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Discharge summary
|
report
|
Admission Date: [**2168-12-2**] Discharge Date: [**2169-1-4**]
Date of Birth: [**2089-8-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Bleeding from Graft site
Major Surgical or Invasive Procedure:
Right BKA
History of Present Illness:
Mr [**Name13 (STitle) **] is a pleasant 79M who underwent a R fem-PT bypass
with what appears to be non-reversed GSV approximately 2 months
ago at [**Hospital3 **]. He was, by report kept inpatient there
for 6 weeks post-operatively, finally discharging home on
[**2168-11-11**]. He had done well at home until this morning when he
had a sudden bout of large volume diarrhea and while in the
bathroom noted a substantial amount of bleeding from the R leg
distal incision site (which overlies the distal anastomosis). He
did not directly visualize the bleeding site as it was obscured
by his clothing and not still bleeding when this was removed.
He was with a visiting nurse at the time who applied pressure
and called EMS.
Per report, he was found hypotensive to the 70's in EMS arrival
and was disoriented and diaphoretic. He was transported to
[**Hospital3 6592**] for further care. In the ED at [**Hospital1 **] he was
normotensive and neurologically appropriate. No bleeding was
noted and he had a hct of 32. He was taking coumadin for a
peri-operative Dx of Afib and his INR was 3.2. WBC at this with
was 27 and there was concern that he may be manifesting an early
septic picture. He was started on broad spectrum Abx (Vanco,
Zosyn) and plans were made to transfer to [**Hospital1 18**] as his surgeon
at [**Hospital 46**] Hosp was not available.
On Transfer, My [**Doctor Last Name **] was stable and had no furhter episodes
of bleeding. He arrives afebrile, not complaining of pain and
completely neuro-motor intact. He states that the index
operation was done for caludicaion with sx at 150 yards. He has
bee able to achieve an active lifestyle, riding his bike, etc,
while at home these last several days. He denies any bleeding
episodes prior to today. He notes no history of local trauma of
that wound.
Past Medical History:
PMH: Duodeneal adenocarcinoma, COPD, HTN, A fib, diverticulosis
PSH: R Fem-PT, [**Name (NI) 65523**] (~3yrs ago)
Social History:
45pkyr smoker, quit 13-14 years ago
1 beer per day
no other drug use
lives independently
Family History:
non-contributory
Physical Exam:
Vital Signs: Temp: 98.1 RR: 16 Pulse: 108 BP: 132/74
Neuro/Psych: Oriented x3, Affect Normal, NAD.
Neck: No masses, Trachea midline, Thyroid normal size,
non-tender, no masses or nodules, No right carotid bruit, No
left
carotid bruit.
Nodes: No clavicular/cervical adenopathy, No inguinal
adenopathy.
Skin: Abnormal: R subcostal incision - well healed; Well healed
RLE incisions until the ankle .
Heart: Regular rate and rhythm.
Lungs: Clear, Normal respiratory effort.
Gastrointestinal: Non distended, No masses, No
hepatosplenomegally, No hernia, No AAA, abnormal: Mildly tender
in the epigastrium.
Rectal: Not Examined.
Extremities: No popiteal aneurysm, No femoral bruit/thrill, No
RLE edema, No LLE Edema, No varicosities, No skin changes.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: P. Ulnar: P.
LUE Radial: P. Ulnar: P.
RLE Femoral: P. Popiteal: D. DP: N. PT: D.
LLE Femoral: P. Popiteal: D. DP: D. PT: D.
DESCRIPTION OF WOUND: Dehissence of the distal incision site,
just posterior to the medial malleolus. There is a shallow
ulcerated area with fibrinous tissue and some inflamed
granulation. No active bleeding or obviously exposed graft.
There is a circumferential area of 1cm of erythema
Pertinent Results:
[**2168-12-2**] 10:20PM GLUCOSE-105* UREA N-28* CREAT-1.8* SODIUM-139
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-19
[**2168-12-2**] 10:20PM WBC-35.7* RBC-3.51* HGB-10.9* HCT-33.5*
MCV-95 MCH-31.1 MCHC-32.6 RDW-15.7*
[**2168-12-2**] 10:20PM NEUTS-81* BANDS-13* LYMPHS-2* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2168-12-2**] 10:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG
CXR ([**2168-12-2**]): No infiltrate, effusion or enlargement of the
cardio-mediastinal sillouhette
EKG ([**2168-12-10**]): Sinus rhythm with atrial premature beats.
Probable intra-atrial conduction delay. Rightward axis is
non-specific and may be within normal limits. Since the previous
tracing of [**2168-12-9**] there is probably no significant change.
Labs on admission:
[**2168-12-2**] 10:20PM BLOOD WBC-35.7* RBC-3.51* Hgb-10.9* Hct-33.5*
MCV-95 MCH-31.1 MCHC-32.6 RDW-15.7* Plt Ct-664*
[**2168-12-2**] 10:20PM BLOOD PT-31.7* PTT-34.2 INR(PT)-3.2*
[**2168-12-2**] 10:20PM BLOOD Glucose-105* UreaN-28* Creat-1.8* Na-139
K-3.9 Cl-100 HCO3-24 AnGap-19
[**2168-12-7**] 03:28AM BLOOD ALT-52* AST-31 AlkPhos-78 TotBili-0.3
[**2168-12-6**] 03:44PM BLOOD Lactate-2.5*
Pertinent labs during course:
[**2168-12-5**] 06:31AM BLOOD WBC-26.7* RBC-3.13* Hgb-9.9* Hct-28.2*
MCV-90 MCH-31.6 MCHC-35.1* RDW-18.5* Plt Ct-359
[**2168-12-12**] 09:25AM BLOOD WBC-21.2* RBC-3.44* Hgb-10.4* Hct-33.4*
MCV-97 MCH-30.2 MCHC-31.2 RDW-18.2* Plt Ct-593*
[**2168-12-19**] 08:23PM BLOOD WBC-9.0 RBC-2.95* Hgb-9.1* Hct-27.9*
MCV-94 MCH-30.8 MCHC-32.6 RDW-17.2* Plt Ct-330
[**2168-12-24**] 05:02AM BLOOD WBC-6.7 RBC-3.59* Hgb-10.9* Hct-33.1*
MCV-92 MCH-30.4 MCHC-32.9 RDW-17.1* Plt Ct-110*
[**2168-12-28**] 02:23AM BLOOD WBC-9.5 RBC-2.92* Hgb-8.9* Hct-27.4*
MCV-94 MCH-30.4 MCHC-32.3 RDW-16.5* Plt Ct-43*
[**2168-12-30**] 08:16PM BLOOD WBC-2.1*# RBC-2.87* Hgb-9.0* Hct-26.1*
MCV-91 MCH-31.3 MCHC-34.5 RDW-16.6* Plt Ct-53*
[**2169-1-2**] 12:33AM BLOOD WBC-8.7# RBC-3.22* Hgb-9.7* Hct-30.4*
MCV-95 MCH-30.0 MCHC-31.7 RDW-16.4* Plt Ct-52*
[**2169-1-3**] 03:59AM BLOOD WBC-9.2 RBC-2.79* Hgb-8.7* Hct-25.7*
MCV-92 MCH-31.1 MCHC-33.8 RDW-16.4* Plt Ct-88*#
[**2169-1-3**] 05:00PM BLOOD WBC-11.0 RBC-3.34* Hgb-10.6* Hct-31.9*
MCV-96 MCH-31.7 MCHC-33.2 RDW-15.7* Plt Ct-85*
[**2168-12-3**] 10:20AM BLOOD Glucose-176* UreaN-34* Creat-1.5* Na-140
K-3.9 Cl-105 HCO3-23 AnGap-16
[**2168-12-6**] 05:26AM BLOOD Glucose-112* UreaN-18 Creat-0.9 Na-141
K-3.7 Cl-110* HCO3-24 AnGap-11
[**2168-12-10**] 04:35AM BLOOD Glucose-125* UreaN-12 Creat-0.7 Na-143
K-3.2* Cl-107 HCO3-29 AnGap-10
[**2168-12-25**] 04:30AM BLOOD Glucose-107* UreaN-16 Creat-0.6 Na-136
K-4.0 Cl-107 HCO3-22 AnGap-11
[**2169-1-2**] 02:30PM BLOOD Glucose-122* UreaN-31* Creat-0.9 Na-156*
K-4.0 Cl-120* HCO3-27 AnGap-13
[**2169-1-3**] 03:59AM BLOOD Glucose-204* UreaN-32* Creat-1.0 Na-150*
K-3.7 Cl-116* HCO3-25 AnGap-13
[**2169-1-3**] 04:14PM BLOOD Glucose-28* UreaN-32* Creat-1.0 Na-149*
K-4.0 Cl-117* HCO3-26 AnGap-10
[**2168-12-27**] 12:12PM BLOOD CK-MB-4 cTropnT-0.02*
[**2168-12-27**] 02:07PM BLOOD CK-MB-4 cTropnT-0.02*
[**2168-12-28**] 07:47AM BLOOD CK-MB-5 cTropnT-0.05*
[**2168-12-26**] 03:56AM BLOOD calTIBC-86* Ferritn-276 TRF-66*
[**2168-12-27**] 07:56PM BLOOD Lactate-6.5* K-3.6
[**2168-12-31**] 02:34AM BLOOD Glucose-106* Lactate-1.8 K-4.1
[**2168-12-24**] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES-
Labs on discharge:
na 145, cl 113, bun 31, gluc 88
k 3.9, hco3 23, cr 1.1
Ca: 8.1 Mg: 2.2 P: 2.4
ALT: 41, AP: 84, Tbili: 1.2
AST: 32, LDH: 178
wbc 13.8, hb 9.9, plt 141
hct 29.4
PT: 21.7 PTT: 48.1 INR: 2.0
IMAGING:
[**12-2**] CXR:
FINDINGS: Single AP upright portable view of the chest was
obtained. The
lungs are hyperinflated, with flattening of the diaphragms,
suggesting chronic obstructive pulmonary disease. Apical pleural
thickening is seen. There may be calcified pleural plaques
overlying the right greater than left lung apices which would
suggest prior asbestos exposure. No prior available for
comparison. No focal consolidation, pleural effusion, or
pneumothorax is seen. Cardiac and mediastinal silhouettes are
small, in keeping with COPD/emphysema.
.
[**12-9**] CXR:
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Overinflation, small bilateral pleural effusions,
retrocardiac
atelectasis. No evidence of focal parenchymal opacity suggesting
pneumonia. Extensive vascular calcifications along the
supra-aortic vessels.
.
[**12-15**] Upper Ext LENIs:
IMPRESSION:
Superficial thrombophlebitis involving the right basilic vein
from the
antecubital fossa extending halfway up the arm. No other
thrombosis involving the upper extremities veins bilaterally
.
[**12-20**] Echo:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is mild global left ventricular
hypokinesis (LVEF = 40%). Right ventricular chamber size and
free wall motion are normal. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. There is a very
small pericardial effusion.
IMPRESSION: No valvular vegetations seen. Mild global left
ventricular systolic dysfunction. Mild calcific aortic stenosis.
.
[**12-27**] CXR:
FINDINGS: AP single view of the chest has been obtained with
patient in
semi-upright position. Comparison is made with the next
preceding similar
study obtained two hours earlier. At that time an acute complete
left-sided whiteout was obtained with mediastinal shift towards
the left. Now partially re-aeration of the lung is observed
indicating clearance of the central airways. There are still
some densities remaining and further progress in re-aeration can
be expected. No pneumothorax developed.
.
[**1-2**] CXR:
FINDINGS: As compared to the previous radiograph, the patient
has received a tracheostomy tube. This tube is in correct
position. The nasogastric tube has been removed. The right PICC
line is in unchanged position.
The pre-existing left apical opacity has markedly decreased in
extent. The
scars in the right and left upper lung parenchyma, however, are
unchanged. Also unchanged is the extent of the bilateral
moderate pleural effusions, although on today's radiograph the
retrocardiac lung parenchyma is better ventilated.
No newly appeared focal parenchymal opacity suggesting
pneumonia.
Brief Hospital Course:
79M with h/o pancreatic adenocarcinoma s/p [**Month/Year (2) **], here with
infected R fem-PT graft, s/p rt bka [**12-6**], infected stump s/p rt
aka [**12-19**], multiple intubations for respiratory distress,
extremely broad antibiotic treatment for VRE bacteremia,
Xanthomonas baceteremia, and HCAP, now s/p trach and PEG
[**2168-12-30**], with respiratory failure, hypernatremia, hypotension
and anemia. See below for discussion of each of his issues. He
was transferred to the MICU a day prior to discharge for
management of his medical issues. Goals of care were discussed
and he agreed to rehab. He does not want to be rehospitalized
if his condition were to change, though.
.
1. Hypoxic Respiratory Failure: Patient likely has baseline
COPD/emphysema. He was intubated and extubated once for
pneumonia, then failed and had a second intubation requiring
tracheostomy placement. He is now with b/l pleural effusions,
grossly fluid overloaded, recovering from xanthomonas pneumonia
on bactrim per ID recs. Also likely [**12-21**] to deconditioning from
prolonged ventilation. The day of discharge, he was weaned off
ventilator and placed on trach mask and tolerated well. In a
goals of care discussion, he stated he would not want to be
ventilated again. He should continue ipratropium and albuterol
inhalers as needed. He should have lasix PRN as his blood
pressure tolerates.
.
2. Hypernatremia: Free water deficit was 1.7L. Improved to
normal today with free water flushes and D5W. He should
continue his current free water flushes and have his labs
checked every few days to make sure it remains in a normal
range. On discharge his sodium was 145.
.
3. Bacteremia: His infectious and abx course is as follows: (per
ID notes)
He was started on broad antibiotic coverage on admission with
vanco/cipro/flagyl; developed worsening limb ischemia, underwent
a right BKA on [**12-6**]; developed systemic toxicity on [**12-10**]; had
VRE bacteremia on [**12-10**] with VRE wound infection of BKA stump;
vanco d/ced on [**12-14**] and switched to linezolid; po vanco
initiated [**2084-12-8**] for empiric C diff coverage; stools neg for C
diff toxin; repeat BC on [**12-18**] re-isolated VRE; underwent RT AKA
amputation on [**12-19**]; resumed cipro, added metronidazole and
continued linezolid; blood cultures from [**12-20**] and [**12-22**] were no
growth; picc line d/ced;
replaced on [**12-22**]; transferred to floor; noted to have aspiration
when eating; formal swallow study on [**12-26**] confirmed aspiration;
developed abrupt onset respiratory distress on [**12-27**]; required
intubation; transferred to the ICU, hypotensive; required
pressor support; BAL performed on [**12-27**] demonstrated abundant
thick secretions in airways; and white plaque noted on bronchial
wall in LLL; right lung was normal. BAL gram stain: GNR and
budding yeast with pseudohyphae; antibiotic regimen revised to
cefepime/gent; linezolid changed to daptomycin. He was briefly
on meropenem and then switched to bactrim when STENOTROPHOMONAS
(XANTHOMONAS) MALTOPHILIA grew in his blood and his sputum on
[**12-27**]. He is to complete a 3 week course of bactrim for his
bacteremia per ID recs. Of note, his WBC was rising on the day
of discharge to 13. He had no fevers and understood that this
was increased today, but he was comfortable with the choice to
try rehab at this time and just continue his current
antibiotics.
.
4. Hypotension: Patient has had persistent hypotension needing
levophed, and albumin boluses throughout his course. Likely [**12-21**]
heart failure and intravascular volume depletion in setting of
infection. On discharge, his BPs were in the low 100s. He was
mentating well.
.
5. Thrombocytopenia: Attributed to linezolid, has recovered from
50 to 88 to 144. HIT ab negative, so SQ heparin was restarted.
Seems to be recovering since linezolid was removed. His WBCs
also fell, so it was thought to be all marrow suppression.
.
6. Atrial Fibrillation: Paroxysmal a fib, during acute illness.
He was on coumadin for short period of time, but it was held for
various procedures. His platelets dropped and he continued to
have a coagulopathy with INR in high 1s to low 2s despite
holding coumadin. He was placed on aspirin 81mg daily. He
should not start coumadin given that the afib was likely in
setting of infection. He is in sinus tach on discharge with
occassional runs of afib in low 100s. He is not on any rate
control because of his blood pressure.
.
7. Oliguria: UOP poor, Cr stable. LOS 19L +. He should be
diuresed with PRN lasix as his blood pressure tolerates.
.
8. s/p AKA: Patient was admitted to the Vascular Surgery service
from the ED with thrombosed right femoral-posterior tibial graft
and over the first few hospital days his leg demarcated and he
was taken to the OR for right below the knee amputation. He
tolerated this procedure well and was transferred to the VICU
post-op. His course was then complicated by bacteremia and he
was deemed to need an AKA. This was also done without
complications. He has a wound that is clean dry and intact, and
he should follow up with vascular surgery as scheduled.
.
9. Goals of Care: Given patient's highly morbid course, and poor
prognosis, we need to discuss with his HCP what his goals of
care are. We discussed with him what he would like, and he
stated he is firmly DNR/DNI. He would not want to be reattached
to the vent, and if his status changed dramatically, he would
consider changing to comfort care. He does not want to get
re-hospitalized in the future. He does want to try and do well
at rehab and stated he was not interested in hospice at this
time. His contacts are [**Name (NI) **], his son, and presumably his HCP,
who is out of town but reachable at [**Telephone/Fax (1) 89734**]. His sister
[**Name (NI) **] was also [**Name (NI) 653**], her number is [**Telephone/Fax (1) 89735**].
.
11. Hypoglycemia: Patient has been intermittently hypoglycemia
throughout his stay. Not on insulin. Perhaps related to
[**Telephone/Fax (1) **], or pancreatic CA. He should stay on finger sticks to
monitor his sugars and get dextrose PRN.
.
12. s/p [**Telephone/Fax (1) 65523**], has mild abdominal pain, but is likely post GT
incisional pain. We continued creon with his tube feeds.
.
13. Malnutrition: Albumin on admission 2.0, cachectic, he was
maintained on tube feeds with plan to try rehab
.
14. HTN: His lisinopril was discontinued on [**2168-12-16**] due to
hypotension and anuria.
Medications on Admission:
B12 1000', Dilt CD 120', Advair 250/50 1'', Lasix 20', klorcon
20meq'; combivent 2puff'''', lisinopril 5', protonix 40',
coumadin 2', vitamin b12 1000mg qd
Discharge Medications:
1. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) [**Date Range **]: One (1) Cap PO QIDWMHS (4 times a day
(with meals and at bedtime)).
2. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Date Range **]: [**11-20**]
Puffs Inhalation q2hrs as needed for dyspnea.
3. ipratropium-albuterol 18-103 mcg/Actuation Aerosol [**Month/Day (2) **]: [**2-22**]
Puffs Inhalation Q4H (every 4 hours).
4. trazodone 50 mg Tablet [**Month/Day (3) **]: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
5. oxycodone-acetaminophen 5-325 mg/5 mL Solution [**Month/Day (3) **]: Five (5)
ML PO Q6H (every 6 hours) as needed for pain.
6. metoclopramide 10 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO QID (4
times a day) as needed for nausea.
7. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (3) **]: One (1) syringe
Injection [**Hospital1 **] (2 times a day).
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
9. aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Normal Saline Flush 0.9 % Syringe [**Last Name (STitle) **]: One (1) syringe
Injection as needed as needed for for PICC line flushes.
11. sulfamethoxazole-trimethoprim 200-40 mg/5 mL Suspension [**Last Name (STitle) **]:
Thirty (30) ml PO every eight (8) hours for 14 days: end date
[**2169-1-18**] (is a total of 3 week course).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Thrombosed RLE graft
Bacteremia
Diarrhea
Atrial fibrillation
Pneumonia
Respiratory Failure
Discharge Condition:
Mental Status: Clear and coherent, although cannot talk well
because of tracheostomy, communicated with yes/no and lip
[**Location (un) 1131**].
Level of Consciousness: Alert and interactive.
Activity Status: bedbound now, on trach mask, in and out to
chair sometimes.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
transferred to [**Hospital1 18**] from [**Hospital3 3583**] for management of your
right foot infection. You were first under the care of the
vascular surgeons and your received a right below the knee
amputation. You tolerated this surgery well. You subsequently
were diagnosed with bacteria in your blood, high sodium levels,
low urine output, diarrhea, and atrial fibrillation. You were
treated with antibiotics for your bacteremia and diarrhea. You
were given blood transfusions and large volumes of intravenous
fluids.
You then had problems breathing and required a breathing tube.
It was hard to improve your breathing enough to remove the
breathing tube, you had a tracheostomy. You are now doing well
through the tracheostomy without the ventilator. You decided
that you wouldn't want to have to use the ventilator again if it
was needed.
You also had a repeat amputation at your hip for worsening
infection. You should follow up with [**Hospital3 **] and with
the vascular surgeons. You had a second amputation higher on
the same leg because of infection and poor healing of the first
amputation.
For your bacteria in your blood stream, you will need about two
more weeks of an oral antibiotic. You are on bactrim for that
reason.
.
DISCHARGE INSTRUCTIONS FOLLOWING BELOW OR ABOVE KNEE AMPUTATION
from your vascular surgeons:
.
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
.
ACTIVITY:
There are restrictions on activity. On the side of your
amputation you are non weight bearing until cleared by your
Surgeon. You should keep this amputation site elevated when ever
possible.
.
You may use the other leg to assist in transferring and pivots.
But try not to exert to much pressure on the amputation site
when transferring and or pivoting. Please keep knee immobilizer
on at all times to help keep the amputation site straight.
.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
.Redness in or drainage from your leg wound(s) .
.Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
.
Do not drive a car unless cleared by your Surgeon.
.
Try to keep leg elevated when able.
.
BATHING/SHOWERING:
.
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
.
You will be helped in the rehab unit to try and regain your
strength and improve your breathing as much as possible.
Followup Instructions:
Please follow up with your doctors at the [**Name5 (PTitle) **] unit.
Please also see the vascular surgeons in follow up:
Completed by:[**2169-1-5**]
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28,869
| 118,633
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32146
|
Discharge summary
|
report
|
Admission Date: [**2148-8-20**] Discharge Date: [**2148-9-16**]
Date of Birth: [**2088-6-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
numbness and weakness
Major Surgical or Invasive Procedure:
- cervical laminectomy and fusion, C3-C7
- insertion of IVC filter
- colonoscopy
History of Present Illness:
Mr. [**Known lastname **] is a 60 year old Jehovah's Witness with history of
cervical spinal stenosis who presents after falling the morning
of admission, after which he felt numbness of his chest from the
nipples down and weakness of all four extremities. He decribes
the fall as a loss of balance. He describes hitting his head
with no more than a second of loss of consciousnesss and
difficulty speaking. He called for help and was taken to
[**Hospital 26380**] Hospital where he was given decadron. He was then
transferred to [**Hospital1 18**], at which point he began to have some
resolution of the numbnesss in his chest, and left leg, but was
left with weakness of the right and left hands, and numbness and
weakness of the right leg.
.
On the floor, he reported spasms of pain moving up and down his
whole spine. He denies fevers, chills, bowel or bladder
incontinence, or a history of IV drug use. He denies IV drug
use. He has had decreased perianal and penile sensation over the
last year, as well as chronic constipation. He reports many
falls and poor balance over the last several years, described as
loss of balance and falling to the right because of inability to
lift his right leg while walking. He has had three years of
progressive right lower extremity numbness and 6-9 months of
right lower extremity weakness making getting in and out of cars
difficult, but he was still able to climb stairs and drive. In
addition, he has had numbness and weakness of the last two
fingers of the right hand and recently has progressed to left
lower extremity numbness.
Past Medical History:
- Polio, as child
- Spinal stenosis, sees a chiropractor
Social History:
The patient lives with his wife and is a former smoker. He quit
drinking 3 months prior to admission, but had consumed [**1-6**]
drinks per day previously. He denies any history of IV drug
abuse and is sexually active only with his wife.
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
GENERAL: obese male, laying in bed, NAD
VITALS: T 97.5 HR 78 BP 104/56 RR 18 Sat 96%RA
SKIN: no rashes, no lesions
HEENT: Anicteric, EOMI, PERRLA
NECK: Mild stiffness with difficulty touching chin to chest.
Tnedernes over occipital muscle conncetions to scull. No masses,
No LAD, Palpable carotid pulses
CHEST: no supraclavicular or axillary LAD, Lungs Clear to
Asculation, No Wheezes/Rhonchi/Crackles
HEART: normal PMI, RRR, No Murmurs/Gallops/Rubs
ABDOMEN: Obese, No scars, NABS, Soft, No palpable organomegaly,
No masses, No guarding, No rebound.
GENITAL: No scrotal masses
RECTAL: Moderate rectal tone, firm brown stool int he vault.
EXT: No clubbing/cyanosis/edema. Good Pulses.
NEURO:
MS: oriented to person, place, time
CN: II-XII intact
Muscle Strength:
Deltoid [**4-6**] B/L
Biceps [**4-6**] B/L
Triceps [**2-5**] B/L
Wrist Ext [**3-7**] B/L
Digit Ext 0/5 B/L
Digit Flex 0/5 B/L
Coord: unable to access do to weakness
Sensory: Bilateral lower extremities have pressure sensation but
no light touch or pinprick sensation. Right upper extremity
pinprick intact over the flexor surface but not the extensor
surface. Left upper extremity pinprick intact over the extensor
surface but not the flexor surface. Joint position absent in
lower ext and normal in upper extremities.
Muscule Stretch Reflexes:
Bic R 2+ L 1+
Tri R 1+ L 1+
[**Last Name (un) 1035**] R 2+ L mute
Pat R 2+ L 2+
Ach R mute L mute
Planter reflexes R Variably Upgoing L Variably Upgoing
4 beat clonus b/l
weak positive [**Doctor Last Name **] sign B/L
Pertinent Results:
[**2148-8-19**] 01:30PM WBC-10.2 RBC-4.91 HGB-15.4 HCT-41.5 MCV-85
MCH-31.3 MCHC-37.0* RDW-13.8
[**2148-8-19**] 01:30PM PLT COUNT-185
[**2148-8-19**] 01:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2148-8-19**] 01:30PM PT-11.6 PTT-23.1 INR(PT)-1.0
[**2148-8-19**] 01:30PM GLUCOSE-136* UREA N-16 CREAT-0.7 SODIUM-141
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
[**9-2**] TSH 1.3
[**9-2**] Iron 23, TIBC 203, Ferritin 769, TRF 156
[**8-31**] cardiac enzymes negative x3 (tropn 0.02, 0.03, 0.02)
.
DISCHARGE LABS [**2148-9-16**]
WBC 9.4, Hb 10.4, Hct 30.5, Plts 321
Na 130, K 3.3 (subsequently given 40 meq PO KCL), Cl 96, HCO3
25, BUN 5, Cr 0.5, Gluc 152
INR 2.7, PTT 110.8 on IV heparin (IV heparin since discontinued)
[**9-15**] UA 1.018, pH 5.0, mod blood, tr prot, leuk neg, nitr neg,
2rbc, 2wbc, no bacteria or yeast
.
STUDIES
.
[**8-19**] T/L spine MRI
No post-traumatic abnormality seen in the thoracic or lumbar
spine.
Moderate-to-severe canal stenosis from L2 through L5,
multifactorial related to DJD and epidural lipomatosis.
.
[**8-20**] C spine MRI
On the sagittal images, there is no malalignment or loss of
vertebral body height.
No suspect marrow lesions are seen.
There is moderately severe spinal stenosis and cord compression
extending from approximately C4 down to C6 with abnormal cord
signal at C6 likely representing myelomalacia from cord
compression. There are large disc osteophyte complexes from C4
through C6, also with probable ossification of the posterior
longitudinal ligament.
There is no evidence for ligamentous injury on the STIR images.
Axial images at C2-C3 demonstrate mild disc bulge without
significant central or foraminal stenosis.
At C3-C4, there is a disc osteophyte complex with mild bilateral
foraminal narrowing. There is mild central stenosis.
At C4-C5, there is a large disc osteophyte complex causing
moderate cord compression and canal stenosis. There is mild
bilateral foraminal narrowing from uncovertebral hypertrophy.
At C5-C6, there is a large disc osteophyte complex causing
severe cord compression and canal stenosis. There is also
moderately severe bilateral foraminal narrowing from
uncovertebral hypertrophy.
At C6-C7, there is a disc osteophyte complex with a central disc
protrusion. There is moderate central stenosis. There is severe
right and moderate left foraminal narrowing from uncovertebral
hypertrophy. Abnormal cord signal is also noted at this level
reflecting myelomalacia from cord compression.
At C7-T1, no significant abnormality is seen except for mild
bilateral foraminal narrowing.
IMPRESSION:
Significant cervical degenerative disease with moderately severe
canal stenosis and cord compression with abnormal cord signal
from C4-C5 through C6- C7.
.
[**8-31**] LENIS
IMPRESSION: Left common femoral vein to proximal superficial
femoral vein occlusive thrombus.
.
[**8-31**] CTA chest
FINDINGS: There are extensive filling defects within bilateral
pulmonary arteries and extending into all branches. The aorta
maintains a normal contour without evidence of dissection. The
heart and pericardium are normal. The lungs demonstrate
bilateral lower lobe atelectasis and small bilateral pleural
effusions. A wedge shaped opacity is seen in the peripheral
right lung base, which may be related to infarction given large
pulmonay emboli. No hilar, axillary or mediastinal
lymphadenopathy.
BONE WINDOWS: No suspicious lytic or sclerotic lesion is
detected. The visualized upper abdomen is unremarkable.
Multilevel degenerative changes are seen throughout the thoracic
spine with DISH.
IMPRESSION: Extensive filling defects within bilateral bilateral
pulmonary arteries extening into all segments of the lungs,
consistent with pulmonary embolus. Wedge shaped opacity in the
right lower lobe, which may be related to pulmonary infarction.
.
[**9-2**] IVC filter placement
IMPRESSION: Successful placement of the G2 IVC filter within the
infrarenal IVC.
.
[**9-2**] TTE
The left atrium is mildly dilated. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). The
right atrium is moderately dilated. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is mildly
dilated. There is focal basal right ventricular free wall
hypokinesis. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
IMPRESSION: Right ventricular cavity enlargement with
hypokinesis of the basal free wall and moderate pulmonary artery
systolic hypertension. This constellation of findings is c/w
pulmonary embolism. Mild mitral regurgitation.
.
Microbiology
[**9-15**] C. diff POSITIVE
[**9-16**] C. diff assay pending
[**9-15**] blood cultures no growth to date as of [**2148-9-16**]
[**9-14**] urine culture negative
[**9-14**] blood cultures no growth to date as of [**2148-9-16**]
[**2148-9-6**] 7:27 pm URINE Source: Catheter.
**FINAL REPORT [**2148-9-8**]**
URINE CULTURE (Final [**2148-9-8**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**9-12**] Colonoscopy
Impression: Polyp at 45cm in the sigmoid colon - polypectomy was
performed.
Otherwise normal colonoscopy to cecum
.
[**9-12**] EGD
Esophagus: Normal esophagus.
Stomach:
Mucosa: Diffuse petechiae were noted in the fundus and stomach
body. These findings are non-specific and may be related to
anti-coagulation.
Duodenum: Normal duodenum.
Impression: Petechiae in the fundus and stomach body, otherwise
normal upper endoscopy.
.
[**9-12**] Colon polyp path ***pending as of [**2148-9-16**]***
.
[**9-16**] CXR
Two radiographs of the chest demonstrate a similar
cardiomediastinal contour to that seen on [**2148-8-31**]. Lungs are
clear. No effusion. Trachea is midline. Ossification about the
mid and distal right clavicle likely represents the sequela of
remote trauma and remains similar in appearance.
IMPRESSION:
No acute cardiopulmonary disease.
Brief Hospital Course:
1. Spinal stenosis: The patient underwent cervical laminectomy
and uninstrumented fusion from C4-C7 with no complications on
[**8-23**]. Post-operatively, he noted somewhat improved upper
extremity strength but limited use of his lower extremities;
truncal sensation was improved. Per the orthopedics spine
service, he needs to wear a soft cervical collar when out of bed
but no collar is required when in bed. He can continue taking
flexeril for leg cramps. ***** He needs to follow up in Dr. [**Name (NI) 64359**] clinic after his rehab stay. He needs to follow up with
a primary care physician as well for management of his other
complex medical issues. *****
.
2. DVT: The patient was found to have a left lower extremity
thrombosis on [**8-31**]. Note that due to his spinal surgery no
pharmacologic prophalaxis was possible. He was started on IV
heparin and a retrievable IVC filter was placed. He will
continue coumadin for his atrial fibrillation.
.
3. Pulmonary embolism: The patient was found to have a pulmonary
embolism on [**8-31**]. An echocardiogram obtained on [**9-2**] showed
evidence of impaired right ventricular function, but troponins
were negative. He should have a repeat echocardiogram in [**3-8**]
weeks to reassess his cardiac function.
.
4. Atrial fibrillation, with rapid ventricular response: On [**8-31**]
the patient experienced palpitations and was found to have a
heart rate in the 140's. He was initially treated with
metoprolol with decrease in his blood pressure to 98/64. He was
changed to a diltiazem drip and then transferred to the MICU for
further management. He was subsequently transistioned to oral
diltiazem, which he will continue for rhythm control. He will be
anticoagulated with coumadin, which will be adjusted as needed
by his outpatient physicians. Of note, he reverted to sinus
rhythm on [**9-15**].
.
5. Heme positive stools: The patient was noted to have heme
positive stools after starting IV heparin, without any
hematochezia or melena. His hematocrit decreased from 38.9 on
[**8-30**] to 32.8 on [**8-31**]; this was thought to be at least partially
due to dilution. He underwent colonoscopy on [**9-12**] which showed
a 1cm pedunculated benign appearing polyp in the sigmoid colon
which was removed; pathology is pending at time of discharge and
needs to be followed up by his outpatient physicians. He will
need a repeat colonoscopy in 3 years.
.
6. Urinary tract infection: The patient was found to have an E.
coli urinary tract infection in the setting of a Foley catheter.
He will complete a 14 day course of ciprofloxacin to finish on
[**2148-9-20**].
.
7. Delirium and anxiety: While in the MICU, the patient
experienced auditory and visual hallucinations. This was likely
multifactorial in etiology, as he had experiences the stresses
of recent surgery, PE and DVT, and was on multiple pain
medications. While on the floor he remained confused at night,
improving with pre-bedtime Seroquel. He can continue taking prn
ativan as needed for anxiety and may benefit from re-evaluation
by psychiatry. Use of sedating medications (including flexeril
and other pain medications) should be minimized to the extent
possible.
.
8. Decubitus ulcer: During his long hospital course, Mr. [**Known lastname **]
developed a decubitus ulcer on his buttocks. He was evaluated by
the wound care nurse who recommended local care. This ulcer will
need to be monitored closely at his rehab facility.
.
9. C. difficile colitis: The patient developed low grade fevers
(Tmax 100.6) prior to discharge but had no abdominal discomfort,
and was hemodynamically stable. As he was having loose stools,
C. diff toxin was sent which was positive ([**9-15**]) sample. He was
started on flagyl on [**9-15**] which he should continue for a 14 day
course.
.
10. Hyponatremia: The patient's sodium trended to the low 30's
during his hospitalization. He will need to have his sodiums
monitored daily while his PO intake is variable.
.
11. Anemia: The patient's iron studies were consistent with
anemia of chronic disease. His hematocrit remained stable during
his course on the floor. He should have his hematocrit monitored
during his stay in rehab with a repeat hematocrit as an
outpatient. Note that as the patient is a Jehovah's Witness he
does not want any blood products.
Medications on Admission:
MEDS at home:
Aspirin 81 mg daily (recently has been taking two per day.
Aleve prn
Saw [**Location (un) **]
Milk Thistle
Glucosamine
.
Meds on transfer:
Lactulose prn
Acetaminophen
Mallox
Bisacodyl
Cyclobenzaprine
Diazepam prn
Colace
dilaudid prn
Ambien 10mg qhs
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever: No more than 4 grams of
acetaminophen (tylenol) in all forms daily.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
6. Flexeril 5 mg Tablet Sig: 1-2 Tablets PO three times a day as
needed for muscle spasms: Please offer patient lower dose and
offer tylenol as alternative to limit sedation.
7. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for agitation.
8. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): hold
for excess sedation, rr<12.
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain: hold for excess sedation, rr<12.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Outpatient Lab Work
Please have your INR and PT measured on [**9-17**]; your rehab
doctors [**Name5 (PTitle) **] adjust your coumadin dose accordingly.
12. Diltiazem HCl 30 mg Tablet Sig: 2.5 Tablets PO four times a
day: hold sbp<100.
13. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
14. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. cervical spondylosis, cervical spinal stenosis, incomplete
spinal cord injury (myelopathy), and central cord syndrome.
2. Pulmonary embolism
3. Deep venous thrombosis
4. Atrial fibrillation
5. Urinary tract infection
6. Delirium
7. Colon polyp, pathology pending
8. C diff colitis
Discharge Condition:
Fair, with limited use of lower extremities and hands
Discharge Instructions:
You were admitted to the hospital after a fall and had decreased
strength and sensation in your legs. An MRI of your neck showed
that the spinal cord was being compressed so you had to undergo
surgery by the orthopedics spine team. Following your surgery,
you had a rapid irregular heart rate (atrial fibrillation) that
required admission to the ICU for control. You also had blood
clots in your left leg and in your lung (pulmonary embolism) and
had a blood clot filter placed in one of your large veins to
reduce the risk of further clots traveling to your lungs. You
were started on blood thinners (heparin) because of the
clotting. You had very small amounts of blood in your stool
after starting the heparin so you underwent a colonoscopy. The
colonoscopy did not show any active bleeding, but you did have
one colon polyp that was removed. Finally, you developed some
diarrhea due to a bacterial infection (C. difficile colitis) and
were started on an antibiotic prior to transfer to the rehab
hospital.
.
You need to wear the neck brace whenever you are out of bed. You
do not need the brace when you are in bed.
Do not lift anything heavier than a gallon of milk. Do not bend
or twist from your neck.
.
Call your doctor and seek medical attention at once if you
develop:
** fevers, chills, sweats, shortness of breath, pain in your
abdomen or chest, bloody or black stools, worsening weakness and
numbness, redness, pain, or discharge from the surgical wounds,
or other symptoms that worry you.
.
Physical Therapy:
out of bed as tolerated with assistance. Must wear the cervical
collar when out of bed. No collar necessary when in bed. no
lifting heavier than 10 lbs. No bending or twisting neck.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) 363**] from orthopedics ([**Telephone/Fax (1) 54028**])
on Thursday [**10-3**] at 9:30 at [**Hospital Ward Name 23**] 2 [**Hospital1 18**] [**Hospital Ward Name 516**].
.
You had a colon polyp removed at colonoscopy on [**2148-9-12**]. Your
physicians should follow up the pathology results.
.
It is very important that you follow up with a primary care
doctor. You will need to have a primary care doctor set up with
the VA (this is the arrangement your wife preferred when we
called on [**2148-9-16**]). The [**Location 1268**] VA will help you
coordinate this.
|
[
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"285.1",
"599.0",
"211.3",
"E888.9",
"952.08",
"041.4",
"788.20",
"997.2",
"008.45",
"415.11",
"276.1",
"997.1",
"721.1",
"707.03",
"344.00",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"45.42",
"45.13",
"81.03",
"38.7",
"45.25"
] |
icd9pcs
|
[
[
[]
]
] |
17504, 17519
|
11267, 15577
|
293, 376
|
17847, 17903
|
3941, 11244
|
19657, 20271
|
2335, 2353
|
15891, 17481
|
17540, 17826
|
15603, 15738
|
17927, 19432
|
2383, 3922
|
19450, 19634
|
232, 255
|
404, 1983
|
2005, 2064
|
2080, 2319
|
15756, 15868
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,412
| 175,428
|
44771+58755
|
Discharge summary
|
report+addendum
|
Admission Date: [**2105-4-13**] Discharge Date: [**2105-4-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Bradycardia, dyspnea
Major Surgical or Invasive Procedure:
Pacemaker insertion
History of Present Illness:
86 y/o M with PMHx of dilated cardiomyopathy (EF of 20-25%),
mitral regurgitation s/p MVR with bioprosthetic valve,
paroxysmal AF, atrial tachycardia, CAD s/p remote inferior MI
who presents with SOB, dizziness, and bradycardia to the 30's.
He had recent medication increases to his metoprolol, digoxin,
and lasix doses. Patient has had a few weeks of shortness of
breath, acutely worse over the last couple of days. He
presented to physical therapy today, was found to have a HR in
the 40s and BP in the 90-100s. His PCP advised him to present
to the ED.
.
In the ED his initial vitals were: 97.6, 35, 14, 135/51, 99% on
3L . He was able to ambulate from chair to bed, mentated well,
and had stable blood pressures. He was found to have HR in
20-30s. Did not receive any atropine. Patient was given 1
liter of IVF. He had no crackles, edema, or hypoxia on exam.
Patient was admitted to CCU for further management.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
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,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
- CRI - baseline cre 1.8 since [**12-27**], etiology unknown per pt.
- CAD - s/p inferior/post MI [**2092**], LHC [**11-26**] no flow limiting
disease.
- dilated cardiomyopathy (EF 30-35% [**8-27**])
- h/o MR - s/p MVR ([**12-27**] 33mm bioprosthetic)
- h/o embolic CVA (loss of peripheral vision in left eye) felt
[**12-23**]
afib [**2092**].
- paroxysmal atrial fibrillation/flutter - s/p DCCV [**4-27**], trial
of amiodarone.
- hyperlipidemia
- h/o trigeminal neuralgia s/p trigeminal ablation procedure
- h/o ?esophageal mass (13 x 8 mm) - [**2-25**] EGD showed gastritis,
duodenitis, but no mass.
- OA
- s/p rotator cuff repair
- s/p orchiectomy for a benign left testicular mass '[**74**]
- h/o diverticula on colonoscopy (no bleeds)
.
- denies h/o DM, PE/DVT, malignancy
Social History:
lives with wife and daughter, independent of adls, former
probation officer. denies tobacco/ivdu. 5 glasses wine/week. no
regular exercise over past 2-3 months [**12-23**] increased fatigue/DOE.
Family History:
Denies renal disease.
.
No premature CAD. Brother and mother died of MI in their 70's.
Physical Exam:
VS: 96.9, 118/52, 34, 17, 96% RA
GENERAL: WDWN male in NAD. AAO x3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
JVP to earlobe
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Bradycardic, 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. Crackles bibasilarly.
Upper respiratory end expiratory wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ edema to mid shins bilaterally.
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:
CBC
[**2105-4-18**] 08:50AM BLOOD WBC-6.5 RBC-3.69* Hgb-11.5* Hct-36.0*
MCV-97 MCH-31.1 MCHC-31.9 RDW-14.9 Plt Ct-137*
[**2105-4-17**] 08:10AM BLOOD WBC-6.8 RBC-3.65* Hgb-11.6* Hct-35.9*
MCV-98 MCH-31.8 MCHC-32.3 RDW-15.2 Plt Ct-125*
[**2105-4-16**] 05:58AM BLOOD WBC-6.8 RBC-3.76* Hgb-11.5* Hct-36.3*
MCV-97 MCH-30.5 MCHC-31.5 RDW-14.7 Plt Ct-130*
[**2105-4-15**] 04:56AM BLOOD WBC-5.9 RBC-3.64* Hgb-11.2* Hct-35.1*
MCV-97 MCH-30.8 MCHC-31.8 RDW-14.7 Plt Ct-117*
[**2105-4-14**] 04:33AM BLOOD WBC-5.1 RBC-3.36* Hgb-10.6* Hct-33.0*
MCV-98 MCH-31.4 MCHC-32.0 RDW-14.8 Plt Ct-108*
[**2105-4-13**] 06:30PM BLOOD WBC-5.3 RBC-3.42* Hgb-10.8* Hct-33.8*
MCV-99* MCH-31.6 MCHC-32.0 RDW-15.0 Plt Ct-101*
Coags
[**2105-4-19**] 08:00AM BLOOD PT-18.3* PTT-28.7 INR(PT)-1.7*
[**2105-4-18**] 08:50AM BLOOD PT-17.5* PTT-29.0 INR(PT)-1.6*
[**2105-4-17**] 08:10AM BLOOD PT-17.2* PTT-80.2* INR(PT)-1.5*
[**2105-4-16**] 05:58AM BLOOD PT-17.6* PTT-68.7* INR(PT)-1.6*
[**2105-4-15**] 04:56AM BLOOD PT-19.6* PTT-90.8* INR(PT)-1.8*
[**2105-4-14**] 04:34PM BLOOD PT-19.7* PTT-64.1* INR(PT)-1.8*
[**2105-4-13**] 06:30PM BLOOD PT-19.8* PTT-28.2 INR(PT)-1.8*
Chemistry
[**2105-4-18**] 08:50AM BLOOD Glucose-101* UreaN-40* Creat-1.7* Na-140
K-4.8 Cl-104 HCO3-27 AnGap-14
[**2105-4-17**] 08:10AM BLOOD Glucose-117* UreaN-34* Creat-1.6* Na-138
K-4.1 Cl-101 HCO3-29 AnGap-12
[**2105-4-16**] 05:58AM BLOOD Glucose-120* UreaN-34* Creat-1.5* Na-142
K-4.3 Cl-104 HCO3-29 AnGap-13
[**2105-4-15**] 08:11AM BLOOD Glucose-104* UreaN-38* Creat-1.6* Na-142
K-4.5 Cl-104 HCO3-29 AnGap-14
[**2105-4-15**] 04:56AM BLOOD Glucose-128* UreaN-40* Creat-1.9* Na-146*
K-5.6* Cl-108 HCO3-25 AnGap-19
[**2105-4-14**] 04:33AM BLOOD Glucose-101* UreaN-42* Creat-2.0* Na-146*
K-4.4 Cl-110* HCO3-29 AnGap-11
[**2105-4-13**] 06:30PM BLOOD Glucose-104* UreaN-47* Creat-2.4* Na-143
K-5.0 Cl-109* HCO3-25 AnGap-14
[**2105-4-18**] 08:50AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.5
[**2105-4-17**] 08:10AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.3
[**2105-4-16**] 05:58AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.3
[**2105-4-15**] 08:11AM BLOOD Albumin-3.9 Calcium-8.9 Phos-2.8 Mg-2.4
[**2105-4-15**] 04:56AM BLOOD Calcium-10.4* Phos-3.6 Mg-3.0*
[**2105-4-14**] 04:33AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.5
[**2105-4-13**] 06:30PM BLOOD Calcium-8.4 Phos-3.5 Mg-2.5
Cardiac Enzymes
[**2105-4-14**] 03:29PM BLOOD CK(CPK)-78
[**2105-4-14**] 04:33AM BLOOD CK(CPK)-133
[**2105-4-14**] 03:29PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2105-4-14**] 04:33AM BLOOD CK-MB-6 cTropnT-0.10*
[**2105-4-13**] 06:30PM BLOOD cTropnT-0.09*
TSH
[**2105-4-14**] 04:33AM BLOOD TSH-4.0
Brief Hospital Course:
86M with PMHx of dilated cardiomyopathy (EF of 20-25%), mitral
regurgitation s/p MVR with bioprosthetic valve, paroxysmal AF,
atrial tachycardia, CAD s/p remote inferior MI who presents with
SOB, dizziness, and bradycardic atrial fibrillation and acute on
chronic systolic heart failure
.
# ATRIAL FIBRILLATION: Presented with atrial fibrillation with
bradycardia most likely due to accumulation of AV nodal blocking
agents (Metoprolol and Digoxin) in the setting of acute on
chronic renal failure. These medicines were held on admission,
and the pt was then noted to have paroxysmal, narrow complex
atrial tachycardias to the 110's. Beta blockade was restarted,
however these paroxysms continued. Beta blockade was uptitrated
and pt went for pacemaker placement. Warfarin was held on
admission and patient was maintained on heparin drip. Warfarin
was restarted following pacemaker placement. His INR was 1.7 on
discharge. He was instructed to have his INR rechecked in two
days in order to further manage his warfarin dosing.
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE: TTE from [**2101**] shows
moderate regional LV systolic dysfunction with akinesis of the
inferior wall, apex, and hypokinesis of the anterior wall. LVEF
of 30-35%. Clinically he was volume overloaded with JVP to
earlobe and pedal edema. The pt was diuresed with IV Lasix which
he responded very well to with dramatic improvement in his
physical exam. The pt was discharged on his original home
regimen of alternating 20 mg and 40 mg of furosemide daily. His
home regimen of lisinopril was held because of hypotension.
Patient will follow up with his cardiologist regarding when to
restart the ACE inhibitorl.
.
# CORONARIES: cath from [**2100**] shows no flow limiting coronary
artery disease. Patient was continued on ASA, metoprolol, and
atorvastatin
.
# CKD - baseline creatinine of 1.8. Patient was admitted with
creatinine of 2.4, which improved to 1.7 by discharge.
.
# Severe MR s/p bioprosthetic MVR: Pt was bridged with Heparin
gtt while Coumadin was initially held.
Medications on Admission:
Atorvastatin 20mg daily
Digoxin 125 mcg daily
Lasix 40mg and 20mg daily alternating
Lisinopril 2.5mg daily
Lorazepam 0.5mg qhs
Toprol 37.5mg daily
Warfarin as directed
Aspirin 81 mg daily
Discharge Medications:
1. Outpatient Lab Work
Please check INR on tuesday [**4-21**] and call results to Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] H. at [**Telephone/Fax (1) 4615**]
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR).
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Lasix 20 mg Tablet Sig: 1-2 Tablets PO once a day: Take 40mg
on Sunday, Tuesday, Thursday, and Saturday. Take 20mg on
Monday, Wednesday, Friday. .
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 2 doses.
Disp:*2 Capsule(s)* Refills:*0*
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Bradycardia
Atrial Tachycardia
Dilated Cardiomyopathy
Paroxysmal Atrial Fibrillation
Coronary Artery Disease
Acute on Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 95715**].
