Humulin N 100 unit/mL Suspension Sig: One (1) Unit
Subcutaneous with meals and at bedtime: Per insulin sliding
scale.
Disp:*qS 30 days* Refills:*2*
14. prednisone 10 mg Tablet Sig: 2.5 Tablets PO once for 1 days:
Take ONCE on [**Last Name (LF) 1017**], [**2173-7-18**] for your last dose of
prednisone.
15. test strips Sig: One (1) strip every four (4) hours: For
use with glucometer.
Disp:*qS 30 days* Refills:*2*
16. Alcohol Wipes Pads, Medicated Sig: One (1) wipe Topical
every four (4) hours.
Disp:*qS 30 days* Refills:*2*
17. syringe (disposable) Syringe Sig: One (1) syringe
Miscellaneous every four (4) hours: Insulin syringe and needle.
Disp:*qS 30 days* Refills:*2*
18. Pepcid (pt taking own home dexlansoprazole in lieu of this
medication)
Discharge Disposition:
Home
Discharge Diagnosis:
End stage renal disease
Living unrelated renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any
of the following:
fever (101 or greater), chills, nausea, vomiting, increased
abdominal pain or distension, constipation, pain/burning/urgency
with urination or incision redness/bleeding/drainage
You may shower; Do not apply powder/lotion/ointment to incisions
No driving while taking pain medication
No heavy lifting (nothing heavier than 10 pounds) or straining
You need to have your blood drawn on [**Last Name (LF) 766**], [**7-19**] for the
following: Chemistry, liver function tests, and tacrolimus
level. The blood should be drawn JUST BEFORE your morning dose
of tacrolimus is due. If you have this done at an outside
hospital, please ensure that the results are called or faxed to
Dr.[**Name (NI) 670**] office ASAP.
You will need to take insulin at home. Please call Dr.[**Name (NI) 670**]
office if you have any questions about your insulin dose. When
your are finished with the prednisone, your blood sugars are
expected to decrease and you may need less insulin.
Followup Instructions:
Department: TRANSPLANT CENTER
When: THURSDAY [**2173-7-22**] at 1:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: THURSDAY [**2173-7-29**] at 8:20 AM
With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: [**Hospital Ward Name **] [**2173-8-2**] at 10:10 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"272.4",
"250.60",
"403.91",
"458.29",
"357.2",
"276.2",
"585.6",
"582.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.92",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
6399, 6405
|
2110, 3722
|
326, 379
|
6507, 6507
|
1502, 2087
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7738, 8650
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|
6658, 7715
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1318, 1483
|
263, 288
|
407, 808
|
6522, 6634
|
830, 989
|
1005, 1088
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,596
| 133,963
|
40787
|
Discharge summary
|
report
|
Admission Date: [**2157-4-18**] Discharge Date: [**2157-4-22**]
Date of Birth: [**2100-12-21**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
left hemiparesis s/p tPA at OSH; called as Code Stroke
Major Surgical or Invasive Procedure:
Intravenous tPA at outside hospital
History of Present Illness:
Patient is Spanish speaking and during emergent situation,
history obtained from her husband, who speaks English and from
review of transfer records.
Ms. [**Known lastname 1005**] is a 56 year old Spanish speaking woman with a
PMH significant for HTN, HLD and DMII who was found down at home
at 2:30 AM. She was last seen normal at 2:00 AM, when she was
reported to be washing dishes by her husband. At 2:30 AM, the
family heard a thud and found her on the ground with slurred
speech and inability to move her left side. She was brought to
OSH, where she had a CT head that was negative for hemorrhage
and
then she received IV tPA at 4:05 AM. Also, her FS was 509 at
OSH,
so she received 10 units Insulin with resulting FS in the 320s
She was then transferred to [**Hospital1 18**] for further management.
ROS: Positive for the slurred speech and left sided weakness as
per HPI. According to her husband, she was more lethargic than
usual over the past few days, with increased sleepiness. No
recent illnesses.
Past Medical History:
-HTN
-HLD
-DM II
Social History:
She lives with her husband and children. She works in a daycare
center. No smoking, drinking or illicit drug use.
Family History:
HTN and DMII in her family. Her husband believes her mother and
brother may have had strokes, though he is not positive.
Physical Exam:
Vitals: T: 97.7 P: 88 R: 18 BP: 214/101 SaO2: 100% 4L NC
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, no murmurs appreciated
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Neurologic:
NIH Stroke Scale score was: 11
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 0
Mental Status: Awake, alert, oriented to person, place and date.
Spanish speaking but able to answer yes/no appropriately to
questions. Speech dysarthric (sounds slurred according to
husband). Able to name objects in Spanish.
Cranial Nerves: Pupils 3mm b/l and sluggishly reactive to light.
VFF to confrontation. EOMI without nystagmus. L lower facial
droop. Palate elevates symmetrically. Tongue protrudes in
midline.
Motor: Left hemiplegia. Flaccid left upper and lower
extremities.
Normal tone and full strength on right.
Sensory: diminished pinprick on left compared to right. No
extinction to DSS.
DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 0 1 0 0
R 2 0 2 1 0
Plantar response was flexor on the right and extensor on the
left.
Coordination: No intention tremor or dysmetria on finger-nose on
right. Unable to assess on left due to weakness.
Gait: deferred given left hemiplegia
Pertinent Results:
Labs on admission:
[**2157-4-18**] 05:45AM BLOOD WBC-8.2 RBC-4.20 Hgb-12.0 Hct-35.2*
MCV-84 MCH-28.5 MCHC-33.9 RDW-13.3 Plt Ct-226
[**2157-4-18**] 05:45AM BLOOD Neuts-73.9* Lymphs-21.3 Monos-3.9 Eos-0.5
Baso-0.4
[**2157-4-18**] 05:45AM BLOOD PT-11.3 PTT-18.1* INR(PT)-0.9
[**2157-4-18**] 05:45AM BLOOD Glucose-260* UreaN-12 Creat-0.6 Na-140
K-4.2 Cl-103 HCO3-27 AnGap-14
[**2157-4-19**] 02:32AM BLOOD ALT-15 AST-15 AlkPhos-74 TotBili-0.7
[**2157-4-19**] 02:32AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0 Cholest-325*
[**2157-4-19**] 02:32AM BLOOD %HbA1c-13.4* eAG-338*
[**2157-4-19**] 02:32AM BLOOD Triglyc-167* HDL-56 CHOL/HD-5.8
LDLcalc-236*
.
Urine/Micro:
[**2157-4-18**] 03:44PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020
[**2157-4-18**] 03:44PM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2157-4-18**] 03:44PM URINE RBC-3* WBC-10* Bacteri-NONE Yeast-NONE
Epi-0
[**2157-4-18**] 03:44PM URINE CastHy-1*
[**2157-4-18**] 03:44PM URINE Mucous-RARE
[**2157-4-20**] 02:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2157-4-20**] 02:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2157-4-20**] 02:15PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
[**2157-4-20**] 02:15PM URINE Mucous-RARE
[**2157-4-20**] URINE CULTURE-PENDING
[**2157-4-18**] URINE CULTURE-NEG
[**2157-4-18**] MRSA SCREEN-NEG
.
Imaging:
[**2157-4-19**] CT HEAD W/O CONTRAST:
Stable extent of acute infarcts as described above with no
evidence of hemorrhagic conversion.
[**2157-4-18**] MR HEAD W/O CONTRAST:
1. Acute infarcts in the right putamen, posterior limb of the
right internal capsule, right corona radiata, and left cerebral
peduncle in the mid brain. No evidence of hemorrhagic
conversion.
2. Chronic small vessel ischemic disease as well as a lacune in
the left
corona radiata.
[**2157-4-18**] CTA HEAD&NECK W&W/O C & RECON:
1. Hypodensity within the right frontal corona radiata, right
putamen, left head of caudate, left lateral thalamus and left
medial temporal lobe
concerning for infarct, age-indeterminate on CT. If clinically
warranted, MRI could be obtained to age these abnormalities.
2. While there is no large-vessel occlusion within the head,
there is slight paucity of distal M3 branches on the right
compared to the left, particularly on the inferior division.
3. Crescentic filling defect of the distal left common carotid
artery which may be secondary to focal atherosclerosis or a
focal dissection, though the latter is less likely as the
location is not typical.
4. Marked irregularity of the right vertebral artery which is
diffusely small in caliber and focal high-grade narrowing of the
left vertebral artery V4 segment intracranially. These likely
reflect a combination of hypoplastic vessels with underlying
atherosclerosis or dissection.
[**2157-4-18**] ECHO:
The left atrium is elongated. No thrombus/mass is seen in the
body of the left atrium. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
No mass or vegetation is seen on the mitral valve. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
Ms. [**Known lastname 1005**] is a 56 year old Spanish speaking woman with a PMH
significant for HTN, HLD and DMII who was found down at home
with slurred speech and left hemiparesis. She was within window
for tPA upon arriving to OSH, so she received the tPA at 4:05 AM
and was sent to [**Hospital1 18**] for further management. Upon arrival to
[**Hospital1 18**], about 15 minutes after IV tPA completed, her NIHSS was
11, for left hemiplegia, left facial droop, dysarthria and
sensory loss on the left. She underwent CTA, which did not show
any major artery flow limiting stenosis or thrombosis. She
therefore was
not sent for interventional angio. Based on the CT scan, it
appears she may have a stroke in the posterior limb of the
internal capsule on the right. She does have numerous vascular
risk factors, including poorly controlled HTN, DMII, and HLD.
She was initially admitted to the neuro ICU in light of
receiving intravenous tPA at OSH.
.
Neurologic: As noted above [**4-18**] CTA revealed patent vasculature.
[**4-18**] MRI head showed acute infarcts in the right putamen,
posterior limb of the right internal capsule, right corona
radiata, and left cerebral peduncle in the mid brain. No
evidence of hemorrhagic conversion. Chronic small vessel
ischemic disease as well as a lacune in the left corona radiata.
CT head 24H s/p tPA showed stable extent of acute infarcts as
described above with no evidence of hemorrhagic conversion.
Stroke Risk Factors were checked: LDL was 236 and we increased
home simvastatin to 80mg daily. HgbA1c 13.4; pt was started back
on home antiglycemics as it appeared pt was not taking
medications regularly. She was also placed on a insulin sliding
scale.
.
Cardiovascular: We allowed for autoregulation of blood pressure
initially to maintain SBP < 180. Home amlodipine 5mg daily to
restarted on [**Last Name (LF) 766**], [**4-25**], with holding parameters of SBP <
100. TTE showd no thrombus/mass is seen in the body of the left
atrium. No atrial septal defect or patent foramen ovale is seen
by 2D, color Doppler or saline contrast with maneuvers.
.
Pulmonary: No acute issues during admission.
.
Gastrointestinal / Abdomen: Pt tolerated PO diet as described
below. GI prophylaxis with famotidine during admission.
.
Nutrition: Evaluated by speech and swallow, cleared for regular
Cardiac/Heart healthy, Diabetic/Consistent Carbohydrate
Consistency: Soft (dysphagia); Thin liquids; medications with
thin liquids.
.
Renal: No acute issues; urine cultures negative x 2.
.
Hematology: Hct remained stable s/p tPA.
.
Endocrine: Pt was restarted on home PO regimen of glyburide and
metformin; insulin sliding scale was administered for goal FSBG
< 150.
.
Infectious disease: No active issues during admission.
.
Patient is discharged acute rehab and will be following up with
Dr. [**First Name (STitle) **] [**Name (STitle) **] as outpatient on [**2157-6-14**]. If patient is
still at the acute rehab facility at this point, please call
[**Telephone/Fax (1) 1694**] to reschedule. Patient is encouraged to follow-up
with neurology/Dr. [**Last Name (STitle) **] after being discharged out of acute
rehab.
Medications on Admission:
-Glyburide/Metformin 2.5/500 2 tabs [**Hospital1 **]
-Amlodipine 5 mg daily
-Simvastatin 20 mg daily
Discharge Medications:
1. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day as
needed for stroke secondary prophylaxis; LDL 236.
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
stroke secondary prevention.
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): [**Month (only) 116**] discontinue once patient has
increased mobility/activity.
4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please start on [**Last Name (LF) 766**], [**4-25**]. Do not administer if systolic BP
less than 100.
8. insulin lispro 100 unit/mL Insulin Pen Sig: Two (2) unit
Subcutaneous three times a day: insulin dose depedent on finger
stick glucose after each meals - please see attached sliding
scale .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
R anterior choroidal artery stroke and small L cerebral peduncle
stroke.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 1005**],
You were admitted due to a stroke. This was thought to be due
to your high blood pressure. You were started on aspirin for
stroke protection.
Your stroke risk factors were checked. Your cholesterol LDL was
236. Your home simvastatin was increased to 80mg daily as your
LDL cholesterol is too high (goal less than 70). You were
checked for blood glucose control with a HgB A1c. The level was
13.4 (goal less than 7.0). Please be sure to take your diabetes
medications as prescribed. You had a cardiac echocardiogram
which demonstrated no cardioembolic source. You need to
continue your blood pressure control. You should not smoke.