You were admitted to the hospital for low heart rate
(bradycardia). This was likely due to the digoxin you were
taking. You were seen by Dr. [**Last Name (STitle) **] and you had a pacemaker
implanted to keep your heart rate from being very low. You
tolerated the procedure well and your device was functioning
properly. An appointment was made for you to follow up in
pacemaker device clinic in one week.
Your coumadin level (INR) was slightly below where it should be
(1.7 on [**4-18**]). Please get your next level checked on
Tuesday. A prescription has been provided.
We made the following changes to your medication:
1. STOP TAKING DIGOXIN
2. START TAKING KEFLEX 500mg for one day
3. INCREASE METOPROLOL XL from 37.5mg daily to 50mg daily (take
2 25mg tablets)
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
1. PACEMAKER DEVICE CLINIC
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2105-4-28**] 1:30
.
2. Dr. [**Last Name (STitle) **] (PRIMARY CARE PHYSICIAN)
Phone: [**Telephone/Fax (1) 4615**] Date/time:
Office will call you with an appt in 1 week.
.
3. CARDIOLOGIST:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time: [**5-22**] at 3:40pm.
Date/Time:[**2105-9-2**] 1:40
.
4. Physical Therapy:
Provider: [**First Name11 (Name Pattern1) 2620**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], PT Phone:[**Telephone/Fax (1) 4832**]
Date/Time:[**2105-4-27**] 9:30
.
5. Anesthesiology:
Provider: [**Name10 (NameIs) 8673**] [**Last Name (NamePattern4) 8674**],
MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2105-5-7**] 1:00
.
Name: [**Known lastname 15177**],[**Known firstname 15178**] Unit No: [**Numeric Identifier 15179**]
Admission Date: [**2105-4-13**] Discharge Date: [**2105-4-19**]
Date of Birth: [**2018-10-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4868**]
Addendum:
Addendum
#. ACE inhibitor - error above. ACE inhibitor was originally
held for acute renal failure, but was restarted once patient's
creatinine returned to baseline. Patient was discharged home on
original home dose of lisinopril.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
[**Name6 (MD) **] [**Last Name (NamePattern4) 4869**] MD [**MD Number(2) 4870**]
Completed by:[**2105-4-19**]
|
[
"428.23",
"428.0",
"V42.2",
"272.4",
"403.90",
"V58.66",
"427.31",
"412",
"427.89",
"584.9",
"414.01",
"425.4",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.72",
"37.83"
] |
icd9pcs
|
[
[
[]
]
] |
12508, 12704
|
6272, 8331
|
283, 305
|
9908, 9908
|
3674, 6249
|
11053, 11493
|
2775, 2863
|
8569, 9643
|
9744, 9887
|
8357, 8546
|
10059, 11030
|
2878, 3655
|
11511, 12485
|
223, 245
|
333, 1743
|
9923, 10035
|
1765, 2545
|
2561, 2759
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
704
| 151,175
|
13338
|
Discharge summary
|
report
|
Admission Date: [**2176-3-24**] Discharge Date: [**2176-4-25**]
Service: [**Location (un) 259**] GENERAL MEDICINE
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 80-year-old man
with a past medical history of coronary artery disease,
polymyalgia rheumatica who presents from outside hospital
with episode of chest discomfort and shortness of breath. He
was in his usual state of health until one week prior to
admission when he began having worsening shortness of breath
and dyspnea on exertion while on vacation at [**State 8842**]. He had
worsening shortness of breath on the day prior to admission,
an episode of chest pain and went to the Emergency Department
at an outside hospital in [**Hospital3 **].
He had electrocardiogram changes which were nonspecific,
possible ST elevation on lead 1 and L, T-wave inversion in 3
and was ruled out for myocardial infarction with CKs and
troponin. Originally started on Aggrastat and heparin which
was discontinued on [**3-24**]. He was continued on beta blocker
and aspirin, started on an ACE inhibitor and Plavix and
received diuresis with intravenous Lasix. He was transferred
to [**Hospital6 256**] and at presentation
he was with shortness of breath which was improved. No chest
pain, no fevers, chills, nausea or vomiting, however he did
have a cough productive of brown sputum.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post cardiac
catheterization many years prior notable for 80% right
coronary artery stenosis treated medically.
2. Prostate cancer three years prior to admission treated
with radiation.
3. Polymyalgia rheumatica, treated with prednisone from
[**July 2172**] and [**2173-3-27**]
4. HCS
5. Status post appendectomy
6. Diverticulosis, status post resection
7. Spinal stenosis
8. Dysphasia
ADMISSION MEDICATIONS:
1. Nitroglycerin
2. Zocor
3. Baclofen
4. Aspirin
5. Hydrocodone
6. Aspirin
ALLERGIES: He has no known drug allergies.
FAMILY HISTORY: Negative
SOCIAL HISTORY: The patient works as a banker. He has a 15
pack year smoking history, but quit 40 years ago.
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Temperature was 97.9??????, blood pressure 108/58,
pulse 90, respirations 20. O2 saturation is 95% on 4 liters.
GENERAL: He is a pleasant man in no acute distress.
HEAD, EARS, EYES, NOSE AND THROAT: Anicteric. Oropharynx is
clear. Jugular venous pressure is 3 cm.
HEART: Regular rate and rhythm, S1 and S2. The patient also
has an S3. No murmurs, rubs or gallops.
CHEST: Bibasilar wet crackles at the bases bilaterally one
half up.
ABDOMEN: Soft, nontender, nondistended, active bowel sounds.
EXTREMITIES: No edema, 2+ dorsalis pedis pulses bilaterally.
Warm extremities.
NEUROLOGIC: Alert and oriented x3, mentating well.
ADMISSION LABS: Notable for CKs 45, 29 and 27, troponin less
than 0.10 x2 and less than 0.15. White blood count was 13.1,
hematocrit 35, platelets 378. Chem-7 146, 4.3, 109, 20, 27,
1.1 and 168. His coagulation studies were normal. Chest
x-ray showed multiple patchy bilateral opacities in the mid
and lower lobes, partially obscuring the mediastinal and
hilar contours. No preliminary vascular engorgements.
HOSPITAL COURSE BY SYSTEMS:
1. PULMONARY: Mr. [**Known lastname **] was aggressively diuresed with
Lasix, as it was felt that he had pulmonary edema. His
oxygen saturation did not improve with his diuresis, in fact
it gradually worsened prompting a chest CT scan on [**3-30**]
which revealed diffuse air space disease predominantly of the
mid and lower lung zones consistent with infectious or
inflammatory process that were groundless opacities
bilaterally. He therefore had multiple serologies checked
and a biopsy done through a VATS procedure on [**2176-3-31**]. The
serologies were notable for positive P-ANCA confirmed by
myeloperoxidase and positive rheumatoid factor and an
elevated ESR, otherwise negative.
He had had the biopsy which revealed acute and organizing
pneumonitis with interalveolar fibrin deposition and type II
pneumocyte hyperplasia, fresh and organizing vascular
thrombi, but no evidence of active vasculitis. Stains were
negative for evidence of infection. Around this time on [**3-30**], he had been transferred to the Medical Intensive Care
Unit because of worsening respiratory status and intubated.
He was started on Cytoxan and Solu-Medrol and improved
respiratory wise over the next few weeks. He was extubated
on [**2176-4-12**] and his sedation was gradually titrated.
Pulmonary wise, he remained stable, but still had an oxygen
requirement on the date of discharge at approximately 2 to 3
liters nasal cannula.
2. CARDIOVASCULAR: The patient presented and was ruled out
for myocardial infarction. The initial feeling was that he
had pulmonary edema from congestive heart failure, however
his echocardiogram revealed a normal left ventricular
ejection fraction. No significant valvular disease and no
evidence of pericardial effusion or tamponade. Therefore,
the aggressive Lasix diuresis was stopped and he was simply
continued on aspirin, Lasix 40 mg intravenous qd, amlodipine,
metoprolol and Isordil. His Lipitor had been stopped because
of elevated CKs and his ACE inhibitor had been stopped
because of his renal function. He did not have any chest
pain or new electrocardiogram changes during his hospital
course and telemetry was discontinued when he left the
Medical Intensive Care Unit.
3. RENAL: The patient developed renal insufficiency which
was believed to be secondary to the aggressive diuresis he
received upon admission and his BUN increased into the 100s
and his creatinine increased to a maximum of 3.7 on [**4-12**]. It
had improved back to 2.2. His urinalysis was noted for muddy
brown casts. His FENA was 5% and SPAP and UPAP were
negative. His GBM was also negative. It was felt that he
probably did not have vasculitis infecting his kidneys and
that it was probably simply acute tubular necrosis. His
renal function had improved by the time of discharge to a
creatinine of 1.4.
4. MUSCULOSKELETAL: When the patient had reversal of his
sedation, it was noted that he was diffusely weak. This
delayed his extubation for a few days. When he was finally
extubated, he had difficulty talking. He had difficulty
moving his head and difficulty moving his extremities. The
neurology and rheumatology services were consulted for this
weakness and after thorough investigation including EMG nerve
conduction studies and a muscle biopsy, the belief was that
this was secondary to a steroid myelopathy or a critical
illness myopathy believed to improve with time and weaning of
his steroids. His strength gradually improved since transfer
to the floor and currently he has 3+ strength in his fingers
and hands, 3+ strength in his toes and feet and 1+ to 2+
strength in the rest of his extremities. He has 3+ strength
in his neck muscles. His extraocular movements are intact.
His LDH and CK had been followed for evidence of muscle
injury and they had been increasing and now are decreasing.
His LDH is currently 363 and his CK is 291 on the date of
discharge.
5. HEME: His hematocrit has remained relatively stable
during this admission. He has no current active bleeding.
6. INFECTIOUS DISEASE: He is currently not on any
antibiotics and has not shown any recent evidence of
infection.
7. FLUIDS, ELECTROLYTES AND NUTRITION: The patient was
having issues with hypernatremia and received D5 water
various times during his admission and free water boluses
through his tube. Because of this and his sodium had
improved to 148 on the day of admission, his feeding was done
through his nasogastric tube initially and he had a G-tube
placed through interventional radiology and the nasogastric
tube was removed. His G-tube has been functioning well with
low residuals and he has been getting Ultracal tube feeds.
DISCHARGE PLAN: The plan is to discharge on the following
medications.
DISCHARGE MEDICATIONS:
1. Cyclophosphamide 120 mg per G-tube qd
2. Heparin 5000 units subcutaneous [**Hospital1 **]
3. Furosemide 40 mg intravenous qd
4. Prednisone 80 mg per G-tube q od x2 weeks, then 70 mg po
q od x2 weeks, then 60 mg po q od indefinitely.
5. Bactrim Double Strength 1 tablet per G-tube 3x per week
6. Amlodipine 10 mg per G-tube qd
7. Metoprolol 75 mg per G-tube [**Hospital1 **]
8. Isordil 40 mg per G-tube tid
9. Lacrilube ointment 1 both eyes prn
10. Colace 100 mg per G-tube [**Hospital1 **]
11. Lansoprazole solution 30 mg per G-tube [**Hospital1 **]
12. Calcium acetate 1 per G-tube tid with meals
13. Aspirin 81 mg po qd
14. Albuterol metered dose inhaler 1 to 2 puffs q6h prn
15. Atrovent metered dose inhaler 2 puffs q6h prn
DISCHARGE INSTRUCTIONS: He will continue on Ultracal tube
feeds full strength at a rate of 70 cc per hour. Residuals
should be checked every four hours and tube feeds should be
held for residuals greater than 100 cc. He should receive
flushes of 120 cc of water q4h. He should have his CBC
checked every week and if his white blood count decreases
below 3.5 or his other blood counts remain dangerously low,
the Cytoxan dose should be decreased. His urine output goal
is greater than 2 liters per day because of his Cytoxan. He
should have active physical therapy. It was notable that he
had no functional impairments prior to admission except for
increased endurance and early fatigue.
FINAL DIAGNOSES:
1. Interstitial lung disease
2. Acute tubular necrosis
3. Renal insufficiency
4. Prostate cancer
5. Critical illness myopathy
6. Positive P-ANCA
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2176-4-25**] 11:22
T: [**2176-4-25**] 11:34
JOB#: [**Job Number 40584**]
cc:[**Telephone/Fax (1) 40585**]
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2176-4-25**] 11:22
T: [**2176-4-25**] 11:34
JOB#: [**Job Number 40584**]
(cclist)
|
[
"584.5",
"515",
"512.1",
"292.81",
"518.81",
"599.0",
"428.0",
"359.4",
"276.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.21",
"44.39",
"96.72",
"96.04",
"96.6",
"38.91",
"33.28"
] |
icd9pcs
|
[
[
[]
]
] |
1982, 1992
|
7996, 8737
|
8762, 9432
|
1838, 1965
|
3223, 7900
|
2129, 2779
|
9449, 10180
|
155, 1363
|
2796, 3195
|
7917, 7973
|
1385, 1815
|
2009, 2114
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,299
| 186,271
|
1488
|
Discharge summary
|
report
|
Admission Date: [**2160-5-22**] Discharge Date: [**2160-5-25**]
Date of Birth: [**2087-7-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Levofloxacin / Ciprofloxacin / Quinolones
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
worsening dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72 y/o M w/severe COPD, FEV 1 0.57, with 2 recent admissions for
PNA on [**5-2**] (treated with Cefpodoxime and Azithromycin) and [**5-6**]
for COPD flare. He was re-admitted to [**Hospital1 18**] [**2160-5-22**] overnight for
respiratory distress (thought to be due to COPD exacerbation
from PNA) and new ARF (creat up to 2.3 from baseline 0.9). He
was started on solumedrol, nebs, IVF and antibiotics. Since
admission he was in "moderate respiratory distress with use of
accessory muscles," per multiple notes, but patient noticed an
acute increase in his dyspnea this afternoon. He denies fever,
chills or cough. Floor team gave lasix 20 IV as he was given a
lot of IVF for renal failure and thought he might have some
component of pulmonary edema. Repeat CXR without CHF but still
with b/l lower lobe infiltrates.
.
Per the family, after returning home from [**Hospital1 **] on [**2160-5-20**] he
has had decreased po intake with minimal solids and then [**2160-5-21**]
he became more lethargic with increased SOB. He has chronic
cough and reports no change in cough. No fever, chills, upper
respiratory symptoms, nausea, vomiting, chest pain, change in
bowel or bladder habits.
Past Medical History:
1. COPD on home O2 (2L), FEV1 0.57 (19% predicted), followed in
Pulmonary by Dr. [**Last Name (STitle) 217**].
2. Bilateral achilles tendon rupture after getting a
fluoroquinolone
3. PE after the above achilles tendon rupture in [**2155**]
4. R hip hematoma [**1-17**] coumadin for PE
5. Bilateral THR [**2141**]
6. Pulmonary nodules on chest CT
7. Tracheobronchomalacia s/p Y stent, subsequently removed later
due to no improvement in symptoms and increase in secretions
8. Mild pulm HTN
9. Incomplete RBBB
10. Osteoporosis
11. retroperitoneal bleed as a complication from anticoagulation
12. tongue bleed from coumadin
13. History of 2 documented episodes of a flutter
Social History:
Lives in [**Hospital1 8**], retired president of the [**Location (un) 511**]
Conservatory of Music and also is a lawyer (was general counsel
to the Equal Employment Opportunities Commission, then taught at
the [**Doctor Last Name 780**] School of Government at [**University/College **]). Smoked 2 ppd x 15
yrs, quit [**2120**]. Married. Daughter is a family medicine physician
at [**Name9 (PRE) 8780**]. Son is in venture capital, lives in [**Location 7349**]. Drinks 1
drink per night.
Family History:
had a child who died of a brain tumor 30 years ago
Physical Exam:
T: 98.6 BP: 129/85 P: 81 RR: 26 97% at 1L NC
Gen: alert and oriented x3, in moderate/severe respiratory
distress, labored breathing, pursed-lip breathing, able to speak
in two-word sentences
HEENT: oral mucosa dry, PERRL, EOMI
Neck: no JVD, + accessory muscle use, no LAD
Lungs: rhonchorous b/l bases, no rales, mild expiratory wheezes
CV: regular, distant heart sounds, unable to hear due to breath
sounds
Abd: Soft, mildly distended but nontender, +bs, umbilical
hernia.
Ext: 2+ pitting edema on L, 1+ pitting edema on R with
erythematous skin changes overlying shins (not new, per pt).
SKIN: multiple ecchymoses on arms, chest, face and chest
erythema
Pertinent Results:
[**2160-5-22**] 08:43PM BLOOD WBC-14.0* RBC-4.02* Hgb-11.9* Hct-35.2*
MCV-88 MCH-29.7 MCHC-33.9 RDW-16.2* Plt Ct-380
[**2160-5-23**] 07:45AM BLOOD WBC-12.8* RBC-3.97* Hgb-11.6* Hct-35.3*
MCV-89 MCH-29.2 MCHC-32.8 RDW-16.1* Plt Ct-391
[**2160-5-24**] 12:30AM BLOOD Neuts-95.7* Bands-0 Lymphs-1.9*
Monos-1.9* Eos-0.2 Baso-0.3
[**2160-5-22**] 08:43PM BLOOD Plt Ct-380
[**2160-5-22**] 08:43PM BLOOD Glucose-154* UreaN-52* Creat-2.3*# Na-138
K-4.5 Cl-100 HCO3-23 AnGap-20
[**2160-5-24**] 12:30AM BLOOD Glucose-227* UreaN-37* Creat-1.1 Na-141
K-3.7 Cl-103 HCO3-25 AnGap-17
[**2160-5-22**] 08:43PM BLOOD CK(CPK)-79
[**2160-5-23**] 07:45AM BLOOD CK(CPK)-97
[**2160-5-24**] 12:30AM BLOOD CK(CPK)-104
[**2160-5-22**] 08:43PM BLOOD cTropnT-0.22*
[**2160-5-23**] 07:45AM BLOOD CK-MB-NotDone cTropnT-0.07* proBNP-711*
[**2160-5-24**] 12:30AM BLOOD CK-MB-7 cTropnT-0.05* proBNP-920*
[**2160-5-23**] 07:45AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.3
[**2160-5-24**] 12:30AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.3
[**2160-5-23**] 09:37PM BLOOD Type-ART Temp-36.7 Rates-/24 O2 Flow-4
pO2-67* pCO2-39 pH-7.39 calHCO3-24 Base XS-0 Intubat-NOT INTUBA
.
CXR: IMPRESSION:
1. Bilateral lower lobe opacities worrisome for pneumonia versus
aspiration.
2. Chronic emphysema.
Brief Hospital Course:
72 y/o M w/severe COPD, FEV 1 of 0.57, on home oxygen,
tracheobronchomalacia, onchronic steroids, recently admitted
with RLL pneumonia and COPD flare, now is admitted [**2160-5-22**] wtih
bilateral pneumonia, COPD flare, renal failure and now worsening
dyspnea.
.
# Dyspnea - pt was started on antibiotics (Ceftriaxone, azithro,
vanco). Given lasix with approximately 1L of urine output, but
no clinical improvement. He was started on nebulizers, unable
to tolerate BIPAP. CTA deferred because of renal dysfunction.
CKs were negative x3, troponin trending down. The patient
continued to be extremely dyspneic, and after extensive
discussion with family, decision was made to pursue comfort
measures without intubation. He was given morphine as needed.
Transferred from MICU to Thoracic surgery service per family
request and expired shortly thereafter on [**2160-5-25**]
.
# ARF: presented with worsened renal failure, resolved with IVF.
.
# OSTEOPOROSIS: On chronic prednisone. Cont fosamax, calcium.
.
# HTN. Hypotensive on admission but resolved with IVF.
- Hold HCTZ
- Restart cardizem as needed.
.
# THRUSH: Nystatin swish/swallow.
.
# PSYCH: Continued celexa for depression and Seroquel.
.
# PPX: Heparin SC. Bowel regimen. PPI, Calcium, Fosamax while
on steroids. Monitor blood glucose.
Medications on Admission:
- zinc
- calcium
- seroquel 12.5 mg po bid
- hydrochlorothiazide 25 mg daily
- prednisone 20/10 alternating
- plavix 75 mg
- asa 325 mg po daily
- Lactulose 30 ml prn
- Miralax packet prn
- celexa 20 mg daily
- cardizem 120 mg daily
- multivitamin
- calcium carbonate 500 mg daily
- vitamin c 500 mg daily
- fosamax 70 mg qtuesday
- spiriva 18 mg daily
- fordail MDI 12 mcg [**Hospital1 **]
- flovent 220 mcg 4 puffs [**Hospital1 **]
- albuterol q4h prn
- xalatan eye drops
- Fentanyl 200 lollipop po q 8 for resp symptoms
- Trazodone 25 mg po qd
.
Meds on transfer:
Serevent
Ipratroprium neb q6h
Albuterol neb q6h
Azithromycin 250 mg po q24 (D#1)
Vancomycin 1 g IV q24 (D#1)
Ceftriaxone 1 g IV q24 (D#1)
Solumedrol 125 mg IV q8h (D#1)
Colace/Bisacodyl/Lactulose
Celexa
Seroquel 12.5 mg po bid
Vitamin C, Zinc, CaCO3, MVI
Plavix 75 mg po daily
Aspirin 325 mg daily
Latanaprost gtt
Alendronate
nystatin oral suspension
Protonix
Trazadone
RISS
Megace
Morphine 1 mg IV q2h prn (was getting for resp distress)
Discharge Disposition:
Expired
Discharge Diagnosis:
pt expired
Discharge Condition:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2160-8-15**]
|
[
"518.84",
"112.0",
"486",
"V12.51",
"V15.82",
"V66.7",
"V43.64",
"733.00",
"V58.65",
"491.21",
"707.8",
"V58.61",
"311",
"584.9",
"519.1",
"426.4",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7123, 7132
|
4765, 6066
|
325, 331
|
7186, 7315
|
3505, 4742
|
2761, 2813
|
7153, 7165
|
6092, 6641
|
2828, 3486
|
268, 287
|
359, 1544
|
1566, 2240
|
2256, 2745
|
6659, 7100
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,477
| 116,942
|
34968
|
Discharge summary
|
report
|
Admission Date: [**2197-3-15**] Discharge Date: [**2197-3-20**]
Date of Birth: [**2137-5-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea, palpitations
Major Surgical or Invasive Procedure:
[**2197-3-15**] Tricuspid Valve repair utilizing a 34mm annuplasty ring
with LV lead placement
.
[**2197-3-17**] Insertion of [**Company 1543**] dual chamber permanent pacemaker,
model # ADDRL1
History of Present Illness:
This is a 59 year old female with history of polymyositis, who
was recently sent in for evaluation of tachy-brady syndrome.
Over past month prior to admission, she reported having
intermittent chest tightness and palpitations. These episodes
lasted approximately 10-40 minutes. She also complained of
intermittent dyspnea and decreased exercise tolerance. She also
reported episodes in which she feels lightheaded and a sensation
of warmth, but denies any dizziness or loss of consciousness.
Subsequent cardiac MRI revealed worsening tricuspid
regurgitation with RA/RV enlargement and also some mitral
regurgitation. Given above findings, cardiac surgery was
consulted and further evaluation was performed. After routine
preoperative evaluation, she was eventually cleared to proceed
with surgical intervention.
Past Medical History:
- Gallbladder polyps
- Polymyositis - biopsy proven. Has refused treatment in the
past due to side effects of prednisone
- Recent Pneumonia, one month prior to admission
- Tricuspid Regurgitation
- Sick Sinus Syndrome
Social History:
Lives with her son [**Name (NI) **]. Nonsmoker. Denies ETOH or drug use.
Daily hour long walks per family.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PREOP EXAM:
BP 103/56 Pulse:54 Resp:18 O2 sat:95/RA
Height:66" Weight:59.1 kgs
General: WDWN female in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] No edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: none Left: none
Pertinent Results:
Admission labs:
[**2197-3-15**] WBC-7.4 RBC-2.71*# Hgb-8.1*# Hct-24.5*# RDW-14.2 Plt
Ct-64*#
[**2197-3-16**] WBC-11.5* RBC-2.84* Hgb-8.3* Hct-25.2* RDW-15.2 Plt
Ct-173
[**2197-3-17**] WBC-15.5* RBC-3.14* Hgb-9.1* Hct-27.7* RDW-15.5 Plt
Ct-120*
[**2197-3-18**] WBC-8.9 RBC-2.95* Hgb-8.6* Hct-26.7* RDW-15.0 Plt
Ct-104*
[**2197-3-19**] WBC-9.4 RBC-2.99* Hgb-8.6* Hct-27.1* RDW-15.2 Plt
Ct-111*
[**2197-3-15**] UreaN-9 Creat-0.4 Na-142 K-3.4 Cl-109* HCO3-28 AnGap-8
[**2197-3-16**] Glucose-100 UreaN-7 Creat-0.3* Na-138 K-4.1 Cl-106
HCO3-30
[**2197-3-17**] Glucose-112* UreaN-8 Creat-0.5 Na-135 K-4.1 Cl-99
HCO3-33*
[**2197-3-18**] Glucose-99 UreaN-6 Creat-0.3* Na-138 K-3.8 Cl-101
HCO3-31 AnGap-10
[**2197-3-19**] UreaN-7 Creat-0.3* Na-140 K-3.8 Cl-101
[**2197-3-16**] Mg-2.0, [**2197-3-19**] Mg-2.0
.
Discharge labs:
[**2197-3-19**] 06:40AM BLOOD WBC-9.4 RBC-2.99* Hgb-8.6* Hct-27.1*
MCV-91 MCH-28.9 MCHC-31.9 RDW-15.2 Plt Ct-111*
[**2197-3-19**] 06:40AM BLOOD Plt Ct-111*
[**2197-3-17**] 03:52AM BLOOD PT-12.7* PTT-26.7 INR(PT)-1.2*
[**2197-3-19**] 06:40AM BLOOD UreaN-7 Creat-0.3* Na-140 K-3.8 Cl-101
[**2197-3-19**] 06:40AM BLOOD Mg-2.0
[**2197-3-18**] Chest x-ray:
Pulmonary edema has not recurred and pulmonary vascular
engorgement has improved. Severe cardiomegaly is stable. Small
right and moderate left pleural effusion are stable, left lower
lobe collapse is more pronounced. No pneumothorax. Transvenous
right ventricular pacer lead may pass into the coronary sinus,
but it does not traverse the ring of the tricuspid valve
prosthesis
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 55% >= 55%
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**2-6**]+) MR.
TRICUSPID VALVE: Moderate to severe [3+] TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Written informed consent was obtained from the
patient. The patient was under general anesthesia throughout the
procedure. No TEE related complications. The patient appears to
be in sinus rhythm. Results were personally reviewed with the MD
caring for the patient.
Conclusions
Prebypass
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is moderately dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**2-6**]+) mitral regurgitation
is seen. Moderate to severe [3+] tricuspid regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results on [**2197-3-15**] at 945am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
LVEF= 50%. Annuloplasty ring seen in the tricuspid position. It
appears well seated . There is trivial tricuspid regurgitation
and no stenosis. Aorta is intact post decannulation. The mitral
regurgitation is trivial.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2197-3-15**] 14:04
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admission to the operating room for
tricuspid valve repair along with placement of a left
ventricular lead, please see operative report for details. In
summary patient had:
1. Tricuspid repair using an [**Doctor Last Name **] MC3 annuloplasty ring,
model number 4900.
2. Left ventricular epicardial lead placement x2.
3. Atrial tissue biopsy.
4. Mediastinal reexploration
Her bypass time was35 minutes with a crossclamp time of 24
minutes.
Following re-operation, she was brought to the CVICU for
invasive monitoring. Within 24 hours, she awoke neurologically
intact and was extubated without incident. She maintained stable
hemodynamics and underwent placement of dual chamber [**Company 1543**]
pacemaker on postoperative day two. She tolerated the procedure
well without complication. Following pacemaker implantation, she
transferred to the cardiac stepdown floor for further care and
recovery. She experienced brief episodes of paroxysmal atrial
fibrillation but ultimately was apaced. Beta blockade was
started and advanced as tolerated. Over several days, she
continued to make clinical improvement with diuresis and she was
medically cleared for discharge to rehabilitation on
postoperative day five. Prior to discharge, pacemaker underwent
interrogation and was found to be functioning within normal
limits. At discharge, incisional pain was well controlled on
Ultram.
Follow up appointments were outlined in discharge paperwork.
Medications on Admission:
metoprolol XL25 mg daily, several Chinese herbal medications
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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin [**Hospital1 1926**] 81 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain management .
Disp:*30 Tablet(s)* Refills:*0*
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days: please take with KCL.
Disp:*10 Tablet(s)* Refills:*0*
7. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 10 days:
please take with Lasix.
Disp:*10 Tablet, ER Particles/Crystals(s)* Refills:*0*
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for dyspnea.
9. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Tricuspid regurgitation- s/p Tricuspid repair
Tachy-brady syndrome, s/p Permanent pacemeker implantation
Polymyositis
Postop Bleeding, s/p re-exploration
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Tramadol
Incisions:
Sternal - healing well, no erythema or drainage
Edema-trace bilat LE
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment 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:
Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 170**]) on [**4-20**] @1pm phone:[**Telephone/Fax (1) 4044**]
EP service/Cardiologist:Dr. [**First Name (STitle) 900**] [**Name8 (MD) 901**], M.D.
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2197-3-30**] 1:40
Provider: [**Name10 (NameIs) **] CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2197-3-28**]
10:00
Device Clinic- [**Hospital Ward Name 23**] 7: [**2197-3-23**] @ 10AM [**Telephone/Fax (1) 62**]
Please call to schedule appointments with:
Primary Care: Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 10349**] in [**5-11**] 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:[**2197-3-20**]
|
[
"458.29",
"424.0",
"424.2",
"710.4",
"998.11",
"E878.8",
"427.31",
"427.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.25",
"34.03",
"37.72",
"39.61",
"37.83",
"37.74",
"35.14"
] |
icd9pcs
|
[
[
[]
]
] |
9606, 9661
|
6775, 8258
|
332, 528
|
9859, 10040
|
2577, 2577
|
10927, 11851
|
1752, 1867
|
8369, 9583
|
9682, 9838
|
8284, 8346
|
10064, 10904
|
3398, 6752
|
1882, 2558
|
271, 294
|
556, 1370
|
2593, 3382
|
1392, 1611
|
1627, 1736
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,044
| 113,652
|
2806
|
Discharge summary
|
report
|
Admission Date: [**2104-11-12**] Discharge Date: [**2104-12-1**]
Date of Birth: [**2034-9-18**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
ABG
History of Present Illness:
70 year old female with chief complaint of sob, weakness.
Started to feel ill on Thankgiving while she was in [**State 2690**]
visiting family and noted chills. Continues to have intermittent
sweats and chills, also devloped progressive fatigue and SOB. By
the time she arrived home [**11-7**], she could only take a few steps
without feeling short of breath. Minimal cough, but does feel
chest "tightness." Tm 100 at home. Other than "sitting still"
Ms. [**Known lastname 13751**] did not find anything that made her symptoms better.
Presented to OSH ED on Friday night (5 days ago) with these
complaints. CXR there showed a pneumonia, and she was d/c home
with a Z-pack which she finished last night. She had a scheduled
follow up at her PCP's office today where she was found to be
sating 83% on RA and was sent to the ED. In the [**Hospital1 18**] ED,
initial VS T 96.5, HR 80, BP 98/66, RR 21, O2 97% 4L NC. The
patient had a CXR that demonstrated a right lung consolidation,
received levofloxacin, and was admitted to the ICU for further
management. Labs in the ED were notable for a bicarb of 20 and
WBC count of 13.7 with 81% PMNs. Pt has no Hx of chronic lung
disease, but has had episodes of "bronchitis" in the past. No
previous ICU admissions. VS upon transfer to [**Hospital Unit Name 153**] were T 98, HR
74, BP 104/60, RR 19, O2 97%5L NC.
In the ICU, the patient felt much better since being placed on
nasal canula. Minimal cough. Denies drenching night seats or
high fevers. She has had a poor appetite, but no nausea or
vomiting.
.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [] All Normal
[ X] Fever [ ] Chills [ ] Sweats [ X] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ ] weight loss
HEENT: [X] All Normal
[ ] Blurred vision [ ] Blindness [ ] Photophobia
[ ] Decreased acuity [ ] Dry mouth [ ] Bleeding gums
[ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ]Tinnitus [ ] Other:
RESPIRATORY: [] All Normal
[ X] SOB [X] DOE [ X] Cough
[ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [ ]Pleuritic
pain
[] no PND:
CARDIAC: [X] All Normal
[ ] Angina [ ] Palpitations [ ] Edema [ ] PND
[ ] Orthopnea [] Chest Pain [ ] Other:
GI: [X] All Normal
[ ] Blood in stool [ ] Hematemesis [ ] Odynophagia
[ ] Dysphagia: [ ] Solids [ ] Liquids
[ ] Anorexia [] Nausea [] Vomiting [ ] Reflux
[ ] Diarrhea [ ] Constipation [ ] Abd pain [ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Frequency [ ] Hematuria []Discharge
[]Menorrhagia
[]unable to urinate
SKIN: [X] All Normal
[] SKs + ecchymoses
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Temp subjectivity
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
.
[+]all other systems negative except as noted above
Past Medical History:
Hypertension
Hyperlipidemia
Depression
Obesity
60-69% left ICA stenosis
Osteopenia
Cholecystectomy [**2089**]
Social History:
Her social history is positive for one to two glasses of wine
a day and she did have a significant smoking history of two
packs per day for 30 years. She quit 20 years ago. Lives alone.
Retired.
Family History:
Her mother passed away last year. Mom had a MI and a TIA as well
as a CHF.
Physical Exam:
VS: T = 100.4 P = 88 BP = 116/64 RR = 24 O2Sat = 94% on 4L NC
GENERAL:
NAD (on O2)
Mentation: Alert, speaks in full sentences.
Eyes:NC/AT, no scleral icterus noted
Ears/Nose/Mouth/Throat: MMM,
Neck: supple
Respiratory: Diffuse rhonchi R lung
Cardiovascular: RRR, nl. S1S2
Gastrointestinal: soft, NT/ND, normoactive bowel sounds
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No edema.
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
Psychiatric: WNL
Pertinent Results:
[**2104-11-12**] 09:45AM WBC-13.7*# RBC-3.66* HGB-10.1* HCT-30.2*
MCV-83# MCH-27.5 MCHC-33.3 RDW-13.4
[**2104-11-12**] 09:45AM GLUCOSE-106* UREA N-16 CREAT-1.0 SODIUM-138
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-20* ANION GAP-20
[**2104-11-12**] 05:24PM TYPE-ART PO2-74* PCO2-32* PH-7.48* TOTAL
CO2-25 BASE XS-0
Brief Hospital Course:
70yo F with HTN and dyslipidemia who was sent to ED from PCP's
office for hypoxia in the setting of community aquired PNA x 2
weeks, refractory to outpatient azithromycin and was admitted to
the ICU for severe pneumonia and sepsis which were complicated
by multisystem failure including respiratory and renal failure.
.
She Presented to the ICU with a Pneumonia like picture.
Stabalized on 4 L 02, but continued to have tachypnea. Due to
difficulty maintaining respiratory rate, patient was electively
intubated. Had imaging consistent with severe right pulmonary
pneumonia as well as progressing rounded left lower lobe
opacities, likely infectious in nature. CT scan complimented
CXR, but was negative for pulmonary effusions. Started on broad
antibiotics including vancomycin, zosyn, and levofloxacin. As
pt had history of traveling to [**State 2690**] within the previous several
weeks multiple tests for fungus, EBV, legionella, AFB,
cryptococcus, sputum, blood, and urine cultures all were
negative. The patient had a BAL after intubation which was
negative for microorganisms including PCP. [**Name10 (NameIs) **] became
progressivley more hypoxic requriing increased PEEP and FiO2.
ARDSnet protocol was instituted as CXR was concerning for
possible ARDS. Trathoracic pressure monitoring was performed
via esophageal balloon manometry. Despite these efforts patient
showed no clinical or radiological improvement and continued to
have difficulty on the vent requiring increased FiO2 and PEEP to
maintain her oxygen saturation. She also developed oliguric
renal failure and CVVH was started. She was gradually weaned of
sedation but did not regain consciousness. Throughout her
hospital stay the ICU team worked closely with the patient's
family and HCP who were aware of the worsening prognosis in the
setting of multi-organ failure and lack of improvement. On
hospital day 20 in accordance with the family's wishes she was
terminally extubated. She expired shortly thereafter with the
family at the bedside.
.
Medications on Admission:
Simvistatin 40 mg Daily
FUROSEMIDE 20mg Daily
Metoprolol XL 25mg daily
OXYBUTYNIN CHLORIDE Extended Release 5mg Daily
RANITIDINE HCL 150 mg Daily
ASPIRIN 325 mg Tablet Daily
CALCIUM CARBONATE-VITAMIN D3 500 mg -400 unit Daily
CLARITIN-D 24 HOUR 240 mg-10 mg
MULTIVITAMIN once daily
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2105-4-2**]
|
[
"995.92",
"783.21",
"458.21",
"414.01",
"038.9",
"280.9",
"V15.82",
"584.5",
"787.91",
"276.4",
"585.6",
"V49.86",
"311",
"272.4",
"278.00",
"403.91",
"733.90",
"507.0",
"623.8",
"238.71",
"486",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"39.95",
"96.72",
"96.6",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
7498, 7507
|
5110, 7139
|
280, 285
|
7553, 7557
|
4772, 5087
|
7608, 7640
|
3959, 4035
|
7471, 7475
|
7528, 7532
|
7165, 7448
|
7581, 7585
|
4050, 4526
|
1881, 3593
|
233, 242
|
313, 1862
|
4541, 4753
|
3615, 3727
|
3743, 3943
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,581
| 119,056
|
1365
|
Discharge summary
|
report
|
Admission Date: [**2130-12-16**] Discharge Date: [**2130-12-22**]
Date of Birth: [**2053-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
cardiac catherization
History of Present Illness:
Patient is a 77 yo man with pmhx CAD s/p CABG (4v disease,
unknown anatomy), PVd s/p atherectomy, HTN, Hyperlipidemia, 2nd
degree AV block s/p PMP who p/w one month of progressive dyspnea
on exertion. Of note, last week the patient had one episode of
epistaxis and melena which has since resolved. He went to his
PCP who checked [**Name Initial (PRE) **] crit and found it to be 32 which was 5 points
lower than [**Month (only) **] when it was at baseline 37. He was guaic
negative in ED and reported that his last BM was brown. He did
have some blood on tissue when he wiped. Patient has also had a
mildly productive cough for the last month, but denies sick
contacts, fevers, chills. He sleeps with 2 pillows because he
feels more comfortable, denies PND. Has LE edema at baseline
that he doesnt feel is worse over the last month. Denies calf
pain and no recent plane trips. He reports that over the last
month his dyspnea on exertion has worsened to the point that he
can't walk up a flight of stairs without getting short of breath
which is new for him. He denies any associated chest pain,
palpatations, N/V/D associated with the sob. Of note, he has
never experienced chest pain even before he had his CABG.
The patient had a chest film in the ED that revealed some mild
edema for which the patient received 20mg IV lasix. The patient
additionally received neb treatments given evidence of
bronchospasm on exam and history of significant COPD.
Of additional note lab values in the ED revealed flat CKs but an
elevated troponin of .76, increased from previous values of .23
-.34 in [**2130-6-17**] in the setting of impaired but stable renal
function ( creatinine 1.3, BL 1.1-1.4).
ECG was performed revealing V-pacing without significant change
from previous. The patient last had an echocardiogram performed
in [**2130-4-17**] revealing mildly depressed EF without focal WMA
although limited in view, as well as diastolic dysfunction.
In the ED the patient received ASA, Plavix 75mg, Lipitor 80mg. A
heparin gtt was not started given initial concern for GI
bleeding and impression that symptoms were not escalating to
suggest ACS. A beta blocker was not administered given history
of significant bronchospasm (Dilt as outpatient).
Past Medical History:
1. CAD s/p 4 vessel CABG [**2118**]
2. HTN
3. COPD
4. BPH s/p turp
5. Second degree AV block s/p PPM
6. Hyperlipidemia
7. PVD s/p atherectomy
8. Multifocal pna [**7-23**]
9. Right RAS
Social History:
Patient lives alone with his cat. He quit smoking 40 years ago
and smoked approx 10-20 years. Rarely drinks etoh and uses no
illicits. Retired art teacher.
Family History:
Father died at age 49 of leaky heart valve. Mother died at 88 of
unknown causes. No siblings.
Physical Exam:
VS T 96.8 HR 79 Bp 130/62 R 20 O2 sat 99% 3 L Wt 78 kg
Gen: Pleasant man, appears slightly winded with talking
Neck- JVP 7 cm b/l, no LAD or thyromegaly
HEENT- NCAT, anicteric, no injections, PERRLA, OP clear, no
exudate, MMM
Cor- distant heart sounds, S1S2 no MGR
Lungs- minimal bibasilar crackles
Abd- +bs, soft, nt, nd, no masses or HSM
Extrem- +1 edema b/l, no cyanosis, left leg shiny and red, not
warm, no hair b/l
Neuro- A/0 x 3
Pertinent Results:
Initial labs:
143 105 19
------------< 79
4.0 26 1.3
GFR 54%
CK 143, 114
MB 8
T 0.76, 0.69
wbc 6.4
hgb 11.3
hct 31.7
plt 260
MCV 82
iron studies: TIBC 347, ferritin 37, iron 21, TRF 267
PT 13.5, PTT 27.5, INR 1.2
CXR: Findings consistent with CHF. Bilateral pleural effusions,
left greater than right.
Cardiac Cath:
1. Three vessel coronary artery disease.
2. Elevation of right and left filling pressures with low
cardiac index.
3. Unsuccessful PCI of the ramus intermedius.
Echo:
The left atrium is mildly dilated. The estimated right atrial
pressure is
0-5mmHg. Left ventricular wall thicknesses and cavity size are
normal. There is mild regional left ventricular systolic
dysfunction with focal hypokinesis of the distal half of the
septum. The remaining segments contract well.
The right ventricular cavity is mildly dilated. The aortic
valve leaflets are moderately thickened but aortic valve
stenosis is not suggested. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-19**]+) mitral regurgitation is seen. There is mild tricuspid
stenosis (area >1.5cm2). There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of [**2130-4-17**],
distal septal hypokinesis is now suggested (may be related to
IVCD as also suggested on
prior study) and the right ventricular cavity now appears
dilated. Trace
aortic regurgitation was present on review of the prior study.
.
Labs on discharge:
[**2130-12-22**] 05:20AM BLOOD WBC-6.6 RBC-3.89* Hgb-10.9* Hct-31.4*
MCV-81* MCH-27.9 MCHC-34.5 RDW-15.9* Plt Ct-264
[**2130-12-22**] 05:20AM BLOOD Glucose-96 UreaN-21* Creat-1.3* Na-138
K-4.2 Cl-102 HCO3-28 AnGap-12
[**2130-12-22**] 05:20AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.4
[**2130-12-15**] 08:40PM BLOOD calTIBC-347 Ferritn-37 TRF-267
[**2130-12-16**] 09:35AM BLOOD Triglyc-81 HDL-57 CHOL/HD-2.5 LDLcalc-70
LDLmeas-81
[**2130-12-20**] 01:43AM BLOOD TSH-3.0
Brief Hospital Course:
A/P: A/P: Patient is a 77 year old Male with history of CAD s/p
4V CABG in [**2118**] who presents with 1 month of worsening DOE with
intial concern for GI bleeding, but subsequently found to have
elevated Troponin and ruled in for NSTEMI.
.
# DOE - Troponin elevated despite stable renal function. On
admission, the patient appeared to be clinically mildly fluid
overloaded which would not completely account for the
significantly elevated troponin. Patient ruled in for NSTEMI.
Patient was taken to cath lab:
.
1. Three vessel coronary artery disease.
2. Elevation of right and left filling pressures with low
cardiac index.
3. Unsuccessful PCI of the ramus intermedius.
.
Given his low CI and high filling pressures and hypotension post
cath, he was sent to the CCU where he underwent diuresis with
stable BP.
.
Anemia was felt to be contributing to his symptoms. Earlier this
month, patient had a hematocrit of 44 at PCPs office and on
admission it was 31. Patient had brown guaic positive stool. He
was transfused one unit of blood and his hematocrit responded
appropriately.
.
COPD could also be contributing to his dyspnea and his
breathlessness improved with nebulizer treatments and advair, as
well as with the above diuresis.
.
# CAD- see above. We continued asa, atorvastatin, diovan. Plavix
held for GIB and diovan held for elevated creatinine initially.
These were subsequently added back.
.
# GI bleed / blood loss anemia- patient reported to have
epistaxis and dark stools one week ago. Had guaic positive stool
on this admission. Transfused one unit with appropriate crit
bump to get crit over 30 in setting of nstemi. We also started
protonix. Pt was told to pursue outpatient GI follow-up and
colonoscopy.
.
# COPD - advair, nebs prn given.
.
# HTN- we held diovan initailly given rising creatinine; added
back prior to discharge. We continued Diltiazem 60mg qid,
converted back to SR on discharge. We gave nitropaste for
further afterload reduction.
.
# Hyperlipidemia - we continued atorvastatin
.
Medications on Admission:
Medications: from Cardiology note [**2130-9-7**]
Aspirin 325mg daily
Plavix 75mg daily
Zocor 40mg daily
Levothyroxine 50 mcg daily
Diovan 80 mg daily
Lasix 20 mg daily
Diltiazem 240 mg SR daily
Salmeterol 50 mcg/Dose q12hours
Fluticasone 110 mcg 2 Puff [**Hospital1 **]
Albuterol q 6 hours PRN
Ipratropium q 6 hours PRN
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Diltiazem HCl 240 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day): rinse mouth after
use.
Disp:*1 diskus* Refills:*2*
7. 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*
8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*60 Tablet, Sublingual(s)* Refills:*2*
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
Disp:*1 bottle* Refills:*1*
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
Disp:*30 neb* Refills:*0*
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
Units, heparin Injection TID (3 times a day): subcutaneous.
Disp:*QS Units, heparin* Refills:*2*
15. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
17. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
18. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
NSTEMI
Guaic positive stool
COPD
Discharge Condition:
Hemodynamically stable and afebrile.
Discharge Instructions:
You were admitted with shortness of breath and were found to
have a heart attack. You were treated with medication and taken
to the catherization lab, after which you required a cardiac
intensive care admission for low blood pressure and heart
failure. You were also found to have blood in your stool and we
held your plavix before catherization and you were given one
unit of blood by transfusion.
Please take all medications as directed.
Please follow-up with all outpatient appointments.
Please call your doctor or return to the ED if you experience
chest pain, shortness of breath, fever, groin pain, vomiting,
blood in your stools or black stools.
Followup Instructions:
The following appointments have already been made for you:
Dr. [**First Name (STitle) 1313**]: [**2131-1-1**] at 1:30 pm Tel. ([**Telephone/Fax (1) 8294**].Provider:
[**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-2-13**] 11:15
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2131-4-24**]
11:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2131-5-15**]
11:30
|
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"401.9",
"414.01",
"440.1",
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icd9cm
|
[
[
[]
]
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[
"99.04",
"88.56",
"37.23",
"88.52"
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icd9pcs
|
[
[
[]
]
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10236, 10306
|
5567, 7588
|
321, 345
|
10383, 10422
|
3579, 5064
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7959, 10213
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10446, 11104
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3123, 3560
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278, 283
|
5083, 5544
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373, 2617
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2639, 2824
|
2840, 2997
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,980
| 177,884
|
38157
|
Discharge summary
|
report
|
Admission Date: [**2189-7-21**] Discharge Date: [**2189-7-24**]
Date of Birth: [**2126-5-23**] Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide / Sesame Oil
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Acute Cardiac Tamponade
Major Surgical or Invasive Procedure:
Pulmonary vein isolation
Pericardiocentesis with drain placement
Arterial line placement
Blood transfusion - 1 unit packed red blood cells
History of Present Illness:
63 yo F h/o HTN, PAF underwent PVI today and during procedure
acutely developed hypotension with bradycardia in AF which
ultimately lead to losing her pulse. CPR was initiated, with two
rounds of epinephrine and one round of atropine. With immediate
concern for acute cardiac tamponade, a blind pericardiocentesis
was attempted, but did not illicit blood. A bed-side echo was
performed which showed a large pericardial effusion with tonic
compression of the right atrium and right ventricle. Pericardial
drain was initiated and 700 cc of blood removed from pericardial
space. Echo then confirmed no active bleeding. O2 sat on blood
was c/w arterial saturation. A dopamine gtt was initiated with
sbp >100. Patient was given protamine to reverse heparin and did
not require any blood products. The right femoral vein sheeth
was removed, but the left femoral vein line remained. An
arterial line was placed. Patient was intubated for the
procedure and ultimately extubated prior to transfer to the CCU.
She was also given 1 gram of Ancef prior to transfer.
.
Upon admission to the CCU, initial vitals were: 97.3 66 20 95%
on face mask, sbps in the 70s on dopamine. (initially at 8 mcg,
however given acute decrease in sbp, dopamine was increased to
10 mcg and bp was >100.) Was also given 1.5 liter bolus of IVFs.
She c/o [**9-27**] pleuritic chest pain. Given 30 mg IV toradol with
minimal relief and IV morphine prn for further pain control. She
also c/o nausea and vomited x 1. Resolved with IV zofran.
.
Patient has had a history of palpitations for several years,
however, only recently diagnosed with paroxysmal atrial
fibrillation in [**2189-2-16**]. At that time, she presented in
sustained atrial fibrillation and DC cardioversion. She was
started on Propafenone and then developed recurrent afib 8 weeks
later. She returned for a second DC cardioversion. Then 3 weeks
later she again developed recurrent atrial fibrillation and had
another DC cardioversion in [**Month (only) **]. She stopped Propafenone in
[**Month (only) **] and started Flecainide. She subsequently reverted back to
afib on Flecainide and this was stopped in early [**Month (only) 205**] and
started Amiodarone [**2189-6-25**]. She has had continued afib since
[**2189-6-14**] and ultimately underwent PVI.