You should continue to eat a low fat healthy diet and follow up
with your primary care physician and stroke Neurology as noted
below.
It was a pleasure taking care of you.
Followup Instructions:
Please be sure to call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 6382**]
[**Last Name (NamePattern1) 29065**], at [**Telephone/Fax (1) 29068**] to schedule an appointment within [**6-5**]
days of leaving your rehabiliation center.
You are scheduled to follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **], who
oversaw your care during this admission:
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2157-6-14**] 2:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2157-4-22**]
|
[
"342.90",
"781.94",
"787.21",
"272.4",
"V45.88",
"434.91",
"250.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11544, 11591
|
7215, 10373
|
360, 397
|
11707, 11707
|
3388, 3393
|
12759, 13452
|
1629, 1752
|
10524, 11521
|
11612, 11686
|
10399, 10501
|
11882, 12736
|
1767, 2431
|
266, 322
|
425, 1441
|
2675, 3369
|
3407, 7192
|
11722, 11858
|
1463, 1481
|
1497, 1613
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,748
| 109,320
|
9768
|
Discharge summary
|
report
|
Admission Date: [**2170-10-16**] Discharge Date: [**2170-10-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
abdominal pain, shortness of breath
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
84 year old male with type 2 DM, hyperlipidemia, HTN, and anemia
presents abdominal pain and "feeling lousy" since the night
prior to admission. The patient reports that the pain began
yesterday before he went to bed, persisted and worsened until
early this am when he decided to go to the ED. He also reports
some mild SOB. Brought to [**Hospital1 18**] by EMS.
.
In ED, SBPs 100s, satting 96% on NRB. CXR showed pulmonary
edema, bilateral effusions. He was given IV lasix with some
improvement in oxygenation followed by an additional IV lasix,
ntg gtt, heparin gtt and plavix 300mg. Abdominal pain,
shortness of breath resolved and on admission to CCU pt reported
that he felt better than he had in a long time.
.
No prior cardiac history.
Past Medical History:
DM, type 2, diagnosed 40 years ago
Hyperlipidemia
Hypertension
Anemia
PVD, claudication
CRI (baseline 1.8)
b/l carotid bruits (right approx 70% peak 323/52, left 60-69%
peak 172)
Prostate CA
Bladder CA
s/p appendectomy
s/p hernia repair
Social History:
Retired truckdriver. Lives with his girlfriend who helps to
take care of him. Ex-smoker (quit 40 years ago), denies alcohol
use.
Family History:
Non-contributory
Physical Exam:
VS T 99.2, HR 65, BP 161/54, RR 29, O2sat 93% on 4L
Gen: Well appearing male in NAD, alert, awake
HEENT: MMM, EOMI
Neck: +JVD (JVP 14), carotid bruit b/l, L>R
CV: normal s1s2, no m/r/g
Resp: crackles bilaterally midway up lung field.
Abd: obese, soft, NT, ND, +BS
Ext: trace pulses b/l, no edema noted
Pertinent Results:
EKG: NSR, nl axis, 1-2 mm STD V4-V6, STE aVR
.
Cardiac cath:
LCMA: diffuse disease and heavily calcified, 60-70% distally
LAD: hazy ostial lesion with non-laminar flow, likely 60-70%
stenosed. Heavily calcified vessel with prox 40%, mid 40-50%,
supplies single diag.
LCx: mid AV groove 40%, branching OM3/LPL with 50% stenosis
prior to bifurcation, small caliber distal AV groove.
RCA: heavily calcified vessel with dense aortic calcium at its
origin; ostial 80% stenosis with mild pressure dampening;
proximal-mid 50%, mid-distal 70%, distal AV groove 50%
Hemodynamics: CO 6.34, CI 3.47
.
Chest CT: IMPRESSION:
1. Limited evaluation of the pulmonary arteries and aorta
without IV
contrast.
2. Pulmonary edema and bilateral pleural effusions.
3. Cholelithiasis.
4. Focal dilatation of the distal right ureter could represent
reflux.
.
[**2170-10-16**] 03:11PM GLUCOSE-185* UREA N-44* CREAT-1.7* SODIUM-138
POTASSIUM-3.4 CHLORIDE-108 TOTAL CO2-20* ANION GAP-13
[**2170-10-16**] 03:11PM ALT(SGPT)-53* AST(SGOT)-23 CK(CPK)-126 ALK
PHOS-107 AMYLASE-63 TOT BILI-0.5
[**2170-10-16**] 03:11PM CK-MB-7 cTropnT-0.58*
[**2170-10-16**] 03:11PM ALBUMIN-2.7*
[**2170-10-16**] 03:11PM %HbA1c-7.1* [Hgb]-DONE [A1c]-DONE
[**2170-10-16**] 03:11PM WBC-9.9 RBC-2.75* HGB-8.8* HCT-25.2* MCV-92
MCH-32.2* MCHC-35.0 RDW-17.4*
[**2170-10-16**] 03:11PM PLT COUNT-239
[**2170-10-16**] 03:11PM PT-13.0 PTT-30.6 INR(PT)-1.1
[**2170-10-16**] 02:40PM TYPE-ART PO2-68* PCO2-34* PH-7.42 TOTAL
CO2-23 BASE XS--1 INTUBATED-NOT INTUBA
[**2170-10-16**] 02:40PM HGB-10.0* calcHCT-30 O2 SAT-92
[**2170-10-16**] 08:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2170-10-16**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2170-10-16**] 08:00AM URINE RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2170-10-16**] 07:54AM LACTATE-1.2
[**2170-10-16**] 07:50AM GLUCOSE-362* UREA N-43* CREAT-1.8* SODIUM-136
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-20* ANION GAP-14
[**2170-10-16**] 07:50AM CK(CPK)-78
[**2170-10-16**] 07:50AM CK-MB-NotDone cTropnT-0.13*
[**2170-10-16**] 06:45AM cTropnT-0.15*
[**2170-10-16**] 06:45AM CK-MB-NotDone
.
Brief Hospital Course:
Mr. [**Known lastname 32923**] is a 84 year old male with DM2 who presented
with shortness of breath and abdominal pain, found to be
consistent with heart failure exacerbation resulting in demand
ischemia vs. UA/NSTEMI, found to have 3VD on cath.
.
Cardiac
1)Ischemia: Mr. [**Known lastname 32923**] presented with heart failure and ST
elevation of aVR. As his ECG was concerning for severe disease,
he was taken to the cath lab for possible evaluation. He was
found to have 3VD and he was evaluated by CV surgery for
possible CABG. He was taken off of Plavix for possible surgery.