.
.
On review of systems, s/he denies any prior history of, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, syncope or presyncope.
Past Medical History:
Hypertension
Lacunar infarct: non-embolic per CT scan done in [**2188-12-19**]
Osteoarthritis
Infertility surgery
Breast biopsy,lumpectomy (benign)
C cection
Cholecystectomy
Knee arthroscopy
Exploratory lapartomy/appendectomy
Social History:
Married. Works part time as a physical therapist.
ETOH: Denies
Tobacco: Denies
Illicit drugs: none
Family History:
Father died of an MI in his 60s. Mother died of renal
failure in her 80s. Brother with diabetes. 2nd Brother had
diabetes and died of lung cancer. One sister who has
palpitations.
Physical Exam:
Discharge Physical Exam
Afebrile, vital signs stable
GENERAL: middle aged female, no acute distress, comfortable
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with no JVD appreciated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. IIRR, normal S1, S2. slight 2 component rub appreciated.
No thrills, lifts. No S3 or S4. Pericardial drain site bandaged,
c/d/i.
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. + bowel sounds
EXTREMITIES: No c/c/e. No femoral bruits. no hematomas,
induration, no back tenderness. minimal tenderness to deep
palpation at left femoral cath site. 2+ DP/PT pulses
bilaterally
Pertinent Results:
[**2189-7-21**] 10:30AM BLOOD WBC-5.2 RBC-4.48 Hgb-13.7 Hct-40.1 MCV-90
MCH-30.6 MCHC-34.2 RDW-13.5 Plt Ct-213
[**2189-7-21**] 04:50PM BLOOD Hct-34.7*
[**2189-7-21**] 06:10PM BLOOD WBC-16.7*# RBC-4.12* Hgb-12.5 Hct-37.7
MCV-92 MCH-30.4 MCHC-33.2 RDW-13.4 Plt Ct-237
[**2189-7-21**] 11:00PM BLOOD Hct-35.9*
[**2189-7-22**] 03:49AM BLOOD WBC-8.5 RBC-3.82* Hgb-11.7* Hct-34.8*
MCV-91 MCH-30.5 MCHC-33.5 RDW-13.5 Plt Ct-223
[**2189-7-23**] 05:19AM BLOOD WBC-10.0 RBC-2.67*# Hgb-8.3*# Hct-24.2*#
MCV-91 MCH-31.1 MCHC-34.4 RDW-13.5 Plt Ct-160
[**2189-7-23**] 08:10AM BLOOD Hct-23.3*
[**2189-7-23**] 02:37PM BLOOD WBC-9.6 RBC-2.99* Hgb-9.3* Hct-27.3*
MCV-91 MCH-31.2 MCHC-34.2 RDW-14.2 Plt Ct-169
[**2189-7-24**] 05:40AM BLOOD WBC-7.4 RBC-2.82* Hgb-8.6* Hct-25.6*
MCV-91 MCH-30.4 MCHC-33.5 RDW-14.2 Plt Ct-163
[**2189-7-24**] 10:33AM BLOOD Hct-26.2*
[**2189-7-21**] 10:30AM BLOOD PT-33.0* PTT-32.0 INR(PT)-3.3*
[**2189-7-21**] 06:10PM BLOOD PT-34.5* PTT-40.6* INR(PT)-3.5*
[**2189-7-22**] 03:49AM BLOOD PT-31.9* PTT-37.0* INR(PT)-3.2*
[**2189-7-23**] 05:19AM BLOOD PT-39.0* PTT-36.5* INR(PT)-4.1*
[**2189-7-24**] 05:40AM BLOOD PT-26.3* INR(PT)-2.5*
[**2189-7-21**] 10:30AM BLOOD Glucose-99 UreaN-13 Creat-0.8 Na-141
K-4.0 Cl-103 HCO3-31 AnGap-11
[**2189-7-21**] 06:10PM BLOOD Glucose-162* UreaN-12 Creat-0.9 Na-145
K-4.0 Cl-110* HCO3-25 AnGap-14
[**2189-7-23**] 05:19AM BLOOD Glucose-116* UreaN-16 Creat-0.8 Na-137
K-3.8 Cl-108 HCO3-25 AnGap-8
[**2189-7-24**] 05:40AM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-139
K-4.1 Cl-108 HCO3-27 AnGap-8
[**2189-7-21**] 06:10PM BLOOD CK(CPK)-90
[**2189-7-23**] 05:19AM BLOOD ALT-58* AST-31 LD(LDH)-183 AlkPhos-55
TotBili-0.3
[**2189-7-21**] 06:10PM BLOOD CK-MB-6 cTropnT-0.24*
[**2189-7-21**] 06:10PM BLOOD Calcium-8.0* Phos-3.6 Mg-1.9
[**2189-7-21**] 06:10PM BLOOD Calcium-8.0* Phos-3.6 Mg-1.9
[**2189-7-22**] 03:49AM BLOOD Calcium-7.5* Phos-3.3 Mg-2.5
[**2189-7-23**] 05:19AM BLOOD Albumin-2.8* Calcium-7.1* Phos-2.5*
Mg-2.1
[**2189-7-24**] 05:40AM BLOOD Calcium-7.6* Phos-1.8* Mg-2.1
MRSA SCREEN (Final [**2189-7-24**]): No MRSA isolated.
Echo [**7-21**]: pre-pericardiocentesis: large pericardial effusion
with tonic compression of the right atrium and right ventricle
post-pericardiocentesis: no residual pericardial effusion
[**7-22**]: The left atrium is dilated. The right atrium is dilated.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
effusion appears loculated. A catheter is seen in the
pericardial space. There are no echocardiographic signs of
tamponade.
IMPRESSION: Two small pockets of pericardial fluid are seen
behind the left and right atria. No echo signs of tamponade.
Normal biventricular systolic function.
Compared with the prior study (images reviewed) of [**2189-7-21**], the
findings are similar to the post-procedure images from that
study
EKG [**7-21**]: Atrial fibrillation. Diffuse non-specific ST-T wave
changes. Compared to the previous tracing of [**2189-7-13**] findings
are similar.
[**7-21**]: Atrial fibrillation. Diffuse non-specific ST-T wave
changes. Compared to tracing #1 there is no change.
[**7-22**]: Atrial fibrillation with rapid ventricular response.
Diffuse non-specific ST-T wave changes, particularly in the
anterior leads, may be due to myocardial ischemia. Clinical
correlation is suggested. Compared to tracing #2 the rate is
increased and the ST-T wave changes are more accentuated on the
currenttracing although this may reflect the higher rate rather
than an ischemic process
CXR [**7-21**]: COMPARISON: No comparison available at the time of
dictation.
FINDINGS: Mildly enlarged cardiac silhouette with drain in situ.
Mild
blunting of the left costophrenic sinus, potentially suggesting
a small left pleural effusion. Mild retrocardiac atelectasis. No
focal parenchymal
opacity suggesting pneumonia. No evidence of pneumothorax.
Brief Hospital Course:
63 yo F h/o recently diagnosed PAF s/p DCCV x3 and failed
propefenone and flecainide, currently on amiodarone and s/p PVI
today c/b acute cardiac tamponade leading to hemodynamic
compromise on dopamine s/p percardial drain.
# Cardiac Tamponade - During the patient's PVI, she became
hypotensive due to acute cardiac tamponade. She was pulseless
for a short period and underwent chest compressions as well as 2
rounds of epinephrine and 1 dose of atropine. A
pericardiocentesis with pericardial drain was performed with
immediate return of ~700cc of oxygenated blood and return of
pulse. The patient was started on dopamine and transported to
the CCU for monitoring. Pulsus paradoxus was monitored with an
arterial line and was < 12. Overnight, the drain put out 45cc
of fluid, so the drain was pulled the following morning. The
dopamine was able to be discontinued the following afternoon and
blood pressures remained stable with IVF hydration, with SBP in
the 100s-110s. Her Hct was followed and she was noted to have a
10 point Hct drop overnight. This was thought to be primarily
dilutional as the day before, she received 5.5L of IV fluids.
She received 1 unit of PRBC and had an appropriate increase in
Hct. Her repeat hematocrit checks were stable and she needed no
more transfusions. She received 2 days of antibiotic
prophylaxis with Ancef for her lines. Her metoprolol and
dilitazem were held as her pressure and rates were controlled
and did not require addition of more agents at the time of
discharge. She had follow-up appointments made with her
outpatient cardiologist on [**Last Name (LF) 766**], [**7-27**] and her PCP on
Wednesday, [**7-29**]. Dr.[**Name (NI) 29750**] office was to get back
with her regarding EP follow-up. She was also instructed to
have a hematocrit checked on [**7-27**].
# Atrial fibrillation - The PVI was not able to be completed due
to the tamponade. She remained in atrial fibrillation during
the hospitalization. She was restarted on amiodarone and a
lower dose of digoxin. Her heart rates were ranging from 90-115
on those medications. She was evaluated by physical therapy and
her heart rate did not increase while she was walking. She was
not started on her home metoprolol or diltiazem per
Electrophysiology recommendations. Her coumadin was held as her
INR was elevated. She was instructed to restart her coumadin at
2.5mg daily, and to have an INR checked on [**7-27**], then to
continue her coumadin per her cardiologist recommendations.
# Chest pain - The patient did complain of sternal chest pain
after being admitted to the CCU. Her pain was initially
controlled with IV morphine; she was then started on
indomethacin 25mg TID for 7 days for post-tamponade
pericarditis. She also developed left sided pleuritic chest
pain which improved greatly by the day of discharge and was also
controlled with indomethacin.
Medications on Admission:
Amiodarone 200 mg [**Hospital1 **]
Digoxin 250 mcg daily (PM)
Diltiazem 240 mg daily (AM)
Metoprolol succinate 100 mg [**Hospital1 **]
Coumadin 2.5 mg MWF, 5 mg all other days
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO three
times a day for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Outpatient Lab Work
Please draw INR and Hematocrit. Have results faxed to Dr. [**Last Name (STitle) **]
and to Dr. [**Last Name (STitle) 3321**].
5. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take until your INR check on [**7-27**], then take as
directed by your cardiologist.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Cardiac tamponade, atrial fibrillation
Secondary: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 20296**],
It was a pleasure taking care of you during your
hospitalization. You were admitted to undergo a Pulmonary Vein
Isolation, a procedure to treat your atrial fibrillation.
During the procedure, you had blood fill the sac the heart sits
in, which made it difficult for your heart to beat. You had CPR
performed which kept blood moving through your body. A catheter
was placed in the sac and drained the blood which relieved the
pressure around your heart. You were started on a medication,
dopamine, that helps increase blood pressure and were monitored
in the Cardiac Care Unit. We were able to stop the dopamine and
your blood pressure remained stable. Your blood levels were
decreased so we gave you a blood transfusion. This was likely
because of you getting fluids through your IV that diluted your
blood. The physical therapists saw you and cleared you to go
home.
We CHANGED two medications:
--> decreased your Digoxin to 125mcg by mouth once a day
--> decreased your Coumadin to 2.5 mg by mouth daily --> Please
have your INR checked on [**Known lastname 766**] [**7-27**] and then take your
coumadin as instructed by your cardiologist.
We ADDED one medication:
Indomethacin 25mg by mouth three times a day for 5 days
We STOPPED two medications:
--> Metoprolol
--> Diltiazem
These medications were stopped per EP recommendations as your
heart rate was fairly controlled, ranging from 90-120.
Please follow up with your scheduled appointments.
If you have any concerns this weekend, you can call Dr. [**Name (NI) 71181**] office to reach the covering physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **]. Dr.[**Name (NI) 29750**] office number is [**Telephone/Fax (1) 1536**].
Followup Instructions:
Dr.[**Name (NI) 29750**] office will call you on [**Name (NI) 766**] to schedule your
follow-up appointment. If you don't hear back from them, please
call his office at [**Telephone/Fax (1) 1536**].
Please follow-up with Dr. [**Last Name (STitle) **] on [**Last Name (LF) 766**], [**7-27**] at
10:45am.
Please follow-up with Dr. [**Last Name (STitle) 3321**] on Wednesday, [**7-29**] at
9:15am.
Completed by:[**2189-7-26**]
|
[
"997.1",
"420.90",
"427.5",
"427.31",
"401.9",
"E879.0",
"715.90",
"423.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.27",
"37.34",
"37.0",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12439, 12445
|
8715, 11610
|
317, 458
|
12562, 12562
|
4727, 8692
|
14489, 14918
|
3672, 3853
|
11836, 12416
|
12466, 12541
|
11636, 11813
|
12713, 14466
|
3868, 4708
|
254, 279
|
486, 3289
|
12577, 12689
|
3311, 3539
|
3555, 3656
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,426
| 158,389
|
10670
|
Discharge summary
|
report
|
Admission Date: [**2138-8-16**] Discharge Date: [**2138-9-3**]
Date of Birth: [**2088-1-13**] Sex: M
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old,
right-handed male with a past medical history of
schizophrenia and substance abuse who was transferred from
[**State 792**]Hospital for further management of a
subarachnoid hemorrhage. Apparently the patient had the
was brought to [**Hospital 792**]Hospital where a CT scan showed
suprasellar bleed with evidence of blood in the right sylvian
fissure. Angiography showed a right MCA aneurysm
at the M1 junction.
The patient was scheduled for surgery at [**Hospital 34994**], but Psychiatry found the patient unable to make
durable power of attorney for healthcare issues and made the
decision to send the patient to [**Location (un) 86**] for further care.
On examination, the patient was in no acute distress.
MEDICATIONS ON ADMISSION: Dilantin 100 mg p.o. t.i.d.,
Nimodipine 60 mg p.o. q.4 hours, Decadron 4 mg IV q.6 hours,
Zantac 50 mg IV q.8 hours.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient lives with his girlfriend.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 109/64,
temperature 97.9??????, pulse 72, respirations 16, 98% on room
air. General: The patient was in no acute distress. HEENT:
Normocephalic, atraumatic. Moist mucous membranes. No
thyromegaly. No cervical lymphadenopathy. No nuchal
rigidity. Pulmonary: Clear to auscultation bilaterally. No
crackles or wheezes. Cardiovascular: Regular, rate and
rhythm. No murmurs, rubs or gallops. Abdomen: Soft,
nontender, nondistended. Positive bowel sounds. Rectal:
Deferred. Extremities: The patient was moving all four
extremities. He had 2+ pulses in the upper and lower
extremities and symmetric. Good capillary refill. Skin: No
rashes noted.
Neurological: The patient was alert and oriented to place,
person, month, and date. Attention: The patient could spell
world backwards. Language was fluent. No paraphrasic
errors. Cranial nerves intact. Motor strength 5 out of 5 in
all muscle groups. Deep tendon reflexes 2+ throughout. The
patient had no drift.
HOSPITAL COURSE: The patient was evaluated by Psychiatric
Service when he was admitted to the Surgical Intensive Care
Unit and found to be unable to have the capacity to make
medical decisions for himself. On [**2138-8-17**], the
patient underwent a patronal craniotomy for clipping of right
MCA aneurysm with placement of right frontal ventricular
drain. There were no intraoperative complications.
Postoperatively the patient was monitored in the Surgical
Intensive Care Unit.
Neurologically the patient was awake and alert, moving all
extremities, with no drift. Dressing was clean, dry and
intact. The patient remanded in the Surgical Intensive Care
Unit until [**2138-8-31**]. During his Intensive Care Unit
stay, the patient spiked a temperature. His line was
cultured, and blood cultures came back positive for
Staphylococcus aureus. The patient was treated with
intravenous Vancomycin for a total of a 14-day course. The
patient was monitored in the Surgical Intensive Care Unit for
two week for the prevention of vasospasm. He was treated
with intravenous fluids at 150 cc/hr with Albumin q.8 hours
250 cc and had daily transcranial Dopplers which showed no
evidence of vasospasm. The patient's neurological status
remained completely stable throughout his stay at the MV
Neuro Intensive Care Unit.
He had a ventricular drain that was in place since the
operation. The ventricular drain was discontinued on [**2138-8-28**], and the patient was transferred to the floor on
[**2138-8-31**]. Neurologically the patient was awake,
alert, and oriented times three, moving all extremities, with
5 out of 5 muscle strength. He has been followed by Physical
Therapy and Occupational Therapy and found to be safe for
discharge to home with 24-hour care from his girlfriend. [**Name (NI) **]
will be followed by Dr. [**Last Name (STitle) 1132**] in the office in [**2-15**] weeks.
DISCHARGE MEDICATIONS: Dilantin 100 mg p.o. t.i.d., Zantac
150 mg p.o. b.i.d., Percocet [**1-14**] tab p.o. q.4-6 hours p.r.n.,
Nimodipine 60 mg p.o. q.4 hours.
CONDITION ON DISCHARGE: Vitals signs were stable, and the
patient is neurologically stable at the time of discharge and
is being discharged to home.
[**First Name8 (NamePattern2) **] [**Last Name (LF) **],[**Name8 (MD) **] M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2138-9-3**] 10:15
T: [**2138-9-3**] 11:25
JOB#: [**Job Number 34995**]
|
[
"998.59",
"790.7",
"305.90",
"V09.0",
"430",
"041.11",
"V11.0",
"458.2",
"996.62"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.51",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
4116, 4255
|
945, 1101
|
2212, 4092
|
1181, 2194
|
172, 918
|
1118, 1158
|
4280, 4681
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,531
| 195,742
|
28026
|
Discharge summary
|
report
|
Admission Date: [**2144-12-21**] Discharge Date: [**2144-12-29**]
Date of Birth: [**2078-7-26**] Sex: M
Service: MEDICINE
Allergies:
Fenofibrate
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
Upper Endoscopy
Gastric emptying study
History of Present Illness:
66 yo M PMH cirrhosis s/p OLT [**7-7**], s/p hernia repair [**11-11**],
recently admitted [**Date range (1) 42768**] with gastroenteritis who now
presents with nausea and vomiting for the past two days. He
reports vomiting "hundreds" of times per day, mostly dry
heaving. PO intake has been very little. No BM x 4 days. He is
passing gas. He did notice some abd distension over the past few
days which has improved. He has been having constant diffuse
abd pain since hernia repair. In addition, he has had some
chills but no fevers.
.
In the emergency department initial vitals were T: 97 HR: 88
BP:167/125 RR:18. CHM7 demonstrated ARF with Cr 8.1. K was 5.6.
No peaked T's on ECG. Pressure dropped suddently to 70's and he
got another 4L IVF. Pressure came up to the 100's systolic.
Pressure then dropped after 6th bag IVF to 70's again. RIJ
placed and levophed started. Renal consult team and hepatology
made aware.
.
In the ICU, pt reports nausea slightly improved after getting
zofran. Reports that he has felt "winded" the past few days,
though no chest pain. No other complaints.
.
REVIEW OF SYSTEMS:
(+)ve:
(-)ve: fever, chest pain, palpitations, rhinorrhea, nasal
congestion, cough, sputum production, hemoptysis, dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, diarrhea, constipation,
hematochezia, melena, dysuria, urinary frequency, urinary
urgency, focal numbness, focal weakness, myalgias, arthralgias
Past Medical History:
OLT [**7-7**]
Liver Cirrhosis followed at [**Hospital3 2358**] by the [**Hospital3 **] team
Anemia
Hepato-renal syndrome
[**2144-11-11**] left incision hernia repair with mesh
.
Social History:
Lives alone, was a drinker until [**2-/2140**], non-smoker. States he
is a retired teacher (AP chem and physics teacher). Healthcare
Proxy: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 68214**] [**Telephone/Fax (1) 68215**]. Dr. [**Last Name (STitle) 3315**] is his PCP.
GI doctor is Dr. [**Last Name (STitle) 57141**].
Family History:
[**Name (NI) **] sister died of pancreatic cancer
Physical Exam:
Tmax: 37.2 ??????C (99 ??????F)
Tcurrent: 37.2 ??????C (99 ??????F)
HR: 100
BP: 106/77(95) {106/77(85) - 131/93(102)} mmHg
RR: 24 (12 - 27) insp/min
SpO2: 100%
Heart rhythm: ST (Sinus Tachycardia)
GEN: Pleasant, NAD
HEENT: NC/AT, PERRL, MMM, OP clear
PULM: CTAB, no wheezes or crackles
CARD: Regular, no m/r/g, +S1, S2
ABD: soft, non-tender, non-distended, well healed triangular
scar
EXT: no LE edema
NEURO: no gross deficits,5/5 strength in all 4 ext
Pertinent Results:
I. Labs
A. Admission
[**2144-12-21**] 12:55PM BLOOD WBC-8.9 RBC-4.04* Hgb-12.6* Hct-39.2*
MCV-97 MCH-31.2 MCHC-32.1 RDW-16.7* Plt Ct-178
[**2144-12-21**] 12:55PM BLOOD Neuts-92.4* Lymphs-3.7* Monos-3.6 Eos-0.1
Baso-0.1
[**2144-12-21**] 12:55PM BLOOD PT-12.8 PTT-25.3 INR(PT)-1.1
[**2144-12-21**] 12:55PM BLOOD Glucose-317* UreaN-81* Creat-8.1*# Na-133
K-5.6* Cl-101 HCO3-10* AnGap-28*
[**2144-12-21**] 12:55PM BLOOD ALT-10 AST-11 AlkPhos-85 TotBili-0.1
[**2144-12-21**] 12:55PM BLOOD Lipase-18
[**2144-12-21**] 05:15PM BLOOD Calcium-6.9* Phos-6.6*# Mg-1.4*
[**2144-12-21**] 12:55PM BLOOD Albumin-4.0
[**2144-12-21**] 05:15PM BLOOD Acetone-MODERATE Osmolal-313*
[**2144-12-22**] 05:54AM BLOOD PTH-167*
[**2144-12-21**] 05:15PM BLOOD Cortsol-31.2*
[**2144-12-21**] 12:55PM BLOOD tacroFK-10.4
[**2144-12-21**] 04:24PM BLOOD pH-7.03* Comment-GREEN TOP
[**2144-12-21**] 08:15PM BLOOD pO2-142* pCO2-22* pH-7.11* calTCO2-7*
Base XS--21
[**2144-12-21**] 04:24PM BLOOD Lactate-1.3
[**2144-12-21**] 05:37PM BLOOD Glucose-191* Lactate-1.5 Na-138 K-5.2
Cl-117* calHCO3-9*
[**2144-12-21**] 05:37PM BLOOD Hgb-11.0* calcHCT-33
[**2144-12-22**] 12:02PM BLOOD freeCa-0.95*
B. Urine
[**2144-12-21**] 04:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2144-12-21**] 04:20PM URINE Blood-NEG Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2144-12-21**] 04:20PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2144-12-21**] 05:30PM URINE Hours-RANDOM Creat-481 Na-11 K-29 Cl-22
TotProt-42 Prot/Cr-0.1
II. Microbiology
[**2144-12-21**] MRSA SCREEN MRSA SCREEN- Negative
[**2144-12-21**] BLOOD CULTURE Blood Culture,
Routine-Negative
[**2144-12-21**] BLOOD CULTURE Blood Culture,
Routine-Negative
[**2144-12-21**] URINE URINE CULTURE-FINAL {STAPHYLOCOCCUS,
COAGULASE NEGATIVE}
III. Radiology
A. CXR ([**12-21**])
HISTORY: Right IJ placement.
FINDINGS: In comparison with the study of [**12-8**], there has been
placement of a right IJ catheter that extends to the mid portion
of the SVC. No evidence of pneumothorax. Continued opacification
at the left base consistent with atelectasis and effusion.
B. KUB ([**12-21**])
IMPRESSION:
1. Nonspecific bowel gas pattern with no evidence to suggest
ileus or
obstruction.
2. Chronic unchanged left lower lung lobe atelectasis.
C. Renal US ([**12-22**])
IMPRESSION: No evidence of renal obstruction, thinning of the
right renal
cortex, likely chronic.
Three Biopsies - Pathology pending, viral studies pending
VIRAL CULTURE: R/O CYTOMEGALOVIRUS-PRELIMINARY; VARICELLA-ZOSTER
CULTURE-PRELIMINARY; VIRAL CULTURE: R/O HERPES SIMPLEX
VIRUS-PRELIMINARY
Gastric Emptying Study:
Patient Consumed:
Egg beaters: 90%
Water: 100%
Toast: 100%
Jelly: 100%
Immediately following the oral ingestion of the radio-labeled
meal, the patient was placed supine in the gamma camera.
Continuous anterior and posterior images of tracer activity in
the stomach and bowel were recorded for 45 minutes. Delayed
anterior and posterior images were obtained at 2, and 3 hours.
Residual tracer activity in the stomach is as follows:
At 45 mins 65% of the ingested activity remains in the stomach
At 2 hours 26% of the ingested activity remains in the stomach
At 3 hours 6% of the ingested activity remains in the stomach
Discharge Labs:
[**2144-12-29**] 07:40AM BLOOD WBC-3.7* RBC-2.61* Hgb-8.5* Hct-24.6*
MCV-94 MCH-32.5* MCHC-34.6 RDW-16.4* Plt Ct-109*
[**2144-12-29**] 07:40AM BLOOD Glucose-124* UreaN-18 Creat-1.8* Na-140
K-4.7 Cl-109* HCO3-25 AnGap-11
[**2144-12-29**] 07:40AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.8
[**2144-12-29**] 07:40AM BLOOD tacroFK-14.6
Brief Hospital Course:
66 yo M PMH cirrhosis, s/p OLT, s/p hernia repair [**11-11**] who
presented with nausea and vomiting, initially admitted to the
MICU with hypotension and acute on chronic renal failure, that
both resolved by discharge.
.
# Nausea/Vomiting - Had EGD which showed ulcerative esophagitis,
gastritis, and duodenitis. Biopsy and viral cultures pending at
time of discharge. Started on pantoprazole, no more episodes of
vomiting as inpatient. Tolerated POs well. Gastric emptying
study was normal and showed no evidence of gastroesophageal
reflux.
.
#. HYPOTENSION: Likely related to volume depletion in setting of
intractable vomiting and little PO intake. No clear source of
infection given afebrile, nl WBC ct, nl CXR, benign UA.
Antibiotics were not initiated. BP returned to [**Location 213**] with
aggressive IVF administration, and remained hemodynamically
stable. Blood cultures and urine cultures negative. Random
cortisol level was normal.
.
#.METABOLIC ACIDOSIS: Likely related to acute on chronic renal
failure and starvation ketoacidosis. Lactate was normal. Patient
was initially started on insulin gtt and D5 gtt out of concern
for diabetic ketoacidosis. Received bicarb in unit and anion gap
resolved by the time of transfer to floor.
.
# ACUTE ON CHRONIC RENAL FAILURE: Likely pre-renal etiology in
setting of vomiting and low PO intake past few days. FeNa was
0.1%. Cr improved to baseline with IVF administration. Renal
ultrasound negative for obstruction. HCTZ was held because of
[**Last Name (un) **], should be discussed with PCP regarding restarting.
.
#. s/p Liver [**Last Name (un) 1326**]: Per [**Last Name (un) **] [**Doctor First Name **], tacrolimus
initially held and home myfortic was changed to MMF IV.
Subsequently, tacrolimus and myfortic were re-started (IV MMF
d/c'd). Per [**Doctor First Name 1326**] Surgery, discharged home on tacrolimus
2mg PO BID. Follow-up labs should be checked on Thursday and
should be faxed to the [**Doctor First Name 1326**] Surgery clinic to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 816**].
Pending Studies
- EGD biopsy results and viral studies
- restarting HCTZ
Medications on Admission:
1. myfortic 180mg [**Hospital1 **]
2. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO EVERY OTHER DAY (Every Other Day).
4. aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. tacrolimus 1 mg Capsule [**Last Name (STitle) **]: Three (3) Capsule PO Q12H (every
12 hours).
6. ferrous sulfate 300 mg (60 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. NPH insulin human recomb 100 unit/mL Suspension [**Last Name (STitle) **]: Fourteen
(14) units Subcutaneous once a day.
8. Lopressor 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
9. pravastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
10. insulin regular human 100 unit/mL Solution [**Last Name (STitle) **]: follow
sliding scale Injection four times a day.
11. hydrochlorothiazide 12.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
once a day: resume on Sunday.
12. NPH insulin human recomb 100 unit/mL Suspension [**Last Name (STitle) **]: Eight
(8) units Subcutaneous pm.
13. calcium carbonate-vitamin D3 600-400 mg-unit Tablet [**Last Name (STitle) **]: One
(1) Tablet PO twice a day.
14. Tricor 145 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: no
substitution
generic causes diarrhea.
15. lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
16. lamivudine 100 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO once a day.
.
Discharge Medications:
1. mycophenolate sodium 180 mg Tablet, Delayed Release (E.C.)
[**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Last Name (STitle) **]: One (1)
Tablet PO EVERY OTHER DAY (Every Other Day).
3. aspirin 81 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
4. tacrolimus 0.5 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO Q12H (every
12 hours).
5. ferrous sulfate 300 mg (60 mg Iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
6. lamivudine 10 mg/mL Solution [**Last Name (STitle) **]: Fifty (50) mg PO DAILY
(Daily).
7. lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
8. Tricor 145 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
9. Vitamin D-3 400 unit Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO twice a day.
10. calcium carbonate 600 mg (1,500 mg) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO twice a day.
11. insulin NPH & regular human 100 unit/mL (70-30) Cartridge
[**Last Name (STitle) **]: Fourteen (14) units Subcutaneous once a day.
12. insulin NPH & regular human 100 unit/mL (70-30) Cartridge
[**Last Name (STitle) **]: Eight (8) units Subcutaneous qPM.
13. insulin regular human 100 unit/mL Cartridge [**Last Name (STitle) **]: see below
units Injection qachs: Please resume prior sliding scale.
14. pravastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
15. Lopressor 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
17. Outpatient Lab Work
Please check chem 7 and tacrolimus level on [**2144-12-31**] and fax
results to [**Date Range **] surgery center [**Telephone/Fax (1) 697**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute renal failure
Metabolic Acidosis
Hypotension
Secondary diagnosis:
s/p liver [**Telephone/Fax (1) **]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 68219**],
It was a pleasure caring for you in the hospital. You were
admitted to the ICU with nausea and vomiting. You had a low
blood pressure requiring blood pressure medications to bring it
up. And you had damage to your kidneys from severe dehydration
which has returned to its baseline function.
You had an endoscopy that showed gastritis, esophagitis, and
duodenitis. and gastric emptying study done that showed normal
movement of your stomach.
The following changes were made to your medications:
We added:
Pantoprazole 40mg PO every 12 hours
We changed:
Tacrolimus to 2mg twice daily
We stopped:
Hydrochlorthiazide - You should talk to your primary care
physician about restarting this at your next appointment
Lansoprazole - you do not need this medication while you are
taking pantoprazole
Followup Instructions:
Please make an appointment to follow up with your liver doctors
and your primary care doctor in the next 2 weeks.
Department: DIGESTIVE DISEASE CENTER
When: TUESDAY [**2145-1-19**] at 7:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], 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: ENDO SUITES
When: TUESDAY [**2145-1-19**] at 7:30 AM
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD ([**Last Name (NamePattern4) 1326**] Surgeon)
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-1-11**] 10:30
Completed by:[**2144-12-30**]
|
[
"458.9",
"585.9",
"250.00",
"V42.7",
"V58.67",
"530.19",
"584.9",
"535.50",
"276.51",
"276.2",
"535.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.16",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12488, 12494
|
6570, 8729
|
294, 336
|
12664, 12664
|
2906, 6204
|
13671, 14493
|
2360, 2411
|
10485, 12465
|
12515, 12515
|
8755, 10462
|
12815, 13648
|
6221, 6547
|
2426, 2887
|
1472, 1784
|
235, 256
|
364, 1453
|
12606, 12643
|
12534, 12585
|
12679, 12791
|
1806, 1985
|
2001, 2344
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,819
| 182,115
|
37979
|
Discharge summary
|
report
|
Admission Date: [**2104-10-14**] Discharge Date: [**2104-11-4**]
Date of Birth: [**2041-8-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2104-10-24**] Aortic Valve Replacement(27mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Tissue) and
Three Vessel Coronary Artery Bypass Grafting with Left internal
mammary graft to the left anterior descending artery and reverse
saphenous vein grafts to the posterior descending artery and
margianl branch
History of Present Illness:
63 y/o male with hx of diffuse atherosclerotic disease and
aortic insufficiency (2+) transferred from OSH after cardiac
catheterization by Dr. [**Last Name (STitle) 8579**] where patient was found to have
multivessel disease: 99% stenosis RCA, 70% LAD, 70% left
circumflex. Transferred to [**Hospital1 18**] to Dr.[**Name (NI) 5786**] service for
evaluation of multivessel PCI vs CABG/ AVR. Patient initially
admitted to OSH for evaluation and management of chronic
abdominal pain x 2 months. Describes pain as a constant burning
pressure that radiates to back and up shoulder blades.
Occassional N/V with pain episodes. Pain comes on about 1 hour
after eating. Relieved by vicodin only. Patient notes
prolonged constipation, especially since initiation of vicodin.
EGD on [**9-23**] showed mild esophagitis and delayed gastric
emptying. MRCP at OSH showed no evidence of biliary or
pancreatic obsrtuction. KUB showed no signs of acute
obstruction.
Patient has also complained of nonradiating substernal chest
pressure with the abdominal pain for the 3 weeks. No associated
SOB, diaphoresis, cough, or other related symptoms.
Nitroglycerin does not relieve pain. Evaluated by nuclear scan
at [**State 792**]Hospital on [**2104-10-3**] which showed dilated RV,
scar in the RV territory and EF of 49%.
On transfer, vital signs were T= 98.1 HR = 66 BP = 131/75 RR =
18 SaO2 = 99% RA. patient was comfortable without acute
complaints although he was concerned that pain would return once
morphine wore off. Also citing concern that he has not had a
bowel movement in 7 days.
Review of Systems:
Pertinent positives: notes exertional calf pain, increased from
common iliac stenting [**4-16**] yeqars ago. Denies any coldness,
ulcers, or paralysis in his lower extremities. Complains of
orthopnea and paradoxical nocturnal dyspnea (uses [**5-18**] pilliows
at night). Denies peripheral edema.
Pertinent negatives: he denies any prior history of stroke,
black stools or red stools, recent fevers, chills or rigors or
othersystemic symptoms.
Past Medical History:
1. CARDIAC RISK FACTORS: HTN, hyperlipidemia
2. CARDIAC HISTORY: CAD with diffuse multivessel disease s/p MI
(age unknown) followed by Dr. [**Last Name (STitle) 38001**]
3. PVD s/p bilateral iliac stents: approx 4 years ago by Dr.
[**Last Name (STitle) 41524**]
4. Abdominal Aortic Aneurysm stable at 3.9 cm by CT on [**10-11**]
5. Common iliac artery aneurysm at 2.5 cm by CT on [**10-11**]
6. Aortic insufficiency
7. Bladder cancer [**2101**] s/p resection
8. Hiatal hernia
9. Chronic kidney disease followed by Dr. [**Last Name (STitle) **]
10. GERD: EGD on [**2104-9-23**] showed mild esophagitis, gastritis,
delayed gastric emptying
Social History:
Divorced 2 times, lives with sister. Currently employed
part-time in hotel laundry. Multiple prior jobs in factories,
mechanics, etc.
-Tobacco history: Quit 3 months ago. Heavy smoking history
since the age of 14
-ETOH: quit 22 years ago
-Illicit drugs: none
Family History:
Extensive family history of heart disease
Father: died of MI at age 59
Mother: died of breast cancer
sisters: CAD
Physical Exam:
VS: T= 98.1 HR = 66 BP = 131/75 RR = 18 SaO2 = 99% RA
GENERAL: chronically ill, sallow gentleman, NAD
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink. Dry
oral mucosa
NECK: Supple, no thyromegaly, normal JVP. B/l carotid bruits
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. grade III/ VI diastolic blowing murmur
heard best at RSB. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. decreased breath sounds
at bases.
ABDOMEN: Soft, mild distention. + tenderness to palpation in
epigastrium. No guarding or rebound. No HSM. Abd aorta not
enlarged by palpation.
EXTREMITIES: No c/c/e. surgical dressing c/d/i on right groin.
No fluctuence or pain to palpitation. + femoral bruits b/l
SKIN: no rashes, ulcers or lesions
PULSES: +2 DP, PT pulses bilaterally
Pertinent Results:
[**2104-10-15**] Carotid Series:
Right ICA stenosis <40%; Left ICA stenosis <40%
[**2104-10-15**] Echocardiogram:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the basal inferior
wall. The remaining segments contract normally and overall LVEF
is preserved (LVEF = 60 %). Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve is bicuspid (fused right and left
raphe) with mildly thickened/restricted leaflets. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). An eccentric jet
of moderate (2+) aortic regurgitation is seen, directed toward
the anterior mitral leaflet. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
[**2104-10-17**] Chest CT Scan:
The ascending aorta measures 4.4 cm and there is mild
calcification of the posterior wall of the ascending aorta.
Diffuse paraseptal and centrilobular emphysematous changes of
the lungs. Asymmetric pulmonary fibrosis affecting the right
lung in subpleural and basilar distribution. 5-mm right lower
lobe pulmonary nodule for which followup is recommended in six
months. Right adrenal adenoma.
[**2104-10-21**] Abdominal Ultrasound:
Unremarkable appearance of the visualized portions of the
pancreas. Abdominal aortic aneurysm, measuring up to 3.9 cm.
Bilateral renal cysts. The largest cyst on the right contains
thin
septations inferiorly. Six-month followup study is recommended.
[**2104-10-24**] Intraop TEE:
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is moderately dilated. There is mild global
left ventricular hypokinesis (LVEF = 40-45 %) with focal
hypokinesis of the inferior base. The remaining left ventricular
segments contract normally. Right ventricular chamber size and
free wall motion are normal. The aortic root is moderately
dilated at the sinus level (4.6-4.8cm). The ascending aorta is
mildly dilated. The descending thoracic aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta. The
aortic valve is bicuspid. There is systolic doming of the aortic
valve leaflets. Moderate to severe (3+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
POSTBYPASS
There is a well seated, well functioning bioprostheis in the
aortic position. No aortic insufficiency is visualized.
Biventricular systolic function remain unchanged compared to
prebypass.
[**2104-11-2**] Chest X-ray(PA and Lat):
The right introducer sheath has been removed. There is no PTX.
The chronic changes in the upper lung fields are no different.
No new focal consolidations are seen. Pulmonary vascular
markings are within normal limits. The cardiac silhouette is
enlarged but no different than prior. Retrocardiac density has
largely resolved. The left CP angle is cut of from view.
IMPRESSION: Improved aeration in the retrocardiac area with no
new consolidations and no features of CHF.
WBC/Hgb/Hct/Plt Ct
[**2104-11-3**] 26.5*
[**2104-11-3**] 7.7/7.9*/23.8*/293
[**2104-11-2**] 8.1/9.2*/27.8*/303
[**2104-11-2**] 25.3*
Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2104-11-4**] 31* 1.7* 4.3
[**2104-11-3**] 26* 1.8* 133 4.6 98 25 15
[**2104-11-2**] 27* 1.6* 4.4
[**2104-11-1**] 28* 1.6* 133 4.6 97 27 14
[**2104-10-29**] 27* 1.5* 132* 4.2 98 24 14
[**2104-10-27**] 23* 1.4* 131* 4.3 93* 30 12
Brief Hospital Course:
63 yo male with hx CAD, aortic valve insufficiency transferred
from OSH after cardiac catheterization on [**2104-10-14**] showed native
three vessel disease: 99% RCA, 70% LAD, 70% Cx stenosis.
Cardiac surgery evaluated patient and felt he was an appropriate
candidate for CABG/ AVR. Preoperative issues included:
1. Abdominal Discomfort: Patient complaints of persistent
abdominal pain prompted initial admission to OSH. Etiology
remained unclear despite extensive prior workup: unimpressive CT
abdoman (bilateral renal cysts), EGD with only mild gastritis.
Patient found to have elevated lipase/ amylase but had negative
MRCP for biliary/ pancreatic ductal dilitation, no evidence of
pancreatic inflammation or masses. Episode of abdominal pain
recurred on [**10-21**], and pancreatic enzymes were found to be mildly
elevated. GI consult felt presentation to be consistent with
acute pancreatitis.
2. Chronic Kidney Disease: According to outside records,
patient's baseline creatinine ranged from 1.4 - 1.7. Patient was
found to have renal artery stenosis > 90% by cardiac
catheterization, no acute intervention indicated.
3. Focal right femoral artery dissection s/p cardiac
catheterization on [**10-14**]: noted to have femoral bruit on physical
exam and found to have R CFA focal dissection by doppler.
Patient subjectively and clinically asymptomatic, distal pulses
intact. Follow up with vascular surgery following discharge
from hospital.
On [**2104-10-24**] patient brought to the operating room at which time
he had aortic valve replacement and coronary bypass grafting
x3...please see operative report for details. He tolerated the
operation well and was transferred to the cardiac surgery ICU in
stable condition. He remained stable in the immediate post-op
period and was extubated on the morning of POD 1. He stayed in
the cardiac surgery ICU for aggressive pulmonary toilet. On POD
3 he was transferred to the stepdown floor. His chest tubes,
pacing wires and invasive monitoring lines were all discontinued
according to cardiac surgery protocol. He developed urination
retention after the foley was removed. He was started on Flomax
and had subsequent successful voiding trial. He was started on
beta blockers and diuretics and these were titrated to response.
On POD 6 he had a short burst of atrial fibrillation and was
treated with increased beta blockade and Amiodarone. Within 24
hours, he converted to sinus rhythm and no further episodes of
atrial fibrillation were noted. Given chronic renal
insufficiency, his creatinine was followed closely. Creatinine
ranged mostly between 1.4 to 1.6, peaking to 1.8 on POD 10.
Discharge creatinine was 1.7. He was also started on
Ciprofloxacin postoperatively for a positive urinalysis. Urine
culture revealed gram negative rods of greater than 100,000
organisms...final culture was pending at discharge. He continued
to make clinical improvements and was eventually cleared for
discharge to home on POD 11.
Medications on Admission:
pravastatin 80', isosorbide 20"', diltiazem 180', plavix 75',
ranitidine 150", metoprolol 25', zetia 10', ASA 81'
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. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-19**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
13. Megestrol 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
15. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Facility:
tba
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Aortic Insufficiency s/p AVR
Post operative atrial fibrillation
Hypertension
Peripheral Vascular Disease
Dyslipidemia
Chronic Renal Insufficiency
Postop Urinary Tract Infection
Acute Pancreatitis - preoperative
Femoral Artery Dissection - preoperative
Renal Artery Stenosis
Lung Nodule
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) 8579**] in [**2-15**] weeks [**Telephone/Fax (1) 23882**]
Dr. [**Last Name (STitle) **] in [**3-18**] weeks (needs 6 months followup of right renal
cyst)[**Telephone/Fax (1) 65924**]
Dr [**First Name (STitle) **] (thoracic surgery) [**Telephone/Fax (1) 170**] regarding lung nodule
follow up.
Dr. [**Last Name (STitle) **] for vascular surgery follow up appt
Completed by:[**2104-11-4**]
|
[
"585.9",
"998.2",
"599.0",
"V10.51",
"272.4",
"414.01",
"427.31",
"788.20",
"443.29",
"753.19",
"424.1",
"746.4",
"564.09",
"403.90",
"E879.0",
"997.1",
"443.9",
"440.1",
"577.0",
"441.4",
"518.89",
"442.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"35.21",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
13567, 13601
|
8670, 11645
|
336, 673
|
13964, 13971
|
4742, 8647
|
14510, 15035
|
3711, 3827
|
11810, 13544
|
13622, 13943
|
11671, 11787
|
13995, 14487
|
3842, 4723
|
2838, 3413
|
2302, 2751
|
282, 298
|
701, 2283
|
2773, 2818
|
3429, 3695
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,620
| 153,631
|
49801
|
Discharge summary
|
report
|
Admission Date: [**2164-2-12**] Discharge Date: [**2164-2-16**]
Date of Birth: [**2120-9-25**] Sex: F
Service: Internal Medicine [**Doctor Last Name **] Firm
HISTORY OF PRESENT ILLNESS: This is a 43-year-old woman with
multiple medical problems including insulin dependent
diabetes mellitus and end-stage renal disease on hemodialysis
admitted to the Intensive Care Unit with hypotension. She
had a recent admission between [**2-6**] and [**2-11**] for a scalp infection. Her scalp abscess developed in
[**2163-12-21**]. She underwent debridement in [**2163-12-21**], but then began to feel ill on po antibiotics and was
admitted from [**2-6**] to [**2-11**] for IV
antibiotics.
She was discharged on [**2-11**] to attend her sister's
wedding. She reports that she had not been feeling well at
all day yesterday or today. She was brought to the Emergency
Department because she was feeling weak. In the Emergency
Department, the patient received a cooling blanket and was
given 1 gram of ceftriaxone and 1 liter of IV fluids.
PAST MEDICAL HISTORY:
1. Right axilla suppurative hydradenitis abscess debridement.
2. Insulin dependent-diabetes mellitus.
3. Hemodialysis for end-stage renal disease.
4. Gastroparesis.
5. Peripheral neuropathy.
6. History of living related donor kidney transplant in [**2150**],
failed and removed after 12 years.
7. Hypertension.
8. Osteoporosis.
9. Personality disorder, not otherwise specified.
10. Hyperlipidemia.
11. Hypothyroidism.
12. Status post simple partial vulvectomy for squamous cell
carcinoma.
13. Thigh abscess debridement.
14. Scalp abscess debridement.
MEDICATIONS:
1. Lantus 12 units at 10 pm.
2. Regular insulin-sliding scale.
3. PhosLo 667 mg tid with meals.
4. Neurontin 300 mg po q day.
5. Levoxyl 0.05 mg po q day.
6. Nephrocaps one po q day.
7. Zocor 20 mg po q day.
8. ASA one tablet po q day.
9. Protamine 2.5 mg at dialysis.
10. Levaquin.
11. Vancomycin.
PHYSICAL EXAMINATION: In general, the patient appeared
tired. Her vital signs revealed a temperature of 91.9, a
heart rate of 63, blood pressure of 75/38, respiratory rate
of 16, and oxygen saturation of 100% on 2 liters nasal
cannula. HEENT: Well-healing anterolateral debridement
site, 2.4 cm fluctuant area near old posterior debridement.
Neck is supple without lymphadenopathy. Lungs are clear to
auscultation bilaterally. Cardiovascular: Regular, rate,
and rhythm, normal S1, S2, no S3, S4, no murmurs, rubs, or
gallops. Abdomen is soft, nontender, nondistended with
positive bowel sounds. Extremities: No clubbing, cyanosis,
or edema. Neurologic: Alert and oriented times three.
PERTINENT LABORATORIES AND DIAGNOSTICS: Patient's white
count was 16.4 up from 11.4, her hematocrit was 37.4, her
platelet count was 614. Her MCV was 94. Her chemistries
were within normal limits with the exception of a glucose of
25, a BUN of 50, and a creatinine of 11.1.
ASSESSMENT AND PLAN: This is a 43-year-old woman with
insulin dependent-diabetes mellitus, hypertension, and
end-stage renal disease on hemodialysis, who is being treated
for scalp abscess who is admitted with hypotension.
HOSPITAL COURSE: The patient was admitted for treatment of
her hypotension and hypothermia as well as for her
hyperglycemia as her blood sugar was found to be in the
600's.
She was seen by Plastic Surgery team in the Emergency
Department, and they performed an incision and drainage of
her right occiput lesion. She was continued on levofloxacin
and Vancomycin. She was seen by the [**Last Name (un) **] Diabetes Team for
management of her diabetes mellitus. She developed both
hyper and hypoglycemia during her hospital course, and these
were managed effectively by changing her insulin doses.
She also developed hyperkalemia during her hospital stay,
most likely related to her hyperglycemia. This also
resolved. The main reason for the patient's hospitalization
was her hypotension.
A hypotension workup revealed no evidence of sepsis,
endocrine dysfunction such as adrenal insufficiency, or
hypovolemia. However, she did receive IV fluids during the
first few days of her hospital stay. She was treated with
midodrine for her hypotension with a satisfactory response.
Her white count decreased on levofloxacin and Vancomycin, and
she was afebrile. Her blood cultures showed no growth, but a
culture of her scalp revealed coag positive Staphylococcus
aureus that was later shown to be resistant to methicillin.
She was started on Amphojel for treatment of her
hyperphosphatemia. The patient's levofloxacin was
discontinued without complication. Her blood pressure
stabilized on her last hospital day, and the decision was
made to discharge her with appropriate followup.
DISCHARGE CONDITION: To home with services.
DISCHARGE STATUS: Good.
DISCHARGE MEDICATIONS:
1. Calcium acetate two tablets po tid with meals.
2. Aspirin 81 mg po q day.
3. Simvastatin 20 mg po q day.
4. Midodrine 10 mg po q day, 5 mg during hemodialysis, and 5
mg before hemodialysis.
5. Aluminum hydroxide 5-10 cc po tid with meals.
6. Gabapentin 300 mg po tid.
7. Protonix 40 mg po q day.
8. Nephrocaps one capsule po q day.
9. Levothyroxine 50 mcg po q day.
10. Vancomycin can be given at hemodialysis.
DISCHARGE DIAGNOSES:
1. Hypotension of unknown origin.
2. End-stage renal disease on hemodialysis.
3. Insulin dependent-diabetes mellitus.
4. Hypercholesterolemia.
5. Skin abscesses.
6. Hypothyroidism.
FOLLOW-UP CARE: The patient was sent home with VNA services.
The visiting nurse was to check blood pressures daily and
make wound dressing changes for her scalp lesion. The
patient was to have followup with all of her doctors as
follows:
1. Plastic Surgery on [**2-28**] at 10:30 am.
2. [**Last Name (un) **] in one month.
3. Dr. [**First Name (STitle) **] in the Autonomic Testing Clinic on [**2-23**]
at 11 am to work the patient up for potential dysautonomia
which may be the cause of her hypotension.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 104081**]
Dictated By:[**Last Name (NamePattern1) 1595**]
MEDQUIST36
D: [**2164-5-15**] 14:58
T: [**2164-5-16**] 10:06
JOB#: [**Job Number **]
|
[
"250.81",
"707.8",
"041.11",
"403.91",
"250.61",
"996.81",
"250.41",
"276.7",
"458.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"86.04"
] |
icd9pcs
|
[
[
[]
]
] |
4756, 4806
|
5265, 6230
|
4829, 5244
|
3162, 4734
|
1966, 3144
|
208, 1056
|
1078, 1943
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,851
| 190,097
|
3194
|
Discharge summary
|
report
|
Admission Date: [**2192-7-29**] Discharge Date: [**2192-8-5**]
Date of Birth: [**2112-7-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfonamides / Ilotycin / Gentamicin
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
MR, A FIB
Major Surgical or Invasive Procedure:
s/p MVR,MAZE
History of Present Illness:
This is an 81 year-old male who had been
followed by his cardiologist for several years with
progression of mitral regurgitation, development of atrial
fibrillation. He was referred for surgical intervention and
after the risks and benefits of the procedure were discussed
with the patient, the patient elected to proceed with
surgery.
Past Medical History:
Mitral regurgitation (see above)
Atrial fibrillation s/p cardioversion x2; treated with
amiodarone until stopped 3 weeks ago
h/o endocarditis ([**2185**]) - Low level consitutional sx without
fever or peripheral stigmata. Multiple BCx positive for Strep
bovis. Treated with 2 wks of penicillin and gentamicin.
Renal insufficiency (Cr 1.6)
Hypothyroidism ([**1-12**] amiodarone)
Hypertension
Hypercholesterolemia
Social History:
The patient lives in [**Location 15005**] with his wife. They are both
retired, and spend their [**Doctor Last Name 6165**] in [**State 108**]. He gets plenty of
exercise, walking ~3 miles per day. He also plays golf, walking
from hole to hole. He denies ever smoking or using illicit
drugs. He drinks only non-alcoholic beer.
Family History:
No known history of valvular heart disease.
Pertinent Results:
[**2192-7-29**] 07:15PM BLOOD WBC-7.1 RBC-3.96* Hgb-13.1* Hct-37.3*
MCV-94 MCH-33.2* MCHC-35.2* RDW-13.3 Plt Ct-269
[**2192-8-5**] 05:50AM BLOOD WBC-8.9 RBC-2.72* Hgb-9.1* Hct-26.1*
MCV-96 MCH-33.4* MCHC-34.7 RDW-14.8 Plt Ct-212
[**2192-8-5**] 05:50AM BLOOD PT-24.3* INR(PT)-2.4*
[**2192-8-5**] 05:50AM BLOOD Plt Ct-212
[**2192-8-5**] 05:50AM BLOOD Glucose-84 UreaN-24* Creat-1.2 Na-131*
K-3.8 Cl-98 HCO3-26 AnGap-11
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
1. The left atrium is moderately dilated. The right atrium is
markedly
dilated.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion
is normal.
3. The aortic root is moderately dilated. The ascending aorta is
moderately
dilated.
4. The aortic valve leaflets are mildly thickened.
5. A bioprosthetic mitral valve prosthesis is present. The
prosthetic mitral
leaflets appear normal. The transmitral gradient is normal for
this
prosthesis.
6. Compared with the prior study (images reviewed) of [**2192-5-24**],
the
prosthetic valve is new.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2192-8-3**] 15:39.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr. [**Known lastname 7049**] was taken to the operating room on [**2192-7-29**] where she
underwent an MVR/MAZW with a 31 mm [**Company 1543**] Mosaic pericardial
tissue valve. He was transferred to the SICU in critical but
stable condition. Patient was weaned to extubate that night on
POD0 without difficulty. Patient continued to be in Afib
post-op, so his amiodarone was conitued (Iv topo on POD1) adn
bblocker, aspirin, and diuresis were started on POD1 as per
protocol and patient was transferred to the floor on POD1 after
CT & med tubes were dc'd. Optho consult was obtained on POD2 [**1-12**]
seeing flashing lights (and pt will f/u as outpt). Patient
continued to do well. lopressor and and lasix were increased on
POD3. Patient had a questionable syncopal episodes, so catotid
dopplers were obtained which were negative, serial hematocrtis
were followed, and ECHO obtained on POD4 (see results section).
Coumadin for afib was started on POD3. Patient remained in house
whiel he became therapeutic on his inr. Foley was dc'd on POD4
without issue and patient got 2 U of blood for a low hct - he
bumped appropriately. Patient was discharged home on POD6 in
good condition with PT and instructions to have his coumadin
checked on tues and firday this week.
Medications on Admission:
coumadin, colchicine 0.5', cozaar 100", lasix 40', levoxyl 100',
lipitor 10', nasacort, nifedipine CR 30', toprol XL 75'
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
14. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime for
10 days: please have your level checked on tuesday at coumadin
clinic.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
s/p MVR,MAZE
CRI
hypothyroidism
Afib
gout
MR
Discharge Condition:
good
Discharge Instructions:
please call the office if you experience fever>101.5, severe
nausea, vomitting, pain, gain more than 2lbs/day or 5lbs in 1
week.
no heavy lifting for a few weeks
no driving while on narcotics
please have your coumdain level checked on tues and friday this
week at the [**Hospital 15006**] clinic
Followup Instructions:
Provider: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 198**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Follow-up appointment
should be in 2 weeks
Completed by:[**2192-8-5**]
|
[
"272.0",
"427.31",
"244.9",
"585.9",
"285.9",
"368.9",
"401.9",
"274.9",
"424.0",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"37.33",
"39.61",
"35.23",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
5827, 5910
|
2875, 4142
|
311, 326
|
5999, 6006
|
1560, 2818
|
6351, 6684
|
1495, 1541
|
4313, 5804
|
5931, 5978
|
4168, 4290
|
6030, 6328
|
262, 273
|
354, 692
|
2852, 2852
|
714, 1129
|
1145, 1479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,662
| 154,319
|
9608
|
Discharge summary
|
report
|
Admission Date: [**2110-6-26**] [**Month/Day/Year **] Date: [**2110-6-27**]
Date of Birth: [**2063-4-22**] Sex: F
Service: MEDICINE
Allergies:
Trazodone
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Chief Complaint: Ingestion/Overdose
Reason for MICU transfer: Needed to be intubated in the ED
Major Surgical or Invasive Procedure:
Intubation by EMS on the way to the hospital
History of Present Illness:
47F PMH depression w/ multiple prior SAs, found unresponsive in
bed at 1400 by husband. Bottle of [**First Name3 (LF) 3461**] (carisoprodol, centrally
acting muscle relaxant) found next to her. Last seen normal at
1130 today. As per EMS, RR of 4, GCS 3, intubated in field with
etomidate and succinyl choline and sedated with midazolam. BP
reportedly in the 80s in the field. Husband denies known h/o
illicit drug use or ETOH abuse, but she has had 12 prior SAs, at
least one of which was with [**First Name3 (LF) 3461**], which she has bought on the
street. Per husband, patient recently threatened suicide
attempt, and was recently d/c from inpatient facility for
depression.
Pt came into the ED sedated, intubated, and with emesis in her
mouth and hair; she was having B/L myoclonic jerks. Unclear if
emesis occurred during intubation or prior. In the ED, vitals
were temp 36, HR 88, BP 156/76, RR 14, 100% (never hypotensive).
ETT placement was verified (18g), and tube was advanced a
little. OG tube was placed and pill fragments were suctioned
out. Patient was seen by Toxicology, who advised IV thymine and
that myoclonic jerking was likely due to drug itself and not
seizure. She got vecuronium for CT scan b/c of myoclonic
jerking. CXR and head CT were unremarkable. She was sent up
from ED on midazolam drip.
On arrival to the MICU, patient was intubated on PS, alert, and
responding to commands. Vitals were 98.3, 91, 118/74, 14, and
100% on PS.
Review of systems:
(+) Per HPI
(-) Not able to be completed with patient initially
Past Medical History:
- Depression/Anxiety with multiple prior suicide attempts
(recent hospitalization at [**Hospital1 18**] [MICU and Deac4] for ingestion
and
[**Hospital1 **] hospitalization and even more recent one ~2 wks ago
elsewhere)
- MAO-I toxicity [**2109-6-14**] during which time she developed ATN,
acute liver injury, and mildly depressed LVEF 55%
- Chronic ETOH Dependence; h/o alcoholism years ago, per husband
- Prescription drug abuse (abuse of Ativan and [**Year (4 digits) 3461**] in the past)
- Hypothyroidisim
Social History:
- Tobacco: No current tobacco use.
- EtOH: Prior alcoholism history, husband reports she has not
had problems with alcohol abuse in years.
- Illicit Drugs: Per husband, denies known history of illicit
drug abuse. However has h/o prescription medication abuse,
including benzodiazepines and [**Year (4 digits) **]. Prior OB/GYN physician at
[**Hospital1 2177**], trained at HMS for med school and [**Hospital1 112**] for residency, now
moving to a different career, has not practiced for 1 year.
Married with 2 kids, lives with husband at home.
Family History:
Patient is adopted
Physical Exam:
EXAM on admission to the MICU [**2110-6-26**]
Vitals 98.3, 91, 118/74, 14, and 100% on PS vent
General: Alert, intubated, following commands
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: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: clonus of B/L ankles
Psych: denies current suicidality
.
[**Month/Day/Year **] EXAM [**2110-6-27**]
Vitals: Tcurrent: 37.1 ??????C (98.8 ??????F), HR: 89 (85 - 106) bpm, BP:
105/66(75) {84/45(53) - 122/87(95)} mmHg, RR: 12 (12 - 22)
insp/min, SpO2: 96%, Heart rhythm: SR (Sinus Rhythm)
General: Alert, oriented x 3, following commands, remembers
events of past 24 hours
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: no clonus of feet or hyperreflexia; nonfocal
Psych: denies current suicidality
Pertinent Results:
[**2110-6-26**] 03:30PM URINE HOURS-RANDOM
[**2110-6-26**] 03:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
[**2110-6-26**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2110-6-26**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2110-6-26**] 03:30PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2110-6-26**] 03:30PM URINE MUCOUS-RARE
[**2110-6-26**] 03:15PM PO2-119* PCO2-38 PH-7.39 TOTAL CO2-24 BASE
XS--1
[**2110-6-26**] 03:15PM GLUCOSE-101 LACTATE-1.0 NA+-139 K+-4.3
CL--109* TCO2-22
[**2110-6-26**] 03:15PM PT-9.5 PTT-26.1 INR(PT)-0.9
[**2110-6-26**] 03:10PM GLUCOSE-104* UREA N-13 CREAT-0.9 SODIUM-138
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-23 ANION GAP-11
[**2110-6-26**] 03:10PM estGFR-Using this
[**2110-6-26**] 03:10PM ALT(SGPT)-17 AST(SGOT)-14 CK(CPK)-63 ALK
PHOS-49 TOT BILI-0.2
[**2110-6-26**] 03:10PM LIPASE-23
[**2110-6-26**] 03:10PM ALBUMIN-3.9
[**2110-6-26**] 03:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2110-6-26**] 03:10PM WBC-3.1* RBC-4.19* HGB-11.3* HCT-35.3* MCV-84
MCH-27.0 MCHC-32.1 RDW-12.7
[**2110-6-26**] 03:10PM NEUTS-54.0 LYMPHS-38.2 MONOS-5.1 EOS-1.8
BASOS-0.9
[**2110-6-26**] 03:10PM PLT COUNT-177
.
CT HEAD [**2110-6-26**]:
FINDINGS: No acute intracranial hemorrhage, large vascular
territory infarct, shift of midline structures, or mass effect
is present. The ventricles and sulci are normal in size and
configuration. The visible paranasal sinuses show mild
ethmoidal mucosal sinus thickening. The mastoid air cells are
well aerated. Secretions are noted in the nasopharynx likely
related to intubated status.
IMPRESSION: No acute intracranial process.
.
Supine AP CXR [**2110-6-26**]:
FINDINGS: Endotracheal tube tip terminates 5.5 cm from the
carina. Orogastric tube tip courses below the diaphragm into
the stomach, off the inferior borders of the film. The heart
size is normal. The mediastinal and hilar contours are
unremarkable. The pulmonary vascularity is normal. There are
mild bibasilar opacities likely reflecting atelectasis. There
is no pleural effusion or pneumothorax though the extreme lung
apices are excluded from the field of view. There are no acute
osseous abnormalities.
IMPRESSION: Endotracheal and orogastric tube tips in standard
positions. Patchy opacities in the lung bases likely reflective
of atelectasis.
.
EKG [**2110-6-26**]: Sinus tach @ 100, NA, QRS 86, QTc 426, no ischemic
changes
Brief Hospital Course:
47F w/ hx depression and multiple suicide attmepts presents
after suicide attempt by ingestion of [**Month/Day/Year 3461**].
.
Active Diagnoses:
# Ingestion - Pt had a sedative toxodrome with obtundation,
likely [**Month/Day/Year 3461**]. As per Toxicology, "[**Month/Day/Year 3461**] is considered a skeletal
muscle relaxant but likely works by agonizing GABA...Jerking
motions are common s/p carisoprodol ingestions, likely due to
myoclonic jerks. These should be self limiting...If jerking
motions are not self-limiting upon paralysis wearing off,
probably reasonable to rule out sz activity w/ EEG, though this
would not likely be from a [**Month/Day/Year 3461**] ingestion." ASA, APAP, ETOH
screens were negative. Patient was able to be weaned from
midazolam and extubated within an hour of arriving to the MICU.
When extubated, she reported that she had taken 15 [**Month/Day/Year 3461**] (unknown
strength) at around 2pm as a suicide attempt. She denies any
other ingestion. She did not have spontaneous myoclonus in the
MICU, but initially had clonus when elicited on exam; this
resolved within 12 hours. Her initial EKG looks WNL (sinus), and
there was no evidence of MAO-I ingestion. Repeat labs are WNL.
Especially given possible aspiration, the patient's respiratory
status was monitored after intubation. No respiratory distress,
fever, or elevated WBC. Repeat EKG was reassuring. Patient was
given PO thiamine. She complained of pleuritic chest pain and
cough the morning after the ingestion, but her lungs were clear
on exam, she was sat-ing well on room on air, and she was not
tachypneic. CXR was WNL and showed no acute cardiopulmonary
process.
.
# Medical Clearance for [**Month/Day/Year 7637**] Hospitalization - The
patient was intubated and possibly aspirated, but we do not
believe she currently has a PNA (see above). If she develops
fever or SOB, she may need to be evaluated for PNA, but right
now she is medically cleared. She is eating, drinking, and is
able to tolerate normal physical activity.
.
# Hypothroidism (?) - Chronic diagnosis. Patient reports that
she's on Synthroid 50mcg at home, but husband and psychiatrist
report that she is not as per psychiatry. She was given one
dose of Synthroid 50mcg the morning after her ingestion, as we
did not know the patient was no longer on this medicaiton. She
then developed tachycardia to 110. We initially thought this
was related to volume depletion and/or anxiety, and she was
given 1L LR. TSH level was sent before she was given the
Synthroid and is still pending. When we realized she is no
longer on this medication, it was discontinued.
.
# Suicidality/Anxiety/Depression - Ingestion was suicide
attempt. Psychiatry was consulted and recommended inpatient
[**Month/Day/Year **] hospitalization. The patient had a 1-to-1 sitter
while in the MICU. Her home Cymbalta, lorazepam, trazodone,
Ambien, and prazosin (for nightmares) were continued. Her home
dextroamphetamine was held.
.
# Transitional Issues
- Pending TSH study. Unclear significance, given critical
illness and intubation. Recommend rechecking in 6 weeks.
Medications on Admission:
Cymbalta 90 mg delayed
lorazepam 1 mg tablet q6-8 hrs
trazodone 150 mg QHS
Ambien CR 12.5 mg QHS
prazosin 2mg QHS (for nightmares)
dextroamphetamine -- unknown dose
Synthroid 50 mcg tablet QD
***Patient's record lists an allergy to trazodone. But she does
not have an allergy to trazodone, and, in fact, takes it
currently. She does have an allergy to tranylcypromine -->
malignant hyperthermia***
[**Month/Day/Year **] Medications:
1. Duloxetine 90 mg PO DAILY
2. Lorazepam 1 mg PO Q8H:PRN Anxiety
Hold for somnolence or RR<10
3. Prazosin 2 mg PO HS
Hold for somnolence or for SBP<100.
4. Thiamine 100 mg PO DAILY
5. traZODONE 150 mg PO HS
Hold for somnolence.
6. Zolpidem Tartrate 10 mg PO HS
Please hold if patient is somnolent.
[**Month/Day/Year **] Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Location (un) 10059**]
[**Location (un) **] Diagnosis:
Primary: Acute respiratory failure, suicide attempt, depression
Secondary: Hypothyroidism.
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Location (un) **] Instructions:
Dear Dr. [**Known lastname **],
It was our pleasure to care for you at [**Hospital1 18**]. You were admitted
for a medication overdose which caused you to become somnolent
and require intubation and mechanical ventilation. We were able
to successfully remove the tube and had you evaluated by the
psychiatry team, who will assume your care.
We made the following changes to your medication:
*** Stop taking dextroamphetamine. Do not start taking this
medication again unless prescribed by a psychiatrist or your
PCP.
*** Start taking thiamine 100mg daily. Do not stop taking this
unless instructed by your PCP or psychiatrist to do so.
There was a question as to if you were taking thyroid
supplementation, although it appears that you were not, and we
are not giving it to you.
Followup Instructions:
Please follow up with the doctors at the [**Name5 (PTitle) **] facility.
Please make an appointment with your PCP within [**Name Initial (PRE) **] week of
[**Name Initial (PRE) **]. Please have your TSH tested within the next 6 weeks.
|
[
"V62.84",
"300.4",
"518.81",
"968.0",
"E950.4",
"244.9",
"301.83",
"333.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7188, 7315
|
377, 423
|
4580, 7165
|
12323, 12562
|
3116, 3137
|
10341, 11194
|
3152, 4561
|
1938, 2004
|
11226, 11319
|
259, 339
|
11351, 11351
|
11513, 12300
|
451, 1919
|
11366, 11478
|
7333, 10315
|
2026, 2538
|
2554, 3100
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,820
| 195,715
|
46196
|
Discharge summary
|
report
|
Admission Date: [**2197-10-19**] Discharge Date: [**2197-10-24**]
Date of Birth: [**2129-3-14**] Sex: F
Service: ORT
HOSPITAL COURSE ADMISSION: Ms. [**Known lastname 32737**] is a pleasant 68-
year-old female, who on [**2197-6-3**] sustained a left
subtrochanteric femur fracture that was managed with a Gamma
nail. Unfortunately, since that time she has had cutting
through the head of the Gamma nail to the point that she now
has a varus deformity of her femoral fracture with possible
nonunion, and the screw of the Gamma nail was cutting into
the upper aspect of her joint into the acetabulum. She
presents today for assessment and opinion regarding possible
surgical management. She was accompanied by her daughter and
husband. She was alert with good mentation and appeared well-
informed in regard to her hip procedure. Recently, she was
seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] who recommended total hip
replacement.
PAST MEDICAL HISTORY: Complex.
History of diabetes.
Deep vein thrombophlebitis.
Coronary artery disease.
Lung resection.
Sleep apnea.
Possible COPD. She is oxygen dependent at times.
PAST SURGICAL HISTORY: Heart bypass in [**2190**].
Appendectomy.
ALLERGIES TO MEDICINES: Ampicillin, Zocor, Bactrim,
cefotetan.
CURRENT MEDICATIONS: Extensive.
1. Celebrex.
2. Coumadin.
3. Furosemide.
4. Ranitidine.
5. Potassium.
6. Lactulose.
7. Lipitor.
8. Isordil.
9. Accupril.
10.Os-Cal.
11.Centrum.
12.Colace.
13.Several vitamins.
14.Oxycodone.
15.Oxycontin.
16.Insulin.
PHYSICAL EXAMINATION: A pleasant female in no apparent
distress. She was not oxygen dependent at this time. She
had a scar on her chest from her previous CABG. She had full
range of motion of her upper extremities, but significant
decreased range of motion of her left hip which is the one
involved. She had severe deformity on minimal range of
motion. Her right hip does not seem to bother her as much.
Her extremities seemed to be well-perfused and warm with a
palpable dorsalis pedis pulse, but not a palpable posterior
tibialis on the left side. She appeared to be sensory intact
to light touch. Sensation: 4 plus/5 motor strength in all
major lower extremity groups. There was no evidence of skin
breakdown or ulceration in her lower extremities. Her
incisions from prior surgery were pristine.
HOSPITAL COURSE: She was seen by Dr. [**Last Name (STitle) 1005**] in the office
who felt the patient would need to have reconstructive
surgery for her left hip. She underwent cardiac clearance
which cleared her for cardiac surgery. She had the insertion
of a vena cava filter preoperatively because she would have
to be off her Coumadin for the surgery. All of this was done
preoperatively. The patient was then considered ready for
surgery.
On [**2197-10-20**], the patient was taken to the operating room.
The preoperative diagnosis was subtrochanteric nonunion of
the left hip. Postop diagnosis was the same. The patient
underwent removal of the Gamma nail on the left side, and
also she underwent a left calcar-replacing hemiarthroplasty.
The patient tolerated the procedure well and was transferred
to the PACU status post in satisfactory and hemodynamically
stable condition.
She continued to do well in the PACU and was stable enough to
be transferred to the CC6 floor where she was seen by
physical therapy. She got up and was walking. On postop day
1, she had her PA catheter that was placed by anesthesia
removed. Physical therapy saw her and felt she was doing
well, but because of her extensive past medical history she
would need to be sent to rehab. The patient was started to
be screened by rehab. She continued to do well.
Postoperatively, her hematocrit was low. She received
transfusions. The day of discharge, her hematocrit was 27.1
which was satisfactory. She was started back on Coumadin
despite the fact that she did have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] umbrella
placed. Her goal INR was to be 1.5-2.0. Her INR the day of
discharge was 1.6, and she was taking 2-3 mg of Coumadin.
The day of discharge it was recommended that she be on 2.5,
but a goal INR should be maintained. She should have INRs
drawn until she is satisfactorily stabilized on her Coumadin
therapy. The patient was accepted at rehabilitation
facility. From an orthopedic point-of-view she was doing
well. Dr. [**Last Name (STitle) 1005**] saw the patient the day of transfer and
felt the patient would be stable enough to go home. She is
to follow-up with Dr. [**Last Name (STitle) 1005**] 10 days from today. She is
to call Dr.[**Name (NI) 4016**] office to schedule an appointment.
Dr.[**Name (NI) 4016**] office number is [**Telephone/Fax (1) 4845**].
DISCHARGE INSTRUCTIONS: She is to be discharged to rehab
full-weightbearing with posterior hip dislocation
precautions. Take her pain medication as ordered. She is to
take her Coumadin as prescribed. Her Coumadin at the time of
discharge was going to be 2.5 mg. However, optimal goal for
her should be 1.5-2.0 on her INR. She is to follow-up with
Dr. [**Last Name (STitle) 1005**] the first Thursday from today to have her
staples removed. She is to keep the wound dry and intact
with a bandage.
DISCHARGE MEDICATIONS:
1. Lasix 80 mg po q am.
2. Ranitidine 150 mg po once daily.
3. Lactulose 10 gm in 15 cc. She is to take 30 cc po bid.
4. Atorvastatin calcium 40 mg po bid.
5. Quinapril hydrochloride 20 mg po once daily.
6. Docusate sodium 100 mg capsule 1 [**Hospital1 **].
7. Bisacodyl 5 mg delayed release 2 tablets po once daily.
8. Nitroglycerin 0.4 mg sublingual 1 tab prn.
9. Calcium carbonate 1,250 mg tablet 1 po bid.
10.Calciferol Vitamin D3 400 units 0.5, [**1-27**] tablet po bid.
11.KCL 10 mEq SR 1 po bid.
12.Isosorbide dinitrate 20 mg po bid.
13.Oxycodone hydrochloride 20 mg tablet SR 1 q 12 h.
14.Percocet 325 mg [**1-27**] po q 4-6 h prn.
15.Oxycodone/acetaminophen 5/325 mg tablet [**1-27**] po q 4-6 h prn
pain.
16.Coumadin 2.5 mg po at bedtime. Goal INR 1.5-2.0.
DISCHARGE DIAGNOSES: Status post left calcar-replacing
hemiarthroplasty.
Status post left subtrochanteric nonunion.
Status post removal of Gamma nail, left side, hip.
Status post coronary artery bypass graft surgery.
Status post postoperative blood transfusion.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16347**]
Dictated By:[**Last Name (NamePattern4) 51424**]
MEDQUIST36
D: [**2197-10-24**] 11:28:05
T: [**2197-10-24**] 12:21:48
Job#: [**Job Number 98229**]
|
[
"285.9",
"733.82",
"V45.81",
"V12.51",
"412",
"996.4",
"780.57",
"998.11",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"78.65",
"99.04",
"81.52"
] |
icd9pcs
|
[
[
[]
]
] |
6109, 6629
|
5317, 6087
|
2399, 4790
|
4815, 5294
|
1210, 1319
|
1592, 2381
|
1341, 1569
|
1017, 1186
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,183
| 155,477
|
1326
|
Discharge summary
|
report
|
Admission Date: [**2183-5-13**] Discharge Date: [**2183-5-19**]
Date of Birth: [**2133-12-5**] Sex: F
Service: MEDICINE
Allergies:
Bacitracin / Morphine / Percocet
Attending:[**First Name3 (LF) 477**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Whole Brain Radiation
History of Present Illness:
Info taken from MICU note and patient interview.
In brief,49 yo F with Stage IV Non-small cell lung cancer who
presented to the ED [**2183-5-13**] with new onset fevers, worsening
respiratory status, + cough, worsening sputum, and fevers. She
had recently received her dose of Navelbine chemotherapy [**5-9**].
Also her husband [**Name (NI) 8148**] that she had some difficulty thinking
specially after last dose of chemotherapy. Per MICU report, she
was also aggitated and there was an intial concern for
withdrawing given her history of drinking.
.
On arrival to MICU, she denied CP or SOB. She received intiially
cefepime and vancomycin on admission. Her cheest x ray showed a
RLL. She was kept on Vancomycin and cefepime. She had a head CT
done that showed multiple new hypodensities in the right
frontal, right temporal, and left centrum semiovale concerning
for metastases. Dexamethasone was started and patient's mental
status improved. Blood cx have remained negative. She is going
for radiation tomorrow.
.
Currently she feels ok. Denied any SOB, chest pain. Her cough is
still there. She has not been febrile over last 24h.
Past Medical History:
Pancreatitis: chronic from etoh use. c/b pseudocyst, currently
managed conservitavly.
GERD
HTN
SMV Thrombosis - not currentyl anticoagulated. Was diagnosed in
[**2182-3-17**], decided to be followed and not anticoagulated.
Stage IV Non-small cell lung cancer
Social History:
Lives with husband. smoked 1ppd x 30 years. Reportedly stopped
drinking.
Family History:
mother died of colon cancer
Physical Exam:
Vitals: T: 97.7 P:100 R:16 BP:126/95 SaO2:100 Ra
General: Awake, alert, NAD. cachectic
HEENT: pupiles equal and reactive to light. EOMO preserved.
oropharinx is clear.
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs R base crackles.
Cardiac: RRR, nl. S1S2, no murmurs
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 2+ , no edema.
Skin: radiation skin changes lower back.
Neurologic: alert, oriented x3., craneal nerves iI xii
preserved, strength 5/5 proximal and distall upper/lower
extremity. coocrdination finger to nose preserved. reflex
++/++++ bilaterally. Attention intact with serial 7's, months
backwards but evidence of subtle cognitive deficits in
reasoning.
Pertinent Results:
[**2183-5-13**] 04:10PM BLOOD WBC-1.2*# RBC-2.73* Hgb-10.1* Hct-30.4*
MCV-111* MCH-37.0* MCHC-33.2 RDW-20.1* Plt Ct-39*#
[**2183-5-14**] 11:16AM BLOOD WBC-0.8* RBC-2.12* Hgb-8.1* Hct-23.3*
MCV-110* MCH-38.4* MCHC-34.9 RDW-17.7* Plt Ct-31*
[**2183-5-14**] 05:34PM BLOOD WBC-0.6* RBC-1.37*# Hgb-5.3*# Hct-15.2*#
MCV-111* MCH-38.7* MCHC-34.9 RDW-18.1* Plt Ct-21*
[**2183-5-15**] 05:00AM BLOOD WBC-0.6* RBC-2.04*# Hgb-7.1*# Hct-21.1*
MCV-104*# MCH-35.1* MCHC-33.8 RDW-22.0* Plt Ct-21*
[**2183-5-16**] 05:35AM BLOOD WBC-1.8*# RBC-3.32* Hgb-11.7* Hct-33.1*
MCV-100* MCH-35.1* MCHC-35.2* RDW-21.3* Plt Ct-33*
[**2183-5-17**] 08:15AM BLOOD WBC-1.9* RBC-3.53* Hgb-12.1 Hct-36.0
MCV-102* MCH-34.4* MCHC-33.7 RDW-20.7* Plt Ct-38*
[**2183-5-18**] 05:50AM BLOOD WBC-2.6* RBC-3.30* Hgb-11.1* Hct-32.9*
MCV-100* MCH-33.7* MCHC-33.8 RDW-20.2* Plt Ct-40*
[**2183-5-19**] 05:06AM BLOOD WBC-6.1# RBC-3.20* Hgb-11.3* Hct-32.5*
MCV-102* MCH-35.3* MCHC-34.8 RDW-20.2* Plt Ct-47*
[**2183-5-15**] 05:00AM BLOOD Gran Ct-420*
[**2183-5-15**] 05:00AM BLOOD Gran Ct-690*
[**2183-5-16**] 05:35AM BLOOD Gran Ct-1140*
[**2183-5-18**] 05:50AM BLOOD Gran Ct-1720*
[**2183-5-19**] 05:06AM BLOOD Gran Ct-5210
[**2183-5-13**] 04:10PM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-131*
K-3.0* Cl-88* HCO3-29 AnGap-17
[**2183-5-14**] 11:16AM BLOOD Glucose-86 UreaN-4* Creat-0.4 Na-135
K-3.5 Cl-104 HCO3-20* AnGap-15
[**2183-5-15**] 05:00AM BLOOD Glucose-182* UreaN-5* Creat-0.1* Na-133
K-4.2 Cl-99 HCO3-25 AnGap-13
[**2183-5-16**] 05:35AM BLOOD Glucose-125* UreaN-7 Creat-0.4 Na-133
K-3.8 Cl-97 HCO3-28 AnGap-12
[**2183-5-17**] 08:15AM BLOOD Glucose-119* UreaN-11 Creat-0.5 Na-135
K-3.3 Cl-100 HCO3-22 AnGap-16
[**2183-5-18**] 05:50AM BLOOD Glucose-109* UreaN-9 Creat-0.4 Na-137
K-4.3 Cl-105 HCO3-22 AnGap-14
[**2183-5-19**] 05:06AM BLOOD Glucose-121* UreaN-13 Creat-0.5 Na-131*
K-4.2 Cl-100 HCO3-21* AnGap-14
[**2183-5-19**] 03:40PM BLOOD Glucose-118* UreaN-15 Creat-0.5 Na-133
K-4.0 Cl-99 HCO3-23 AnGap-15
[**2183-5-14**] 12:53AM BLOOD ALT-40 AST-32 LD(LDH)-334* CK(CPK)-33
AlkPhos-89 TotBili-0.9
[**2183-5-13**] 04:10PM BLOOD cTropnT-<0.01
[**2183-5-14**] 12:53AM BLOOD CK-MB-2 cTropnT-<0.01
[**2183-5-14**] 11:16AM BLOOD Calcium-7.7* Phos-2.0* Mg-1.3*
[**2183-5-15**] 05:00AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.3*
[**2183-5-16**] 05:35AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8
[**2183-5-17**] 08:15AM BLOOD Calcium-9.1 Phos-3.5 Mg-1.4*
[**2183-5-18**] 05:50AM BLOOD Calcium-9.1 Phos-2.8 Mg-1.5*
[**2183-5-19**] 05:06AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.8
[**2183-5-14**] 11:16AM BLOOD VitB12-1425*
[**2183-5-14**] 11:16AM BLOOD TSH-1.1
[**2183-5-14**] 12:53AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
CXR: [**5-13**]
Lung volumes are mildly diminished with asymmetric density over
the right hemidiaphragm. Blunting of the right costophrenic
angle is again identified anteriorly. There is a rounded mass
lesion seen in the mid central right upper lung projecting
between the posterior aspects of the right fifth and sixth ribs.
Mediastinum is unremarkable. The cardiac silhouette is within
normal limits for size. No pneumothorax is appreciated.
IMPRESSION: Mass lesion recently characterized on [**2183-3-20**]
PET CT. There is increased density over the right dome of the
liver which may represent an early focal infiltrate. Pneumonia
must be suspected until proven otherwise given neutropenic
status.
.
CXR: [**5-14**]
Part of lung apices obscured by patient's chin. The previously
noted right lower lobe opacity appears more prominent today
suggesting right lower lobe pneumonia. The right upper lung
spiculated mass is less readily evident. There are no other
focal consolidations. The cardiomediastinal silhouette is
normal. There is no pulmonary edema. There is no pleural
effusion or pneumothorax.
IMPRESSION: Right lower lobe pneumonia.
.
CT head: Multiple new hypodensities in the right frontal, right
temporal, and left centrum semiovale concerning for metastases
in this patient with known metastatic lung cancer. An MRI before
and after IV contrast administration is recommended for further
evaluation. These findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
at the time of this dictation.
Brief Hospital Course:
# Altered Mental Status: The patient was admitted to the ICU for
altered mental status. She was found to have new brain
metastasis with edema. She was started on dexamthasone 4mg
q6hours with marked improvement of her mental status. She then
began receiving whole brain radiation. She was continued on the
dexamethasone on discharge but at 4mg q8hours to be tapered as
necessary as an outpatient. On the day of discharge, she was
drowsy in the morning and inattentive. Later in the day, she was
more alert, able to perform attention testing but cont to have
subtle cognitive deficits. The patient demonstrated significant
anxiety at the thought of staying. per her outpt fellow, she has
baseline moderate anxiety.She was started on Zyprexa. Given that
she will have 24 hour supervision at home, it was decided that
she was safe for discharge.
# Pneumonia: The patient was admitted for altered mental status.
CXR noted RLL PNA. She was started on on Cefepime and
Vancomycin. These abx were continued while she was neutropenic.
She received neupogen. When she was no longer neutropenic, she
was switched to bactrim and levofloxacin to complete at 10 day
course of abx. She was monitored for 48 hours and remained
without fever or clinical worsening.
.
# Non-Small Cell Lung CA: Started on dexamethasone and whole
brain radiation for new brain mets. She also became neutropenic
and was started on neupogen.
Medications on Admission:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation. Disp:*30 tablets*
Refills:*6*
2. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Transdermal every
seventy-two (72) hours. Disp:*30 patches* Refills:*2*
5. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
6. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO four times a
day.
8. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for sinus congestion.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*6*
11. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO once a day.
12. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. Amylase-Lipase-Protease 56,000-20,000- 44,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed
Release(E.C.) PO three times a day: take before meals.
15. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
17. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-23**]
hours as needed for pain.
18. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours. Disp:*120 Tablet(s)* Refills:*3*
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
Disp:*30 tablets* Refills:*6*
2. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours.
Disp:*30 patches* Refills:*2*
5. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
6. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO four times a
day.
8. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for sinus congestion.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*6*
11. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO once a day.
12. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2)
sprays Nasal once a day.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
14. Amylase-Lipase-Protease 56,000-20,000- 44,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed
Release(E.C.) PO three times a day: take before meals.
15. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
17. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 8 days: to end on [**2183-5-26**].
Disp:*16 Tablet(s)* Refills:*0*
18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days: to end on [**2183-5-26**].
Disp:*8 Tablet(s)* Refills:*0*
19. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**3-23**]
hours as needed for pain.
20. Dexamethasone 4 mg Tablet Sig: Two (2) Tablet PO every eight
(8) hours.
Disp:*120 Tablet(s)* Refills:*3*
21. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Non-Small Cell Lung Ca
Brain Metastasis
Altered Mental Status
Pneumonia
Discharge Condition:
improved- lethargy resolved, pneumonia improved
Discharge Instructions:
You were admitted with confusion. You were found to have
pneumonia and were started on antibiotics. You were also found
to have brain metastasis with edema that caused your altered
mental status. Your confusion cleared with steroids and
radiation. You were also started on Zyprexa for anxiety and
confusion.
.
If you have confusion, lethargy, fever, chills or trouble
breathing, you should return to the emergency room.
Followup Instructions:
You should call radiation oncology to arrange for further
radiation. ([**Telephone/Fax (1) 8082**]
.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**]
Date/Time:[**2183-5-22**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7706**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2183-5-22**] 9:00
Provider: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2183-5-22**] 10:00
[**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]
|
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68,453
| 138,310
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39620
|
Discharge summary
|
report
|
Admission Date: [**2136-8-17**] Discharge Date: [**2136-8-21**]
Date of Birth: [**2072-12-4**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Colostomy
Major Surgical or Invasive Procedure:
Colostomy Takedown
History of Present Illness:
Mr. [**Known lastname **] received a diverting colostomy in [**8-/2135**] during a 6
week hospitalization to facilitate healing s/p debridement for
Fournier' gangrene. He saw Dr. [**First Name (STitle) 2819**] on [**4-23**] for consultation of
colostomy reversal.
Past Medical History:
DM, HTN, CAD s/p MI ([**2125**]), Fournier's Gangrene, PVD, Peripheral
neuropathy, hypercholesterolemia, CKD, shock liver
Social History:
Reports [**1-15**] pack per day cigarettes,
States the he has discontinued EtOH use
denies illicit drug use.
Family History:
Non-contributory
Physical Exam:
General: AAOx3, NAD.
HEENT: EOMI, PERRL. Oropharynx clear.
Neck: No LAD.
CV: Normal S1, S1. RRR. No m/r/g.
Pulmonary: CTAB. No w/r/r.
Abdomen: Two incision with staples, c/d/i, no surrounding
erythema. Bowel sounds present. Appropriately tender, no rebound
guarding.
Extremities: Warm, well perfused. No c/c/e.
Neuro: Motor function grossly intact.
Pertinent Results:
[**2136-8-20**] 06:05AM BLOOD WBC-9.2 RBC-3.11* Hgb-9.3* Hct-27.5*
MCV-88 MCH-30.0 MCHC-34.0 RDW-15.5 Plt Ct-249
[**2136-8-20**] 06:05AM BLOOD Glucose-133* UreaN-18 Creat-1.1 Na-139
K-3.3 Cl-106 HCO3-21* AnGap-15
[**2136-8-19**] 06:40AM BLOOD ALT-15 AST-17 LD(LDH)-238 AlkPhos-81
Amylase-45 TotBili-0.6
[**2136-8-19**] 06:40AM BLOOD Lipase-12
[**2136-8-18**] 03:10PM BLOOD cTropnT-0.02*
[**2136-8-20**] 06:05AM BLOOD Calcium-8.8 Phos-1.6* Mg-2.1
[**2136-8-19**] 06:40AM BLOOD VitB12-432 Folate-10.8
[**2136-8-20**] 06:05AM BLOOD Ammonia-17
[**2136-8-19**] 06:40AM BLOOD TSH-1.3
Brief Hospital Course:
Admit date: [**2136-8-17**]
Discharge date: [**2136-8-21**]
Pre-operative diagnosis: Diverting colostomy.
Post-operative diagnosis: Colostomy reversal.
Pending labs: None
Imaging: Chest X-rays
[**8-17**] 14:40 : Opacification of the left lung likely represents a
combination of collapse,
edema and effusion.
[**8-17**] 16:50 : Bilateral pleural effusions and bilateral
infiltrates left greater than right
are unchanged. Moderate perihilar edema is unchanged.
[**8-19**] 10:00 : There is no pulmonary vascular congestion. Lungs are
generally well aerated with minimal peribronchial prominence in
the right middle lobe area. Pleural spaces are clear.
Medication changes: None
Brief hospital course:
Mr. [**Known lastname **] was admitted for elective colostomy reversal on
[**2136-8-17**]. Before transfer to the OR, he received one unit of
packed RBCs given his history of MI and his HCt of 26.7 of [**8-9**].
He received another unit of packed RBCs intraoperatively along
with 2L of NS. The colostomy reversal was successful; however,
Mr. [**Known lastname **] developed acute pulmonary edema in the PACU with
desaturation to 75% and was unable to be bridged with BiPAP. He
required intubation and transfer to the ICU for management. Mr.
[**Known lastname **] was extubated 3 hours later (still HD#0, [**8-17**]). The
morning of POD#1 he was noted to become agitated requiring some
IV sedatives and the agitation resolved, and was transferred to
the general surgery floor. He was placed on CIWAA protocol
though he denies EtOH. On POD# 2, he became acutely delirious
and agitated, accusing the nursing staff of stealing his
medications and conspiring against him. He refused medications
and lab draws and further cares. He removed his IV lines and
attempted to leave down the back stairway. Security was called
and he was escorted back to his room. He refused to allow staff
to take vital signs and was continuing to express paranoia and
stating that the nursing staff were conspiring with the doctors
against [**Name5 (PTitle) **], and were laughing at him. He required IM haldol x2
and vital signs with blood glucose were checked and were normal.
A 1:1 sitter was placed and psychiatry was consulted who agreed
that the patient did not have capacity to leave AMA. His
daughter informed medical staff that the patient is paranoid at
baseline and has decompensated in the hospital in the past,
specifically with prior surgeries requiring prolonged hospital
stays. She reports he was a heavy EtOH user but hasn't been in
the last year. Further labs were checked for reversible causes
of delirium and were normal. He again attempted to leave that
night and required IM seroquel. An EKG was checked which showed
normal QT interval. POD#3 the agitation largely resolved. He was
transitioned to a regular diet. He refused further blood draws.
He was seen by PT and OT who cleared the patient for discharge.
POD#4 he had minimal abdominal pain and was not requiring any
narcotics. He was ambulating and passing flatus. He agreed to
and was set up with home PT evaluation to assess mobility in his
home. His vital signs were normal and he has scheduled follow up
appointment with Dr. [**First Name (STitle) 2819**].
Medications on Admission:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
4. glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Colostomy reversal
Congestive heart failure with respiratory failure
Diabetes
Post operative Delirium
Hypertension
Peripheral neuropathy
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:
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2998**]
Date/Time:[**2136-8-27**] 2:15
Schedule a followup appointment with your PCP [**Last Name (NamePattern4) **] [**1-15**] weeks.
Completed by:[**2136-8-21**]
|
[
"440.20",
"518.4",
"357.2",
"585.9",
"V55.3",
"285.9",
"412",
"293.0",
"403.90",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.52",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6324, 6381
|
2609, 5124
|
301, 322
|
6561, 6561
|
1305, 1884
|
8789, 9069
|
903, 921
|
5737, 6301
|
6402, 6540
|
5150, 5714
|
6744, 8380
|
8395, 8766
|
936, 1286
|
2580, 2586
|
252, 263
|
350, 615
|
6576, 6720
|
637, 760
|
776, 887
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,930
| 145,134
|
51908
|
Discharge summary
|
report
|
Admission Date: [**2107-1-24**] Discharge Date: [**2107-1-25**]
Date of Birth: [**2046-4-11**] Sex: M
Service: MEDICINE
Allergies:
Epogen
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
septic shock, from OSH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a 60 year old man with ESLD/ESRD and [**Hospital **]
transferred to [**Hospital1 18**] from [**Hospital3 **]. As per his wife on [**Name (NI) 2974**]
he got back from HD and says his stomach hurt more than usual.
Saturday he didn't feel like drinking much, although he had some
pedialyte, and his stomach pain continued. He had no fever, but
he broke a sweat on Sunday and felt hot and nauseated. He
vomited a couple of times but there was no report of blood. He
developed SOB, and he tried to use supplemental oxygen that they
had left over from a few years ago, but they were unable to get
the equipment to work so they called an ambulance and he was
brought to the ED at [**Hospital3 **].
.
At [**Hospital3 **] his CXR was found to be clear. There is report
that he had seizure at the OSH but it was not documented
anywhere. His Hct was 33, and he reportedly begain vomiting
coffee ground emesis with a likely aspiration event, so he was
intubated. He reportedly had gross blood rectally as well. NGT
was placed with coffee ground substance. He was hypotensive, so
a R femoral cordis was placed and he was started on dopamine and
transferred to [**Hospital1 18**].
.
In the ED his vitals were 96.1, 89, 107/53 on dopamine. Initial
ABG was 7.02/76/302 and lactate was 13.5. CXR showed likely
aspiration in the lung bases. CT head for report of seizure was
negative for bleed. CT abd showed partial jejunal SBO, no
mesenteric ischemia. Surgery was curbsided in the ED and felt he
was being treated for possible SBO anyway with NGT. He was
broadly covered with Vanc/Levo/Flagyl/Ceftaz/CTX. He was given
Decadron and thiamine as well as IV PPI. He was aggressively
fluid resuscitated with a total of 4L NS and 7L LR. Levophed was
added for a brief time before being discontinued. The hepatology
service was consulted and recommended admission to the MICU for
stabilization before upper endoscopy. He was ordered for 2U PRBC
and sent up on vent settings of AC 100% 370 25 10. His last gas
before being admitted to the MICU was 7.00/74/110 with lactate
of 9.8.
Past Medical History:
# HCV cirrhosis ([**2104**]): Prior encephalopathy, no esophageal
varices
# Anemia of chronic disease
# ESRD ([**3-/2105**]): HD every Monday, Wednesday, [**Year (4 digits) 2974**]
# Atrial tachycardia
# COPD
# Hypothyroidism
# Abdominal hernia
# SBO at terminal ileum s/p adhesion lysis, stricturoplasty
([**12-20**])
Social History:
# Tobacco: Less than 1 pack/week x 14 years
# Alcohol: Past [**1-16**] drinks/day, now abstinent
# Recreational drugs: Past marijuana, no IVDU
# Employment: Disability, former [**Doctor Last Name **] in glass industry
# Personal: Lives with wife in [**Name (NI) 3597**], [**Name (NI) **]
Family History:
Notable for alcoholism, hyperlipidemia, thyroid disease, anemia.
Physical Exam:
expired
Pertinent Results:
[**2107-1-24**] 10:30PM GLUCOSE-102 UREA N-59* CREAT-5.2* SODIUM-136
POTASSIUM-5.6* CHLORIDE-99 TOTAL CO2-15* ANION GAP-28*
[**2107-1-24**] 10:30PM CK(CPK)-534*
[**2107-1-24**] 10:30PM CK-MB-10 MB INDX-1.9 cTropnT-0.07*
[**2107-1-24**] 10:30PM ALBUMIN-2.8* CALCIUM-7.7* PHOSPHATE-8.7*
MAGNESIUM-2.5
[**2107-1-24**] 10:30PM WBC-9.3 RBC-4.07* HGB-12.5* HCT-40.0 MCV-98
MCH-30.8 MCHC-31.3 RDW-16.6*
[**2107-1-24**] 10:30PM PLT COUNT-201
[**2107-1-24**] 10:21PM TYPE-ART TEMP-36.4 RATES-/0 TIDAL VOL-100
PEEP-18 PO2-62* PCO2-63* PH-7.00* TOTAL CO2-17* BASE XS--16
INTUBATED-INTUBATED VENT-CONTROLLED
[**2107-1-24**] 10:21PM LACTATE-8.6*
[**2107-1-24**] 08:30PM TYPE-[**Last Name (un) **] TEMP-36.4 RATES-20/ PEEP-18 PO2-83*
PCO2-68* PH-6.99* TOTAL CO2-18* BASE XS--16 INTUBATED-INTUBATED
VENT-CONTROLLED
[**2107-1-24**] 08:30PM LACTATE-7.9*
[**2107-1-24**] 05:48PM TYPE-MIX RATES-24/ TIDAL VOL-450 PEEP-10
O2-100 PO2-95 PCO2-75* PH-6.98* TOTAL CO2-19* BASE XS--16
AADO2-564 REQ O2-90 -ASSIST/CON INTUBATED-INTUBATED
[**2107-1-24**] 05:48PM LACTATE-8.9*
[**2107-1-24**] 05:22PM GLUCOSE-142* UREA N-60* CREAT-5.1*#
SODIUM-137 POTASSIUM-5.2* CHLORIDE-99 TOTAL CO2-18* ANION
GAP-25*
[**2107-1-24**] 05:22PM GLUCOSE-105 UREA N-59* CREAT-5.0*# SODIUM-140
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-20* ANION GAP-23*
[**2107-1-24**] 05:22PM ALBUMIN-2.4* CALCIUM-7.6* PHOSPHATE-8.5*#
MAGNESIUM-1.7
[**2107-1-24**] 05:22PM ALBUMIN-2.2* CALCIUM-6.9* PHOSPHATE-7.5*#
MAGNESIUM-1.6
[**2107-1-24**] 05:22PM WBC-7.5 RBC-4.18*# HGB-13.4*# HCT-41.4
MCV-99* MCH-32.1* MCHC-32.5 RDW-17.2*
[**2107-1-24**] 05:22PM WBC-4.5 RBC-4.24*# HGB-13.3*# HCT-41.5 MCV-98
MCH-31.4 MCHC-32.1 RDW-16.3*
[**2107-1-24**] 05:22PM PLT COUNT-225
[**2107-1-24**] 05:22PM PT-22.3* PTT-51.3* INR(PT)-2.1*
[**2107-1-24**] 05:22PM PLT COUNT-220
[**2107-1-24**] 05:22PM PT-27.7* PTT-150* INR(PT)-2.8*
[**2107-1-24**] 04:32PM VoidSpec-QNS SAMPLE
[**2107-1-24**] 01:56PM TYPE-ART PO2-110* PCO2-74* PH-7.00* TOTAL
CO2-20* BASE XS--14 INTUBATED-INTUBATED
[**2107-1-24**] 01:56PM GLUCOSE-95 LACTATE-9.8* NA+-138 K+-4.1
CL--103
[**2107-1-24**] 01:56PM HGB-10.3* calcHCT-31
[**2107-1-24**] 10:30AM ALT(SGPT)-400* AST(SGOT)-517* CK(CPK)-68 ALK
PHOS-241* TOT BILI-0.7
[**2107-1-24**] 10:30AM cTropnT-0.08*
[**2107-1-24**] 10:30AM ALBUMIN-2.6*
[**2107-1-24**] 10:30AM CALCIUM-6.7* PHOSPHATE-11.4*# MAGNESIUM-2.3
[**2107-1-24**] 10:30AM WBC-6.5 RBC-3.32* HGB-10.3* HCT-33.2*
MCV-100* MCH-31.0 MCHC-31.0 RDW-16.0*
[**2107-1-24**] 10:30AM NEUTS-37* BANDS-36* LYMPHS-19 MONOS-0 EOS-1
BASOS-0 ATYPS-0 METAS-7* MYELOS-0 NUC RBCS-12*
[**2107-1-24**] 10:30AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+
[**2107-1-24**] 10:30AM PT-19.9* PTT-44.4* INR(PT)-1.9*
Brief Hospital Course:
Mr. [**Known lastname **] is a 60 year old man with ESLD/ESRD and [**Hospital **]
transferred to [**Hospital1 18**] from [**Hospital3 **]. As per his wife on
[**Name (NI) 2974**] he got back from HD and says his stomach hurt more than
usual. Saturday he didn't feel like drinking much, although he
had some pedialyte, and his stomach pain continued. He had no
fever, but he broke a sweat on Sunday and felt hot and
nauseated. He vomited a couple of times but there was no report
of blood. He developed SOB, and he tried to use supplemental
oxygen that they had left over from a few years ago, but they
were unable to get the equipment to work so they called an
ambulance and he was brought to the ED at [**Hospital3 **].