They requested an echocardiogram and carotid ultrasound. He
was found to have right ICA 70-79% stenosis, left ICA 60-69%
stenosis. It was also noted that the patient had aortic
calcifications on CT scan. The above risk factors in addition
to his renal disease and advanced age pushed the decision
towards medical management. Plavix and aspirin were restarted.
.
2) LV function: The patient had a echo done on [**10-17**] which
showed an EF>60%. However, it was felt that the patient's
shortness of breath was likely secondary to pulmonary edema as
he had a PCWP >18. He was diuresed during this admission
(78kg->73kg) and electrolytes were followed. Diuresis resulted
in improved oxygen saturation and he was weaned from 4L NC to 2L
NC. Given appearance on CXR, there was some concern he may have
underlying lung disease. Would consider outpatient PFTs and
chest CT for further evaluation. He was discharged to home with
home O2 and PCP f/u.
.
3) Hypertension: Mr. [**Known lastname 32923**] had persistently high blood
pressures on hospital day [**2-2**]. He was placed on a nitro drip,
started on metoprolol. He was switched back to his outpatient
regimen of labetolol 900mg [**Hospital1 **], valsartan 160mg [**Hospital1 **], and norvasc
10mg QD. The nitro drip was weaned off on HD4 and imdur was
started in its place. Off of the nitro drip his SBPs have been
in the 150-160s which is probably appropriate for him given his
heart disease.
.
4) Renal: The patient's baseline creatinine is 1.8. He was
given a dye load during catheterization and therefore his
creatinine was carefully monitored. He has a slight increase in
creatinine which was felt to be due to diuresis. At discharge,
the patient's creatinine was at baseline.
.
5) Neuro: Mr. [**Known lastname 32923**] was disoriented during the admission,
occassionally unable to name the hospital and the date, likely
due to acute delerium on baseline dementia. His mental status
appeared to improve throughout the day. His delirium was likely
due to the hospitalization. He was closely monitored for signs
of infection and his CXR was clear of infiltrate and UA was
negative.
.
6) Anemia: The patient reports a history of anemia for which he
receives procrit every 3 weeks. He received 2U on this
admission with a less than expected bump in hematocrit. He was
guaiac negative and following hematocrits increased
appropriately.
7) Endocrine: Mr. [**Known lastname 32923**] has type 2 DM, with a HgbA1c of
7.1%. He was placed on a regular insulin sliding scale, with
QACHS finger sticks, but given his daily requirements was also
placed on fixed dose glargine. He was discharge on home insulin
and was instructed to measure fingersticks [**Hospital1 **] prior to his PCP
f/u appointment so that his insulin regimen can be appropriately
adjusted.
8) FEN: The patient was diuresed and therefore electrolytes were
checked frequently. He was repleted as necessary. He was
taking good PO. His B12 level was checked as he was on
supplementation as an outpatient and was found to be within
normal limits. He was continued on supplemental B12 while an
inpatient.
9) PPx: He was given pneumoboots while he was unable to
ambulate.
Medications on Admission:
Avandia 8mg daily
Insulin 2U qam (plus novolog)
Procrit (every 3 weeks)
Cilostazol 100mg [**Hospital1 **]
Lipitor 80mg daily
Diovan 320 daily
Glyburide 15.0 qam
Labetolol 600mg [**Hospital1 **]
Furosemide 40mg daily
ASA 81mg daily
Norvasc 10mg daily
Vitamin B12
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: 0.25 Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. insulin
insulin sliding scale per attached scale.
9. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous once a day.
Disp:*1 1* Refills:*2*
10. syringe
0.5 cc insulin syringe with 25 guage needle
dispense 100 refill 2
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO BID (2 times a
day).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
13. oxygen
3.5L O2/min continuous for portability pulse dose system.
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding
scale units Subcutaneous prn, per attached sliding scale.
Disp:*1 1* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Congestive heart failure
Coronary artery disease
Secondary:
Diabetes mellitus, type 2
Anemia
Renal insufficiency
Discharge Condition:
Stable. The patient is chest pain free, denies shortness of
breath and is ambulating on his own.
Discharge Instructions:
You were admitted for a small heart attack. You underwent
cardiac catheterization and were found to have multivessel
coronary artery disease. After evaluation by the surgeons, it
was decided that medical management of your heart disease would
be the best treatment for you. It is therefore important that
you take all of your medications as prescribed.
You are taking some new medications including a medication
called plavix. Additionally, you are taking a medication called
Imdur which is used to treat high blood pressure and the dose of
your labetolol has been increased to 900mg twice daily, from
600mg twice daily.
The other medications remain the same.
Please keep all outpatient appointments.
If you begin to experience any shortness of breath, chest pain,
lightheadedness or dizziness please call 911 or your physician
[**Name Initial (PRE) 2227**].
.
Please discuss with your PCP about getting pulmonary function
tests as an outpatient.
Followup Instructions:
You need to follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5292**] on Thursday
[**10-25**] at 10 am. [**Telephone/Fax (1) 5294**].
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 8937**] in
cardiology on [**10-30**] at 1:00pm.
|
[
"285.9",
"585.9",
"V10.46",
"272.4",
"433.30",
"401.9",
"410.71",
"428.0",
"293.0",
"250.00",
"414.01",
"V10.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"88.53",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
9535, 9593
|
4134, 7924
|
301, 326
|
9760, 9860
|
1884, 4111
|
10865, 11235
|
1529, 1547
|
8236, 9512
|
9614, 9739
|
7950, 8213
|
9884, 10842
|
1562, 1865
|
226, 263
|
354, 1105
|
1127, 1365
|
1381, 1513
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,473
| 159,740
|
250
|
Discharge summary
|
report
|
Admission Date: [**2151-2-21**] Discharge Date: [**2151-3-19**]
Date of Birth: [**2084-2-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2-23**] Redo sternotomy, CABG x 2, MVRepair (#26 annuloplasty band)
History of Present Illness:
66 yo M admitted preoperatively.