.
At [**Hospital3 **] his CXR was found to be clear. There is report
that he had seizure at the OSH but it was not documented
anywhere. His Hct was 33, and he reportedly begain vomiting
coffee ground emesis with a likely aspiration event, so he was
intubated. He reportedly had gross blood rectally as well. NGT
was placed with coffee ground substance. He was hypotensive, so
a R femoral cordis was placed and he was started on dopamine and
transferred to [**Hospital1 18**].
.
In the ED his vitals were 96.1, 89, 107/53 on dopamine. Initial
ABG was 7.02/76/302 and lactate was 13.5. CXR showed likely
aspiration in the lung bases. CT head for report of seizure was
negative for bleed. CT abd showed partial jejunal SBO, no
mesenteric ischemia. Surgery was curbsided in the ED and felt he
was being treated for possible SBO anyway with NGT. He was
broadly covered with Vanc/Levo/Flagyl/Ceftaz/CTX. He was given
Decadron and thiamine as well as IV PPI. He was aggressively
fluid resuscitated with a total of 4L NS and 7L LR. Levophed was
added for a brief time before being discontinued. The hepatology
service was consulted and recommended admission to the MICU for
stabilization before upper endoscopy. He was ordered for 2U PRBC
and sent up on vent settings of AC 100% 370 25 10. His last gas
before being admitted to the MICU was 7.00/74/110 with lactate
of 9.8.
.
In the MICU he continued to be resuscitated with another liter
each of NS and LR. His BP began to drop and phenylephrine,
vasopressin, and norepinehprine were added. 2 Units FFP were
given. A high-flow triple lumen catheter was placed in the left
groin. Upper endoscopy by hepatology showed no evidence of
active bleeding as well as a small duodenal ulcer and a possible
small [**Doctor First Name **]-[**Doctor Last Name **] tear. He remained persistently acidemic,
limited by the air trapping he began to exhibit at higher
respiratory rates. His fluids were switched to 3 amps of bicarb
in 1L D5W, of which he has recieved four so far. Given his
difficulty oxygenating despite being on 100% FiO2 and high PEEP
(up to 20), he was considered for CVVH by renal.
CVVH was started and patient's acidemia continued. Pt was on
max pressors with MAPs persistently in the 30s and 40s. Pt
remained on maximal ventilatory support with sustained pH's at
7.0 and lactates greater than 10. Pt was transcutaneously paced
with intermiitent capture. At 8:30 pm, no spontaneous cardiac
activity was appreciated and there was electrical mechanical
dissociation between capture and pacing. At 11:52, after
discussions with the family, transcutaneous pacing was
discontinued and patient was terminally extubated. Pt's family
consented to autopsy and pathology was notified.
Medications on Admission:
midodrine 5mg tid
aranesp 300mcg/0.6mL synringe SQ qweek
MVI 1 cap qd
omeprazole 40mg qd
liothyronine 25mcg qd
amiodarone 200mg qd
oxycodone 5mg 1-2 tabs q4-6h prn
ferrous sulfate 325mg qd
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
septic shock
GI bleed
ESLD
ESRD
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
|
[
"507.0",
"276.51",
"995.92",
"427.31",
"530.7",
"496",
"532.90",
"585.6",
"572.8",
"571.5",
"244.9",
"070.70",
"572.4",
"276.2",
"785.52",
"038.9",
"537.89",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.93",
"96.71",
"39.95",
"99.04",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9735, 9744
|
6010, 9466
|
290, 297
|
9819, 9829
|
3187, 5987
|
9885, 9896
|
3078, 3144
|
9706, 9712
|
9765, 9798
|
9492, 9683
|
9853, 9862
|
3159, 3168
|
228, 252
|
325, 2414
|
2436, 2756
|
2772, 3062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,516
| 129,381
|
31378
|
Discharge summary
|
report
|
Admission Date: [**2190-4-13**] Discharge Date: [**2190-4-18**]
Date of Birth: [**2122-5-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
Admitted for TIPS
Major Surgical or Invasive Procedure:
TIPS procedure
therapeutic paracentesis
History of Present Illness:
67F with etoh cirrhosis on [**First Name3 (LF) **] list, varices, refractory
ascites, SBP, HTN, hyperlipidemia, presented for an elective
TIPS procedure for ascites. She underwent the procedure this
evening. Unfortunately the procedure was unsuccessful and also
resulted in complications. The liver capsule was perforated and
the gallbladder was perforated as well. Per the IR fellow, the
plan was to treat with Unasyn for 24 hours because of the
gallbladder perforation. Of note, the contents of the
gallbladder were drained during the procedure to prevent
peritoneal irritation. Because of the perforation of the liver
capsule, the plan was to check q 8 hour hct. EBL was 50cc. 3.4 L
of ascites were drained during a paracentesis prior to the
attempted TIPS. The IR resident called to communicate the
results of the procedure and the plan for treatment over the
evening. The PACU nurse notified us because of BP in the 80s
systolic for a brief period, while urine output was 180cc over
the past hour. The BP was 120/60 at the start if the procedure
although lowered to 90s systolic with sedation during the
procedure. A 500cc fluid bolus was administered in the PACU with
BP rise to 90s to 100s systolic.
Past Medical History:
HTN
hyperlipidemia
colonic polyps
back pain
IBS
Diarrhea
Per OMR notes underwent an upper GI endoscopy on [**2189-6-9**]
that demonstrated grade 2 varices in the lower third of the
esophagus without ulceration.
colonoscopy on [**2189-4-9**] for evaluation of diarrhea. She
had erythematous and friable mucosa in the proximal colon and a
few nonbleeding colonic angiodysplastic lesions; otherwise, the
evaluation was normal
She has also had an episode of spontaneous bacterial peritonitis
Social History:
She is a nonsmoker. She has a significant alcohol history,
drinking 3-5 drinks per day. She has been abstinent
since [**2189-1-22**]. She has no history of tattoos, IV drug use,
marijuana, or piercing. She has no history of hepatitis.
Her social history is significant for the fact that she has a
high school education. She is employed as a circuit board
worker. She is married. She has two sons ages 44 and 43 who are
healthy. She has five brothers and five sisters.
Family History:
father who died at age 60 of alcoholic cirrhosis. Her mother is
92 and still alive and well.
Physical Exam:
T 98.3 p 82 bp 96/46 12 100 3L
GEN: sleepy though arousable
HEENT: R IJ venous access cite with bandage c/d/i. perrl, eomi,
MM slighly dry
Chest: CTAB
CV: RRR, no m/r/g
Abd: soft, NT. no capiut medusae, no flank hematoma
EXT: w/d, no edema
Pertinent Results:
[**2190-4-13**] 06:21PM BLOOD Hct-31.1*
[**2190-4-14**] 02:55AM BLOOD WBC-6.0 RBC-3.17*# Hgb-9.3* Hct-27.5*
MCV-87 MCH-29.2 MCHC-33.7 RDW-14.5 Plt Ct-81*
[**2190-4-15**] 06:14AM BLOOD WBC-8.9 RBC-4.09*# Hgb-11.8*# Hct-34.2*
MCV-84 MCH-29.0 MCHC-34.7 RDW-14.2 Plt Ct-77*
[**2190-4-16**] 05:00AM BLOOD WBC-8.4 RBC-4.19* Hgb-12.1 Hct-34.8*
MCV-83 MCH-28.9 MCHC-34.8 RDW-14.4 Plt Ct-88*
[**2190-4-17**] 06:15AM BLOOD WBC-9.7 RBC-4.24 Hgb-12.4 Hct-35.2*
MCV-83 MCH-29.4 MCHC-35.4* RDW-14.8 Plt Ct-102*
[**2190-4-18**] 06:15AM BLOOD WBC-5.4 RBC-3.88* Hgb-11.1* Hct-32.1*
MCV-83 MCH-28.6 MCHC-34.5 RDW-15.2 Plt Ct-87*
[**2190-4-15**] 06:14AM BLOOD PT-18.8* PTT-40.8* INR(PT)-1.7*
[**2190-4-16**] 05:00AM BLOOD PT-16.4* PTT-37.3* INR(PT)-1.5*
[**2190-4-17**] 06:15AM BLOOD PT-16.8* PTT-39.0* INR(PT)-1.5*
[**2190-4-18**] 06:15AM BLOOD PT-16.8* PTT-41.4* INR(PT)-1.5*
[**2190-4-14**] 02:55AM BLOOD Glucose-94 UreaN-21* Creat-1.0 Na-137
K-4.4 Cl-117* HCO3-13* AnGap-11
[**2190-4-14**] 08:59PM BLOOD Glucose-154* UreaN-21* Creat-1.1 Na-135
K-4.0 Cl-112* HCO3-12* AnGap-15
[**2190-4-15**] 06:14AM BLOOD Glucose-92 UreaN-17 Creat-1.1 Na-132*
K-3.6 Cl-112* HCO3-12* AnGap-12
[**2190-4-16**] 05:00AM BLOOD Glucose-119* UreaN-19 Creat-1.2* Na-133
K-3.4 Cl-111* HCO3-12* AnGap-13
[**2190-4-17**] 06:15AM BLOOD Glucose-101 UreaN-19 Creat-1.2* Na-132*
K-3.4 Cl-110* HCO3-11* AnGap-14
[**2190-4-18**] 06:15AM BLOOD Glucose-97 UreaN-20 Creat-1.1 Na-133
K-3.3 Cl-109* HCO3-14* AnGap-13
[**2190-4-16**] 05:00AM BLOOD ALT-280* AST-277* AlkPhos-60 TotBili-3.3*
[**2190-4-17**] 06:15AM BLOOD ALT-225* AST-179* LD(LDH)-328* CK(CPK)-43
AlkPhos-69 TotBili-2.8*
[**2190-4-18**] 06:15AM BLOOD ALT-143* AST-98* AlkPhos-70 TotBili-2.0*
[**2190-4-16**] 05:00AM BLOOD Albumin-2.4* Calcium-8.1* Phos-3.0 Mg-1.9
[**2190-4-17**] 06:15AM BLOOD Albumin-2.5* Mg-1.6
[**2190-4-18**] 06:15AM BLOOD Albumin-2.8* Mg-1.7
.
RADIOLOGY Final Report
-59 DISTINCT PROCEDURAL SERVICE [**2190-4-13**] 8:25 AM
LIVER OR GALLBLADDER US (SINGL; -59 DISTINCT PROCEDURAL SERVIC
Reason: Please assess for focal liver lesions, ascites and
hepatic v
[**Hospital 93**] MEDICAL CONDITION:
67 year old woman with cirrhosis and history of ascites
requiring frequent paracentesis.
REASON FOR THIS EXAMINATION:
Please assess for focal liver lesions, ascites and hepatic
vessel patency.
INDICATION: 67-year-old female with cirrhosis and ascites.
COMPARISON: Abdomen CT, [**2189-10-5**].
FINDINGS: The liver is shrunken and nodular with a coarse
appearance, but no focal masses are identified. There is no
intrahepatic biliary dilatation, however, the common duct
appears slightly ectatic measuring 0.7 cm. No gallstones are
identified. The spleen is mildly enlarged measuring 13.2 cm.
There is a large amount of ascites identified within the
abdomen.
DOPPLER EXAMINATION: Color Doppler and pulsed-wave Doppler
images were obtained. The main portal vein, right portal vein,
and left portal vein are all patent with hepatopetal flow.
Appropriate arterial waveforms are identified in the main
hepatic artery with sharp upstrokes. Appropriate flow is seen in
the IVC, the hepatic veins, and the splenic vein.
IMPRESSION:
1. Shrunken nodular coarse liver with no focal masses.
2. Patent hepatic vasculature with appropriate waveforms.
3. Massive ascites.
4. Mild splenomegaly.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2190-4-13**] 3:16 PM
.
RADIOLOGY Final Report
[**Numeric Identifier 73947**] PARACENTESIS INITAL PROC [**2190-4-13**] 2:20 PM
Reason: Please place TIPS.
[**Hospital 93**] MEDICAL CONDITION:
67 year old woman with cirrhosis and ascites requiring
paracentesis q 4 weeks. Candidate for liver [**Hospital **]
REASON FOR THIS EXAMINATION:
Please place TIPS.
INDICATION: 67-year-old female with cirrhosis and ascites
requiring paracentesis. Candidate for liver [**Hospital **]. Please
place TIPS.
RADIOLOGISTS: The procedure was performed by Drs. [**Last Name (STitle) 7748**] and
[**Name5 (PTitle) 19420**], the attending radiologist, who was present and
supervised throughout the entire procedure.
PROCEDURE AND FINDINGS: After explaining the risks and benefits
of the procedure, a written informed consent was obtained from
the patient. The patient was placed supine on the angiographic
table and the patient's right abdomen was prepped and draped in
standard sterile fashion. Paracentesis was performed under
ultrasound guidance.
Subsequently, the right neck was prepped and draped in standard
sterile fashion. General anesthesia was administered throughout
the entire procedure.
The right internal jugular vein was accessed with a
micropuncture kit system under ultrasonographic guidance. A
0.035 [**Doctor Last Name **] wire was advanced through the micropuncture sheath
into the inferior vena under fluoroscopic guidance. The
micropuncture sheath was exchanged for a 10 French [**First Name8 (NamePattern2) **] [**Last Name (un) 2493**]
tip sheath that was placed with tip in the inferior vena cava.
Access was gained into the right hepatic vein.
The TIPS procedure was unsuccessful because of venous anatomy
and a small liver. Multiple punctures were made, and the liver
capsule was transgressed on two occasions, and gallbladder was
entered and evacuated.
All the catheters and vascular sheath were removed and manual
compression was held for at least 15 minutes until hemostasis
was achieved on the right neck. The patient was transferred to
the PACU in good condition.
COMPLICATIONS: Liver capsule transgression on two occasions;
gallbladder puncture.
IMPRESSION:
1. Unsuccessful TIPS procedure.
2. Paracentesis was performed and 3 liters plus 380 mL of fluid
was removed.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2190-4-16**] 7:21 PM
CHEST (PORTABLE AP)
Reason: assess for intraparenchymal lung disease, R pleural
effusion
[**Hospital 93**] MEDICAL CONDITION:
67 year old woman with liver disease/TIPs, now with tachycardia
with decreased br sounds at R base with fremitus.
REASON FOR THIS EXAMINATION:
assess for intraparenchymal lung disease, R pleural effusion or
other pathology.
Decreased breath sounds right base.
CHEST AP.
Comparison is made with the prior chest x-ray of [**2190-1-22**].
The heart and mediastinum are normal. The lung fields are clear.
Costophrenic angles are sharp. There has been no significant
change since the prior chest x-ray.
There is apparent difference in density between the right and
left lung. This is due to technical reasons only.
IMPRESSION: Chest clear.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10270**]
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Approved: SAT [**2190-4-17**] 12:47 PM
Brief Hospital Course:
# Unsuccessful TIPS: The patient was admitted for a TIPS
procedure but the procedure was unsuccessful and complicated by
liver capsule and gallbladder puncture as documented in the
reports section. The patient had transient hypotension after
the procedure and was monitored in the ICU. In addition she was
given antibiotic prophylaxis. Upon discharge her vital signs
and hematocrit were stable. She will return for repeat TIPS in
the near future, after extensive discussion of the pros and
cons.
# Cirrhosis: The patient was continued on her ciprofloxacin for
SBP prophylaxis. Her nadolol and diuretics were held during her
hypotensive period but restarted on discharge.
Medications on Admission:
furosemide 40 mg p.o. daily
Propranolol 20 mg p.o. [**Hospital1 **]
multivitamin one p.o. daily
Protonix 40 mg p.o. daily
Aldactone 100 mg p.o. [**Hospital1 **]
ciprofloxacin 250 mg daily
Magnesium oxide 400 mg PO TID
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Brinzolamide 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic QAM
(once a day (in the morning)).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Propranolol 20 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
cirrhosis
TIPS procedure with gallbladder and liver perforation
hypertension
Discharge Condition:
hemodynamically stable
Discharge Instructions:
You were admitted to the hospital for a TIPS procedure.
Complications of the procedure resulted in damage to your
gallbladder and your liver, which required close monitoring and
blood transfusions both on the floor and in the intesive care
unit.
Please continue to take your medications as prescribed. Follow
up with your physicians as listed below. If you develop fever,
confusion, or any other concerning symptom please contact a
physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at [**Telephone/Fax (1) 2422**] to arrange for an
appointment prior to your TIPS procedure, envisaged in about 2
weeks from now. You will be contact[**Name (NI) **] regarding the date and
time of your TIPS procedure.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] [**Name11 (NameIs) **] SOCIAL WORK Date/Time:[**2190-5-19**]
10:00
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2190-5-19**] 11:00
Completed by:[**2190-4-25**]
|
[
"401.9",
"564.1",
"458.29",
"E870.0",
"789.59",
"998.2",
"276.2",
"571.2",
"V49.83",
"456.21",
"272.0",
"572.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
11614, 11620
|
9889, 10569
|
333, 375
|
11741, 11766
|
2998, 5095
|
12289, 12876
|
2628, 2722
|
10839, 11591
|
8934, 9048
|
11641, 11720
|
10596, 10816
|
11790, 12266
|
2737, 2979
|
276, 295
|
9077, 9866
|
403, 1611
|
1633, 2124
|
2140, 2612
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,082
| 114,194
|
39582
|
Discharge summary
|
report
|
Admission Date: [**2180-9-14**] Discharge Date: [**2180-9-26**]
Date of Birth: [**2107-5-25**] Sex: F
Service: NEUROSURGERY
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Cerebellar Hemorrhage
Major Surgical or Invasive Procedure:
EVD Placement
History of Present Illness:
Patient is a 73 yo female with a PMH of peripheral vascular
disease, s/p thrombolytics and angioplasty for ischemia of left
foot, hypothyroidism and hypercholesterolemia, who presented
with acute onset vertigo, nausea, vomiting, and lethargy.
[**Name (NI) **] sister relates the story stating that the patient was
in a normal state of health this morning when was sitting in a
chair by the window and developed acute nausea,vomiting,
incontinence of stool and diarrhea. She felt weak and
lightheaded and her sister called an ambulance. At the OSH
ED,she was noted to be slightly hypothermic with a temperature
of 93.9 (rectal) F. A bear hugger was applied and sepsis work-up
started. Head CT revealed posterior fossa hemorrhage involving
the right cerebellar hemisphere with intraventricular extension
and filling of the fourth ventricle and filling of the third.
Patient is on plavix and was transfussed platelets in the ED.
Past Medical History:
- Peripheral vascular disease, recent stent to left leg, anatomy
- Hypothyroidism, on Levothyroxine.
- Hypercholesterolemia, not being treated.
- H/o Bell's Palsy.
- H/o cellulitis.
Social History:
Patient lives at home, without services. Speaks English. Smokes
one pack per day. No alcohol. No illicits.
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM:
Gen: intubated.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: arrousable to pain
Cranial Nerves:
eyes fixed to R, pupils reactive to light BL, + gag and
corneals,
Motor: Normal bulk. Tone increased in legs and arms, neck.
Reflexes: Reflexes were symmetric bilaterally. Toes upgoing
bilaterally.
UPon discharge:
Alert and Orieted, Motor exam full.
Pertinent Results:
ADMISSION LABS:
[**2180-9-14**] 03:30PM WBC-4.0 RBC-4.12* HGB-11.2* HCT-33.8* MCV-82
MCH-27.1 MCHC-33.0 RDW-14.6
[**2180-9-14**] 03:30PM PT-12.5 PTT-24.5 INR(PT)-1.1
[**2180-9-14**] 03:35PM GLUCOSE-103 LACTATE-2.0 NA+-141 K+-4.3
CL--104 TCO2-26
DISCHARGE LABS:
IMAGING:
CT Head [**9-14**]:
IMPRESSION:
1. Left cerebellar hemisphere hemorrhage extending into the
fourth, third and bilateral lateral ventricles with minimally
increased blood in the posterior [**Doctor Last Name 534**] of the left ventricle
compared to CT scan obtained earlier today.
2. New focus of subarachnoid hemorrhage in the right parietal
region.
3. Unchanged tonsillar herniation. No evidence of uncal or
subfalcine
herniation.
4. Mildly dilated temporal horns is concerning for impending
hydrocephalus. Dr. [**Last Name (STitle) 49784**] was notified of updated findings at
5:25 p.m. on [**2180-9-14**]
CT Head [**9-14**]:
IMPRESSION:
1. Status post ventriculostomy catheter from a right frontal
approach with
decompression of the lateral ventricles.
2. Relatively unchanged appearance and left cerebellar
intraparenchymal
hemorrhage and intraventricular hemorrhage of the third, fourth,
and occipital horns of the lateral ventricles.
3. Density along the sulcus in the right parietal region may
represent a
component of subarachnoid hemorrhage, although it is not changed
significantly over the prior couple of studies
CT Head [**9-16**]
IMPRESSION:
1. Similar size and configuration of the left cerebellar
hemispheric
hemorrhage with surrounding edema.
2. Similar amount of blood extending into and expanding the
fourth ventricle.
3. Decrease in the amount and density of the blood in the third
ventricle.
4. Unchanged intraventricular hemorrhage and small right
parietal
subarachnoid hemorrhage.
5. The size and configuration of the ventricles is similar to
the most recent prior study.
CT head [**2180-9-18**]
IMPRESSION:
1. Since prior examination, mild increase in size of the lateral
ventricles
and third ventricle, for which close interval followup is
recommended.
2. Interval improvement of hemorrhage within the third
ventricle.
3. Stable areas of intraventricular hemorrhage, subarachnoid
hemorrhage, and left cerebellar intraparenchymal hemorrhage.
CT [**2180-9-23**]:
Status post removal of right EVD. Small amount of
pneumocephalus. Stable left cerebellar hemorrhage. No evidence
of new
hemorrhage. Evaluate for underlying cause of the hemorrhage as
clinically
indicated.
Brief Hospital Course:
The patient was admitted to the NSurg service in the ICU for Q 1
hour neuro checks. An emergent EVD was placed for relief in
increased ICP, and the level was kept at 10mm above the tragus.
Her Blood pressure was kept less than 160. Her plaxix was
discontinued. She was able to be extubated HD#2, she was
following commands and moving all 4 extremities.ICP remained in
normal range. She had trial of EVD clamping on HD#4 but after a
few hours her exam declined even though ICP remained in normal
range and EVD was opened. Clamping trial occured again and was
successful with stable CT and the EVD was removed HD#8.Her exam
was much brighter, her N/V stopped and she passed speech and
swallow evaluation. She developed atrial flutter which was
treated successfully but then returned. Cardiology was consulted
to assist, she has been on Amiodarone IV and transitioned to PO
with resolution of flutter she is to continue a month course of
treatment. Her thyroid function tests were found to be abnormal
with a TSH of 26, T4 4.3, T3 of 32, endocrine recommended
resuming her Levothyroxine at 100mcg daily.
On [**9-26**] family precieved her mental status to be worse in the
afternoon so a head CT was repeated that was unchanged from
previous studies without any acute changes.
She is at the time of discharge alert and oriented with a full
motor exam.
Medications on Admission:
Levothyroxine, Plavix,Simvastatin
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 weeks.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain/fever.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
6. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation q4hprn () as needed for wheezing/ sob.
7. Diltiazem HCl 30 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. HydrALAzine 10 mg IV Q6H:PRN SBP > 140
9. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
cerebellar hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair
?????? 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.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 3 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2180-9-26**]
|
[
"427.32",
"507.0",
"427.31",
"518.81",
"263.9",
"305.1",
"272.0",
"431",
"V49.72",
"244.9",
"348.4",
"443.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"02.43",
"96.6",
"96.05",
"02.39"
] |
icd9pcs
|
[
[
[]
]
] |
6920, 6963
|
4612, 5967
|
297, 312
|
7029, 7029
|
2109, 2109
|
8300, 8562
|
1617, 1635
|
6052, 6897
|
6984, 7008
|
5993, 6029
|
7180, 8277
|
2379, 4589
|
1666, 1786
|
236, 259
|
2053, 2090
|
340, 1269
|
1836, 2037
|
2126, 2362
|
7044, 7156
|
1291, 1476
|
1492, 1601
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,690
| 158,749
|
6977
|
Discharge summary
|
report
|
Admission Date: [**2117-2-5**] Discharge Date: [**2117-2-23**]
Date of Birth: [**2074-1-15**] Sex: M
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: A 43-year-old man, with a
significant past medical history for IV drug use, who has had
fever and shortness of breath for 1-2 weeks. He received a
course of Zithromax at an outside hospital for presumed
pneumonia with no relief. Chest x-ray done by primary care
showed with ?evidence of emboli. CT of the chest with
evidence of bilateral pulmonary lesions. Admitted to outside
hospital and noted to have a diastolic murmur. An echo at
that time revealed 4+ aortic insufficiency with a 2 cm
vegetation on his tricuspid valve, and a 1 cm vegetation on
the aortic valve. Systolic PA pressure was 70 mmHg. He was
transferred to [**Hospital Ward Name 26168**] [**First Name (Titles) **] [**Last Name (Titles) **] for further
evaluation and treatment.
PAST MEDICAL HISTORY:
1. Degenerative joint disease.
2. Hypercholesterolemia.
3. IV drug use.
MEDS AT HOME: Methadone 37 mg q am.
MEDS ON TRANSFER:
1. Vancomycin 1 gm IV bid.
2. Gentamicin 100 mg IV x 1 dose.
3. Methadone 37 mg qd.
4. Tylenol 1 gm po q 6 h prn.
SOCIAL HISTORY: IV drug use, heroin. The patient reports
his last use was up to 2 years ago. Family unaware of his
history of abuse. He was started on methadone in [**2115-2-22**].
Positive ETOH--6 beers per day. Positive tobacco--25 pack
years. He is currently married and lives at home with his
wife.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAM AT ADMISSION: Temperature 99.6, heart rate
90-100, blood pressure 112/60, respiratory rate 24, O2 sat
95% on room air.
GENERAL: The patient is diaphoretic and tachypneic.
HEENT: Anicteric. No conjunctival petechiae. Pupils are
equally round and reactive to light.
NECK: No JVD with 3+ carotid pulses.
CARDIOVASCULAR: Tachycardic with a diastolic murmur.
LUNGS: Diminished breath sounds at the bases bilaterally.
Coarse rhonchi throughout.
ABDOMEN: Rigid but nontender. Liver 4 cm below the costal
margin.
EXTREMITIES: Positive [**Last Name (un) 1003**] lesions. No ulcer or splinter
hemorrhages.
NEUROLOGIC: Alert and oriented x 3, but somewhat confused
and unable to fully answer all questions.
HOSPITAL COURSE: The patient was admitted to the medical
service. The cardiology service and infectious disease
services were consulted upon admission. The patient
underwent a full medical work-up, including a CT of his
chest, his head, and his abdomen. Additionally, the patient
was seen by the cardiology service, the infectious disease
service, the ophthalmology service, and the dental service,
as well as cardiac surgery, and the orthopedic service for an
effusion of the knee. His blood cultures showed Staph
aureus, and his antibiotics were adjusted accordingly.
On the [**2-8**], the patient underwent cardiac
catheterization, as recommended by CT surgery, to evaluate
any coronary disease. Please see cath report for full
details. In summary, the cath showed that he had minimal
plaquing and mild luminal irregularities with no
flow-limiting stenoses. The patient also had a
transesophageal echocardiogram which showed a tricuspid valve
vegetation of 2.3 x 1 cm attached to the septal leaflet, at
least mild TR, and aortic valve vegetation 1.4 x 0.4 cm, with
severe AR, and a question of flail segment with no abscesses.
No vegetations on the mitral valve and multiple jets of
mitral regurgitation. No pulmonic valve vegetations, and
normal LV. CT of his head at that time showed multiple
embolic brain infarcts, and the neurology service was also
consulted at that time.
The patient was accepted for aortic valve replacement, and on
[**2-9**], he was brought to the operating room where he
underwent an aortic valve replacement. Please see the OR
report for full details. In summary, the patient had an
aortic valve replacement with a #23 CE pericardial valve, and
resection of the tricuspid valve vegetation. His bypass time
was 118 minutes with a crossclamp time of 80 minutes. He
tolerated the operation well and was transferred from the
operating room to the Cardiothoracic Intensive Care Unit. At
the time of transfer, the patient's mean arterial pressure
was 70 with a CVP of 11. He was in a sinus rhythm at 95
beats per minute. He had Levophed at 0.13 mcg/kg/min, and
propofol at 10 mcg/kg/min. The patient did well in the
immediate postoperative period. His anesthesia was reversed.
He was weaned from the ventilator and successfully extubated.
On postoperative day #1, he remained hemodynamically stable
with Nitroglycerin infusion to control his blood pressure.
He was continued on his antibiotic courses which, at that
time, included clindamycin, gentamicin, oxacillin and
vancomycin. During the course of postoperative day #1, the
patient was begun on diuretics, as well as beta blockers, and
his chest tubes were discontinued. The patient remained
hemodynamically stable, and on postoperative day #2, he was
weaned from his IV Nitroglycerin and begun on Norvasc for
blood pressure control. Additionally, the patient had a PICC
line placed, and was seen by the orthopedic team for
evaluation of his left knee effusion that had grown Staph
aureus from an aspiration done earlier prior to his surgery.
The knee was again aspirated and sent for Gram stain and
culture.
On postoperative day #3, the patient remained hemodynamically
stable. He was begun on ACE inhibitors and transferred to
the floor for continuing postoperative care and cardiac
rehabilitation. Throughout this period, the patient
continued to be followed by the infectious disease service.
On postoperative day #4, the patient remained stable. His
temporary pacing wires were removed, and he was scheduled for
a left knee arthroscopy by the Orthopedic Department. On day
#5, the patient underwent an arthroscopy and a washout. He
continued to progress from inactivity and a cardiac surgery
standpoint. However, he did continue to have low-grade
fevers with a mildly elevated white blood cell count
throughout this period. Over the next week, the patient's
white blood cell count continued to normalize. He continued
to have low-grade fevers which were felt to be a result of
splenic, pulmonary and cerebral infarcts. He continued on
his clindamycin and oxacillin as recommended by the ID team.
His activity level was increased with the assistance of the
nursing staff and the physical therapy staff. He had a
repeat head CT which showed no change from his previous head
CT.
On postoperative day #12, it was decided that the following
day the patient would be stable and ready for discharge to
home. On postoperative day #13, arrangements were made for
the patient to be followed for outpatient services to
maintain antibiotic course throughout [**3-24**], and on
postoperative day #14, the patient was discharged to home.
DISCHARGE PHYSICAL EXAM - VITAL SIGNS: Temperature 99.8,
heart rate 79, sinus rhythm, blood pressure 118/69,
respiratory rate 18, O2 sat 99% on room air, weight
preoperatively 152 pounds and at discharge 142 pounds.
NEUROLOGICAL: Alert and oriented x 3. Moves all
extremities. Follows commands. Motor strength 5/5
bilaterally. Sensation intact.
RESPIRATORY: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm, S1, S2. Sternum stable.
Incision with Steri-Strips, opened to air, clean and dry.
ABDOMEN: Soft, nontender, nondistended with active bowel
sounds.
EXTREMITIES: Warm and well-perfused with no edema.
LAB DATA: White count 7.2, hematocrit 24.2, platelets 528,
sodium 135, potassium 4.3, chloride 101, CO2 28, BUN 17,
creatinine 1.2, glucose 92, PT 13.9, PTT 27.5, INR 1.3.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg qd.
2. Colace 100 mg [**Hospital1 **].
3. Oxacillin 2 gm q 4 h through [**3-24**].
4. Clindamycin 150 mg q 6 h until dental issues resolved.
5. Metoprolol 25 mg q 12 h.
6. Percocet 5/325, 1-2 tabs q 4-6 h prn pain.
7. Methadone 37 mg qd.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement with a #23
[**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve and status post
tricuspid valve vegetation resection.
2. Hypercholesterolemia.
3. Degenerative joint disease.
4. Status post arthroscopy of the knee.
CONDITION AT DISCHARGE: Good.
FOLLOW-UP: He is to be discharged home with VNA and [**Hospital 5065**]
Healthcare Services. He is to have follow-up in the [**Hospital 409**]
Clinic in 2 weeks, follow-up in the [**Hospital **] Clinic on [**3-23**]
with Dr. [**Last Name (STitle) 26169**], and follow-up with Dr. [**Last Name (STitle) 70**] in 6
weeks. He is also to have follow-up with his primary care
provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5361**], in 3 weeks. Additionally, the patient
can have follow-up with the [**Hospital 8183**] Clinic as needed.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2117-2-23**] 09:30
T: [**2117-2-23**] 10:18
JOB#: [**Job Number 26170**]
|
[
"428.0",
"711.06",
"272.0",
"444.89",
"038.11",
"041.11",
"431",
"421.0",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"81.91",
"37.22",
"35.21",
"88.72",
"80.46",
"38.93",
"88.56",
"35.14"
] |
icd9pcs
|
[
[
[]
]
] |
1522, 2264
|
8024, 8304
|
7746, 8003
|
2282, 7723
|
8319, 9169
|
175, 929
|
951, 1062
|
1212, 1505
|
1080, 1195
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,059
| 198,999
|
12129
|
Discharge summary
|
report
|
Admission Date: [**2108-3-23**] Discharge Date: [**2108-4-7**]
Service: Cardiothoracic
CHIEF COMPLAINT: Transfer from an outside hospital for
workup and treatment of endocarditis.
HISTORY OF PRESENT ILLNESS: An 87 year old man with a
history of cardiomyopathy and hypertension along with sick
sinus syndrome status post pacemaker placement who was
transferred from [**Hospital6 38016**] for management
of questionable endocarditis. The patient presented to the
[**Hospital 28159**] Hospital on [**3-21**] with complaints of 1?????? weeks
of persistent intermittent fevers, arthralgias, chills,
anorexia, nausea, vomiting and diarrhea. The patient was
admitted to the hospital where blood culture two out of two
came back with Methicillin-susceptible Staphylococcus aureus
as did a urine culture. The patient subsequently had a
culture on [**3-22**] which at the time of admission was growing
gram positive cocci in clusters consistent with
Staphylococcus. The patient was initially treated with
Vancomycin but was switched to Oxacillin once the
sensitivities were returned. He had a transesophageal
echocardiogram which revealed tricuspid vegetation and was
diagnosed with endocarditis and transferred for further
management.
PAST MEDICAL HISTORY: 1. Cardiomyopathy; 2. Sick sinus
syndrome, status post permanent pacer; 3. Hypertension; 4.
Diverticulosis; 5. Benign prostatic hypertrophy status post
transurethral resection of prostate; 6. Mild peripheral
neuropathy; 7. Status post appendectomy; 8. Small abdominal
aortic aneurysm; 9. Anxiety disorder.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: On transfer from [**Hospital 28159**] Hospital
1. Amiodarone 200 mg q.d.
2. Flonase
3. Prevacid 30 mg q.d.
4. Multivitamin
5. Oxacillin 2 gm intravenously q. 6 hours
6. Tylenol 650 q. 4 hours prn
7. Phenergan
8. Ativan
9. Proscar 5 mg q.d.
10. Prozac 20 mg q.d.
SOCIAL HISTORY: He lives with his wife in [**Name (NI) 38017**]
[**State 350**]. Son is an Infectious Disease specialist.
remote tobacco use and rare alcohol use.
PHYSICAL EXAMINATION: Physical examination at the time of
admission revealed vital signs with heartrate of 76, blood
pressure 110/60, respiratory rate 24, and oxygen saturations
95% on 2 liters. Temperature was 101.3. General, alert, ill
appearing gentleman. Head, eyes, ears, nose and throat,
pupils were equally round and reactive to light. Extraocular
motions intact. Mucous membranes were dry. Oropharynx
benign. Neck is supple with no lymphadenopathy.
Jugulovenous pressure is at 7 cm. Cardiovascular: Regular
rate and rhythm, II/VI systolic ejection murmur at the right
sternal border with radiation to the neck. Respiratory is
clear to auscultation bilaterally. Abdomen is soft,
nontender, nondistended with positive bowel sounds.
Extremities warm, no cyanosis, clubbing or edema. Small
petechiae, left third digit and left great toe.
Neurological, alert and oriented times three. Cranial nerves
2 through 12 grossly intact, nonfocal examination.
LABORATORY DATA: Laboratory data at the time of admission
revealed white count 15.8, hematocrit 36.8, platelets 31,000.
INR 1.2, PTT 36.7. Sodium 140, potassium 4.1, chloride 108,
carbon dioxide 22, BUN 43, creatinine 1.0, glucose 81. Blood
from outside hospital on [**3-21**], 2 of 2 bottles of
Methicillin-susceptible Staphylococcus aureus, on [**3-22**], 2
of 2 bottles with gram positive cocci in clusters resembling
Staphylococcus as a preliminary report, [**3-23**], 4 of 4
bottles pending, urine from [**3-21**], Methicillin-susceptible
Staphylococcus aureus.
HOSPITAL COURSE: Following admission the patient was seen by
Infectious Disease as well as Electrophysiology. Repeat
transesophageal echocardiogram was done which showed a 5.5 cm
mass on the pacer wire, likely not suitable for a
transcutaneous extraction following identification of this
mass Cardiothoracic Surgery was consulted and the patient was
evaluated for open removal of his permanent pacing wires. He
was accepted by Cardiothoracic Surgery and on [**3-28**], he
was brought to the Operating Room at which time he underwent
pacer wire extraction via sternotomy. Please see the
operation report for full details. The patient tolerated the
surgery well and was transferred from the Operating Room to
the Cardiothoracic Intensive Care Unit. He did well in the
immediate postoperative period. His anesthesia was reversed.
He was weaned from the ventilator and successfully extubated.
He remained in the Cardiothoracic Intensive Care Unit
throughout postoperative day #1 as he required Neosynephrine
infusion to maintain an adequate blood pressure. Throughout
postoperative day #1 and in the morning of postoperative day
#2 the patient was weaned from his Neosynephrine infusion and
on the morning of postoperative day #2 he was transferred
from the Cardiothoracic Intensive Care Unit to Far 6 for
continuing postoperative care and cardiac rehabilitation. On
postoperative day #3 the patient was noted to have a period
of confusion and incoherent speech, however, his neurological
examination was nonfocal in nature. Given the nature of the
patient's recently cardiac surgery as well as his vegetation
that was on his pacing wires the patient was brought for a
head computerized axial tomography scan to rule out an
embolic event. The computerized axial tomography scan was
negative and the confusion was felt to be related to hospital
psychosis versus infection. On chest x-ray the patient had a
right upper lobe infiltrate and therefore his intravenous
antibiotic coverage was expanded to include not only
Oxacillin but also Ceftazidime and Flagyl. On postoperative
day #4 the patient's neurological status was noted to be
improved, however, at that time a new truncal rash was noted.
The rash was felt to be a result of his intravenous
antibiotic. Because the patient had Oxacillin sensitive
Staphylococcus infection his Oxacillin was continued and his
Ceftazidime and Flagyl were discontinued. The patient's rash
continued to be a problem extending not only to his trunk but
also to his upper extremities. Dermatology was consulted and
they agreed that it was most likely a drug rash due to the
Oxacillin and therefore his Oxacillin was changed to
Vancomycin. For the next several days the patient continued
to show slow progress and he remained afebrile and
hemodynamically stable and remained on his intravenous
Vancomycin and on postoperative day #8 a PICC line was placed
for longterm intravenous antibiotic use. On postoperative
day #9 it was felt that the patient was stable and ready for
transfer to rehabilitation for continuing postoperative care
and rehabilitation. At that time he was screened by several
rehabilitation centers. It was expected that he will be
ready and accepted for discharge within the next several
days. At this time the patient's condition is stable. His
physical examination as of this time is vital signs with
temperature 98, heartrate 74 sinus rhythm, blood pressure
107/60, respiratory rate 18, and oxygen saturations 90%, on
40% shuttle. Weight preoperatively is 82.3 kg. At discharge
is 79.9 kg.
Laboratory data revealed white count 14.7, hematocrit 25.8,
platelets 222, PT 13.3, PTT 34.1, INR 1.2. Sodium 135,
potassium 4.6, chloride 104, carbon dioxide 24, BUN 24,
creatinine 1.5, glucose 136.
Physical examination is alert and oriented times three.
Moves all extremities, follows all commands. He can be
confused at times but easily reoriented. Respiratory, coarse
rhonchi throughout. Breathsounds diminished bilaterally at
the bases, left greater than right. Strong productive cough.
Cardiovascular, regular rate and rhythm, S1 and S2. Sternum
is stable. Incision with steri-strips, open to air, clean
and dry. Abdomen is soft, nontender, nondistended with
normoactive bowel sounds. Extremities are warm and well
perfused with 1 to 2+ pedal edema. He has a generalized rash
to the trunk, arms and legs that is resolving.
DISCHARGE DIAGNOSIS:
1. Status post pacemaker lead extraction
2. Cardiomyopathy
3. Sick sinus syndrome
4. Hypertension
5. Diverticulosis
6. Benign prostatic hypertrophy status post transurethral
resection of prostate
7. Abdominal aortic aneurysm
8. Status post appendectomy
9. Mild peripheral neuropathy
10. The patient has an allergy to Oxacillin.
DISCHARGE MEDICATIONS:
1. Colace 100 mg b.i.d.
2. Amiodarone 200 mg q.d.
3. Heparin 5000 units subcutaneously b.i.d.
4. Protonix 40 mg q.d.
5. Enteric coated Aspirin 325 q.d.
6. Proscar 5 mg q.d.
7. Lasix 20 mg q.d.
8. Potassium chloride 20 mEq q.d.
9. Vancomycin 1 gm q. 24 hours to be continued through [**4-25**]. Vancomycin levels need to be checked on [**4-8**],
following pre and post levels on [**2117-4-8**]. Motrin 600 mg q. 6 hours prn
12. Tylenol 650 mg q. 4 hours prn
13. Percocet 5/325 one to two tablets q. 4 hours prn
FOLLOW UP: The patient is to return to [**Hospital6 649**] for a chest computerized axial tomography scan
in two weeks. He is to have follow up with the Infectious
Disease Clinic to be arranged following his chest
computerized axial tomography scan. He is to have follow up
with electrophysiology, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in six weeks and
follow up with Cardiothoracic Surgery, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**]
also in six weeks, the patient's expected date of transfer to
rehabilitation is [**2108-4-8**].
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2108-4-6**] 16:40
T: [**2108-4-6**] 19:47
JOB#: [**Job Number 38018**]
|
[
"038.11",
"427.31",
"V09.0",
"745.5",
"996.61",
"482.41",
"425.4",
"997.1",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"35.14",
"38.93",
"42.23",
"39.61",
"37.77",
"37.33"
] |
icd9pcs
|
[
[
[]
]
] |
8416, 8936
|
8055, 8393
|
3647, 8034
|
8948, 9817
|
2112, 3629
|
117, 194
|
223, 1247
|
1270, 1923
|
1940, 2089
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,516
| 180,793
|
46555
|
Discharge summary
|
report
|
Admission Date: [**2144-7-22**] Discharge Date: [**2144-7-26**]
Date of Birth: [**2073-6-17**] Sex: F
Service: VASCULAR SURGERY
HISTORY OF THE PRESENT ILLNESS: The patient is a 71-year-old
female with a history of peripheral vascular disease and
COPD, who the day prior to admission had gone for an
angiography at the [**Hospital **] Hospital. Postprocedure, she had
felt lightheaded and dizzy and was kept overnight and
discharged on the morning of admission. She was sent home
after a workup which included a CT which was done to rule out
a hematoma which was reportedly negative. When she arrived
home, she continued to complain of lightheadedness, left
groin pain, and once these symptoms failed to resolve, the
family felt that it was necessary to have her brought here
for evaluation.
She was brought to the Emergency Room and upon entering the
triage area, she promptly had a hypotensive episode where the
systolic blood pressure went down to the 50s. She was
immediately brought to the Resuscitation Bay and was
resuscitated aggressively. Her blood pressure was recovered.
She never lost a pulse or rhythm during this time. An
emergent CT was done and demonstrated a large anterior wall
hematoma. She was then evaluated by the Vascular Surgery
Service and admitted.
PAST MEDICAL HISTORY:
1. COPD.
2. Peripheral vascular disease.
3. DVT.
ADMISSION MEDICATIONS:
1. Vioxx.
2. Aspirin.
3. Albuterol.
4. Atrovent.
5. Prilosec.
6. Pletal which is being held.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient denied any ETOH use. She does
have a history of tobacco use, two packs per day for 50
years.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.1, heart rate 93, blood pressure 130/74, respirations 20,
98% on 2 liters nasal cannula. General: She was awake and
alert. She was tachycardiac but a regular rhythm. Chest:
Clear. Abdomen: Soft, tender along the left flank and
anterior abdominal wall. The left groin had a hematoma but
was nonpulsatile and she had distal Doppler signals of both
lower extremities.
LABORATORY/RADIOLOGIC DATA: Her hematocrit on initial
admission was 27.8. BUN and creatinine 14 and 0.8. INR was
1.0.
EKG on admission included sinus tachycardia with no evidence
of ischemia.
CT of the abdomen revealed enlarged left pelvic hematoma
extending from the right posterior rectus sheath up to the
left parapsoas region.
HOSPITAL COURSE: The patient was transfused with 4 units of
packed red blood cells and 4 units of FFP. She was
transferred to the Surgical Intensive Care Unit with large
bore central access and serial hematocrits. She remained
hemodynamically stable after her initial hypotensive episode.
She demonstrated no end-organ injury with maintaining good
respiratory status, renal status, and liver functions. She
never developed any coagulopathy.
On hospital day number two, the patient was moved to the
Vascular Intensive Care Unit and remained in stable
condition. Her hematocrit remained stable at 34. She
received no other blood products.
On hospital day number three, her diet was advanced which she
tolerated. She was allowed to get out of bed and ambulate
without difficulty. The hematoma had decreased in size
considerably and was much softer. She is currently stable
for discharge with follow-up with Dr. [**Last Name (STitle) **].
DISCHARGE DIAGNOSIS:
1. Hypovolemic shock.
2. Anterior abdominal wall hematoma, status post
angiography.
3. Hypertension.
4. Chronic obstructive pulmonary disease.
5. Peripheral vascular disease.
DISCHARGE MEDICATIONS:
1. Vioxx.
2. Aspirin.
3. Albuterol.
4. Atrovent.
5. Prilosec.
6. Pletal which is being held.
7. Percocet 5/325 one to two p.o. q. four hours p.r.n.
8. Colace 100 mg p.o. b.i.d.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) **] in
one to two weeks, will call for an appointment. This is
mainly to just evaluate her hematoma and also discuss the
findings of her lower extremity angiogram, and possible
surgical intervention.
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2144-7-26**] 01:14
T: [**2144-7-26**] 13:25
JOB#: [**Job Number 98854**]
|
[
"443.9",
"401.9",
"998.0",
"496",
"998.12"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3627, 4084
|
3423, 3604
|
2473, 3402
|
1403, 1557
|
1717, 2455
|
1327, 1380
|
1574, 1702
|
4109, 4401
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,609
| 199,675
|
19276
|
Discharge summary
|
report
|
Admission Date: [**2109-10-4**] Discharge Date: [**2109-10-12**]
Date of Birth: [**2047-11-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
Diarrhea and dehydration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 yo female with metastatic colon cancer (to liver), currently
treated with Irinotecan, 5FU, Leukovorin, Avastin and Decadron
presents with profuse watery diarrhea since [**2109-9-28**]. Patient
started first cycle of chemotherapy on [**9-19**], at which time she
received 10mg decadron, irinotecan, 5FU, leukovorin and avastin.