Past Medical History:
CAD s/p CABGx2 [**2124**], PPM, multiple PCI, NIDDM, GERD s/p dilation
of esophageal stricture, proxysmal A.fib, HTN
Social History:
retired communications technician
Physical Exam:
NAD
Admission exam unremarkable
Brief Hospital Course:
Mr. [**Known lastname 2487**] was admitted on [**2151-2-21**]. He remained on heparin and
nitroglycerin until he was taken to the operating room on
[**2151-2-23**] where he underwent a redo sternotomy, CABG x 2, and MV
repair. He was transferred to the SICU in critical but stable
condition on propofol, insulin, epinephrine, levophed,
milrinone, vasopressin. He was seen by electrophysiology for his
permenant pacer as well as for atrial fibrillation with pressor
dependency. He was started on amiodarone. His IABP was removed
on POD #2. He was started on heparin for a fib. He was started
on tube feeds. He was seen by heart failure who recommended
TEE/cardioversion, and he was cardioverted successfully, but he
reverted to a fib. He remained in the ICU, on inotropes and
pressors for many days. They were slowly weaned off with stable
hemodynamics. Bilateral chest tubes were placed for large
effusions. On [**3-6**] he was extubated. His milrinone was weaned
to off. On [**3-11**] he was seen by vascular surgery for R flank and
RLQ pain with a hematacrit and BP drop, retroperitoneal bleed
was found on CT scan, his heparin was stopped and he was
transfused. His creatinine rose to 3.0 after the bleed and
stabilized at 1.6. Anticoagulation was stopped, and his
hematocrit stabilized without further intervention.
He was transferred to the floor on POD #20. His creatinine rose
to 1.6, but has remained there. His Lasix was decreased due to
his creatinine. He'd had a persistent, small, right apical
pneumothorax which was unchanged with his pleural chest tube on
suction, water seal, or clamped. It was therefore removed, and
his post-removal chest x-ray showed no change. His
hemodynamics, and respiratory status have remained stable, his
oxygen saturation on room air is 94-95%, and he is ready to be
discharged home today.
Medications on Admission:
lisinopril, asa, zocor, reglan, protonix, toprol, actos,
glucotrol, plavix
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. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 6 days: then 200 mg daily until discontinued by Dr.
[**Last Name (STitle) 1295**].
Disp:*40 Tablet(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Pioglitazone 15 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
Units Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: as directed
Units Subcutaneous once a day.
Disp:*1 vial* Refills:*2*
14. Insulin syringes
1/2 cc syringes
Dispense # 100 with 2 refills prn
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital1 **]
Discharge Diagnosis:
CAD
MI [**2124**]
CABG x 2 [**2124**]
A fib
HTN
NIDDM
GERD
Esophageal dilation
Mult PCI
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 1295**] next week
Dr. [**Last Name (Prefixes) **] 2 weeks
Dr. [**Last Name (STitle) 931**] 2 weeks
Completed by:[**2151-3-19**]
|
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"401.9",
"530.81",
"512.1",
"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"99.62",
"34.04",
"00.17",
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icd9pcs
|
[
[
[]
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4330, 4384
|
730, 2573
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332, 405
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4516, 4524
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2698, 4307
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4405, 4495
|
2599, 2675
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4548, 4800
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4851, 5007
|
674, 707
|
282, 294
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433, 467
|
489, 607
|
623, 659
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,455
| 110,475
|
5802
|
Discharge summary
|
report
|
Admission Date: [**2121-3-27**] Discharge Date: [**2121-4-2**]
Date of Birth: [**2042-6-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Hematocrit drop, presumed GIB
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
2 units of packed red blood cells
History of Present Illness:
78 yo M w/ prior MWT, PVD (s/p SFA stending on [**2-16**] admission
started on [**Month/Year (2) 4532**]), DM, HTN, HCV/EtOH abuse, urinary retention
who presents to the ED from PCP's office in setting of
confusion, weakness and hypotension.
.
Of note, the patient had partial amputation of his right great
toe, caused by vasulopathy. The patient was recently admitted to
[**Hospital1 18**] for right SFA and popliteal stenting at which time he was
started on [**Hospital1 **] and pletal. In addition, course was
complicated by UTI (Klebsiella) and monitored for EtOH
withdrawal. The patient has been at [**Hospital3 **] until
this Monday when he returned home. He is unsure of his current
medications. He denies any drinking since before [**3-3**]
when he was initially hospitalized. The patient thinks he may
have had some dark stools earlier in the week. The patient
further mentions taking two Aleve per night for back pain. Mr.
[**Known lastname 23050**] has an abrasion on his upper lip but cannot remember
any trauma. He denies any recent incidents of nausea, vomiting.
He denies pain, chest pain, dyspnea, hematemesis of known
history of liver disease, but states that he has been drinking
since he was 16 years old. He does not remember his earlier
endoscopy or any diagnosis of [**Doctor First Name **]-[**Doctor Last Name **] tears.
In the ED, initial VS were 98.3F 94 81/44 100% on unknown amount
of O2. He received 1.2L of NS, with SBPs to low 100s. Labs
revealed an HCT of 21 (baseline 30), thrombocytosis, BUN/Cr
18/1.1, Lactate of 2.4 and normal coags. WBC was wnl. Given
these findings, was started on PPI gtt and admitted for further
evaluation to MICU. CXR was negative for acute process and CT
head revealed no .
.
On arrival to the MICU, the patient was resting comfortably and
had no complaints. He was being prepared for endscopy
Past Medical History:
-Peripheral arterial disease
-Diabetes
-Hypertension
-Hep C
-Urinary retention requiring straight cath at home{has refused
TURP}
-hx of GI bleed with resolving [**Doctor First Name 329**] [**Doctor Last Name **] tear
-ETOH abuse(active)
-Dyslipidemia
-Right superficial femoral artery and tibioperoneal trunk
stenting for nonhealing hallux ulcer. sp right partial hallux
amputation [**2120**]
Social History:
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):
alcohol:hx of drinking regularly since he was 16 and has
desribed himself as a recovering alcoholic for the last 20 yrs
and attends AA but does have relapses and last night he said
that he drank a [**1-6**] pt of whiskey and a beer, denies w/d sz of
blackouts
drugs: denies
tob:smoked 4ppd until 15 yrs ago
caffeine: [**2-7**] cups of coffee a day
Grew up in the [**Location (un) 86**] area. Entered National Guard in [**2055**] and
ultimately sent to [**Country 2784**]. Returned in the early 50s and
started working as a court officer. He was married once. He and
his ex-wife divorced about 25 years ago but still are in close
contact. She is remarried. He has a son who owns a local paper
company who recently got married. Currently lives alone in a
senior living facility in JamaicaPlain but was recently
discharged from [**Hospital 100**] Rehab following vascular surgery.
Family History:
Noncontributory
Physical Exam:
Admission Exam:
SBP 80s --> 110s, HR high 90s
General: Alert, oriented x 3, no acute distress, can state the
days of the week forward and backward
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD
CV: Heart sounds quiet, but S1, S2 no murmurs auscultated
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, midline scar, bowel
sounds present
GU: No foley
Ext: Warm and without edema, patient has had amputation of right
great toe
Skin: Hyperkeratosis and sloughing of dead skin on feet
Neuro: CNIII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
guiac + w dark stool
Discharge Exam:
VS: 97.5 110/60 65 18 100%RA
General: Alert, A&Ox3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, no LAD, No JVD
CV: Heart sounds quiet, reg rate and rhythm, nl S1/S2, no
murmurs auscultated
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, midline scar, bowel
sounds present
GU: No foley
Ext: Warm extremities bilaterally, no edema, patient has had
amputation of right great toe, 1+ DP b/l
Skin: Hyperkeratosis and sloughing of dead skin on feet,
melanotic lesion and dual colored dark lesion with irregular
borders in midline of back. superficial abrasion over right
knee.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
normal sensation of feet bilaterally
Pertinent Results:
Admission Labs:
[**2121-3-27**] 01:00PM BLOOD WBC-7.6 RBC-2.60*# Hgb-6.2*# Hct-21.6*#
MCV-83 MCH-23.9* MCHC-28.7*# RDW-16.4* Plt Ct-603*#
[**2121-3-27**] 01:00PM BLOOD Neuts-84.5* Lymphs-12.2* Monos-2.8
Eos-0.1 Baso-0.3
[**2121-3-27**] 01:00PM BLOOD PT-11.0 PTT-24.8* INR(PT)-1.0
[**2121-3-27**] 01:00PM BLOOD Glucose-183* UreaN-18 Creat-1.1 Na-135
K-4.5 Cl-103 HCO3-22 AnGap-15
[**2121-3-27**] 01:00PM BLOOD ALT-35 AST-48* LD(LDH)-200 AlkPhos-41
TotBili-0.3
[**2121-3-27**] 01:00PM BLOOD Lipase-60
[**2121-3-27**] 01:00PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.1
[**2121-3-27**] 01:00PM BLOOD Hapto-60
[**2121-3-27**] 01:00PM BLOOD TSH-2.1
[**2121-3-27**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2121-3-27**] 01:34PM BLOOD Lactate-2.4*
[**2121-3-27**] 08:57PM BLOOD Lactate-1.1
[**2121-3-27**] 08:47PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.016
[**2121-3-27**] 08:47PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
[**2121-3-27**] 08:47PM URINE RBC-3* WBC->182* Bacteri-FEW Yeast-NONE
Epi-1
[**2121-3-27**] 08:47PM URINE CastHy-4*
Hct trend (received 2 units PRBCs on [**3-28**] in AM):
[**2121-3-27**] 01:00PM BLOOD WBC-7.6 RBC-2.60*# Hgb-6.2*# Hct-21.6*#
MCV-83 MCH-23.9* MCHC-28.7*# RDW-16.4* Plt Ct-603*#
[**2121-3-27**] 06:36PM BLOOD Hct-18.5*
[**2121-3-28**] 01:02AM BLOOD Hct-23.2*#
[**2121-3-28**] 05:16AM BLOOD WBC-7.2 RBC-3.02* Hgb-7.4* Hct-23.9*
MCV-79* MCH-24.4* MCHC-30.8* RDW-17.0* Plt Ct-479*
[**2121-3-28**] 03:13PM BLOOD Hct-25.7*
[**2121-3-28**] 11:38PM BLOOD WBC-9.1 RBC-3.44* Hgb-8.2* Hct-27.9*
MCV-81* MCH-23.9* MCHC-29.5* RDW-17.1* Plt Ct-577*
[**2121-3-29**] 08:34AM BLOOD WBC-8.4 RBC-3.57* Hgb-8.6* Hct-28.7*
MCV-81* MCH-24.1* MCHC-30.0* RDW-17.4* Plt Ct-523*
Micro:
[**3-27**] Blood culture
[**3-27**] MRSA screen
[**3-27**] Urine Culture negative
[**3-27**] HELICOBACTER PYLORI ANTIBODY TEST positive
Imaging:
CXR [**2121-3-27**]: 1. No evidence of acute disease.
2. Newly apparent nodular focus projecting along the right lower
lung, probably a nipple shadow, although a pulmonary nodule
should be considered. When clinically appropriate, repeat PA
view with nipple markers is recommended.
.
CT head w/o contrast [**2121-3-27**]:
1. No evidence of acute intracranial process.
2. Age-related atrophy.
3. Chronic small vessel ischemic disease.
.
CT abdomen/pelvis w/o contrast [**2121-3-27**]:
IMPRESSION:
1. No evidence of retroperitoneal or intramuscular hematoma.
2. Left adrenal hypoattenuating mass is likely an adenoma.
3. Multiple bladder diverticula.
4. Extensive atherosclerotic disease and coronary artery
disease.
5. Old right posterior rib fractures and anterior wedge
compression of L2 and
multilevel lumbar degenerative disease.
6. Multiple tiny renal cysts, too small to characterize but
without
concerning features.
7. Right femoral stent is noted, patency cannot be assessed.
.
EGD [**2121-3-27**]:
Impression: Small hiatal hernia
Mild erythema and friability in the antrum compatible with mild
gastritis
Normal mucosa in the duodenum
Otherwise normal EGD to second part of the duodenum
Recommendations: The findings do not account for the symptoms
Serial hcts, monitor stool output; consider extraluminal blood
losses given recent femoral puncture. Would consider non-urgent
colonoscopy prior to d/c if within patient wishes and no
extraluminal bleeding site localized. Would discuss
[**Month/Day/Year 4532**]/aspirin with vascular surgery. Given overall well
appearance of the patient, would seem in favor of continuing if
stent high risk for occlusion.
.
[**2121-3-29**] CXR: PA and lateral upright chest radiographs were
reviewed in comparison to [**2121-3-27**].
Heart size and mediastinum are unremarkable. Lungs are
essentially clear. No pleural effusion or pneumothorax is
demonstrated. Hyperinflation of the upper lungs most likely
reflects emphysema.
No nodular opacity along the right lower lung is currently
demonstrated, most likely reflecting nipple shadow on the prior
examination.
.
Colonoscopy [**2121-3-31**]:
Polyp in the proximal ascending colon (polypectomy)
Polyp in the distal ascending colon (polypectomy)
Polyp in the hepatic flexure (polypectomy, endoclip)
Otherwise normal colonoscopy to terminal ileum
Brief Hospital Course:
The patient is a 78-year-old man with a history of alcohol
abuse, Mallroy [**Doctor Last Name **] tear, peripheral vascular disease, and
diabetes who presents with confusion, weakness and hypotension,
susequently found to a large hematocrit drop.