She tolerated this well except for fairly severe hyperglycemia
(to 400),which required one visit to the EW but no hospital
admission. She then had the 2nd half of the first cycle of
chemotherapy on [**9-26**], which included 5mg decadron, 5FU,
irinotecan and leucovorin. She then began having watery diarrhea
on [**9-28**]. She was advised to start taking Ciprofloxacin by her
oncologist on [**9-30**]. She had a temp to 100.6 at home and had
dry heaves, otherwise no other constitutional sx. On [**10-3**], pt
was too weak to get up, brought to EW at [**Hospital 8125**] Hospital for
evaluation. There, bp was 83/47 on arrival, down to 62/28 after
1L NS, remained 70s-80s/30s-40s after 2nd liter IVF. Received 2g
ceftazidime and 500mg flagyl. Labs notable for Na 129, K 5.1,
bicarb 14, creat 1.5 (baseline 0.8). Blood cx sent. Pt
transferred to [**Hospital1 18**] [**Hospital Unit Name 153**] due to severe hypotension. In the [**Hospital Unit Name 153**]
she continued to be hypotensive with SBP's of 90's and given 2L
NS in 4 bnoluses with mild improvement and antihypertensives
were held. Since she was neutropenic with ANC of 450 with no
obvious source of infection she was started on broad antibiotic
coverage of ceftazidime, flagyl and gentamycin. She remained
afebrile, SBP improved to 90's to 120's overnight, and
creatinine continued to trend down. Infectious workup including
blood Cx, Urine Cx, chest Xray, O and P as well as stool
cultures were sent, and all of which are negative thus far. Pt
has continued to put out 2.5L/d diarrhea despite symptomatic
treatment with octreotide and loperamide.
Past Medical History:
1.Metastatic colon cancer, dx [**2-7**], s/p LAR [**2-7**] and
rt.ureterolyisis and now enrolled in chemo protocol. Followed by
Dr. [**First Name (STitle) **]. First cycle of chemo was [**9-19**] and [**9-26**]. Next cycle
in 2 weeks.
2. HTN
3. DM2
4. s/p vitrectomy R eye [**7-10**]
5. CHF TTE in [**1-9**] symmetric LVH with mildly depressed systolic
function [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], moderate AS with valve area 1.0 and
gradient of 45 lateral wall hypokinesis w/EF 50%
6. Caesarian section
Social History:
1. Divorced and lives with her daughter, currently on diability
but able to get around her house with a cane, no tobacco or EtOH
use. 2 very supportive daughters.
Family History:
1. Son passed away 9y ago from HCC at age 27. Father died of
unknown type of cancer. Maternal grandmother with CVA in 70's
and grandfather had CVA in his 80's. No other FH of DM, CVA,
sudden cardiac death, HTN or CA.
Physical Exam:
Physical Exam:I=2250 IV and 900 PO Out= 2.5L stool, 700 urine
VS: temp 97.8 HR 83 bp 106/37 RR 15 98%[**Female First Name (un) **]
Gen: very pleasant elderly female, looks older than stated age.
pale. looks very tired but is awake, alert and lucid.
HEENT: PERRL. pale conjunctiva. o/p with MMM, no elevated JVP
Neck: supple, no JVD, no LAD, bilat carotid bruit
Lungs: CTA bilat
CV: rrr nl s1s2 3/6 SEM at LUSB w/rad to carotids, no pistol
shot pulses
Abdomen: obese, soft, nt/nd, nabs
Ext: slightly cool feet, 1+ DP pulses bilat, trace ankle edema.
Skin: slightly cool, dry, no rash noted
Neuro: awake, alert, lucid, excellent historian.
Pertinent Results:
[**2109-10-4**] 11:38PM GLUCOSE-235* UREA N-39* CREAT-1.4* SODIUM-133
POTASSIUM-5.6* CHLORIDE-106 TOTAL CO2-15* ANION GAP-18
[**2109-10-4**] 11:38PM ALT(SGPT)-31 AST(SGOT)-23 LD(LDH)-219 ALK
PHOS-246* AMYLASE-39 TOT BILI-0.5
[**2109-10-4**] 11:38PM ALBUMIN-2.5* CALCIUM-7.5* PHOSPHATE-3.7
MAGNESIUM-1.6
[**2109-10-4**] 11:38PM GRAN CT-450*
[**2109-10-7**] 06:40AM BLOOD Gran Ct-1290*
[**2109-10-5**] 04:50AM BLOOD ALT-29 AST-23 LD(LDH)-217 AlkPhos-224*
Amylase-25 TotBili-0.4
[**2109-10-9**] 06:50AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.4
[**2109-10-5**] 01:05PM BLOOD Cortsol-59.4*
[**2109-10-5**] 12:05PM BLOOD Cortsol-46.1*
Brief Hospital Course:
Diarrhea-Volume of diarrhea decreased throughout the
hospitalization, but continued to have a very watery
consistency. Recent history of daughters with diarrhea was
concerning for infectious etiology, although lack of abdominal
cramping make toxin producing secretory diarrhea unlikely. She
remained afebrile with no elveated WBC now off antibiotics for 4
days. Cdiff, stool culture and O and P continued to be negative
althogh fecal leukocytes were present. Most likely cause was
thought to be recent chemotherapy regimen of decadron,
irinotecan, 5FU, leukovorin and avastin with most offensive
[**Doctor Last Name 360**] in causing diarrhea being irinotecan and leukovorin. We
continued to treat diarrhea with octreotide, loperamide,
kaolin/pectin and cholestyramine along with modified [**Last Name (un) **] diet.
On th day of discharge she had only 1bm in the last 24 hours,
and was able to use the bed pan.
Hypotension-Vigorous response of SBP to fluid resuscitation
never requiring pressors made hypovolemia most likely cause in
combination with her AS. Lactate never measured but clinically
she has never presented as being septic with fever. We held on
her outpatient antihypertensive medications and added back only
atenolol on [**10-10**]. Pt was orthostatic with PT on [**10-10**], but this
resolved with IV hydration with 1L NaBicarb and SBP remained
>103.
ARF-Due to prerenal state with loss of intravascular volume
through diarrhea now back to baseline. Low GFR during
hypovolemic state also may have caused hyperkalemia. Creatinine
continued to improve with IV hydration and improved PO intake.
DM-Pt initially taken off her outpatient glyburide due to poor
PO intake while in ICU. Glyburide added bakc on [**10-10**] since she
was taking PO well and BS remained in th low 200's although they
continued to remain poorly controlled on her outpatient dose of
5mg qd.
Metastatic colon CA-Held off on irinotecan, 5FU, leukovorin and
avastin due to diarrhea and informed pt that longterm
chemotherapy plan would be discussed once her diarrhea resolved
and she was discharged home.
Depression-Stable on her outpatient Celexa 20mg qd.
FEN-Previous electroylte abnornalities were all consistent with
diarrhea and hypovolemia including hypovolemic hyponatremia and
loss of bicarb in diarrhea. Hypercalcemia was due to continue
Lasix use in prerenal state.
Px-She was placed on SC heparin, pneumoboots, and PPI continued
while she was in hospital but discontinued on discharge.
Code-Full
Medications on Admission:
1. Amlodipine 10mg daily
2. Atenolol 25mg daily
3. Celexa 20mg daily
4. Fe sulfate 325mg tid
5. Glipizide 5mg daily, increased to 10mg daily after [**9-19**] when
became hyperglycemic s/p decadron
6. Lasix 40mg daily
7. Lisinopril 20mg daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for back pain.
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Loperamide HCl 2 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day) as needed for diarrhea.
Disp:*80 Capsule(s)* Refills:*0*
5. Kaolin-Pectin 5.85-130 g-mg/30 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day).
Disp:*1800 ML(s)* Refills:*2*
6. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
Disp:*1 tube* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Diarrhea and dehydration
Discharge Condition:
Hemodynamically stable but diarrhea continued
Discharge Instructions:
If you experience increasing diarrhea, fever, chills, nausea,
vomiting, inability to eat or keep up with fluid loss in
diarrhea by drinking, you should call Dr. [**First Name (STitle) **] but if he is
not available you should go back to the emergency room. You
should also continue taking the loperamide and kaopectate when
you leave the hospital but only use it if diarrhea comes back.
You were also started on the antibiotic Levofloxacin for a
urinary tract infection which you should take for the next four
days as prescribed.
Followup Instructions:
Provider: [**Name11 (NameIs) 5558**],[**Name12 (NameIs) 5557**] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 4054**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2109-10-18**] 10:00
Provider: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2109-10-18**] 10:00
|
[
"424.1",
"458.9",
"276.5",
"401.9",
"197.7",
"E933.1",
"276.7",
"584.9",
"288.0",
"276.1",
"428.0",
"153.2",
"787.91",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8170, 8176
|
4626, 7131
|
342, 348
|
8245, 8292
|
3972, 4603
|
8870, 9274
|
3077, 3297
|
7424, 8147
|
8197, 8224
|
7157, 7401
|
8316, 8847
|
3326, 3953
|
278, 304
|
376, 2323
|
2345, 2879
|
2895, 3061
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,096
| 119,559
|
34667
|
Discharge summary
|
report
|
Admission Date: [**2161-8-27**] Discharge Date: [**2161-9-1**]
Date of Birth: [**2080-5-3**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides)
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal pain, s/p [**Doctor First Name **]
Major Surgical or Invasive Procedure:
[**Doctor First Name **]
History of Present Illness:
This is an 81 year-old female with a history of CAD s/p MI with
stent placement 1 year ago, HTN, hypothyroidism, who presented
to an OSH with abdominal pain radiating to the back. CT scan
there showed multiple stones in a dilated CBD and gall bladder
with evidence of both intra and extrahepatic dilitation. She was
found to have elevated liver enzymes and was transferred to
[**Hospital1 18**] for further management.
.
Here, here labs were notable for a leukocytosis to 23, markedly
elevated liver and pancreatic enzymes, but she remained
hemodynamically stable and was afebrile. She was taken to [**Hospital1 **],
who placed a stent in her CBD and extracted multiple stones, the
largest of which was 1.4mm. She was given levo and flagyl.
.
She is transferred to the [**Hospital Unit Name 153**] post [**Hospital Unit Name **] before transfer back to
the floor in the care of general surgery for monitoring. She is
currently afebrile, BP 130/58, HR 90 satting 98% on 2L by nc.
Past Medical History:
HTN
CAD s/p MI in [**2160**] s/p stent placement on plavix
Hypothyroidism
Hyperlipidemia
GERD
Social History:
no alcohol, tobacco, illicits. Lives with longtime family
friend, husband recently passed away.
Family History:
history of MI in father in his 40's.
Physical Exam:
Vitals: T: 98.6 BP: 139/46 HR: 82 RR: 16 O2Sat: 96%2L
GEN: no acute distress
HEENT: EOMI, PERRL, sclerae slightly icteric, no epistaxis or
rhinorrhea, MM dry, OP Clear
NECK: JVP at 5cmH20, carotid pulses brisk, no bruits, no
cervical lymphadenopathy, trachea midline
COR: RRR, soft II/VI SM at LUSB non radiating, normal S1 S2,
radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mildly distended, +BS, no HSM, no masses. Mild
tenderness to deep palpation in RUQ, with no rebound or
guarding.
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Plantar reflex
downgoing.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
.
At Discharge:
Vitals:T-97.9, HR-140 bursts of AFIB, decreased to 69-70 sinus,
BP-140/59, RR-22, RA-98%
GEN: NAD, A/Ox3
CV:RRR, tachycardic w/ bursts of AFIB, no m/r/g
RESP: LCTAB
ABD: +BS, soft, NT/ND, RUQ decreased TTP
EXTREM: no c/c/e
Pertinent Results:
[**2161-8-27**] 11:35AM BLOOD ALT-199* AST-266* LD(LDH)-304*
AlkPhos-650* Amylase-2596* TotBili-2.5* DirBili-2.2* IndBili-0.3
[**2161-8-28**] 04:11AM BLOOD ALT-175* AST-181* LD(LDH)-189
AlkPhos-545* Amylase-895* TotBili-3.3*
[**2161-8-27**] 11:35AM BLOOD WBC-23.1* RBC-3.90* Hgb-11.8* Hct-35.8*
MCV-92 MCH-30.3 MCHC-33.1 RDW-13.3 Plt Ct-389
[**2161-8-28**] 04:11AM BLOOD WBC-18.4* RBC-3.47* Hgb-10.3* Hct-31.2*
MCV-90 MCH-29.8 MCHC-33.1 RDW-13.2 Plt Ct-324
[**2161-8-29**] 06:20AM BLOOD WBC-16.4* RBC-3.36* Hgb-10.2* Hct-30.6*
MCV-91 MCH-30.3 MCHC-33.3 RDW-13.3 Plt Ct-299
[**2161-8-30**] 06:15AM BLOOD WBC-13.8* RBC-3.43* Hgb-10.3* Hct-30.8*
MCV-90 MCH-30.2 MCHC-33.6 RDW-13.3 Plt Ct-319
[**2161-8-31**] 06:55AM BLOOD Glucose-104 UreaN-26* Creat-1.1 Na-142
K-3.6 Cl-108 HCO3-24 AnGap-14
[**2161-8-30**] 06:15AM BLOOD ALT-69* AST-30 AlkPhos-400* Amylase-102*
TotBili-0.8
[**2161-8-31**] 06:55AM BLOOD Amylase-97
.
Abdomen CT on [**2161-8-27**]:
IMPRESSION:
1. Cholelithiasis.
2. Intra- and extra-hepatic ductal dilation. By report, there is
choledocholithiasis on an outside study, however, that CT is not
available for comparison at this time. Consider MRCP if further
imaging is required.
Ductal dilatation in this pattern highly suggests
choledocholithiasis and
that diagnosis is not excluded even in lgiht of the US exam
results.
3. Abnormal morphology of the lower pole of the left kidney
without focal masslesion. This is not well visualized on this
study. Correlation with the outside CT is recommended, or if
this study is not available, then cross- sectional imaging (CT
or MRI) on a non-urgent basis is recommended.
.
[**Year (4 digits) **] [**8-27**]
Impression: Bulging of the major papilla.
Multiple etones at the CBD.
A sphincterotomy could not be performed as patient was on
Plavix.
A biliary stent was placed.
(stent placement)
Brief Hospital Course:
[**8-27**] MICU Course: Patient was admitted for monitoring after
[**Month/Day (4) **] for gallstone pancreatitis. She was taken to [**Month/Day (4) **], who
placed a stent in her CBD and extracted multiple stones, the
largest of which was 1.4mm. No sphinceterotomy was performed due
to home medications of ASA and plavix. Her blood pressure
remained stable and her amylase and lipase dramatically improved
and her liver enzymes also trended down after the procedure.
She had improvement in her leukocytosis. She was started on
empiric levofloxacin and metronidazole post-procedure. Due to
continued stability, she was transferred to general surgery
service for further monitoring. Amlodipine, hydrochlorothiazide
and lisinopril were held initially, with plan to restart before
discharge. Aspirin and clopidogrel were also held for recent
procedure, with plan to restart these also prior to discharge,
given history of coronary artery stent.
.
[**8-28**]: Patient transferred to the surgical floor. Pt advanced to
clear liquids. PT went into afib. Lopressor 5mg x 3 and one
dose of diltiazem was given with conversion to NSR. PT
asymtomatic. Cardiac enzymes negative x 2.
[**8-29**]: Pt advanced to regular diet. Afib for 30 minutes Lopressor
5mg x 3, spontaneous conversion.
[**8-30**]: Patient on regular diet. PT consulted. In the P.M. pt
again went into afib rate to the 140s. Lopressor 5mg x 3 and a
total of 20 mg of Diltiazem was administered without conversion
but with satisfactory rate control to the 80s -90s. At midnight
patient spontaneously converted to NSR.
[**8-31**]: Pt again went into afib rate 90-110s. 5 mg lopressor given
for rate control. Pt's cardiologist and pcp [**Name (NI) 79508**] no known
history of afib. Pt placed on all verified home cardiac
medications except ASA and plavix. PT also changed to PO
antibiotics. Tolerating & diet well medications well. Discussed
surgical options for gallbladder removal with Dr. [**Last Name (STitle) 5182**].
Agreed to have removal of gallbladder arranged at local
hospital. Patient will follow-up with PCP for referral.
[**9-1**]: Patient had another burst of AFIB overnight to 150's,
managed with 5mg IV Lopressor. COnverted to normal sinus. Blood
pressures stable. Lisinopril and Norvasc doses increased to home
doses confirmed per Cardiologist. Patient has a follow-up
appointment with Cardiologist Thursday [**2161-9-3**] for further
management of new onset Atrial Fibrillation. Visiting Nurse
services have been arranged for Blood pressure and heart rate
assessment tomorrow. S
.
Patient was advised to resume Aspirin 81mg daily, and HOLD
Plavix in setting of future gallbladder removal. If Plavix must
be resumed, this information must be relayed to the General
Surgeon to prevent post-operative bleeding complications. Both
the patient, and Cardiology office were informed.
Medications on Admission:
hctz
toprol XL 25mg
aspirin 81
synthroid 88mcg
plavix
crestor
lisinopril 40mg
norvasc
nexxium
Discharge Medications:
1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days: Take with food. Disp:*30 Tablet(s)*
Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days: Take with food. Disp:*9 Tablet(s)*
Refills:*0*
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed. Disp:*qs * Refills:*0*
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: HOLD
for Gallbladder SURGERY.
1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days: Take with food.
Disp:*30 Tablet(s)* Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days: Take with food.
Disp:*9 Tablet(s)* Refills:*0*
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*qs * Refills:*0*
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: HOLD
for Gallbladder SURGERY.
1. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 9 days: Take with food.
Disp:*30 Tablet(s)* Refills:*0*
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days: Take with food.
Disp:*9 Tablet(s)* Refills:*0*
10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*qs * Refills:*0*
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
12. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day: HOLD
for Gallbladder SURGERY.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary:HTN
Gallstone pancreatitis
Paroxysmal Atrial Fibrillation
.
Secondary:
HTN, CAD s/p MI, stent placement [**2160**], hypothyroidism, s/p
appendectomy
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain
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.
* 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.
* 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.
.
Atrial Fibrillation:
-You have been newly diagnosed with an atrial fibrillation which
is an increased heart rate.
-Please follow-up with your Cardiologist on Thursday for further
management of this new diagnosis.
-Please continue with your Aspirin. HOLD the Plavix due to your
upcoming removal of your gallbladder.
Followup Instructions:
1. Please follow-up with your Cardiologist, Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] on
Thursday [**2161-9-3**] at 9am for further evaluation of your new
diagnosis of Atrial Fibrillation.
2. Please follow-up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 31010**] within 1
week to arrange for removal of your gallbladder at your local
hospital.
.
Previous Appointments:
1. Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2161-10-1**] 10:00
2. Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2161-10-1**] 10:00
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2161-9-1**]
|
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25,557
| 182,371
|
29701
|
Discharge summary
|
report
|
Admission Date: [**2128-5-20**] Discharge Date: [**2128-5-22**]
Date of Birth: [**2052-2-13**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Shellfish / Iodine
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 76 yo woman with history of CAD s/p CABG in
[**2124**] (SVG->LAD, SVG->OM1 occluded since [**2125**], SVG->RCA) and
critical aortic stenosis (valve area 0.68cm2 and gradient of 25
by cath [**12-7**]) s/p aortic valvuloplasty in [**3-6**] who is
transferred from OSH after an episode of chest pain. Of note, pt
is has an appointment to discuss possible percutaneous AVR at
[**Hospital1 112**] next Tuesday.
.
Pt was grocery shopping today when she developed SOB and nausea.
When she came home to lie down, she developed a dull chest
pressure. No diaphoresis, no back, jaw or arm pain, no
dizziness. Her husband called an ambulance; en route she
recieved 325 aspirin po and 1 NTG SL. On arrival to OSH, she was
reportedly feeling better and her sx had resolved after
receiving dose of nitro. BP was reported as 80/61 initially. Of
note, her BP was L 124/90 and R 227/104 at one pt. On D/C from
OSH, BP was 124/62, pulse 82 presumably in the left arm. EKG
showed no changes and first set of CE was negative at OSH.
Pt has had similar episodes of chest pressure in the past,
usually precipitated by exertion though sometimes at rest, and
almost always followed by palpitations. Her last similar episode
was a few weeks ago and resolved with rest. She says that the
valvuloplasty in [**Month (only) 547**] did not improve her symptoms much. She
has DOE and decreased ET to 30 ft. She has had increasing
trouble going up the stairs at home for the past month, and
feels general fatigue. She reports sometimes having SOB at
night, but no increased pillow number. No leg swelling. She has
no recent illnesses except for should bursitis two weeks ago for
which she is taking prednisone at home.
On arrival, pt feels that most of her sx have resolved. She does
not have chest pain or SOB. She feels fatigued.
On review of systems, she denies any prior history of stroke,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for chest pain, dyspnea on
exertion, paroxysmal nocturnal dyspnea, no orthopnea, no ankle
edema, palpitations, no syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
[**2125-1-3**] Cardiac Catheterization performed for symptoms of
unstable angina
[**2125-1-4**] PTCA to mid LAD
[**2125-1-11**] Coronary Artery Bypass Graft x 3 (Saphenous vein graft
-> Left anterior descending, Saphenous vein graft -> Obtuse
marginal, saphenous vein graft-> right coronary artery). A LIMA
was not used due to retrograde L vertebral flow and concern of
future left subclavian artery steal.
[**12-7**] Cardiac cath with severe 3VD: LAD w/ 100% proximal
occlusion. Cx patent up to a tortuous OMB branch. RCA with prox
TO. SVG to the OM TO proximally. SVG to RCA was patent. RCA w/
70-80% stenosis in the origin of the R-PDA. SVG to LAD patent
with the LAD having diffuse moderate plaquing throughout the
supplied vessel that was <40% stenosis.
[**3-6**] Aortic valvuloplasty; [**Location (un) 109**] went from 0.6 to 1 cm2
.
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Autoimmune Hepatitis with cirrhosis (Child's Class A)
Anemia
Aortic stenosis
TIA [**6-/2125**] (significant R sided ICA stenosis)
Peripheral Vascular Disease
Seizure in [**5-5**] (oral numbness, followed by R hand/R leg
numbness and weakness. has been on Keppra, but was
self-discontinued by patient due to symptoms of depression).
Carotid artery disease
L sided subclavian steal
h/o SVT in [**12/2125**]
s/p appendectomy
Social History:
Retired, married lives with husband and 2 adult children. Used
to work at [**Company 2892**] as a tlephone operator for 20 years. She denies
tobacco, illicit drug, or ETOH use.
Family History:
5 brothers and sisters who are currently in their 60s all with
CAD. Many of them have required CABG.
Physical Exam:
Gen: pt lying in bed in NAD
HEENT: PERLA
CV: S1/S2, 3/6 systolic ejection murmur at sternal border
radiating to axilla; bounding R carotid pulse; no JVD
BP in R arm: 240/120, BP in L arm 128/84
Chest: clear to auscultation bilaterally, no wheezes/rales
Abd: soft, obese, NT/ND
Ext: no edema, DP pulses 2+ bilaterally, radial pulses 2+
bilaterally, PT pulses 2+ bilaterally
Neuro: AOx3, no gross motor deficits, no gross sensory deficits
Pertinent Results:
[**2128-5-20**] 10:21PM CK-MB-2 cTropnT-<0.01
[**2128-5-21**] 05:20AM BLOOD CK-MB-2 cTropnT-<0.01
.
.
EKG: at OSH [**2128-5-20**] 13:14p- NSR rate 96. LAD. RBBB. LVH with
repole abnormalities showing ST depressions in I, II, V2-V6. STE
in AVR. TWI in AVL, V1-3. Unchanged from prior.
.
.
ECHO [**2128-5-21**]: Left Ventricle - Ejection Fraction: 70%. Aortic
Valve - Peak Gradient: *56 mm Hg. Aortic Valve - Valve Area:
*0.8 cm2. The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Mild to moderate ([**11-29**]+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**11-29**]+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. IMPRESSION: Calcific aortic valve disease
with severe stenosis and mild to moderate regurgitation. Mild
symmetric left ventricular hypertrophy with normal global and
regional biventricular systolic function. Compared with the
prior study (images reviewed) of [**2128-2-26**], aortic transvalvular
gradients are slightly higher. The other comparable findings are
stable. Prior study was a focused post-valvuloplasty
examination.
.
.
CARDIAC CATHETERIZATION [**2127-12-4**]:
1. Selective coronary angiography in this right dominant system
demonstrated three vessel disease. The LMCA had no
angigoraphically
apparent disease but was viewed via a non selective injection.
The LAD had a 100% proximal occlusion. The Cx was noted to be
patent up to a tortuous OMB branch. The RCA had a proximal total
occlusion.
2. Arterial conduit angiography revealed the SVG to the OM to
have a
total occlusion in the proximal section of the vessel. The SVG
to the RCA was patent, and the RCA contained a 70-80% stenosis
in the origin of the R-PDA. The SVG to the LAD was patent with
the LAD having diffuse moderate plaquing throughout the supplied
vessel that was <40% stenosis.
3. Limited resting hemodynamics revealed elevated right and left
sided filling pressures. The RVEDP was 17 mmHg and the LVEDP was
30 mmHg. The pulmonary pressures were moderately to severely
elevated with a PASP of 60 mmHg. There was severe systemic
arterial hypertension with a central pressure of 297/113 mmHg.
The cardiac index was decreased at 2.4 L/min/m2. The SVR was
notably increased at 3467 dynes-sec/cm5 and the PVR was also
increased at 246 dynes-sec/cm5. Pullback of the catheter from
the LV to the aorta revealed a transaortic gradient of 26 mmHg
with a calculated aortic valve area of 0.68 cm2.
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Severe aortic stenosis.
3. Moderate diastolic ventricular dysfunction.
4. Moderate primary pulmonary hypertension.
5. Severe systemic arterial systolic and diastolic hypertension.
.
.
CARDIAC CATH [**2128-2-26**]:
1. Resting hemodynamics revealed severe aortic stenosis with a
calculated valve area of 0.68mm2. There were elevated left sided
filling pressures with a mean PCWP of 16mmHg, and LVEDP of
23mmHg. There was severe systemic hypertension with a BP of
205/64 and a mean of 116mmHg.
2. Following aortic balloon valvuloplasty, the calculated valve
area
improved to 0.96mm2 with a PCWP of 16mmHg.
3. Supravalvular aortography demonstrated 1+ aortic
regurgitation.
4. Abdominal aortography demonstrated vessel diameter > 6mm from
the
aorta to the femoral arteries.
5. Successful aortic balloon valvuloplasty using an 18mm x 6cm
Tyshak II balloon.
.
FINAL DIAGNOSIS:
1. Severe aortic stenosis.
2. Elevated left sided filling pressures.
3. Severe system arterial hypertension.
4. Successful aortic balloon valvuloplasty.
Brief Hospital Course:
76 yo woman with history of CAD s/p CABG in [**2124**] (SVG->LAD,
SVG->OM1 occluded since [**2125**], SVG->RCA) and severe aortic
stensosis s/p valvuloplasty ([**2128-2-26**]) with post-procedure aortic
valve area of 1cm2, who presents from outside hospital with
hypertensive urgency after an episode of chest pain. Likely [**12-30**]
undertreatment of HTN at home and worsening aortic stenosis.
.
# Chest pain - Likely due to HTN urgency; also consideried
worsening AS. ACS ruled out. No further episodes of CP. No SOB
during hospitalization. Because of her left subclavian stenosis,
used right arm to optain BP measurments. The goal was to get her
pressures into the 150s systolic. After initially getting 10mg
labetolol IV x 1, she was treated with valsartan 80mg daily and
carvedilol 6.25mg [**Hospital1 **] which brought pressure into the 140s-160s
SBP. Valsartan was increased to 160mg daily before d/c.
.
# Aortic stenosis - s/p valvuloplasty in [**3-6**] where valve area
opened from 0.68 to 1cm2. Echo during this admission showed a
valve area of 0.8-1cm2. She did not have CP during this hospital
stay, but the team planned to hold nitro in the event of
symptoms given her severe AS. She has an appointment to be
evaluated at [**Hospital1 112**] Tuesday [**2128-5-25**] to be evaluated for potential
percutaneous valve replacement.
.
# CAD -s/p CABG in [**2124**] (SVG->LAD, SVG->OM1 occluded since [**2125**],
SVG->RCA); has severe coronary artery disease and widespread
peripheral vascular disease. ASA 81mg daily and pravastatin 20mg
daily were continued during the admission. Home meds were held
initially, but valsartan and cavedilol were started on day 1 of
admission.
.
# HTN- [**Month (only) 116**] have poorly controlled HTN at home. She does not take
home BP readings, and says that when she goes to doctors'
appointments, it varies which arm her pressure is taken on. it
is possible that outpatient providers have titrated her meds
based on left-sided pressures. A number of BP meds that she was
discharged on in [**Month (only) 547**] have subsequently been d/c'd. See above
under "chest pain" for the course of treating her HTN on this
admission.
.
# Hyperlipidemia - pravastatin 20mg daily was continued during
admission.
.
# Anxiety- The patient was previously [**Doctor First Name **] Ativan PRN at home.
She was not experiencing anxiety during hospitalization, so no
BZDs given.
.
# Seizures- Seizure history not clearly documented. Pt says she
had EEG in past that was negative, but she was started on Keppra
by output neurologist. Keppra 500mg [**Hospital1 **] was continued during
admission.
.
CODE: FULL CODE as per [**Doctor First Name 41215**] (health care proxy)
.
DISPO: home
Medications on Admission:
HOME MEDICATIONS
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Diovan- 80mg daily
5. Amoxicillin prior to dental work
Of note, on last discharge in [**3-6**] pt was prescribed the
following, though does not currently take at home:
1. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Triamterene-Hydrochlorothiazid 37.5-25 mg Tablet Sig: One (1)
Tablet PO once a day.
4. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for Anxiety.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Partners [**Name (NI) **] care of [**Hospital1 **]
Discharge Diagnosis:
aortic stenosis
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**].
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up
more than 3 lbs.
Please take your medicines as prescribed and keep your follow up
appointments. You were admitted to the hospital for high blood
pressure and this will help keep your blood pressure at a good
level.
Your valsartan dose was increased to 160 mg daily. You have
been given a new prescription for this.
We also started a new medication for your heart and blood
pressure. This is called carvedilol and it was started at 6.25
mg each day. You have also been given a prescription for this.
Followup Instructions:
Please followup with your cardiologist after discharge. Please
keep your appoitnment at [**Hospital6 1708**] on Tuesday
[**5-25**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
|
[
"345.90",
"401.0",
"272.4",
"424.1",
"414.00",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12942, 13023
|
8918, 11630
|
313, 320
|
13096, 13096
|
4908, 7807
|
13922, 14186
|
4326, 4428
|
12418, 12919
|
13044, 13075
|
11656, 12395
|
8740, 8895
|
13247, 13899
|
4443, 4889
|
2806, 3647
|
263, 275
|
348, 2693
|
13111, 13223
|
3678, 4115
|
2715, 2786
|
4131, 4310
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,040
| 159,038
|
35105
|
Discharge summary
|
report
|
Admission Date: [**2109-9-11**] Discharge Date: [**2109-9-17**]
Date of Birth: [**2088-12-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
21M involved in high speed MVC vs tree on [**9-11**].
Major Surgical or Invasive Procedure:
C4,5,6 Posterior instrumented fusion, laminectomy.
Repair of severe scalp laceration
History of Present Illness:
Patient is a 20M who presented to [**Hospital1 18**] ER after being involved
in high speed MVC involving a tree.
Past Medical History:
None
Social History:
Non-contributory
Family History:
non-Contributory
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: 98.4 BP:200palp HR:78 RR: 20 O2Sats: 95% RA
Gen: Anxious, with obvious & large actively bleeding scalp
laceration. AOx3, combatitive at times.
HEENT: normocephalic, traumatic with scalp laceration as above.
Pupils: PERRL EOMs;intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, anxious.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R symmetric, seemingly full strentgh throughout upper and
lower extremities, though giving out to pain.
L
Sensation: Intact to light touch
Propioception intact
On Discharge:
AOx3, full strength throughout upper extremities(somewhat
limited to pain), full strength in the lower extremities.
Incisons are clean, dry intact without drainage
Pertinent Results:
Labs On Admission:
[**2109-9-11**] 05:45PM BLOOD WBC-11.9* RBC-5.22 Hgb-13.8* Hct-42.2
MCV-81* MCH-26.4* MCHC-32.6 RDW-12.6 Plt Ct-314
[**2109-9-11**] 05:45PM BLOOD PT-13.0 PTT-26.6 INR(PT)-1.1
[**2109-9-11**] 09:24PM BLOOD Glucose-150* UreaN-15 Creat-0.9 Na-135
K-4.4 Cl-107 HCO3-22 AnGap-10
[**2109-9-11**] 09:24PM BLOOD Calcium-7.6* Phos-3.7 Mg-1.4*
[**2109-9-11**] 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2109-9-11**] 05:46PM BLOOD Glucose-115* Na-146 K-3.6 Cl-99*
calHCO3-26
Labs On Discharge:
[**2109-9-16**] 06:30AM BLOOD WBC-12.7* RBC-2.77* Hgb-7.7* Hct-23.4*
MCV-84 MCH-27.6 MCHC-32.8 RDW-13.2 Plt Ct-412#
[**2109-9-16**] 06:30AM BLOOD Glucose-112* UreaN-7 Creat-0.9 Na-133
K-3.6 Cl-95* HCO3-30 AnGap-12
[**2109-9-16**] 06:30AM BLOOD Calcium-8.1* Phos-3.5 Mg-1.9
[**2109-9-12**] 03:16PM BLOOD Glucose-110* Lactate-1.2 Na-134* K-4.4
Cl-105
[**2109-9-12**] 03:16PM BLOOD Hgb-9.7* calcHCT-29 O2 Sat-98 COHgb-1
MetHgb-0
Radiological Studies:
Head CT [**9-11**]:
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Large left subgaleal hematoma with laceration and no evidence
of fracture.
C-Spine CT [**9-11**]:
IMPRESSION:
1. Anterolisthesis (5-mm) of C5 on C6, with right locked and
left perched
facet. Associated fractures at C5 and C6 right transverse
process with
involvement of the transverse foramen. CTA is recommended to
evaluate for
vertebral artery injury given the fractures of the transverse
foramen.
CT Chest/Abdomen/Pelvic [**9-11**]:
IMPRESSIONS:
No evidence for acute intrathoracic or intra-abdominal injury.
CTA of Neck [**9-11**]:
IMPRESSION:
1. Mild narrowing of the proximal right vertebral artery from C4
through C6, in the region of the right transverse foramen
fractures. This may be due to edema or spasm from nearby
hematoma. There is no definite intraluminal flap to suggest
dissection and no definite evidence of intramural hematoma on
the subsequent MRI. Allowing for vertebral artery dissection,
MRI with fat- saturation could be obtained for further
evaluation.
2. Redemonstration of traumatic injury at the C5-C6 level with
anterolisthesis of C5 on C6, a right C5 locked facet, and C5 and
C6 right
transverse process fractures as well as a fracture through the
left C5
pedicle.
MRI C-Spine [**9-12**]:
IMPRESSION:
1. C5-C6 anterolisthesis with slight narrowing of the spinal
canal. No other cervical spinal malalignment.
2. Edema in the interspinous ligaments from C4 through C7
suggestive of
ligamentous injury.
3. No evidence for abnormal signal within the spinal cord. No
evidence for
intradural abnormality.
4. Fractures characterized on recent CT scan are not visualized
on this
study.
Head CT [**9-14**]:
IMPRESSION: No acute intracranial process, with decrease in size
of left
large subgaleal hematoma.
Chest X-Ray [**9-14**]:
IMPRESSION: Frontal and lateral view shows moderate-to-severe
enlargement of the cardiac silhouette shown on CTA on [**9-11**] to reflect cardiomegaly and not pericardial effusion. Lungs
are clear. There is no pleural effusion or good evidence for
central adenopathy.
Cardiac Echocardiogram [**9-16**]:
Interpretation pending:
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.3 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *5.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.5 cm
Left Ventricle - Fractional Shortening: 0.31 >= 0.29
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.4 m/sec
Mitral Valve - E/A ratio: 1.75
Mitral Valve - E Wave deceleration time: 175 ms 140-250 ms
Brief Hospital Course:
Patient was admitted to [**Hospital1 18**] on [**9-11**] after being involvedin
high speed MVC versus a tree. Upon arrival to [**Hospital1 18**], patient
was taken urgent to the operating room for repair of an
extremely substantial scalp laceration, and intubation. Imaging
performed in the emergency department identified injuries to his
cervical spine requiring surgical fixation. This was performed
on [**9-12**] without incident. Post-operatively, there were JP drains
in both the galeal wound as well as cervical wound. Both drains
were removed on POD#2. On [**9-14**], patient began to spike
temperatures to 102 degrees, blood cultures, urinalysis, and
chest x-rays were performed. Chest x-ray was read as negative
for infection, however a large cardiac silouhette was
identified. This was thought to be due to malrotation,however a
Surface echo was recommended, and performed to further rule this
out. He subsequently has also had unremarkable urinalysis, and
stable elevated WBC. Temperatures have continued to spike
despite any clear source for infection. Wounds have been clean,
dry, and intact. His temperature elevations are thereby thought
to be due to chronic atelactasis from poor compliance with
incentive spirometry usage. He was then discharged on [**9-17**] in
the setting of a normal temperature(99.5), with instructions to
survey his incision daily as well as taking his temperature
twice daily. He was also given instructions to continue to use
his incentive spirometry. Follow up plans for scalp laceration
repair, discussed in patient discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed.
Disp:*60 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. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
Disp:*70 Tablet(s)* Refills:*0*
7. Wound Care
Apply bacitracin daily to your scalp wound, using care not to
apply within your hair line. Make sure wound is cleaned daily.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
C5-6 fracture s/p MVC
Discharge Condition:
Neurologically intact.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? Wear your cervical collar as instructed.
?????? You may shower briefly without the collar; unless you have
been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
?????? Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
*Please be sure to use your incentive spirometer 10 times per
hour. This is EXTREMELY important.
*Please take your temperature twice daily, if it is elevalted
for two [**Location (un) 1131**] in a row; please call our office.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine.
?????? Any weakness, numbness, tingling in your extremities.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage or foul odor.
?????? Fever greater than or equal to 102?????? F.
?????? Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Care Directions for Scalp laceration & Repair
1. Wash your hair at some point this week (use care to not wet
your neck incision).
2. Apply bacitracin daily to the visible suture line of your
scalp laceration(do not apply within the hair)
Followup Instructions:
Follow Up Instructions/Appointments
For Neck Surgery:
??????Please return to the office in 10 days for removal of your
staples, and a wound check.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 14074**] to be seen in 4 weeks.
??????You will need a CT-scan prior to your appointment.
For Scalp Laceration:
1. Call to arrange a follow up appointment for this friday for
suture removal at the plastic surgery clinic. Their phone
number is: ([**Telephone/Fax (1) 7138**].
Completed by:[**2109-9-17**]
|
[
"900.89",
"518.0",
"873.0",
"401.9",
"998.2",
"E823.0",
"429.3",
"805.06",
"805.05"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.03",
"81.62",
"86.59",
"96.71",
"03.53",
"96.04",
"39.31",
"03.59"
] |
icd9pcs
|
[
[
[]
]
] |
7947, 7966
|
5562, 7134
|
373, 460
|
8032, 8057
|
1606, 1611
|
10157, 10716
|
680, 698
|
7189, 7924
|
7987, 8011
|
7160, 7166
|
8081, 10134
|
743, 1038
|
1421, 1587
|
280, 335
|
2151, 5539
|
488, 602
|
1625, 2132
|
1053, 1407
|
624, 630
|
646, 664
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,949
| 130,852
|
41938
|
Discharge summary
|
report
|
Admission Date: [**2199-9-21**] Discharge Date: [**2199-9-21**]
Date of Birth: [**2133-4-23**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
CC:[**CC Contact Info 91040**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
66 RHM with alcohol excess, HTN, anxiety presents after a fall
while intoxicated. Very limited history from patient who says he
fell 10 weeks ago and then later 3 weeks ago. Per OSH records
which are also scant, he was seen to fall backwards and was
admitted via police. At OSH CT showed traumatic ICH and he was
transferred to [**Hospital1 18**] for assessment. At OSH he was given IV
fosphenyton 1g and IV thiamine 100mg in addition to TDAP. It
also appears that he vomited and had bleeding from his head
wound
prior to cleaning and one staple was placed by the [**Hospital1 18**] ED.
While at the [**Hospital1 18**] ED he fell again trying to get out of bed and
was rescanned showing no significant change.
Patient currently feels well and denies headache or visual
symptoms. Intoxicated and smells strongly of alcohol.
Neurological ROS, the pt denies headache, loss of vision,
blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
Patient denies all other ROS
Past Medical History:
PMHx:
Alcohol excess w previously abnormal LFTs
HTN
BPH
Anxiety
Depression
No previous operations per patient
Social History:
Social Hx:
Lives alone
Retired oil industry worker and now owns real estate
Independently mobile
Ex smoker quit [**2170**] prev 20/day
Alcohol [**2-15**] martinis per night ? more
Denies illicits
Family History:
Family Hx:
Mother - heart problems and had pacemaker
Father 0 renal failure and prostate ca
Sibs well
Physical Exam:
PHYSICAL EXAM:
O: T:98.8 BP: 150/80 HR: 84 RR 18 O2Sats 97%RA
Gen: Comfortable. Sizeable occipital head lac which appears old
-staple in place.
Mild [**Last Name (un) 91041**] L>R.
HEENT: Pupils: 5->3.5 bilaterally EOMs - nystagmus in all
directions esp lateral gaze likely [**1-16**] alcohol intoxication
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2 withourt murmurs.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Bilateral Dupuytren's contracture.
Dstal pulses palpable.
Mild pitting edema to the mid shin bilaterally.
Calves SNT.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-14**] objects immediately and 0/3 at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Limb exam:
Normal tone throughout.
Motor:
Power full throughout.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right. 2 2 2 2 1
Left. 2 2 2 2 1
Plantar reflexes flexor bilaterally
Cerebellar: Mild UE dysmetria no heel-shin ataxia. RAMs were
normal.
Pertinent Results:
OSH CT read [**2199-9-20**]
Small left frontal ICH without associated mass effect.
Curvilinear parietal extra-axial high attenuation is presumably
related to motion artifact, although given the additional ICH, a
follow-up CT should be performed to more definitvely exclude a
small amount of extra axial blood.
No hydrocephalus or midline shift. No mass effect. Mild diffuse
cerebral atrophy, with midl chronic white matter heterogeneity.
No visualized skull fracture.
Smal scalp hematomas noted. Tiny focus of high attenuation in
teh
right posterior parietal scalp, probable foreign body.
Repeat CT head [**2199-9-21**]
Prelim read
Small focus of left frontal SAH is unchanged from the OSH CT a
few hours earlier.
CT C spine [**2199-9-21**]
Preliminary Report !! WET READ !!
1. No fx.
2. Moderate to severe degenerative changes at C6/7 with
posterior
disc protrusion narrowing the spinal canal. If concern for
spinal
cord injury, MRI
might be considered.
Labs:
[**2199-9-21**] 03:39AM BLOOD WBC-8.1 RBC-5.02 Hgb-16.8 Hct-48.4 MCV-97
MCH-33.5* MCHC-34.7 RDW-14.2 Plt Ct-190
[**2199-9-21**] 03:39AM BLOOD Neuts-69.3 Lymphs-24.0 Monos-4.6 Eos-1.5
Baso-0.7
[**2199-9-21**] 03:39AM BLOOD PT-12.1 PTT-21.7* INR(PT)-1.0
[**2199-9-21**] 03:39AM BLOOD Glucose-136* UreaN-14 Creat-1.0 Na-143
K-3.7 Cl-104 HCO3-23 AnGap-20
[**2199-9-21**] 03:39AM BLOOD ALT-29 AST-33 AlkPhos-49 TotBili-0.5
[**2199-9-21**] 03:39AM BLOOD Albumin-4.2
[**2199-9-21**] 03:39AM BLOOD ASA-NEG Ethanol-223* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Urine:
[**2199-9-21**] 03:39AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2199-9-21**] 03:39AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2199-9-21**] 03:39AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
Pt was monitored closely overnight in ICU and remained
neurologically intact. He received dilantin for seizure
prophylaxis. He also received thiamine and folate. he was
discharged to home to f/u in 2 weeks with PCP.
Medications on Admission:
CC:[**CC Contact Info 91040**]
HPI:
66 RHM with alcohol excess, HTN, anxiety presents after a fall
while intoxicated. Very limited history from patient who says he
fell 10 weeks ago and then later 3 weeks ago. Per OSH records
which are also scant, he was seen to fall backwards and was
admitted via police. At OSH CT showed traumatic ICH and he was
transferred to [**Hospital1 18**] for assessment. At OSH he was given IV
fosphenyton 1g and IV thiamine 100mg in addition to TDAP. It
also appears that he vomited and had bleeding from his head
wound
prior to cleaning and one staple was placed by the [**Hospital1 18**] ED.
While at the [**Hospital1 18**] ED he fell again trying to get out of bed and
was rescanned showing no significant change.
Patient currently feels well and denies headache or visual
symptoms. Intoxicated and smells strongly of alcohol.
Neurological ROS, the pt denies headache, loss of vision,
blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
Patient denies all other ROS
PMHx:
Alcohol excess w previously abnormal LFTs
HTN
BPH
Anxiety
Depression
No previous operations per patient
Medications prior to admission:
Metoprolol 25mg [**Hospital1 **]
Lisinopril 10mg qd
Diazepam 5mg PRN anxiety
paroxetine 30mg qd
All: NKDA
Social Hx:
Lives alone
Retired oil industry worker and now owns real estate
Independently mobile
Ex smoker quit [**2170**] prev 20/day
Alcohol [**2-15**] martinis per night ? more
Denies illicits
Family Hx:
Mother - heart problems and had pacemaker
Father 0 renal failure and prostate ca
Sibs well
PHYSICAL EXAM:
O: T:98.8 BP: 150/80 HR: 84 RR 18 O2Sats 97%RA
Gen: Comfortable. Sizeable occipital head lac which appears old
-staple in place.
Mild [**Last Name (un) 91041**] L>R.
HEENT: Pupils: 5->3.5 bilaterally EOMs - nystagmus in all
directions esp lateral gaze likely [**1-16**] alcohol intoxication
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. Normal S1/S2 withourt murmurs.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Bilateral Dupuytren's contracture.
Dstal pulses palpable.
Mild pitting edema to the mid shin bilaterally.
Calves SNT.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**2-14**] objects immediately and 0/3 at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Limb exam:
Normal tone throughout.
Motor:
Power full throughout.
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right. 2 2 2 2 1
Left. 2 2 2 2 1
Plantar reflexes flexor bilaterally
Cerebellar: Mild UE dysmetria no heel-shin ataxia. RAMs were
normal.
Investigations:
CT/MRI:
OSH CT read [**2199-9-20**]
Small left frontal ICH without associated mass effect.
Curvilinear parietal extra-axial high attenuation is presumably
related to motion artifact, although given the additional ICH, a
follow-up CT should be performed to more definitvely exclude a
small amount of extra axial blood.
No hydrocephalus or midline shift. No mass effect. Mild diffuse
cerebral atrophy, with midl chronic white matter heterogeneity.
No visualized skull fracture.
Smal scalp hematomas noted. Tiny focus of high attenuation in
teh
right posterior parietal scalp, probable foreign body.
By my read - small left frontal ICH/SASH with minimal blood in
suprasellar space
Repeat CT head [**2199-9-21**]
Prelim read
Small focus of left frontal SAH is unchanged from the OSH CT a
few hours
earlier.
CT C spine [**2199-9-21**]
Preliminary Report !! WET READ !!
1. No fx.
2. Moderate to severe degenerative changes at C6/7 with
posterior
disc protrusion narrowing the spinal canal. If concern for
spinal
cord injury, MRI
might be considered.
Labs:
[**2199-9-21**] 03:39AM BLOOD WBC-8.1 RBC-5.02 Hgb-16.8 Hct-48.4 MCV-97
MCH-33.5* MCHC-34.7 RDW-14.2 Plt Ct-190
[**2199-9-21**] 03:39AM BLOOD Neuts-69.3 Lymphs-24.0 Monos-4.6 Eos-1.5
Baso-0.7
[**2199-9-21**] 03:39AM BLOOD PT-12.1 PTT-21.7* INR(PT)-1.0
[**2199-9-21**] 03:39AM BLOOD Glucose-136* UreaN-14 Creat-1.0 Na-143
K-3.7 Cl-104 HCO3-23 AnGap-20
[**2199-9-21**] 03:39AM BLOOD ALT-29 AST-33 AlkPhos-49 TotBili-0.5
[**2199-9-21**] 03:39AM BLOOD Albumin-4.2
[**2199-9-21**] 03:39AM BLOOD ASA-NEG Ethanol-223* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Urine:
[**2199-9-21**] 03:39AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.004
[**2199-9-21**] 03:39AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2199-9-21**] 03:39AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Discharge Medications:
1. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
traumatic brain injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Take medication as prescribed.
Followup Instructions:
Please follow up with local PCP [**Last Name (NamePattern4) **] [**1-18**] weeks with head CT
recommended by Dr [**Last Name (STitle) **].
Completed by:[**2199-9-21**]
|
[
"600.00",
"300.00",
"873.0",
"V15.82",
"E885.9",
"305.01",
"852.01",
"311",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59"
] |
icd9pcs
|
[
[
[]
]
] |
11443, 11449
|
5612, 5832
|
338, 344
|
11515, 11515
|
3736, 5589
|
11720, 11889
|
1936, 2039
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11294, 11420
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11470, 11494
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5858, 7207
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11665, 11697
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7663, 8215
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7239, 7647
|
269, 300
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372, 1573
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8528, 11271
|
11530, 11641
|
1595, 1707
|
1723, 1920
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,931
| 145,902
|
5217+55650
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-6-18**] Discharge Date: [**2140-6-25**]
Date of Birth: [**2082-8-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Shoulder/Back Pain
Major Surgical or Invasive Procedure:
1. Debridement of right foot with podiatry [**2140-6-20**]
2. Bone sampling of right foot with podiatry [**2140-6-24**]
History of Present Illness:
Mr. [**Known lastname 284**] is a 57 y/o M with a h/o Type I Diabetes s/p
kidney/pancreas transplant in [**2125**] now with failure of his
pancreas graft on insulin who presented to the ER with right
shoulder and back pain. Over the past few days that pain
worsened, he noticed the pain worsened with inspiration. He
denied any associated SOB, palpitations, n/v/d, cough, nasal
congestion, sore throat or fever/chills. He tried percocet for
the pain which helped somewhat, but when the pain continued he
came to the ER for further evaluation.