.
# Anemia, probable GI bleed: The patient has a history of
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear and gastritis. His anemia and episode of
hypotension was thought to be secondary to hypovolemia from a GI
bleed. The patient received a bolus of normal saline and two
units of packed red blood cells. His hematocrit responded by
improving from 18 to 23. GI performed an endoscopy which showed
gastric erythema and friability, but no obvious source of GI
bleed. Because he had recently undergone stenting of peripheral
artery, a retroperitoneal bleed remained on the differential. CT
of abdomen and pelvis showed no evidence of RP bleed. His
hematocrit remained stable and steadily increasing, so he was
transferred to the Medicine service with plans to perform
colonoscopy after appropriate preparation. His aspirin and
[**Last Name (NamePattern1) **] were held. After contacting his vascular surgeon, his
[**Name (NI) **] continued to be held in the setting of a likely lower GI
bleed. ASA was restarted. Colonoscopy showed 3 polyps but no
active bleeding. The polyps were biopsied. The patient's
hematocrit remained stable and he had no more bloody stools.
Discharged with plans for close outpatient follow-up and repeat
hematocrit on [**2121-4-3**]. Crit on discharge was 30.2.
.
# Presumed urinary tract infection: The patient has a history of
urinary retention requiring straight catheterization. His
urinalysis in the ICU was suggestive of infection so he was
started on ceftriaxone therapy. Urine culture showed mixed
bacteria growth, without evidence of UTI. Ceftriaxone was
stopped and a repeat Ucx was unremarkable. Antibiotics not
restated.
.
# Alcohol abuse: Patient has history of alcohol abuse, according
to old records. It appears he has been at home the last few
days, which means he may have started drinking again, though the
patient denies it. He was placed on CIWA, though he never
triggered and did not require benzodiazepines. He was provided
thiamine and folate. Social work was consulted. The patient was
discharged on thiamine and folate.
.
# Diabetes: Provided insulin sliding scale while in hospital.
.
# Urinary retention: Continued home tamsulosin.
.
# Incidentalomas:
Left adrenal adenoma.
Multiple bladder diverticula
Old right posterior rib fxs.
Anterior wedge compression of L2
.
Transitional Issues:
- Repeat hematocrit on [**4-3**]. Hematocrit on dischare was 30.2. If
drifting downwards, GI would recommend capsule study.
- Patient should have dermatology follow up for two skin lesions
noted on his upper back
- F/u GI biopsies. Patient is concerned about these and would
like to be contact[**Name (NI) **] about results
- F/u H. Pylori stool antigen
Medications on Admission:
-cilostazol 100 mg Tablet 1 Tablet(s) by mouth twice a day
-clopidogrel [[**Name (NI) **]] 75 mg Tablet 1 Tablet(s) by mouth once a
day
-metformin 500 mg Tablet 1 Tablet(s) by mouth twice a day
-pantoprazole 40 mg Tablet, Delayed Release (E.C.) 1 Tablet
Qday
-tamsulosin 0.4 mg Capsule, Ext Release 24 hr 1 Capsule Qhs
-aspirin 81 mg Tablet, Delayed Release (E.C.) daily
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 100**] Senior Life for Home Care
Discharge Diagnosis:
Primary Diagnosis: Gastrointestinal bleed
Secondary Diagnosis:
Peripheral Vascular Disease s/p stent placement
Alcohol Abuse
Diabetes
Skin lesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 23050**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted because you were feeling weak
and were found to have very low blood levels. It was presumed
that you were bleeding from your intestines. You had a scope of
your upper and and lower intestinal tract which showed polyps
but no active bleeding. You did not have any further episodes of
bleeding and your blood counts improved during your time in the
hospital. You are safe for discharge home. Your primary care
doctor should follow up on the results of the biopsies of the
polyps. You should have your blood counts rechecked on Friday
[**2121-4-4**] and the results faxed to your primary doctor. Please
also discuss with your primary care doctor getting a referral to
dermatology to look at the skin lesions on your back.
Please continue all your home medications with the exception of
the following, which have been changed:
1) Please START Thiamine 100mg daily
2) Please Start Folic acid 1mg daily
3) Please START Simethicone 40mg four times daily as needed for
gas
4) START mupirocin cream; apply this on the rash under your nose
twice a day
Followup Instructions:
Department: BIDHC [**Location (un) **]
With: [**First Name11 (Name Pattern1) 3295**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3296**] [**Last Name (NamePattern1) 3297**], MD
Phone # [**Telephone/Fax (1) 608**]
Specialty: Primary Care
When: TUESDAY [**2121-4-8**] at 1 PM
Building: 545A Centre St. ([**Location (un) 538**], MA) None
Campus: OFF CAMPUS
Department: VASCULAR SURGERY
When: THURSDAY [**2121-5-15**] at 1:30 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2121-4-2**]
|
[
"600.01",
"070.70",
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"272.4",
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"250.00",
"535.50",
"709.9",
"305.00",
"V15.82",
"684",
"553.3",
"447.9",
"285.1",
"401.9",
"348.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.42"
] |
icd9pcs
|
[
[
[]
]
] |
12898, 12974
|
9503, 12093
|
333, 385
|
13165, 13165
|
5188, 5188
|
14500, 15229
|
3708, 3725
|
12995, 12995
|
12495, 12875
|
13316, 14477
|
3740, 4398
|
4414, 5169
|
12114, 12469
|
264, 295
|
413, 2267
|
13058, 13144
|
5204, 9480
|
13014, 13037
|
13180, 13292
|
2289, 2683
|
2699, 3692
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,042
| 119,892
|
30690
|
Discharge summary
|
report
|
Admission Date: [**2120-4-25**] Discharge Date: [**2120-5-1**]
Date of Birth: [**2064-3-25**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
IV TPA
History of Present Illness:
56 yo man with hx angioplasty in [**2116**] for cad, hx afib prior to
that (none documented since, on no anticoag), p/w fall to L at
work and sudden onset L sided weakness (face, arm and leg) at
4:30PM; CODE STROKE activated. Pt had been in USOH prior to
event, and fall was witnessed by colleagues - pt collapsed to L
against a filing cabinet, noted by colleagues to be weak on the
L
with facial droop on L as well. EMS got call at 5PM and pt
arrived in ER at 5:30PM. VS in field included BG 91, BP 116/68,
HR 60. Neurology at bedside upon pt arrival. NIHSS score 6 for
facial droop (2), motor/arm (1), mild dysarthria (1), and
extinction to DSS (2). Pt himself initially denied L sided
weakness and denied that anything was wrong either with strength
of limbs or with speech. He had been noted by EMS to at times
be
unable to move his L arm, and at other times able to touch his
nose with L hand. C/o no other sx except mild L temple
headache.