.
In the ED, initial vs were: 100.5, 131, 113/53, 28, 96% on RA.
He triggered on arrival for tachycardia. He was noted to be
febrile with a Tmax of over 101, a CXR was done that was
consistent with atelectasis, so a d-dimer was checked, which was
positive. Since he was unable to get a CTA he was empirically
started on a heparin gtt for anti-caogulation. He was given
ceftriaxone to cover a UTI or possible PNA, given 3L NS with
improvement in his HR to the 110's and admitted to the ICU, due
to multiple medical concerns in a patient on immune suppresion.
VS on transfer were: 115, 167/95, 21, 97% on RA.
.
On the floor, his intial VS were: 98.9, 117, 171/76, 16, 97% on
RA. He currently has no complaints after receiving some pain
medication for his shoulder.
.
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 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:
Type 1 diabetes, status post kidney and pancreas transplant [**2125**]
with subsequent 'burnout' of the pancreatic graft, now on
insulin
Congestive heart failure, EF 60% on echo [**2-28**], nl valves
Hypertension
Hyperlipidemia
PVD s/p L BKA and multiple digit amputations
DVT in [**2133**]
Chronic Kidney Disease baseline Cr 1.6
Tertiary Hyperparathyroidism s/p parathyroidectomy (three
lobes).
Sleep apnea
Social History:
Previously smoked 2 ppd for 10 years, but quit 20 years ago.
Drinks alcohol rarely on social occasions. Denies use of illicit
drugs.
Family History:
Multiple family members/generations with diabetes.
Physical Exam:
On Admission:
Constitutional: No(t) Fatigue, Fever
Eyes: No(t) Blurry vision
Ear, Nose, Throat: No(t) Dry mouth, No(t) Epistaxis
Cardiovascular: Chest pain, No(t) Palpitations, No(t) Edema,
Tachycardia, No(t)Orthopnea
Respiratory: No(t) Cough, Dyspnea, No(t) Tachypnea, No(t) Wheeze
Gastrointestinal: No(t) Abdominal pain, No(t) Nausea, No(t)
Emesis, No(t) Diarrhea, No(t) Constipation
Genitourinary: No(t) Dysuria
Musculoskeletal: No(t) Joint pain
Endocrine: Hyperglycemia
Neurologic: No(t) Headache
Pain: No pain / appears comfortable
DISCHARGE:
VS: 98.6 98.6 147/87 124-159/69-100 72-102 20 99%RA
8H 100/600
24H 1670/1600+, BMX1
GEN: pleasant gentleman, sitting up in wheelchair, appears
comfortable
HEENT: NCAT, non-icteric sclera, MMM
Neck: supple, JVP not elevated
Lungs: no use of access mm, CTAB without wheezes or crackles
CVS: RRR, s1, s2 clear, [**2-28**] murmur loudest LLSB
Chest: right chest lump with no erythema, non-tender
Abdomen: +BS, soft, nontender, non-distended, no rebound.
Ext: no peripheral edema. S/p L BKA. R TMA wrapped in dressing.
Right shoulder with no bony deformities, no effusion, no warmth
or erythema. Multiple finger amputations.
Skin: warm, well perfused, no [**Location (un) **]
NEURO: awake, alert, moving all extremities, no gross deficits
Pertinent Results:
Admission labs:
[**2140-6-18**] 05:50PM BLOOD WBC-8.3# RBC-3.87* Hgb-10.6* Hct-32.5*
MCV-84 MCH-27.3 MCHC-32.6 RDW-16.0* Plt Ct-242
[**2140-6-18**] 05:50PM BLOOD Neuts-87.6* Lymphs-7.8* Monos-3.9 Eos-0.4
Baso-0.3
[**2140-6-18**] 05:50PM BLOOD PT-12.7 PTT-23.7 INR(PT)-1.1
[**2140-6-18**] 05:50PM BLOOD Glucose-93 UreaN-55* Creat-1.9* Na-138
K-5.0 Cl-103 HCO3-22 AnGap-18
[**2140-6-18**] 05:50PM BLOOD ALT-20 AST-26 AlkPhos-97 TotBili-0.2
[**2140-6-18**] 05:50PM BLOOD Calcium-9.6 Phos-2.2* Mg-1.9
[**2140-6-18**] 05:50PM BLOOD D-Dimer-1086*
[**2140-6-18**] 07:17PM BLOOD Cyclspr-<30 rapmycn-12.5
Discharge labs:
Na 139 K 4.8 Cl 103 HCO3 25 BUN 37 Cr 1.8
Cyclosporin level pending, [**Last Name (un) 1380**] level pending
WBC 4.0 Hct 28.9 Hgb 9.1 Plt 364
Chest X-Ray:
IMPRESSION: Low lung volumes with streaky opacities at the lung
bases, likely atelectasis, though infection is not completely
excluded.
CT Abdomen:
IMPRESSION:
1. Allowing for non-contrast technique, no definite CT evidence
of
pancreatitis in the native or transplanted pancreas. However a
negative CT does not exclude clinical diagnosis of pancreatitis.
Recommend correlation with laboratory values.
2. Incomplete evaluation of left lower quadrant renal transplant
without
contrast, non-specific mild perinephric stranding. No obvious
hydronephrosis or perinephric collection.
Bilateral Lower Extremity Ultrasound:
IMPRESSION: No evidence of DVT.
RENAL U/S [**2140-6-19**]:
IMPRESSION: Left lower quadrant renal graft without
hydronephrosis or
perinephric fluid collection. Stable mildly elevated resistive
indices
ranging from 0.77 to 0.84, previously 0.79 to 0.8.
FOOT X-RAY [**2140-6-20**]: IMPRESSION: Mild rarefaction of the
trabecula at the site of the distal plantar ulcer. Underlying
osteomyelitis cannot be excluded and MRI is recommended.
V/Q [**2140-6-20**]: IMPRESSION: Normal lung scan. Normal lung scan
rules out recent pulmonary embolism.
MRI RIGHT FOOT [**2140-6-22**]:
Preliminary Report !! PFI !!
1. Large ulcer at the base of the fourth metatarsal bone with
enhancement and signal abnormality in the soft tissue suggesting
possible complex fluid, less likely granulation tissue.
Disruption of the cortical definition of the fourth metatarsal
bone in the vicinity concerning for osteomyelitis.
2. Edema at the base of the second, third, fourth and fifth
metatarsal and
cuboid bone, could be related to Charcot's foot.
3. Status post amputation of multiple rays, diffuse atrophy of
the muscles
and subcutaneous edema could be related to neuropathic changes
or cellulitis.
4. Edema at the fifth metatarsal and cuboid bone with cortical
irregularity could reflect past excision changes; however, given
close proximity of ulcer, cannot exclude osteomyelitis.
5. Edema at the second and third metatarsals adjacent to the
site of ulcer
with preserved cortex; however, due to close proximity to ulcer
cannot exclude osteomyelitis.
6. Several soft tissue ulcers, as described above.
7. Abnormal signal in the Achilles tendon suggesting tendinosis
of the
Achilles tendon.
TTE [**2140-6-23**]:
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve, but cannot
be fully excluded due to suboptimal image quality. The mitral
valve leaflets are mildly thickened. No masses or vegetations
are seen on the mitral valve, but cannot be fully excluded due
to suboptimal image quality. Physiologic mitral regurgitation is
seen (within normal limits). [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No vegetations or abscess seen. Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Calcified aortic and mitral
valves without frank stenosis or regurgitation.
RIGHT SHOULDER X-RAY [**2140-6-22**]:
FINDINGS: The visualized right lung and ribs are grossly normal.
Moderate AC joint degenerative changes with joint space
narrowing and osseous
proliferation. Normal glenohumeral joint. No fractures. No
dislocation.
Atherosclerotic vascular calcifications.
IMPRESSION: No fracture identified.
U/S RIGHT CHEST [**2140-6-22**]:
IMPRESSION: Findings most consistent with diffuse hematoma in
the area of
prior port position. Please note that superinfection cannot be
excluded.
There is no focal fluid collection
LINE PLACEMENT [**2140-6-24**]:
IMPRESSION:
1. New left-sided PICC line in standard position.
2. Small bilateral pleural effusion is unchanged.
MICRO:
[**2140-6-20**] 12:48 pm SWAB Source: right foot wound.
GRAM STAIN (Final [**2140-6-20**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
BLOOD CX [**2140-6-18**]:
[**2140-6-18**] 6:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final [**2140-6-19**]):
Reported to and read back by DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 725PM
[**2140-6-19**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
[**2140-6-24**] 11:42 am TISSUE
Source: bone biopsy rt foot RECEIVED SWAB.
GRAM STAIN (Final [**2140-6-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
BLOOD CX [**2140-6-18**]: no growth
BLOOD CX [**6-20**], [**6-21**], [**6-22**]: PENDING
URINE CULTURE (Final [**2140-6-20**]): <10,000 organisms/ml
Brief Hospital Course:
Mr. [**Known lastname 284**] is a 57 year old male with a h/o Type I DM s/p
kidney/pancreas transplant who presents with pleuritic
back/shoulder pain, fever, and a positive d-dimer concerning for
possible PE. He was intially admitted to the MICU and started on
heparin gtt empirically for PE. He was covered broadly with abx
initially given fever and possible consolidation on CXR. He was
transferred to the medicine floors when he defervesced.
Eventually V/Q was able to be done, which showed no PE. One
blood culture grew MSSA, and possible source was right foot
ulcer. Podiatry was consulted, and he was debrided with cultures
sent. Given probed to bone, osteomyelitis was of concern. Given
MSSA bacteremia, ID was consulted. MRI of the foot showed
possibly osteomyelitis, but more likely to be chronic
osteomyelitis. Bone biopsy was done with podiatry and sent for
biopsy, which was pending at the time of discharge. He was
discharged on Naficillin for MSSA bacteremia for 4 weeks with ID
follow-up, and silvadene cream for his foot.
# MSSA Bacteremia: Initially presented with fever to 102, with
broad differential which included PNA vs. ostemyelitis vs.
septic joint vs. asbcess. He was covered broadly in the ICU with
Vancomycin and Zosyn. He defervesced and blood cultures grew
MSSA. He was transitioned to Cefazolin on the medicine floor.
Possible source was diabetic right foot ulcer. Podiatry was
consulted, and he was debrided with cultures sent which showed
multiple bacteria. ID was consulted and abx switched to
Nafcillin. TTE was done, and showed no vegetations. MRI of the
foot showed possible osteomyelitis, most likely chronic per
podiatry & radiology review. Per review of the images with
podiatry and radiology, decision was made to not debride further
and to treat with Silvadene cream indefinitely (as this has
worked in the past per podiatry). Pt had ultrasound of right
chest wall (previous site of line), which showed hematoma with
no discrete fluid collection. He will follow-up with repeat
imaging as an outpatient.
He remained afebrile during his hospital course. He was treated
with 4 week course of Nafcillin 2gm every 6 hours for 4 week
course. He will follow-up in [**Hospital 4898**] clinic with weekly safety
labs.
# Right shoulder pain: Differential included PE vs. PNA vs.
musculoskeletal vs. septic joint vs. abscess. Given pleuritic
component, tachycardia, and a positive d-dimer, he was started
on heparin gtt initially for concern for PE. LENI's showed no
DVT. V/Q scan was ordered, but could not be done initially.
Eventually, V/Q scan showed no PE, and heparin gtt was
discontinued. Given fever (see below), and MSSA, concern for
soft tissue infection. An ultrasound of the right chest wall
showed hematoma, with no discrete fluid collection, which was
not able to be drained given gelled hematoma per radiology
review. His shoulder pain improved and he had full mobility of
that arm. He will follow-up with repeat imaging as an
outpatient.
# Right foot osteomyelitis, chronic: As above. Pt had
debridement with podiatry and bone biopsy done [**2140-6-24**], pending
at the time of discharge. Podiatry recommended silvadene cream
and no further debridement. Final read of MRI pending at time of
discharge. He will follow-up with Podiatry on discharge.
# Tachycardia: Baseline tachycardic to 110's, increased to 130
on admission likely [**2-24**] to pain and fever. Improved as treated
for the above, with heart rate ranging 70s-100.
# DM Type I s/p pancreas transplant: Graft currently failing,
now back on insulin. Continued home dose glargine and humalog
sliding scale. Pt was hyperglycemic requiring uptitration of
lantus in house. This will need to continue to be adjusted at
[**Month/Day (2) **].
# ERSD s/p transplant: Cr was currently at baseline. Continued
immunosuppresive regimen with sirolimus, prednisone and
cyclosporin. Patient had ultrasound of transplanted kidney
showing no hydronephrosis or acute process. Continued sodium
bicarb supplementation. Continued omeprazole, calcium and
vitamin D. Rapamycin was discontinued, and Cyclosporin dose was
increased. Pt will need daily cyclosporin levels on discharge
for dose adjustment (to be faxed to transplant for adjustment).
# Hypertension: On lisinopril at home, held while in ICU. This
was restarted at the same dose on the floors.
# PVD s/p multiple amputations: Continued ASA.
TRANSITIONAL CARE:
1. CODE: FULL
2. FOLLOW-UP:
- PCP after rehab
- RENAL Transplant
- ID in [**Hospital 4898**] clinic with safety labs
- Podiatry
- recommend repeat imaging of right upper chest
3. MEDICAL MANAGEMENT:
- START Nafcillin for 4 weeks
- START Silvadene cream for right foot
- START Oxycodone-Acetaminophen prn
- STOP Sirolimus
- INCREASED Cyclosporin dose from 25 q12hrs to 125mg q12hrs
(with daily levels for adjustment)
- Increased dose of Lantus
4. OUTSTANDING TASKS:
- BLOOD CULTURES [**Date range (1) 15523**] pending, bone biopsy right foot [**2140-6-24**]
pending, final read MRI pending
Medications on Admission:
- Atorvastatin 20 mg daily
- Prednisone 5 mg daily
- Sodium Bicarbonate 650 mg 1 PO TiD
- Multivitamin daily
- Aspirin 325 mg daily
- Cyclosporine Modified 25 mg Q12H
- Sirolimus Solution 1 or 2 mg PO DAILY alternate doses to
average of 1.5mg daily.
- Omeprazole 20 mg daily
- Tamsulosin 0.4 mg CR HS .
- Lisinopril 10 mg daily
- Insulin Glargine 18 u HS
- ISS regular: twice a day: 4 with breakfast, 6 at lunch
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. insulin glargine 100 unit/mL Cartridge Sig: Eighteen (18)
units Subcutaneous twice a day.
8. insulin regular human 100 unit/mL Solution Sig: as directed
Injection as directed: take 4 units with breakfast, 6 units with
lunch.
9. Citracal + D 315-200 mg-unit Tablet Sig: One (1) Tablet PO
once a day.
10. sodium bicarbonate 325 mg Tablet Sig: as directed Tablet PO
three times a day: two Tablet(s) by mouth twice daily and 1 at
noon .
11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical
DAILY (Daily): Please apply a dime size amount to the right foot
plantar ulcer site daily.
Disp:*1 tube* Refills:*2*
13. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain: do NOT exceed more than
6 tablets daily. This medication may cause sedation, do NOT take
this while doing heavy activity.
Disp:*30 Tablet(s)* Refills:*0*
14. cyclosporine modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
Disp:*60 Capsule(s)* Refills:*0*
15. cyclosporine modified 25 mg Capsule Sig: One (1) Capsule PO
every twelve (12) hours: in addition to 100mg capsule for 125mg
every 12 hours.
Disp:*60 Capsule(s)* Refills:*0*
16. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gram
Intravenous Q6H (every 6 hours) for 4 weeks: to be completed
[**2140-7-16**].
Disp:*224 gram* Refills:*0*
17. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Thirty
Two (32) units Subcutaneous at bedtime.
18. insulin lispro 100 unit/mL Insulin Pen Sig: as directed
Subcutaneous as directed: with meals & at bedtime
150-200: 2 units
201-250: 4 units
251-300: 6 units
301-350: 8 units
351-400: 10 units
.
19. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary Diagnoses:
1. MSSA Bacteremia
2. Right foot infection, likely chronic osteomyelitis
3. Right chest wall fluid collection
Secondary Diagnoses:
1. Type 1 Diabetes
2. s/p renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 284**],
It was a pleasure taking care of you during this admission. You
were admitted for right shoulder pain. Given concern for clot in
the lungs, were initially started on heparin. However, we did a
scan, that showed no clot and the heparin was discontinued. You
were also found to have fevers and started on intravenous
antibiotics. The blood cultures showed staph bacteria, and you
were treated with an antibiotic, which you will need to continue
for 4 weeks. We had podiatry see you for the foot ulcer, which
they debrided. For the foot we checked an MRI, which showed some
infection, which the podiatrists recommended treating with
silvadene cream. A bone bopsy was done, but the results were not
back yet prior to your discharge. We also did more imaging of
the right chest, which showed a fluid collection but nothing
need to be drained. This fluid collection can be reassessed with
imaging as an outpatient when you see ID.
We had to put in a line for you to get antibiotics when you
leave the hospital.
The following medications were changed during this admission:
- STOP Sirolimus
- STOP Insulin regular with meals
- START Naficillin 2 g IV Q6H for 4 Weeks, day 1 = [**2140-6-19**], day
to be completed [**2140-7-16**]
**You will be seen by the infectious disease [**Month/Day/Year 21334**] [**Last Name (NamePattern4) **] [**2140-7-13**],
and if the infection does not seem to be clearing, they may need
to extend this antibiotic duration.
- START silver sulfadiazine 1 % Cream 1 application applied to
the foot daily (until you hear from Dr. [**Last Name (STitle) **] that this can be
stopped)
- START Oxycodone-Acetaminophen 1-2 tablets every 6 hours as
needed for pain (do NOT exceed more than 6 tablets per day, this
medication can also make you drowsy & you should not take this
while you are doing any heavy activity).
- INCREASE the dose of Cyclosporin from 25mg to 125mg every 12
hours
**You will need to have daily levels checked until this is
stable, and may need re-adjustment.
- INCREASE the dose of the Lantus insulin from 18 units to 32
units daily.
**The [**Last Name (STitle) 21334**] [**First Name (Titles) **] [**Last Name (Titles) **] [**Name5 (PTitle) **] need to be adjusted based on
your blood sugars. You will also be on a sliding scale of
Humalog insulin while you are there as well for better blood
sugar control.
- START Insulin Lispo per sliding scale with meals
**This may also may need to be adjusted by the [**Name5 (PTitle) 21334**] [**First Name (Titles) **] [**Name5 (PTitle) **] (this was changed out for the regular insulin for
better control while you are in the hospital)
Please continue all the other medications you were taking prior
to this admission. Again, it was a pleasure to take care of you!
Followup Instructions:
Please follow-up with the following appointments:
Department: PODIATRY
When: WEDNESDAY [**2140-6-29**] at 8:40 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: TRANSPLANT CENTER
When: WEDNESDAY [**2140-7-6**] at 11:30 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2140-7-13**] at 9:30 AM
With: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please make sure you keep your appointment in [**Hospital 4898**] clinic with
the Infectious Diseases [**Hospital **]. [**First Name (Titles) **] [**Last Name (Titles) 21334**] are [**Name5 (PTitle) 7941**]
your progress on your antibiotics as well as watching you for
any significant side effects.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2140-8-4**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10000**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will also need to see your primary care doctor, Dr. [**Last Name (STitle) 1968**],
once you are discharged from [**Last Name (STitle) **]. Please give his
office a call at [**Telephone/Fax (1) 250**] to schedule this appointment.
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
Completed by:[**2140-6-25**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 3540**]
Admission Date: [**2140-6-18**] Discharge Date: [**2140-6-25**]
Date of Birth: [**2082-8-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3541**]
Addendum:
Final pathology foot biopsy:
DIAGNOSIS:
Soft tissue, right foot, biopsy (A):
Fragments of mature bone with remodeling and features suggestive
of chronic osteomyelitis and fibrovascular tissue with chronic
inflammation and fibrin deposition.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2876**] - [**Location (un) 3542**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3543**]
Completed by:[**2140-6-29**]
|
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"790.7",
"731.8",
"785.0",
"996.86",
"997.69",
"719.41",
"041.11",
"998.12",
"682.2",
"713.5",
"250.81",
"704.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.68",
"77.49",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
25210, 25405
|
11460, 16471
|
323, 445
|
19572, 19572
|
4216, 4216
|
22533, 25187
|
2841, 2893
|
16933, 19238
|
19356, 19485
|
16497, 16910
|
19723, 22510
|
4829, 9423
|
2908, 2908
|
19506, 19551
|
9879, 11250
|
1807, 2242
|
265, 285
|
9458, 9707
|
473, 1788
|
4232, 4813
|
2922, 4197
|
11284, 11437
|
19587, 19699
|
2264, 2675
|
2691, 2825
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,061
| 191,258
|
12183
|
Discharge summary
|
report
|
Admission Date: [**2133-4-17**] Discharge Date: [**2133-4-24**]
Date of Birth: [**2078-1-19**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 27363**] is a 55-year-old
woman who underwent coronary artery bypass graft on [**3-20**]
of this year. Postoperative course was significant for
atrial fibrillation and she was discharged home ultimately on
[**2133-3-28**]. She developed shortness of breath on [**3-31**] at home and was admitted to [**Hospital **] Hospital. Upon
admission, the patient was noted at [**Hospital **] Hospital to have
bilateral pleural effusion. She ruled out for myocardial
infarction. She underwent bilateral thoracentesis and
continued with left loculated effusion. On the [**4-3**], the patient underwent a CT scan which revealed a
gallbladder with some sludge, however over the next few days
she developed right upper quadrant pain. Her right upper
quadrant ultrasound was negative, but on [**2133-4-8**] the
HIDA scan was positive for cholecystitis. She was taken to
the Operating Room on [**2133-4-9**] for acute cholecystitis
and gallbladder was noted at that time to be gangrenous and
he underwent a laparoscopic cholecystectomy at that time.
Over the next couple of days, the patient's distal portion of
her sternal [**Year (4 digits) **] was noted to have increasing erythema. She
was locally debrided at the bed side. Her incision continued
to have increasing erythema. She had positive blood culture
at that time and positive pleural fluid for strep mutans.
She was taken to the Operating Room at [**Hospital **] Hospital on
[**2133-4-15**] for a sternal [**Year (4 digits) **] debridement and at that
time the patient was found in the Operating Room to have an
unstable sternum and she was transferred to [**Hospital6 1760**] on [**2133-4-17**] for further
treatment of a sternal [**Year (4 digits) **] dehiscence.
MEDICATIONS:
1. NPH insulin 18 units subcutaneous q a.m., 9 units
subcutaneous q p.m.
2. Tequin 400 mg intravenous qd
3. Vancomycin 1 gm intravenous [**Hospital1 **]
4. Aspirin
5. Accupril
PAST MEDICAL HISTORY:
1. Coronary artery bypass graft on [**2133-3-20**]
2. Insulin dependent diabetes
3. Hypercholesterolemia
4. Status post cholecystitis on [**4-9**] previously
described
5. Status post laser eye surgery
6. Status post sternal [**Month (only) **] debridement as also previously
described
ADMISSION PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.0??????, pulse 84 in normal sinus
rhythm, blood pressure 130/70, oxygen saturation on room air
is 94%. Her respiratory rate was 25.
NEUROLOGIC: The patient was grossly intact, albeit anxious.
RESPIRATORY: Her lung sounds were diminished throughout,
although clear.
CORONARY: Regular rate and rhythm.
EXTREMITIES: Warm and dry to touch.
GASTROINTESTINAL: Within normal limits.
CHEST: Her sternal incision was entirely open. Sternal
wires are clearly visible on admission and her sternum was
clearly dehisced.
HOSPITAL COURSE: A plastic surgery consultation was obtained
and Dr. [**Last Name (STitle) 13797**], the plastic surgeon, was in agreement that
the patient required a sternal debridement. She was taken to
the Operating Room the following day where she underwent a
debridement of her sternum as well as an omental flap and
bilateral pec flaps with advancement flaps. The patient
tolerated the procedure well. She was transported
postoperatively from the Operating Room to the Cardiac
Surgery Recovery Unit. She was placed on amiodarone
intravenously due to some atrial fibrillation that she had
previously had before going to the Operating Room. She was
also on intravenous Neo-Synephrine drip due to some
hypotension. She was empirically placed on levofloxacin and
vancomycin antibiotics for broad spectrum coverage.
On postoperative day #1, the patient was weaned from
mechanical ventilator and extubated. On postoperative day
#2, she continued to be hemodynamically stable and was
transferred from the Intensive Care Unit to the telemetry
floor in stable condition. She was begun with rehabilitation
physical therapy and began to ambulate at that time.
Amiodarone was converted to po. She remained in normal sinus
rhythm. [**Location (un) 1661**]-[**Location (un) 1662**] drains remained in placed and her
[**Location (un) **] remained clean, dry and intact. The patient continued
to progress well over the next few days. The final culture
of the sternal tissue revealed no growth. The final culture
of fluid from the [**Location (un) **] revealed rare growth of alpha strep,
moderate growth of coagulase negative strep of two different
morphologies, however this was an abbreviated work up due to
multiple bacterial types which may be attributed to a
contaminant.
Today, postoperative day #6, [**2133-4-24**] the patient is
hemodynamically stable and ready to be discharged home with
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] assessment. Her condition today is
as follows:
VITAL SIGNS: Temperature 98.9??????, pulse 74, blood pressure
116/66, respiratory rate 18, room air oxygen saturation is
93%.
LUNGS: Clear to auscultation.
CORONARY: Regular rate and rhythm.
ABDOMEN: Benign. Her [**Last Name (Titles) **] is clean, dry and intact with
bilateral [**Location (un) 1661**]-[**Location (un) 1662**] drains in place.
MOST RECENT LABORATORY VALUES FROM [**2133-4-23**]: Magnesium
1.8, potassium 3.5, hematocrit of 25.6.
Th[**Last Name (STitle) 1050**] is to be discharged home today. She is to follow
up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13797**] on [**Last Name (LF) 2974**], [**2133-5-1**] at
9:15 on the [**Hospital Ward Name 516**] [**Last Name (un) 469**] Clinical Center on the [**Location (un) **]. She is to follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] here
and to call for an appointment to see Dr. [**Last Name (Prefixes) **] in one
month.
DISCHARGE CONDITION: Stable
DISCHARGE DIAGNOSIS:
1. Sternal [**Last Name (Prefixes) **] dehiscence, status post sternal debridement
and omental and pectoral flaps
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2133-4-24**] 09:33
T: [**2133-4-24**] 09:55
JOB#: [**Job Number 38126**]
|
[
"V45.81",
"250.00",
"998.3",
"272.0",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"77.61",
"96.71",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
6012, 6020
|
6041, 6406
|
3034, 5990
|
2470, 3016
|
184, 2124
|
2146, 2448
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,244
| 187,349
|
51495
|
Discharge summary
|
report
|
Admission Date: [**2130-5-28**] Discharge Date: [**2130-6-7**]
Date of Birth: [**2060-8-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization [**2130-5-29**]
CABGx2 (Lima->Lad, SVG->pda) [**2130-5-30**]
History of Present Illness:
69 yo man with known coronary artery disease and systolic heart
failure who has had progressive symptoms of heart failure,
including increasing exertional dyspnea, over the past couple of
months. 1-2 weeks ago his dose of furosemide was increased to
40 mg daily due to new, progressive lower extremity edema. On
the night of [**5-25**], he was awakened from sleep with severe dyspnea
in the setting of dietary indiscretion earlier that night. It
was associated with substernal chest discomfort that was not
relieved by belching; he also had nausea without emesis. He
presented to an OSH where he was found to be in atrial
fibrillation with ST segment depressions V4-V6 on his initial
EKG; his second troponin returned at 7.68. He was treated with
heparin gtt, eptifibatide gtt, ASA, metoprolol, and clopidogrel.
He also received furosemide IV for treatment of congestive
heart failure with effective diuresis. He spontaneously
converted to sinus rhythm early in his hospital course and has
remained in sinus since. He was transferred here for cath given
his NSTEMI.
Past Medical History:
1. CAD s/p MI x3
2. systolic heart failure (EF 25-30%)
3. hypertension
4. dyslipidemia
5. diabetes mellitus type II since [**2115**]
6. tobacco abuse
7. atrial fibrillation
8. left nephrectomy [**2068**]
Social History:
Smokes one pack of cigarettes daily. Drinks 2-3 beers nightly.
No illicit drug use. Married, lives with his wife. Retired [**Name2 (NI) 2318**]
employee.
Family History:
Brother died of sudden cardiac death from an MI. Sister age 79
recently had an MI. Father died of "a bad heart." Mother died
at 81 from "old age."
Physical Exam:
T-98.1 BP-131/67 HR-80 RR-16 Weight-199 pounds
Gen: Pleasant, obese, non-toxic
Neck: Soft, supple, no LAD, 2+ carotid pulses, very faint R
carotid bruit
CV: RRR, normal S1 and S2, II/VI flow murmur at the base, no r/g
Pulm: Scant bibasilar crackles
Abd: Soft, non-tender, non-distended, active bowel sounds
Back: No CVA or paraspinal tenderness
Ext: 1+ BLE pitting edema to the knees, 2+ DP/femoral/radial
pulses, no femoral bruits
Neuro: Alert, appropriate
Pertinent Results:
OSH Labs:
WBC-5.1 Hct-38.8 MCV-85.9 Plt-171
Na-138 K-4.7 Cl-103 Bicarb-29 BUN-17 Cr-1.0 Glu-295 Ca-9.1
Serial CK/MB: 250/26.7
Serial Troponin I: 0.20, 7.68, 5.43, 4.68
BNP: 582
U/A: trace protein, trace LE, o/w negative
EKG (initial): atrial fibrillation at roughly 150 beats per
minute, normal axis, 1-2 mm ST segment depressions V4-V6
EKG ([**5-27**]): normal sinus rhythm at 80 beats per minute, normal
axis, normal intervals, 0.5-1 mm ST segment depressions V4-V6, T
wave flattening I and aVL
OSH TTE (per report): EF 25-30%, multiple regional WMA
[**2130-5-29**] Carotid Duplex Ultrasound
Mild to moderate plaque in the bilateral internal carotid
arteries, right worse than left. This is associated with
diameter reductions between 40 and 59% in diameter in the right
internal carotid artery and less than 40% in diameter in the
left internal carotid artery. Antegrade flow in the bilateral
vertebral arteries
[**2130-5-29**] Cardiac Catheterization:
1. Selective coronary angiography revealed a left dominant
system with
three vessel coronary artery disease. The short calcified LMCA
had a 50%
proximal taper. The diffusely calcified LAD had serial 90%
lesions
proximally with a normal distal vessel. The dominant LCX had
extensive
calcification with a 90% lesion at the origin of the OM2 and
LPDA with
no angiographically apparent flow limiting lesions distally.
2. Resting hemodynamics demonstrated moderately elevated right
sided
(mean RA 21 mmHg), pulmonary (mean PA 28 mm Hg) and left sided
pressures
(mean PCWP 21 mmHg) with no gradient upon movement of the
catheter from
the ventricle to the aorta. The cardiac index was moderately
depressed
(1.9 l/min/m2).
3. Left ventriculography was deferred for high left sided
pressures.
[**2130-5-29**] ECHO
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. There is moderate
global left
ventricular hypokinesis. Inferior akinesis is present. Overall
left
ventricular systolic function is moderately depressed.
3. The aortic valve leaflets are moderately thickened.
4. The mitral valve leaflets are mildly thickened. There is
moderate
thickening of the mitral valve chordae. Mild (1+) mitral
regurgitation is
seen.
[**2130-6-6**] 06:15AM BLOOD WBC-11.0 RBC-3.35* Hgb-9.4* Hct-29.1*
MCV-87 MCH-28.2 MCHC-32.4 RDW-17.0*
[**2130-6-7**] 06:10AM BLOOD K-4.7
[**2130-5-29**] 10:00AM BLOOD ALT-15 AST-17 AlkPhos-51 Amylase-26
TotBili-0.8
Brief Hospital Course:
Mr. [**Known lastname 106768**] was admitted to the [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2130-5-28**] for further management of his myocardial
infarction. A cardiac catheterization was performed which
revealed a 50% stenosed left main, a 90% stenosed left anterior
descending artery, a 90% stenosed circumflex artery and an
occluded right coronary artery. Due to the severity of his
disease, the cardiac surgical service was consulted for surgical
revascularization. A carotid duplex ultrasound was performed
which revealed a 40-59% stenosed right and less then a 40%
stenosed left internal carotid artery. An echocardiogram was
performed which revealed an ejection fraction of 30-35%, mild 1+
mitral regurgitation, [**12-25**]+ tricuspid regurgitation and a mildly
dilated left atrium. On [**2130-5-30**], Mr. [**Known lastname 106768**] was taken to the
operating room where he underwent coronary artery bypass
grafting to two vessels. Postoperatively he was taken to the
cardiac surgical intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname 106768**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. Amiodarone and coumadin were started given
his preoperative atrial fibrillation. He was then transferred to
the cardiac surgical step down unit for further recovery. Mr.
[**Known lastname 106768**] was gently diuresed towards his preoperative weight. The
physical therapy service was consulted for assistance with his
postoperative strength and mobility. His drains and pacing wires
were removed per protocol. The [**Last Name (un) 387**] diabetes service was
consulted for assistance with his diabetes medication
management. As his sugars were elevated, insulin was started.
Mr. [**Known lastname 106769**] INR was markedly elevated on postoperative day 5
and as he remained in normal sinus rhythm, it was decided to
discontinue his coumadin and amiodarone. Vitamin K was given
with good effect. As Mr. [**Known lastname 106769**] blood pressure remained low,
it was elected to wait until his blood pressure improved prior
to starting an ace-inhibitor. Thus, an ace-inhibitor should be
started as an outpatient given his low ejection fraction and
preoperative myocardial infarction. Mr. [**Known lastname 106768**] continued to
make steady progress and was discharged to [**Hospital **] Health Care
Rehabilitation on postoperative day eight. he will follow-up
with Dr. [**Last Name (STitle) 70**] and Dr. [**Last Name (STitle) 1637**] as an outpatient.
Medications on Admission:
1. aspirin 325 mg daily
2. metoprolol 50 mg twice daily
3. atorvastatin 80 mg daily
4. clopidogrel 75 mg daily
5. accupril 40 mg daily
6. eptifibatide gtt
7. heparin gtt
8. insulin glargine 30 units qAM
9. pantoprazole 40 mg daily
10. regular insulin sliding scale
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet 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 Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
[**Month (only) 116**] discontinue when leaves rehab.
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days: Then discontinue .
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: While taking narcotics.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
9. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) Units
Subcutaneous Breakfast.
10. Humalog 100 unit/mL Solution Sig: Per sliding scale Per
sliding scale Subcutaneous QACHS: Fingersticks QACHS.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Preop MI
Coronary Artery Disease
Diabetes
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) No bathing or swimming for one month.
3) No lifting more then 10 pounds for 1 month.
4) Do not apply lotions, creams or ointments to wound. Use
sunscreen on wound if directly exposed to sun once scar has
formed.
5) No driving for 1 month.
6) Report any weight gain of more then 2 pounds in 24 hours.
7) Report any fever greater then 100.5
8) Insulin and diabetes teaching.
9) fingerstick blood sugar QACHS.
10) Sliding scale humalog per institutional protocol
11) Please start Ace Inhibitor when BP can tolerate for preop MI
and low ejection fraction.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 70**] in 6 weeks ([**Telephone/Fax (1) 1504**]
Follow-up with your cardiologist/Primary care physician
[**Last Name (NamePattern4) **].[**Last Name (STitle) 1637**] in 2 weeks. ([**Telephone/Fax (1) 68572**]
Please call physicians for appointments.
Appointments arranged by [**Last Name (un) **] Diabetes Physician:
[**Name10 (NameIs) **] clinic [**6-12**] at 2:15PM
[**Hospital **] [**Hospital 982**] Clinic [**6-12**] at 1:00PM
[**Last Name (un) **] Diabetes Teaching [**6-16**] at 8:30AM and 10:30PM
Completed by:[**2130-6-7**]
|
[
"272.4",
"412",
"250.00",
"410.71",
"305.1",
"428.30",
"V45.73",
"427.31",
"V17.3",
"428.0",
"401.9",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.56",
"36.11",
"37.23",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9033, 9106
|
5031, 7630
|
331, 418
|
9191, 9197
|
2579, 5008
|
9893, 10467
|
1935, 2086
|
7945, 9010
|
9127, 9170
|
7656, 7922
|
9221, 9870
|
2101, 2560
|
281, 293
|
446, 1521
|
1543, 1748
|
1764, 1919
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,969
| 146,679
|
52240
|
Discharge summary
|
report
|
Admission Date: [**2153-6-17**] Discharge Date: [**2153-6-20**]
Date of Birth: [**2089-1-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with Drug Eluting Stents to Right
Coronary Artery
History of Present Illness:
64yo man w hx of CAD s/p 2 BMS RCA and LIMA-DIAG approx 8yrs ago
who presents with sudden onset chest pain. He was walking the
[**Hospital3 15290**] and noted sudden right arm and chest pain a/w nausea
and diaphoresis. It improved slightly with rest but given
persistence, called EMS. They gave ASA and NTG.
.
In the ER: diaphoretic w VS 97.6 138/74 100% NRB RR23 HR 54. EKG
w sinus brady, STE 35mm III>II and aVF, STD I, aVL V1-V2 w Qs in
II, III, aVF. Code STEMI called. He was given morphine 4mg,
zofran 4mg, 2L NS, plavix 600, heparin 5000, integrillin, and
taken to the cath lab.
.
In the cath lab, he had right dominant system, occluded mid LAD,
patent LIMA to diag, RCA occluded at prior stent. Thrombectomy
of RCA followed by dilatation and placement of two endeavor
stents. TIMI 3 flow post procedure. Pt was in transient afib
requiring metop 2.5 then converted to sinus. He received 4L
during hosp course for hypotension to SBP 100s. Has had brisk
UOP and stable BP and HR postprocedure.
.
Currently, he feels well. He has no specific complaints. Reports
that he has not taken ASA for >2 weeks.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: CAD, hyperlipidemia, borderline
hyperglycemia
2. CARDIAC HISTORY: 2 BMS to RCA [**3-5**] AMI 8 yrs ago. LIMA to DIAG
3mo later given 85% stenosis.
- stress [**12-9**] "normal"
3. OTHER PAST MEDICAL HISTORY:
- hyperlipidemia
- borderline hyperglycemia
- no hypertension
Social History:
-Tobacco history: never
-ETOH: 1-2 beers per night
-Illicit drugs: no
-lives alone. has son and "estranged wife"
-prior legal work. Not working currently.
Family History:
F died AMI 49
GF died AMI 55
Physical Exam:
On admission -
VS 97.3 83 140/89 16 99% RA
GEN: pleasant, comfortable, NAD
HEENT: MMM, no oral lesions
NECK: supple, JVP 7
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. Access in Right
femoral
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+
Pertinent Results:
=======
Labs
=======
[**2153-6-17**] 03:20PM BLOOD WBC-13.1* RBC-5.20 Hgb-14.6 Hct-42.3
MCV-81* MCH-28.0 MCHC-34.5 RDW-13.3 Plt Ct-238
[**2153-6-18**] 05:08AM BLOOD WBC-9.9 RBC-4.15* Hgb-11.9* Hct-33.7*
MCV-81* MCH-28.6 MCHC-35.1* RDW-13.8 Plt Ct-175
[**2153-6-19**] 05:35AM BLOOD WBC-8.2 RBC-4.82 Hgb-13.2* Hct-40.2
MCV-84 MCH-27.3 MCHC-32.7 RDW-13.7 Plt Ct-195
[**2153-6-17**] 03:20PM BLOOD Glucose-123* UreaN-17 Creat-1.2 Na-142
K-3.1* Cl-107 HCO3-17* AnGap-21*
[**2153-6-17**] 09:07PM BLOOD Glucose-115* UreaN-14 Creat-1.0 Na-143
K-4.3 Cl-111* HCO3-24 AnGap-12
[**2153-6-18**] 05:08AM BLOOD Glucose-108* UreaN-14 Creat-1.2 Na-141
K-4.0 Cl-108 HCO3-26 AnGap-11
[**2153-6-19**] 05:35AM BLOOD Glucose-92 UreaN-12 Creat-1.0 Na-144
K-4.2 Cl-109* HCO3-26 AnGap-13
[**2153-6-20**] 05:35AM BLOOD Glucose-92 UreaN-15 Creat-1.2 Na-144
K-4.7 Cl-108 HCO3-29 AnGap-12
[**2153-6-17**] 09:07PM BLOOD CK-MB-157* MB Indx-12.7*
[**2153-6-18**] 05:08AM BLOOD CK-MB-196* MB Indx-11.5*
[**2153-6-18**] 01:03PM BLOOD CK-MB-133* MB Indx-9.0*
[**2153-6-20**] 05:35AM BLOOD Triglyc-111 HDL-42 CHOL/HD-3.3 LDLcalc-73
.
==========
Cardiology
==========
C. Cath [**2153-6-17**]
1. Two vessel coronary artery disease.
2. Inferior STEMI with acute RCA occlusion.
3. Regional left ventricular systolic dysfunction.
4. Sucecssful percutaneous thrombectomy and stenting of the mid
and
distal RCA with two non-overlapping Endeavor DES.
5. Successful closure of the RCFA with a 6 French Angioseal
.
TTE [**2153-6-18**]
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild to moderate regional left
ventricular systolic dysfunction with severe hypokinesis of the
basal 2/3rds of the inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 40 %). Right
ventricular chamber size is normal with free wall hypokinesis.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Regional left ventricular and global right
ventricular systolic dysfunction c/w CAD (proximal RCA
distribution). Mild mitral regurgitation.
Brief Hospital Course:
64yo man w hx of CAD s/p 2 BMS RCA and LIMA-DIAG approx 8yrs ago
who presents with sudden onset chest pain. Had in-stent
thrombosis of RCA BMS now s/p successful clot retrieval and [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) 5175**] (x2). Patient has stable hemodynamics and asymptomatic
currently.
.
# STEMI IMI. As above; s/p DES x2 to RCA within prior stents.
TIMI 3 flow postintervention. CK peaked at 1698. Received
integrellin pericath and then maintained on plavix, aspirin 325
mg daily x1 mo. followed by 162 mg daily. Lipid panel was at
goal but patient continued on pravachol until cholesterol can be
rechecked as outpatient. Patient was started on lopressor and
low dose lisinopril. Will follow up with outpatient cardiologist
at [**Hospital3 **]. Passed PT prior to discharge. TTE revealed EF
40%, which will need to be repeated in the future. Likely
decrease in EF due to ischemia.
.
CODE: full, discussed
DISPO: CCU followed by cardiology floor
CONTACT: wife is HCP [**Telephone/Fax (1) 108054**]. ONLY CALL IN EMERGENCY
Medications on Admission:
Pravachol 60
ASA 81
prior BB - stopped [**3-5**] side effects
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*3*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*11*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*3*
5. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*11*
6. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual every 5 minutes for total 3 tablets: If you still
have trouble breathing, nausea after 3 doses, call 911.
Disp:*1 bottle* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*11*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Disp:*90 Tablet(s)* Refills:*3*
9. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*3*
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*11*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Inferior ST Elevation Myocardial Infarction
SECONDARY:
Hypertension
Hyperlipidemia
Coronary Artery Disease
Discharge Condition:
stable.
Discharge Instructions:
You had a heart attack and needed 2 more stents in your right
coronary artery. You will need to take aspirin for the rest of
your life and Plavix every day for at least one year and
possibly longer. These 2 drugs together will help you avoid
another heart attack. Do not stop taking Plavix unless Dr. [**Last Name (STitle) 911**]
tells you to. It is very important to take all your medicines
every day, talk to your cardiologist if you find that side
affects are becoming a problem.
[**Name (NI) **] lifting more than 10 pounds for one week. No baths or pools
for one week, you may shower.
.
New medicines:
1. Plavix: to keep the stents open and prevent another heart
attack
2. Aspirin: works with Plavix to keep the stents open
3. Metoprolol: to lower your heart rate and help it recover
4. Lisinopril: to lower your blood pressure and help your heart
recover
5. Continue to take Pravastatin for your cholesterol but
increase the dose to 80 mg daily.
.
Please call Dr. [**Last Name (STitle) 108055**] if you notice that your symptoms of
fatigue and trouble breathing return, if you have any evidence
of unusual bleeding, if you have any chest pain or fevers or any
other unusual symptoms. Please get a blood pressure cuff at home
and check your blood pressure at different times of the day.
Please keep a log to show to your doctors.
Followup Instructions:
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 20391**], MD Phone: [**Telephone/Fax (1) 108056**] Date/time: Tuesday [**6-26**] at 9:45am.
.
Primary Care:
[**Last Name (LF) 108057**],[**First Name3 (LF) **] Phone: [**Telephone/Fax (1) 108058**] Date/time: Please call to
make an appt in [**4-4**] weeks
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2153-6-21**]
|
[
"410.41",
"V45.81",
"E879.0",
"997.1",
"272.4",
"427.31",
"414.01",
"458.9",
"996.72",
"276.2",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.46",
"88.53",
"88.56",
"36.07",
"00.66",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
8071, 8077
|
5790, 6837
|
326, 402
|
8237, 8247
|
3356, 5767
|
9630, 10120
|
2555, 2586
|
6950, 8048
|
8098, 8216
|
6863, 6927
|
8271, 9607
|
2601, 3337
|
2160, 2270
|
276, 288
|
430, 2047
|
2301, 2365
|
2069, 2140
|
2382, 2539
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,705
| 197,564
|
43444
|
Discharge summary
|
report
|
Admission Date: [**2178-8-24**] Discharge Date: [**2178-8-26**]
Date of Birth: [**2133-6-10**] Sex: M
Service: MEDICINE
Allergies:
Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45M with past medical history significant for severe asthma with
>100 hospitalizations & 17 intubations who presents with
shortness of breath, wheezing, and cough for the past few days,
consistent with an asthma exacerbation.
Patient says he was in his usual state of health until a few
nights ago when he felt incresing shortness of breath. He was
also noticing some increasing cough with sputum. No
fevers/chills. No sick contacts.
[**Name (NI) **] was recently admitted from [**Date range (1) 93487**] for similar
symptoms, thought to be [**1-29**] COPD exacerbation and was dc'd on a
5 day course of azithromycin. He followed up with his
pulmonologist a week later who encouraged smoking cessation but
did not make and changes to his medications.
He is very knowledgeable with regards to his asthma and
triggers, feels they are brought on by weather changes as well
as seasonally. He self increased his dose of prednisone from 30
mg to 50 mg PO this morning. Since his symptoms were not
improving, he decided to go to the ED.
In the ED, initial VS were T 98.8, HR 127, BP 151/107, RR 18,
SpO2 99% RA. Labs were notable for lactate 4.0. Preliminary read
of CXR showed no acute cardiopulmonary process. EKG was sinus
tachycardia @ 122 bpm, consistent with prior. Patient received 2
Duo-Nebs (albuterol/ipratropium), 2 additional albuterol nebs,
magnesium sulfate 2g, and solu-medrol 80mg IV (pt requested only
80mg because he takes prednisone at home and has a h/o avascular
necrosis) with significant improvement in his symptoms. VS on
transfer were T 97.4, HR 106, BP 146/88, RR 16, 96%RA.
On arrival to the MICU, patient says he is breathing "at or
near" his baseline. His VS were: 95 126/84 99 21 94% RA
Review of systems:
(+) Per HPI, shortness of breath, non-productive cough, dyspnea,
wheezing
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- Severe asthma with >100 hospitalizations, multiple intubations
(17), most recent prolonged admission was in [**2169**], which was
complicated by MRSA and xanthomonas bronchitis
- OSA on CPAP at night
- Avascular necrosis of the hip s/p left TKR [**6-/2175**] and shoulder
from prolonged steroid use
- GERD
- H/o L Achilles tendon rupture s/p repair
Social History:
Smokes five cigarettes a day, ~30 pack-year history. Drinks ~1
bottle of wine per week. Occasionally uses marijuana. He is
currently living with his wife and young daughter in his
mother's house in [**Location (un) 583**]. Currently has a lot of social
stressors; his house in [**Location (un) 5503**] is being foreclosed. He
lost his job as a school bus driver in [**Month (only) **], and his
unemployment benefit is about to run out. He is taking classes
at [**Location (un) 6188**] Community College hoping to eventually work as a
compliance officer or as a hazmat official. He is married, has
three children (two daughters ages 19 & 4, one son age 17).
Family History:
Maternal history of cancer and asthma.
Physical Exam:
ADMISSION EXAM:
95 126/84 99 21 94% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: end expiratory wheezing heard throughout posterior lung
fields, diminished air entry at bases, no crackles/rhonchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
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.
Discharge Exam:
Vitals: T 97.9, BP 142/73, HR 78, RR 16, SpO2 95%
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: no increaesed work of breathing or accessory muscle use.
scant scattered expiratory wheezing heard throughout posterior
lung fields, good air exchange throughout all lung fields, no
crackles/rhonchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
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, normal gait.