No visual or hearing changes, problems swallowing, hearing
problems, or other sx except as above. Stat head CT showed
hyperdense L MCA, and CTA showed clot at M1. TPA given at
6:30PM
(bolus) and infusion to be run for 1hr after.
Past Medical History:
PMH:
CAD s/p angio in [**2116**]
Hx afib prior to angio/stent placement, not documented since
Hx L diaphragm paralysis after neck surgery
No hx htn, high chol, dm to pt's knowledge (though on lipitor)
Social History:
Social History:
Lives with wife, has kids; no tob, few drinks etoh/nt, no drugs;
works in office
Family History:
Family History:
No strokes or heart attacks in family. Father with DM.
Physical Exam:
Admission Examination:
afebrile 116/68 HR 56 99%RA 16 wt 200 lbs
General appearance: white male, NAD
HEENT: moist mucus membranes, clear oropharynx
Neck: supple, no bruits
Heart: regular rate and rhythm, no murmurs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues
Rectal: nl, guaiac neg stool
Mental Status: The patient is alert and attentive, could provide
accurate history. Language is intact with no errors, normal
[**Location (un) 1131**] and comprehension, repetition, naming. There is however
anosagnosia, with pt repeatedly saying L side working fine; no
hand agnosia.
Cranial Nerves: The visual fields are full to confrontation, but
there is extinction to DSS on L, and he has a R gaze preference,
though no gaze palsy. The optic discs are normal in appearance.
Eye movements are normal, with no nystagmus. Pupils react
equally to light 3.5->2 bilat, both directly and consensually.
Sensation on the face is intact to light touch, pin prick per
pt,
with no ext to DSS. Facial movements are notable for L droop.
Hearing is intact to finger rub. The palate elevates in the
midline. The tongue protrudes in the midline and is of normal
appearance. Mild dysarthria for labial sounds.
Motor System: There is 5-/5 strength at the left deltoid and
tricep, 4+/5 at finger extensors on L, 5-/5 L hamstring,
elsewhere mms are full stength. There is no tremor, or abnormal
movements. There is L drift and vacillation.
Reflexes: The tendon reflexes are mildly depressed on L [**Hospital1 **]/[**Last Name (un) **]
compared to R. Knees and ankles equal. The L toe is up, R is
down.
Sensory: Sensation is intact to LT, position, but he has
intermittent extinction to DSS on the left to tactile and visual
stim, neglects L side.
Coordination: L F->N Ataxia is not out of proportion to weakness
or neglect, improves with looking at hand on L; no ataxia
elsewhere. The R finger/nose test normal.
Gait: deferred for now
Pertinent Results:
CT head [**2120-4-25**]:
IMPRESSION:
Relatively "hyperdense" proximal right MCA, raising the
possibility of acute embolic or thrombotic occulsion of this
vessel, with no definite evidence of acute major vascular
territorial infarct on this non- contrast head CT. Please refer
to concurrent CTA, including post-processed CT perfusion study
for more complete assessment of this finding.2. No acute
hemorrhage.
CTA head and neck [**2120-4-25**]:
IMPRESSION: Findings consistent ischemia within the right middle
cerebral artery territory, due to embolic occlusive fragment
seen near the origin of the right middle cerebral artery on CT
angiography.
CT head [**2120-4-26**]: New hypodense region within the right basal
ganglia with associated slight edema and mass effect on the
ventricular system suggests acute stroke; however, no
complication including no intracranial hemorrhage is detected
CTA chest [**2120-4-30**]: IMPRESSION:
1. No evidence of pulmonary embolism.
2. Multifocal, patchy air space disease. Findings nonspecific
but differential diagnosis includes infectious or inflammatory
process, including cryptogenic organizing pneumonia. While this
is an atypical distribution for aspiration, given the patient's
clinical history, this would also be a consideration.
TEE [**2120-5-1**]:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. Mild to
moderate ([**12-26**]+) mitral regurgitation is seen. There is no
pericardial effusion. No aortic atheroma.
IMPRESSION: No cardiac source of embolism seen.
Brief Hospital Course:
Patient presented to ED with exam of NIHSS of 6 as per above.
He has a hyperdense right MCA sign confirmed by cut off on CTA
and
decreased CBF on perfusion. Mechanism of stroke is likely
cardioembolic from
atrial fibrillation. Patient received IV tPA after risk of 6.4%
risk of ICH discussed with family and patient . No complications
after bolus and infusion and patient monitored in ICU 24 hours
with no complications. He was transferred to Neurology floor
where he was noted to have a normal neurological exam with only
some very mild left pronator drift. The patient was on telemetry
and no arrhythmias noted. He had an echocardiogram which was
poor quality so had a transesophageal echocardiogram which
showed no cardiac embolic source for stroke. Patinet complained
of shortness of breath during his hospital stay that persisted
for two days. He had nml cardiac enzymes, nml EKG and chest
ct-with perfusion which showed some lung space disease and small
pleural effusions. His shortness of breath improved with
ambulation and incentive spirometry. Patient worked with Pt/OT
who felt he did not need any inpatient or home PT/OT service.
Medications on Admission:
Meds:
Digoxin 250mcg
ASA 81 mg
Nadolol unknown dose
Lipitor 10 mg
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*120 Tablet(s)* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
4. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day:
please do NOT take medication till your PCP checks INR blood
level and tells you to continue the medication.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
stroke
Discharge Condition:
stable
Discharge Instructions:
Take medications as instructed
Followup Instructions:
DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] Neurology [**Hospital 4038**] Clinic
Phone:[**Telephone/Fax (1) 44**] [**2120-5-29**] 4:30 pm [**Hospital 18**] [**Hospital 878**] Clinic
[**Hospital Ward Name 23**] bldng [**Location (un) **]. YOU MUST CALL TO CONFIRM THIS
APPOINTMENT
|
[
"434.91",
"V45.82",
"412",
"414.01",
"342.80",
"427.31",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
7959, 7965
|
6190, 7335
|
335, 343
|
8016, 8025
|
4107, 6167
|
8105, 8398
|
1930, 1988
|
7452, 7936
|
7986, 7995
|
7361, 7429
|
8049, 8081
|
2003, 2455
|
276, 297
|
371, 1558
|
2756, 4088
|
2470, 2740
|
1580, 1783
|
1815, 1898
|
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