Pertinent Results:
ADMISSION LABS:
[**2178-8-24**] 09:45AM BLOOD WBC-8.8 RBC-5.19 Hgb-15.7 Hct-46.4 MCV-90
MCH-30.4 MCHC-33.9 RDW-13.3 Plt Ct-265
[**2178-8-24**] 09:45AM BLOOD Neuts-84.2* Lymphs-9.1* Monos-2.5 Eos-3.6
Baso-0.7
[**2178-8-24**] 09:45AM BLOOD Plt Ct-265
[**2178-8-24**] 09:45AM BLOOD Glucose-169* UreaN-12 Creat-0.9 Na-141
K-3.5 Cl-105 HCO3-23 AnGap-17
[**2178-8-24**] 09:45AM BLOOD Albumin-4.6 Calcium-9.2 Phos-1.6*# Mg-2.1
[**2178-8-24**] 10:08AM BLOOD Lactate-4.0*
Discharge Labs:
[**2178-8-26**] 01:51AM BLOOD WBC-26.4* RBC-4.66 Hgb-14.2 Hct-42.8
MCV-92 MCH-30.4 MCHC-33.1 RDW-13.5 Plt Ct-283
[**2178-8-26**] 01:51AM BLOOD Neuts-93.8* Lymphs-2.7* Monos-3.3 Eos-0.1
Baso-0.1
[**2178-8-26**] 01:51AM BLOOD Glucose-136* UreaN-19 Creat-1.0 Na-143
K-4.3 Cl-110* HCO3-20* AnGap-17
[**2178-8-26**] 01:51AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.3
[**2178-8-25**] 08:24AM BLOOD Lactate-2.6*
[**2178-8-24**] 08:34PM BLOOD Type-[**Last Name (un) **] pO2-57* pCO2-35 pH-7.45
calTCO2-25 Base XS-0
Microbiology:
[**2178-8-24**] 9:50 am BLOOD CULTURE: Pending. No growth to date.
Imaging:
[**2178-8-24**] EKG: Sinus tachycardia. Probable left atrial
abnormality. Compared to the previous tracing of [**2178-5-16**] sinus
tachycardia persists but heart rate is slower.
[**2178-8-24**] CXR:
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Brief Course:
Mr. [**Known lastname **] is a 45M with past medical history significant for
severe asthma with >100 hospitalizations & 17 intubations who
presents with shortness of breath, wheezing, and cough for the
past few days, consistent with an asthma exacerbation. He was
admitted to the ICU and treated with duonebs, magnesium sulfate,
steroids, and azithromycin for possible concominant COPD
exacerbation. He never required intubation and was weaned off
nasal cannula and returned to baseline. He was discharged to
home from the ICU.
Active Issues:
# Asthma/COPD exacerbation: Patient has h/o severe asthma with
>100 hospitalizations and multiple intubations and presented
with 2-3 days worsening dyspnea, wheezing and productive cough.
Pt's respiratory distress is likely secondary to asthma
exacerbation and probable COPD exacerbation given his h/o severe
persistent asthma on chronic steroids with continued tobacco
abuse. Environmental allergies, stress, tobacco are all likely
factors in acute exacerbation. CXR was negative for any focal
process/pneumonia, blood cultures are pending, and pt has
remained afebrile. Dyspnea improved w/ Duo-Nebs, Magnesium
sulfate and solumedrol 80mg IV in ED. In the MICU, pt received
albuterol/ipratropium nebs q6h with clinical improvement in
wheezing. He received solumedrol 60mg q6h on day of admission
and transitioned to prednisone po 60mg q6h on [**2178-8-25**]. Pt was
started on 4 day course of azithromycin (500mg on day 1, 250mg
day 2,3,4) to be completed on [**2178-8-27**], given suspected COPD
exacerbation. Peak flows were 350 on [**8-24**] and 300 on [**8-25**]. Pt
continued to improve clinically with diminished wheezing on
physical exam and no dyspnea even while ambulating. He felt that
he was back at his baseline. His prednisone was tapered to 60 mg
[**Hospital1 **] on the day of discharge which he will take on [**8-26**] and [**8-27**],
then taper further to 60 mg daily which he will continue until
he follows up with his pulmonologist Dr. [**Last Name (STitle) **].
# Lactic acidosis: Had elevated lactate 4.0 on day of admission,
likely type b lactic acidosis due to local hypoxia from muscle
fatigue and toxin induced from albuterol. Lactate was
down-trending to 2.6 upon discharge from the MICU.
# Leukocytosis: Pt had leukocytosis of 19.8 with 90.3% neut and
6.3% lymph on [**8-25**]. This is likely from steroids. Infection,
particularly pneumonia, was not suspected as patient's chest
x-ray was negative and he clinically improved with steroid and
nebulizer treatments.
Chronic Issues:
# Obstructive sleep apnea: pt was continued on nocturnal CPAP.
# Gerd: Pt contnued home omeprazole.
# Tobacco use: Patient was counseled on the importance of
smoking cessation especially in the setting of his asthma and
frequent exacerabtions.
Transitions of care:
1. Full Code
2. Contact: Wife [**Name (NI) 93485**] [**Telephone/Fax (1) 93486**]
3. Pending labs: [**8-24**] Blood Cultures (no growth to date)
4. Follow up:
-Dr. [**Last Name (STitle) **] [**Name (STitle) **] (transition from hospital to PCP)
-Dr. [**Known firstname **] [**Last Name (NamePattern1) **] (pulmonologist)
[**Hospital 26283**] clinic for OSA
5. Medication Changes:
-Continue azithromycin 250 mg through [**2178-8-27**] (1 more day after
discharge)
-Continue prednisone 60 mg [**Hospital1 **] for [**2178-8-26**] and [**2178-8-27**], then
decrease to 60 mg daily until patient sees Dr. [**Last Name (STitle) **]
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
Aerosol Inhaler 2 puffs inh every 4 hours prn wheezing
FLUTICASONE - fluticasone 50 mcg/actuation Nasal Spray, Susp 1
spray intranasal twice a day
FLUTICASONE [FLOVENT HFA] - Flovent HFA 220 mcg/actuation
Aerosol Inhaler 6 puffs twice a day
IPRATROPIUM-ALBUTEROL [DUONEB] - DuoNeb 0.5 mg-3 mg(2.5 mg
base)/3 mL Neb Solution 1 inhalation four times a day as needed
for prn
MONTELUKAST [SINGULAIR] - Singulair 10 mg tablet 1 Tablet by
mouth once a day every day
PREDNISONE - prednisone 10 mg tablet 3 Tablets by mouth once a
day; increase to 6 tabs a day with asthma flare with usual
taper.
SALMETEROL [SEREVENT DISKUS] - Serevent Diskus 50 mcg/dose for
Inhalation 1 puff inh twice a day
SULFAMETHOXAZOLE-TRIMETHOPRIM - sulfamethoxazole-trimethoprim
400 mg-80 mg tablet 1 Tablet(s) by mouth once a day for pcp
prophylaxis TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] -
Spiriva with HandiHaler 18 mcg & inhalation capsules 1 puff Inh
daily
OMEPRAZOLE - omeprazole 20 mg capsule, delayed release 1 Capsule
by mouth twice daily
GUAIFENESIN [MUCINEX]
LORATADINE - loratadine 10 mg tablet 1 Tablet by mouth once a
day as needed for allergy symptoms
MAGNESIUM OXIDE - magnesium oxide 400 mg capsule 1 capsule by
mouth daily
ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000
unit capsule 1 Capsule(s) by mouth twice a week x 4 weeks
NICOTINE [NICOTROL NS] - Nicotrol NS 10 mg/mL Nasal Spray [**12-29**]
sprays(s) nasal per hour as needed for craving [**12-29**] sprays/hour;
no more than 5 doses (10 sprays) per hour, no more than 4
doses/day
NICOTINE (POLACRILEX) [COMMIT] - Commit 4 mg Buccal Lozenge 1
lozenge every 1-2 hours for first six weeks, then taper to q2-4
hours x 2 weeks, then q 4-8 hours x 2 weeks. Max 20 pieces in 24
hours
Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Montelukast Sodium 10 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Nicotine Lozenge 4 mg PO Q4H:PRN craving
9. PredniSONE 60 mg PO BID
Tapered dose - DOWN
RX *prednisone 20 mg 3 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
10. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Duration: 4 Weeks
11. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses
12. Loratadine *NF* 10 mg Oral daily allergies
13. Tiotropium Bromide 1 CAP IH DAILY
14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
15. ipratropium bromide *NF* 0.02 % Inhalation [**Hospital1 **] wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Asthma exacerbation
Secondary: Obstructive sleep apnea, Tobacco abuse
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 ICU with an asthma exacerbation. We
treated you with nebulizer treatments, magnesium, and steroids,
and your breathing improved.
You should continue taking steroids 60 mg twice a day for [**8-26**]
and [**8-27**] then switch to 60 mg daily until you see your
pulmonologist Dr. [**Last Name (STitle) **]. His office will call you to schedule
an appointment in the next 1-2 weeks. If you don't hear from
them in 2 days you should call at [**Telephone/Fax (1) 612**] to schedule an
appointment.
You should also continue taking azithromycin through [**8-27**]
It is extremely important that you stop smoking. Continuing to
smoke will lead to recurrent asthma exacerbations and can cause
permanent damage to your lungs. We strongly encourage you to
quit smoking.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2178-9-3**] at 9:30 AM
With: Dr. [**Last Name (STitle) **] [**Name (STitle) **]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] North [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
We are working on a follow up appointment for your
hospitalization in Pulmonary and Sleep with Dr. [**Known firstname **] [**Last Name (NamePattern1) **] as
well as Sleep Specialist. They are scheduled in the same office.
It is recommended you be seen within 2 weeks of discharge with
Dr. [**Last Name (STitle) **] and within 1 month for Sleep. The office will
contact you at home with both appointment information. If you
have not heard within 2 business days please call the office at
[**Telephone/Fax (1) 612**].
Completed by:[**2178-8-27**]
|
[
"493.22",
"V43.64",
"530.81",
"288.60",
"V58.65",
"305.1",
"300.00",
"327.23",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12876, 12882
|
6620, 7163
|
394, 400
|
13006, 13006
|
5276, 5276
|
14004, 15263
|
3673, 3714
|
11957, 12853
|
12903, 12985
|
10112, 11934
|
13157, 13981
|
5758, 6597
|
3729, 4442
|
4458, 5257
|
9617, 9818
|
2181, 2606
|
9838, 10086
|
347, 356
|
7178, 9174
|
428, 2162
|
5293, 5741
|
13021, 13133
|
9458, 9606
|
9190, 9437
|
2628, 2981
|
2997, 3657
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,331
| 171,888
|
28732
|
Discharge summary
|
report
|
Admission Date: [**2198-7-31**] Discharge Date: [**2198-7-31**]
Date of Birth: [**2144-2-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
ABDOMINAL PAIN
Major Surgical or Invasive Procedure:
54 year old male with h/o advanced sigmoid adenocarcinoma with
multiple liver mets, s/p colonic stent. d/c from OSH [**2198-7-23**] to
NH for ?hospice care. Developed acute abdominal pain at 1215
this AM. presented to ED with tympanic abdomen and large amount
free air of CXR. Evaluated by surgery. No plan for OR. Intubated
in ED await family arrival at bedside.
History of Present Illness:
54 M with metatstatic sigmoid adencarcinoa with colonic stents
now with perforation. Found by clinical suspicion and air under
the diaphragm
Past Medical History:
HTN, adenoCA colon
Physical Exam:
Intubated Sedated
Lungs Coarse
Heart rrr
Abd distended very tender
Rectal guiac pos no masesse
ext no edema
Temporal waisting
Pertinent Results:
[**2198-7-31**] 03:45AM PT-17.6* PTT-29.0 INR(PT)-1.6*
[**2198-7-31**] 03:45AM PLT SMR-HIGH PLT COUNT-549*
[**2198-7-31**] 03:45AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL TARGET-1+
[**2198-7-31**] 03:45AM NEUTS-58 BANDS-24* LYMPHS-14* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-2* MYELOS-0
[**2198-7-31**] 03:45AM WBC-10.7 RBC-4.93 HGB-12.3* HCT-40.2 MCV-82
MCH-25.0* MCHC-30.7* RDW-20.7*
[**2198-7-31**] 03:45AM ACETONE-NEG
[**2198-7-31**] 03:45AM ALBUMIN-2.4* CALCIUM-8.9 PHOSPHATE-4.9*
MAGNESIUM-3.0*
[**2198-7-31**] 03:45AM LIPASE-30
[**2198-7-31**] 03:45AM ALT(SGPT)-37 AST(SGOT)-108* ALK PHOS-[**2176**]*
AMYLASE-68 TOT BILI-3.4*
[**2198-7-31**] 03:45AM GLUCOSE-101 UREA N-14 CREAT-0.7 SODIUM-136
POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-17* ANION GAP-29*
[**2198-7-31**] 04:39AM GLUCOSE-50* LACTATE-10.2*
[**2198-7-31**] 04:50AM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2198-7-31**] 04:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-4* PH-7.0
LEUK-NEG
Brief Hospital Course:
Patient sne dto ciu. Hypotensive on pressors. Was made CMO by
family expired short after
Discharge Disposition:
Expired
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Metastasic Colon carcer
Cardiorespiratory arrest
Discharge Condition:
expired
Completed by:[**2198-7-31**]
|
[
"995.92",
"038.9",
"153.3",
"401.9",
"197.7",
"518.81",
"569.83",
"785.59",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"00.17"
] |
icd9pcs
|
[
[
[]
]
] |
2308, 2345
|
2195, 2285
|
329, 694
|
2437, 2475
|
1068, 2172
|
2366, 2416
|
922, 1049
|
275, 291
|
722, 864
|
887, 907
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
222
| 137,006
|
48543+59102
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-6-11**] Discharge Date: [**2142-6-19**]
Date of Birth: [**2073-7-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Zocor
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Left lower lobe nodule
Major Surgical or Invasive Procedure:
[**2142-6-11**]: Left VATS converted to left anterior thoracotomy,
resection of superior segment of the left lower lobe,
mediastinal
lymph node dissection
History of Present Illness:
The patient is a 69-year-old woman who had undergone an x-ray
for shoulder pain that had disclosed bilateral lung
abnormalities. A CT scan was performed and confirmed a solid
nodule in the superior segment of her left lower lobe highly
suspicious for malignancy as well as a bulla in the right lower
lobe with a thickened cyst wall also concerning for malignancy.
A PET scan was performed subsequent to the CT scan. This showed
that the left lower lobe nodule showed an SUV of 16.4 as well as
a left hilar node with an uptake of 9.6. The lesion in the
right lower lobe showed an SUV of 7.5, also suspicious for
malignancy.
There was no other site of FDG avidity on the study. She also
underwent an [**Month/Day/Year 4338**] scan on [**2142-5-24**], that was negative for
metastatic disease. In addition, a PFT was performed in [**Month (only) **]
[**2141**] disclosing FEV1 of 133% of predicted and a diffusion
capacity of 82% of predicted.
Dr. [**First Name (STitle) **] performed a mediastinoscopy as well as bronchial
brushing on
[**2142-5-24**]. The mediastinoscopy was negative for carcinoma.
The bronchial brushing of the left lower lobe superior segment
was also negative.
The lesions in her right lower and left lower lobe are likely to
represent
synchronous primary lung cancers rather than stage IV disease
based upon a negative mediastinoscopy and no signs of metastatic
disease on her PET/CT scan. As a result, on [**2142-6-11**], a Left
VATS converted to a left anterior thoracotomy, a resection of
superior segment of the left lower lobe, and a mediastinal lymph
node dissection were all performed. A right lower lobectomy is
actively being considered as a future treatment option.
Past Medical History:
1. Coronary artery disease - MI x3 with her first MI at age 34.
The patient underwent a CABG in [**2118**]. Status post LAD
drug-eluting stent in [**2136**]. She is followed by Dr. [**Last Name (STitle) 120**].
2. Peripheral [**Last Name (STitle) 1106**] disease status post angioplasty of the
right leg - [**1-/2141**]
3. Chronic kidney disease
4. Renal artery stenosis status post right renal artery stent-
[**2141-5-25**]
5. Carotid stenosis status post left internal carotid stent-
08/[**2136**].
6. Gout
7. Polymyalgia rheumatica
8. Hypertension
9. Hypercholesterolemia
10. Osteoarthritis
11. Endometrial polyps- The patient has been followed by Dr.
[**Last Name (STitle) **].
12. GI bleed secondary to diverticulosis
13. Urinary incontinence
Social History:
The patient is married and lives with her
husband in [**Name (NI) 3146**]. She is retired from doing secretarial work,
but in this setting was exposed to both tobacco smoke and diesel
fumes. She smoked two packs per day for 20 years, but quit in
[**2118**]. No alcohol. She does not use an assistive device. She
walks for exercise.
Family History:
The patient's father died of CAD as did her mother. Two
brothers have CAD. A sister has had multiple TIAs.
Physical Exam:
GENERAL: Well-appearing anxious appearing elderly lady in no
apparent distress. Alert. Engaged in conversation. Moves
steadily without the aid of an assistive device.
HEENT: Normocephalic, atraumatic. Pupils equal, round and
reactive to light. Extraocular motion intact. Anicteric
sclerae. Moist mucous membranes. No lesions in the oropharynx.
Clear tympanic membranes bilaterally with normal light reflex.
Minimal cerumen.
NECK: Supple. No cervical or supraclavicular lymphadenopathy.
No appreciable thyromegaly or thyroid nodules.
CARDIAC: Regular rate and rhythm. S1, S2. No murmurs, rubs,
or
gallops. No carotid bruits.
PULMONARY: Good effort. Clear to auscultation bilaterally. No
wheezes, rales, or rhonchi.
ABDOMEN: Obese. Soft. Nontender. Nondistended. Positive
bowel sounds. No appreciable masses or hepatosplenomegaly.
EXTREMITIES: Warm. No clubbing, cyanosis, or edema. 1+
dorsalis pedis pedal pulses bilaterally.
NEUROLOGIC: Cranial nerves II through XII intact. Able to
perform the get up and go test without difficulty. Negative
Romberg.
BREASTS: Without dimpling or puckering of the skin. No
appreciable masses. No nipple discharge. No axillary
lymphadenopathy.
Pertinent Results:
[**2142-6-11**] 09:31PM URINE HOURS-RANDOM CREAT-114 SODIUM-57
[**2142-6-11**] 08:36PM TYPE-ART PO2-84* PCO2-45 PH-7.26* TOTAL
CO2-21 BASE XS--6
[**2142-6-11**] 08:36PM LACTATE-3.7*
[**2142-6-11**] 08:36PM O2 SAT-94
[**2142-6-11**] 08:36PM freeCa-1.24
[**2142-6-11**] 08:09PM GLUCOSE-167* UREA N-38* CREAT-1.7* SODIUM-137
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-18* ANION GAP-16
[**2142-6-11**] 08:09PM CK(CPK)-865*
[**2142-6-11**] 08:09PM CK-MB-10 MB INDX-1.2 cTropnT-0.06*
[**2142-6-11**] 08:09PM CALCIUM-9.4 PHOSPHATE-4.7* MAGNESIUM-2.3
[**2142-6-11**] 08:09PM WBC-12.3* RBC-3.45* HGB-10.5* HCT-31.6*
MCV-92 MCH-30.4 MCHC-33.2 RDW-15.8*
[**2142-6-11**] 08:09PM PLT COUNT-367
[**2142-6-11**] 02:32PM TYPE-ART PO2-78* PCO2-41 PH-7.27* TOTAL
CO2-20* BASE XS--7
[**2142-6-11**] 02:32PM GLUCOSE-165*
[**2142-6-11**] 02:32PM freeCa-1.35*
[**2142-6-11**] 02:17PM GLUCOSE-172* UREA N-37* CREAT-1.5* SODIUM-137
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-15* ANION GAP-18
[**2142-6-11**] 02:17PM estGFR-Using this
[**2142-6-11**] 02:17PM CK(CPK)-416*
[**2142-6-11**] 02:17PM CK-MB-6 cTropnT-0.04*
[**2142-6-11**] 02:17PM CALCIUM-10.5* PHOSPHATE-4.4 MAGNESIUM-2.6
[**2142-6-11**] 02:17PM WBC-13.2* RBC-3.97* HGB-12.0 HCT-36.1 MCV-91
MCH-30.2 MCHC-33.2 RDW-15.4
[**2142-6-11**] 02:17PM PLT COUNT-365
[**2142-6-11**] 12:07PM TYPE-ART PO2-274* PCO2-33* PH-7.38 TOTAL
CO2-20* BASE XS--4 INTUBATED-INTUBATED
[**2142-6-11**] 12:07PM GLUCOSE-173* LACTATE-3.8* NA+-137 K+-3.9
CL--107
[**2142-6-11**] 12:07PM HGB-12.4 calcHCT-37 O2 SAT-99
[**2142-6-11**] 12:07PM freeCa-1.09*
[**2142-6-11**] 10:40AM TYPE-ART PO2-233* PCO2-36 PH-7.42 TOTAL
CO2-24 BASE XS-0
[**2142-6-11**] 10:40AM GLUCOSE-143* LACTATE-2.2* NA+-138 K+-3.6
CL--104
[**2142-6-11**] 10:40AM HGB-12.1 calcHCT-36 O2 SAT-99
[**2142-6-11**] 10:40AM freeCa-1.19
[**2142-6-11**] 09:23AM TYPE-ART PO2-78* PCO2-46* PH-7.34* TOTAL
CO2-26 BASE XS--1 INTUBATED-INTUBATED
[**2142-6-11**] 09:23AM GLUCOSE-122* LACTATE-1.2 NA+-139 K+-3.7
CL--104
[**2142-6-11**] 09:23AM HGB-12.3 calcHCT-37 O2 SAT-93
[**2142-6-11**] 09:23AM freeCa-1.21
Brief Hospital Course:
The patient is a 68 year old Female who on [**6-11**] had a Left VATS
converted to left anterior thoracotomy, a resection of superior
segment of the left lower lobe, and a mediastinal lymph node
dissection. She developed postoperative Atrial Fibrillation with
a rapid ventricular rate soon afterwards and her blood pressure
was initially 80/40, leading to a transfer to the intensive care
unit. By [**6-14**], the patient had rate stabilized at around 110-120
and her pressures was around 109/47. Amiodarone had begun being
loaded as per cardiology recommendations and so it was felt, Ms.
[**Known lastname 94074**] could be transferred to the floor. After coming to the
floor, Ms. [**Known lastname 94074**] gradually improved clinically though with
persistence of her atrial fibrillation. As per Cardiology
recommendations, on [**6-15**] an initial dose of Warfarin was given
along with Heparin anticoagulation. The patient remained within
the target aPTT and PTT ranges and so therapy continued. By
[**6-17**], the patient had converted to normal sinus rhythm, was rate
controlled and had improved clinically to the point where she
could follow up on an outpatient basis with her coumadin and
amiodarone medications. The patient was informed and agreed to
the mandatory scheduled INR checks in the coumadin clinics.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
2. Atacand HCT 16-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
4. Imdur 30 mg Tablet Sustained Release 24 hr Sig: [**11-22**] Tablet
Sustained Release 24 hr PO once a day.
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual q5min as needed for chest pain.
Disp:*30 units* Refills:*2*
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Medication
Please take all other medications as directed by your PCP.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
[**Hospital1 18**]-[**Location (un) **]--please check INR twice a week. Goal INR is
between 2 and 3. Please call PCP with results.
13. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left lower lobe lung nodule.
Coronary Artery Disase s/p MI x 3
Perpheral [**Location (un) **] Disease
Hypertension/Hyperlipidemia, Gout, polymyalgia rheumatica
PSH: PCI x several, L carotid stent, aortic stent, renal
stents, s/p CCY
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, or cough
-Chest pain
-Incision develops drainage
Chest-tube site cover with a bandaid
Coumadin for atrial fibrillation: INR Goal 2.0-2.5
Call Dr. [**Last Name (STitle) **] office for coumadin dosing.
Blood Draw on XXX
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] (office phone number is [**Telephone/Fax (1) 170**]) on
the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
Report to the 4th [**Location (un) **] Department for a Chest X-Ray 45
minutes before your appointment.
Follow-up with Dr. [**Last Name (STitle) **] for further Coumadin dosing. (The
office has been notified).
Also please call [**Hospital1 18**] [**Location (un) **] at [**Telephone/Fax (1) 102141**] for an
appointment on Tuesday to have your INR checked and coumadin
assessed.
Completed by:[**2142-6-17**] Name: [**Known lastname 16484**],[**Known firstname 540**] Unit No: [**Numeric Identifier 16485**]
Admission Date: [**2142-6-11**] Discharge Date: [**2142-6-19**]
Date of Birth: [**2073-7-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor / Zocor
Attending:[**First Name3 (LF) 1999**]
Addendum:
see discharge summary
Chief Complaint:
The patient is a 69-year-old woman who had undergone an x-ray
for shoulder pain that had disclosed bilateral lung
abnormalities. A CT scan was performed and confirmed a solid
nodule in the superior segment of her left lower lobe highly
suspicious for malignancy as well as a bulla in the right lower
lobe with a thickened cyst wall also concerning for malignancy.
A PET scan was performed subsequent to the CT scan. This showed
that the left lower lobe nodule showed an SUV of 16.4 as well as
a left hilar node with an uptake of 9.6. The lesion in the
right lower lobe showed an SUV of 7.5, also suspicious for
malignancy.
There was no other site of FDG avidity on the study. She also
underwent an MRI scan on [**2142-5-24**], that was negative for
metastatic disease. In addition, a PFT was performed in [**Month (only) **]
[**2141**] disclosing FEV1 of 133% of predicted and a diffusion
capacity of 82% of predicted.
Dr. [**First Name (STitle) **] performed a mediastinoscopy as well as bronchial
brushing on
[**2142-5-24**]. The mediastinoscopy was negative for carcinoma.
The bronchial brushing of the left lower lobe superior segment
was also negative.
The lesions in her right lower and left lower lobe are likely to
represent
synchronous primary lung cancers rather than stage IV disease
based upon a negative mediastinoscopy and no signs of metastatic
disease on her PET/CT scan. As a result, on [**2142-6-11**], a Left
VATS converted to a left anterior thoracotomy, a resection of
superior segment of the left lower lobe, and a mediastinal lymph
node dissection were all performed. A right lower lobectomy is
actively being considered as a future treatment option.
Major Surgical or Invasive Procedure:
[**2142-6-11**]: Left VATS converted to left anterior thoracotomy,
resection of superior segment of the left lower lobe,
mediastinal
lymph node dissection
History of Present Illness:
The patient is a 69-year-old woman who had undergone an x-ray
for shoulder pain that had disclosed bilateral lung
abnormalities. A CT scan was performed and confirmed a solid
nodule in the superior segment of her left lower lobe highly
suspicious for malignancy as well as a bulla in the right lower
lobe with a thickened cyst wall also concerning for malignancy.
A PET scan was performed subsequent to the CT scan. This showed
that the left lower lobe nodule showed an SUV of 16.4 as well as
a left hilar node with an uptake of 9.6. The lesion in the
right lower lobe showed an SUV of 7.5, also suspicious for
malignancy.
There was no other site of FDG avidity on the study. She also
underwent an MRI scan on [**2142-5-24**], that was negative for
metastatic disease. In addition, a PFT was performed in [**Month (only) **]
[**2141**] disclosing FEV1 of 133% of predicted and a diffusion
capacity of 82% of predicted.
Dr. [**First Name (STitle) **] performed a mediastinoscopy as well as bronchial
brushing on
[**2142-5-24**]. The mediastinoscopy was negative for carcinoma.
The bronchial brushing of the left lower lobe superior segment
was also negative.
The lesions in her right lower and left lower lobe are likely to
represent
synchronous primary lung cancers rather than stage IV disease
based upon a negative mediastinoscopy and no signs of metastatic
disease on her PET/CT scan. As a result, on [**2142-6-11**], a Left
VATS converted to a left anterior thoracotomy, a resection of
superior segment of the left lower lobe, and a mediastinal lymph
node dissection were all performed. A right lower lobectomy is
actively being considered as a future treatment option.
Past Medical History:
1. Coronary artery disease - MI x3 with her first MI at age 34.
The patient underwent a CABG in [**2118**]. Status post LAD
drug-eluting stent in [**2136**]. She is followed by Dr. [**Last Name (STitle) 2124**].
2. Peripheral vascular disease status post angioplasty of the
right leg - [**1-/2141**]
3. Chronic kidney disease
4. Renal artery stenosis status post right renal artery stent-
[**2141-5-25**]
5. Carotid stenosis status post left internal carotid stent-
08/[**2136**].
6. Gout
7. Polymyalgia rheumatica
8. Hypertension
9. Hypercholesterolemia
10. Osteoarthritis
11. Endometrial polyps- The patient has been followed by Dr.
[**Last Name (STitle) 7015**].
12. GI bleed secondary to diverticulosis
13. Urinary incontinence
Social History:
The patient is married and lives with her
husband in [**Name (NI) 3744**]. She is retired from doing secretarial work,
but in this setting was exposed to both tobacco smoke and diesel
fumes. She smoked two packs per day for 20 years, but quit in
[**2118**]. No alcohol. She does not use an assistive device. She
walks for exercise.
Family History:
The patient's father died of CAD as did her mother. Two
brothers have CAD. A sister has had multiple TIAs.
Physical Exam:
GENERAL: Well-appearing anxious appearing elderly lady in no
apparent distress. Alert. Engaged in conversation. Moves
steadily without the aid of an assistive device.
HEENT: Normocephalic, atraumatic. Pupils equal, round and
reactive to light. Extraocular motion intact. Anicteric
sclerae. Moist mucous membranes. No lesions in the oropharynx.
Clear tympanic membranes bilaterally with normal light reflex.
Minimal cerumen.
NECK: Supple. No cervical or supraclavicular lymphadenopathy.
No appreciable thyromegaly or thyroid nodules.
CARDIAC: Regular rate and rhythm. S1, S2. No murmurs, rubs,
or
gallops. No carotid bruits.
PULMONARY: Good effort. Clear to auscultation bilaterally. No
wheezes, rales, or rhonchi.
ABDOMEN: Obese. Soft. Nontender. Nondistended. Positive
bowel sounds. No appreciable masses or hepatosplenomegaly.
EXTREMITIES: Warm. No clubbing, cyanosis, or edema. 1+
dorsalis pedis pedal pulses bilaterally.
NEUROLOGIC: Cranial nerves II through XII intact. Able to
perform the get up and go test without difficulty. Negative
Romberg.
BREASTS: Without dimpling or puckering of the skin. No
appreciable masses. No nipple discharge. No axillary
lymphadenopathy.
Pertinent Results:
[**2142-6-19**] WBC-8.0 RBC-3.15* Hgb-9.2* Hct-27.9* Plt Ct-352#
[**2142-6-16**] WBC-8.3 RBC-2.74* Hgb-8.1* Hct-24.4* Plt Ct-230
[**2142-6-11**] WBC-13.2* RBC-3.97* Hgb-12.0 Hct-36.1 Plt Ct-365
[**2142-6-16**] Glucose-91 UreaN-27* Creat-1.1 Na-140 K-4.1 Cl-106
HCO3-25
[**2142-6-11**] Glucose-172* UreaN-37* Creat-1.5* Na-137 K-4.0 Cl-108
HCO3-15*
[**2142-6-19**] INR 2.8 [**2142-6-18**] INR 3.8 [**2142-6-17**] INR 1.9 [**2142-6-16**]
INR 1.3
CXR [**2142-6-15**]
IMPRESSION:
1. Status post left chest tube removal, with no pneumothorax.
2. Improved right lung aeration with persistent left basilar
atelectasis or consolidation.
Echocardiogram: [**2142-6-13**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with basal
to mid inferior and infero-lateral hypokinesis. 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 arch is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
The patient is a 68 year old Female who on [**6-11**] had a Left VATS
converted to left anterior thoracotomy, a resection of superior
segment of the left lower lobe, and a mediastinal lymph node
dissection. She developed postoperative Atrial Fibrillation with
a rapid ventricular rate soon afterwards and her blood pressure
was initially 80/40, leading to a transfer to the intensive care
unit. By [**6-14**], the patient had rate stabilized at around 110-120
and her pressures was around 109/47. Amiodarone had begun being
loaded as per cardiology recommendations and so it was felt, Ms.
[**Known lastname **] could be transferred to the floor. After coming to the
floor, Ms. [**Known lastname **] gradually improved clinically though with
persistence of her atrial fibrillation. As per Cardiology
recommendations, on [**6-15**] an initial dose of Warfarin was given
along with Heparin anticoagulation. On [**2142-6-17**], she developed
rapid A Fib into the 130s. Her lopressor was increased to 37.5
[**Hospital1 **] which she converted to sinus rhythm. Cardiology was
reconsulted and felt she had tachy-brady syndrome, and
recommended she be discharged home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor
which was arranged. On [**6-18**] her INR was 3.8 the coumadin was
held and a repeat INR on [**6-19**] was 2.8. She was discharged to
home with coumadin 1 mg and to follow-up with Dr. [**Last Name (STitle) **] her PCP
for further coumadin dosing, follow-up with cardiology Dr.[**Last Name (STitle) **].
[**Name (NI) 2124**] and Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
Atacand HCT 16-12.5 mg daily, clopidogrel 75 mg daily, imdur 15
mg daily, prednisone 10 mg daily, allopurinol 300 mg qpm,
lopressor 50 mg [**Hospital1 **], simvastatin 10 mg daily, TNG 0.3 prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
2. Atacand HCT 16-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
4. Imdur 30 mg Tablet Sustained Release 24 hr Sig: [**11-22**] Tablet
Sustained Release 24 hr PO once a day.
5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual q5min as needed for chest pain.
Disp:*30 units* Refills:*2*
6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: [**11-22**] Tablet PO BID (2
times a day).
Disp:*75 Tablet(s)* Refills:*2*
10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
[**Hospital1 8**]-[**Location (un) **]--please check INR twice a week. Goal INR is
between 2 and 3. Please call PCP with results.
12. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily) for 7 days: Please take starting [**2142-6-18**] for exactly 1
week.
Disp:*14 Tablet(s)* Refills:*0*
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 18 days: Please talk to your primary care provider about
getting [**Name Initial (PRE) **] refill after this course of medication complete.
Disp:*18 Tablet(s)* Refills:*0*
15. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
1. Atacand HCT 16-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
3. Imdur 30 mg Tablet Sustained Release 24 hr Sig: [**11-22**] Tablet
Sustained Release 24 hr PO once a day.
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual q5min as needed for chest pain.
Disp:*30 units* Refills:*2*
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: [**11-22**] Tablet PO BID (2
times a day).
Disp:*75 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
[**Hospital1 8**]-[**Location (un) **]--please check INR twice a week. Goal INR is
between 2.0-2.5 Please call PCP with results.
10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Coumadin 1 mg Tablet Sig: One (1) Tablet PO as directed to
maintain INR 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 42**] VNA
Discharge Diagnosis:
Left lower lobe lung nodule.
Coronary Artery Disase s/p MI x 3
Perpheral Vascular Disease
Hypertension/Hyperlipidemia, Gout, polymyalgia rheumatica
PSH: PCI x several, L carotid stent, aortic stent, renal
stents, s/p CCY
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 6019**] office [**Telephone/Fax (1) 1477**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, or cough
-Chest pain
-Incision develops redness or drainage
-or if you have any symptoms that concern you.
Coumadin for atrial fibrillation: INR Goal 2.0-2.5
Call Dr. [**Last Name (STitle) **] office for coumadin dosing.
Blood Draw on [**6-20**] at the [**Hospital1 8**] [**Location (un) **] coumadin clinic.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 1477**] on [**2142-7-3**] at 11:30am on
the [**Hospital Ward Name 600**] [**Hospital Ward Name **] Clinical Center, [**Location (un) 1579**].
Follow-up with Dr. [**Last Name (STitle) 1431**] on [**2142-7-3**] at 2:30pm [**Hospital Ward Name **]
Clinical Center.
Follow-up with Dr. [**Last Name (STitle) **] on [**2142-7-3**] at 3:30pm [**Hospital Ward Name **] Clinical
Center
Report to the 4th Radiology Department for a Chest X-Ray 45
minutes before your appointment.
Follow-up with Dr. [**Last Name (STitle) **] for further Coumadin dosing. (The
office has been notified).
Also please call [**Hospital1 8**] [**Location (un) **] at [**Telephone/Fax (1) 16486**] for an
appointment on Wednesday to have your INR checked and coumadin
assessed.
Call Dr.[**Name (NI) 16487**] office (cardiology) for follow-up
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 2001**]
Completed by:[**2142-6-19**]
|
[
"427.31",
"196.1",
"274.9",
"162.5",
"V64.42",
"V45.82",
"272.4",
"412",
"414.00",
"725",
"V45.81",
"403.90",
"443.9",
"585.9",
"427.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.39",
"40.3"
] |
icd9pcs
|
[
[
[]
]
] |
23930, 23987
|
18909, 20537
|
12955, 13112
|
24252, 24259
|
17333, 18886
|
24753, 25801
|
15973, 16084
|
20780, 23907
|
24008, 24231
|
20563, 20757
|
24283, 24730
|
16099, 17314
|
11227, 12917
|
13140, 14830
|
14852, 15602
|
15618, 15957
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,106
| 195,209
|
23781+23782+23783+23784
|
Discharge summary
|
report+report+report+report
|
Admission Date: [**2101-2-15**] Discharge Date: [**2101-3-3**]
Date of Birth: [**2055-5-18**] Sex: M
Service: CSU
ADMISSION DIAGNOSES: Hypertensive urgency.
Rule out myocardial infarction.
DISCHARGE DIAGNOSES: Multivessel coronary artery disease -
status post cardiac catheterization, status post coronary
artery bypass grafting x6.
Postoperative atrial fibrillation, atrial flutter.
Hypertension.
Diabetes mellitus type 2 (new diagnosis).
Embolic cerebrovascular accident.
Blood loss anemia.
Pleural effusions.
Question of pneumonia versus aspiration pneumonia.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname **] was thought to be
a generally healthy 45-year-old gentleman who had not seen a
physician in over 20 years who presented to the ER with
complaints of increasing shortness of breath and was found at
[**Hospital1 **] to have significantly increased blood pressure to
180s-190s. He was transferred to the [**Hospital1 190**] for further workup. He was initially admitted
to the medical service for management of his hypertensive
urgency and further workup of his dyspnea.
On exam, he was afebrile. His pulse was in the 60s. His blood
pressure was between 180 and 190 systolic with a diastolic of
95-100. He is otherwise breathing at a rate of 22 and
saturating 96% on room air. His exam was notable for a few
crackles at the bases of his lungs. But otherwise, his heart
was regular and otherwise there was no rub. He had trace
edema in his extremities. His exam is otherwise essentially
unremarkable.
His admission white count was 10.3 with a hematocrit of 42.
His BUN and creatinine were notably 32 and 1.6 and his blood
sugar was 194. His CK, CK-MB, and troponins were normal.
Notably, a chest x-ray showed no evidence of failure. But his
EKG showed some T-wave inversion in the lateral leads. He was
therefore admitted to the medical service for rule out MI and
further cardiac workup.
HOSPITAL COURSE: Patient was admitted as noted above. His
cardiac enzymes were negative for evidencing any myocardial
infarction. But given his significant risk factors, it is
felt that he needed to be worked up somewhat further. He
continued to have significant elevations of his blood
pressure which were controlled with combination of various
nitrate drips along with beta-blockade, diuretics, and ACE
inhibitors.
During this time, he was monitored in the cardiac intensive
care unit. He subsequently underwent noninvasive cardiac
stress testing, which did not show any evidence of ischemia;
but he was quite symptomatic during this time. Therefore, he
subsequently underwent cardiac catheterization which in fact
showed 3 vessel coronary artery disease with elevated left-
sided filling pressures.
His cardiac catheterization from [**2101-2-17**] showed that
he had a left dominant system with a 90% stenosis at the
origin of the left anterior descending with an 80% distal
lesion. His left circumflex had a large trifurcating ramus
with an 80% lesion in all 3 branches and 99% OM-1 lesion,
which was intermittently occluded, and 90% lesion of the PDA.
He had an intra-aortic balloon pump placed periprocedural and
urgent cardiac surgical consultation was obtained at which
time it is felt that patient would most benefit from coronary
artery bypass grafting.
He was taken to the operating room on [**2101-2-18**] at which
time he had a 6-vessel coronary artery bypass grafting with
LIMA to LAD, SVG to PDA to OM, SVG to IR to IR, SVG to IR.
Cardiopulmonary bypass time was 97 minutes and the cross-
clamp time was 68 minutes. There were no intraoperative
complications. Patient was transferred to the cardiac surgery
recovery unit postoperatively intubated on Levophed,
propofol, insulin, and milrinone drips.
Postoperatively, patient's blood pressures were quite labile
requiring vigilant monitoring of his hemodynamic medications.
But we were able to stabilize his blood pressure and his
cardiac index. We removed his intra-aortic balloon pump on
postoperative day 2 without complication. He was difficult to
extubate initially secondary not to problems with
oxygenation, but problems with mentation. We minimized his
sedation and narcotics in order to allow him to clear, but
subsequently quite slow in clearing.
It was noted on postoperative day 4, the patient was having
significantly decreased movement of his left side and also
given his change in mentation, that there is concern that
neurologic process might be occurring. We attempted to rule
out any infectious and metabolic etiologies, which were
negative. Subsequently, a stat CT scan of the head showed no
evidence of major infarction, or mass, or hemorrhage. But a
neurology consultation was obtained, who recommended MR of
the brain, which showed diffuse multiple punctate infarcts
involving the white matter in both cerebral hemispheres, in
the frontal and parietal lobes, and also small left acute
cerebellar infarct. These were consistent with microembolic
CVA, which likely occurred periprocedural.
He was started on Plavix and this statin. But it is felt by
neurology that he should not be anticoagulated at this time
as there is no further source of emboli. His cardiac status
was also compromised postoperatively by multiple episodes of
atrial flutter, which subsequently degenerated to atrial
fibrillation. Electrophysiology service was consulted for
assistance in management of this and initially had the
patient scheduled for ablation of his A-flutter. But as it
converted to atrial fibrillation, it is felt he should be
maintained on Coumadin and amiodarone. Will subsequently
follow up with electrophysiology as an outpatient.
He otherwise never evidenced any sort of ischemia or
congestive heart failure postoperatively, and had good
results from his surgery. Patient notably came in
hyperglycemic. Workup included a HBA1C which was found to be
8.3, which was consistent with history of diabetes mellitus.
He was seen by [**Hospital **] Clinic who started him on a regimen of
oral medications and insulin and continued to follow him
throughout his hospitalization. By the time of his discharge,
his blood sugars were well controlled on combination of oral
medications and glargine at night along with an insulin-
sliding scale.
Notably, patient's white blood cell count was elevated early
in the postoperative period on postoperative day 3 along with
low grade temperatures with occasional fevers to 101. He was
pancultured at that time and his urine and blood cultures
never evidenced any growth. His central line was changed and
removed. But the catheter tip also never evidenced any
growth. His sputum cultures consistently grew out
oropharyngeal flora and his chest x-ray showed what was left
pleural effusion process, but could not definitively rule out
a pneumonia. He was therefore treated empirically with
vancomycin and Zosyn for possible pneumonia versus aspiration
pneumonia. Was started on a 2-week course of this, which he
will finish at rehab.
By the time of his discharge, he had been afebrile with a
white blood cell count, which had been trending down. As
noted above, the patient was anticoagulated with Coumadin for
his atrial fibrillation with a Heparin drip used as a bridge.
He did have a formal swallow evaluation which showed that he
was able to take liquids and solids without difficulty or
risk for aspiration.
By postoperative day 13, patient was alert and mentating
well. He was moving all his extremities with a slight deficit
in the left upper and left lower extremity and the strength
each [**1-22**]. His lungs were essentially clear bilaterally. He
was in a sinus rhythm. His abdomen was otherwise soft. His
wound was healing well without significant drainage, and he
only had trace edema in the lower extremities. His white
blood cell count was 15.5 with a hematocrit of 29.5. His
platelets are 366. His INR was 1.5. His BUN and creatinine
were 27 and 1.6. His weight was 115 kg with a preoperative
weight of 107 kg.
As he had been afebrile, hemodynamically normal, and was just
receiving physical and occupational therapy, it is felt that
he can be discharged to rehabilitation in fair condition.
He was discharged to rehab on the following medications:
Lopressor 100 mg p.o. t.i.d., Lasix 20 mg p.o. q.12h.,
potassium chloride 20 mEq p.o. q.12h., Colace 100 mg p.o.
b.i.d., aspirin 82 mg p.o. once daily, Percocet 5-325 take 1-
2 tablets every 4-6 hours as needed for pain, Plavix 75 mg
p.o. once daily, Lipitor 10 mg p.o. once daily, Protonix 40
mg p.o. once daily, Norvasc 10 mg p.o. once daily, Glipizide
5 mg p.o. b.i.d., amiodarone 200 mg p.o. t.i.d. for 4 weeks,
Ambien 5 mg p.o. nightly as needed, Flomax 0.4 mg p.o.
nightly, lisinopril 10 mg p.o. once daily, Coumadin 4 mg p.o.
nightly with continued followup of his PT/INR for a goal of
2.0-2.5, insulin glargine 9 units subcutaneously nightly,
Humalog insulin-sliding scale, vancomycin 1 gram IV q.12h.
for 7 more days for a total course of 2 weeks, Zosyn 4.5
grams IV q.8h. for 7 more days for a total of 2 weeks.
He was to followup with Dr. [**Last Name (STitle) **] of electrophysiology in
clinic in 1 month and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of cardiology in 1
month. He is to followup with the [**Hospital **] Clinic with Dr.
[**Last Name (STitle) 174**] if possible upon discharge from rehab for management of
his blood sugars, and he was to followup with the Neurology
[**Hospital 4038**] Clinic in 2 weeks and Dr.[**Name (NI) 27686**] office in 4
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2101-3-3**] 10:46:03
T: [**2101-3-3**] 11:30:36
Job#: [**Job Number 60716**]
Admission Date: [**2101-2-15**] Discharge Date: [**2101-3-3**]
Date of Birth: [**2055-5-18**] Sex: M
Service: CSU
ADMISSION DIAGNOSES: Hypertensive urgency.
Rule out myocardial infarction.
DISCHARGE DIAGNOSES: Multivessel coronary artery disease -
status post cardiac catheterization, status post coronary
artery bypass grafting x6.
Postoperative atrial fibrillation, atrial flutter.
Hypertension.
Diabetes mellitus type 2 (new diagnosis).
Embolic cerebrovascular accident.
Blood loss anemia.
Pleural effusions.
Question of pneumonia versus aspiration pneumonia.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname **] was thought to be
a generally healthy 45-year-old gentleman who had not seen a
physician in over 20 years who presented to the ER with
complaints of increasing shortness of breath and was found at
[**Hospital1 **] to have significantly increased blood pressure to
180s-190s. He was transferred to the [**Hospital1 190**] for further workup. He was initially admitted
to the medical service for management of his hypertensive
urgency and further workup of his dyspnea.
On exam, he was afebrile. His pulse was in the 60s. His blood
pressure was between 180 and 190 systolic with a diastolic of
95-100. He is otherwise breathing at a rate of 22 and
saturating 96% on room air. His exam was notable for a few
crackles at the bases of his lungs. But otherwise, his heart
was regular and otherwise there was no rub. He had trace
edema in his extremities. His exam is otherwise essentially
unremarkable.
His admission white count was 10.3 with a hematocrit of 42.
His BUN and creatinine were notably 32 and 1.6 and his blood
sugar was 194. His CK, CK-MB, and troponins were normal.
Notably, a chest x-ray showed no evidence of failure. But his
EKG showed some T-wave inversion in the lateral leads. He was
therefore admitted to the medical service for rule out MI and
further cardiac workup.
HOSPITAL COURSE: Patient was admitted as noted above. His
cardiac enzymes were negative for evidencing any myocardial
infarction. But given his significant risk factors, it is
felt that he needed to be worked up somewhat further. He
continued to have significant elevations of his blood
pressure which were controlled with combination of various
nitrate drips along with beta-blockade, diuretics, and ACE
inhibitors.
During this time, he was monitored in the cardiac intensive
care unit. He subsequently underwent noninvasive cardiac
stress testing, which did not show any evidence of ischemia;
but he was quite symptomatic during this time. Therefore, he
subsequently underwent cardiac catheterization which in fact
showed 3 vessel coronary artery disease with elevated left-
sided filling pressures.
His cardiac catheterization from [**2101-2-17**] showed that
he had a left dominant system with a 90% stenosis at the
origin of the left anterior descending with an 80% distal
lesion. His left circumflex had a large trifurcating ramus
with an 80% lesion in all 3 branches and 99% OM-1 lesion,
which was intermittently occluded, and 90% lesion of the PDA.
He had an intra-aortic balloon pump placed periprocedural and
urgent cardiac surgical consultation was obtained at which
time it is felt that patient would most benefit from coronary
artery bypass grafting.
He was taken to the operating room on [**2101-2-18**] at which
time he had a 6-vessel coronary artery bypass grafting with
LIMA to LAD, SVG to PDA to OM, SVG to IR to IR, SVG to IR.
Cardiopulmonary bypass time was 97 minutes and the cross-
clamp time was 68 minutes. There were no intraoperative
complications. Patient was transferred to the cardiac surgery
recovery unit postoperatively intubated on Levophed,
propofol, insulin, and milrinone drips.
Postoperatively, patient's blood pressures were quite labile
requiring vigilant monitoring of his hemodynamic medications.
But we were able to stabilize his blood pressure and his
cardiac index. We removed his intra-aortic balloon pump on
postoperative day 2 without complication. He was difficult to
extubate initially secondary not to problems with
oxygenation, but problems with mentation. We minimized his
sedation and narcotics in order to allow him to clear, but
subsequently quite slow in clearing.
It was noted on postoperative day 4, the patient was having
significantly decreased movement of his left side and also
given his change in mentation, that there is concern that
neurologic process might be occurring. We attempted to rule
out any infectious and metabolic etiologies, which were
negative. Subsequently, a stat CT scan of the head showed no
evidence of major infarction, or mass, or hemorrhage. But a
neurology consultation was obtained, who recommended MR of
the brain, which showed diffuse multiple punctate infarcts
involving the white matter in both cerebral hemispheres, in
the frontal and parietal lobes, and also small left acute
cerebellar infarct. These were consistent with microembolic
CVA, which likely occurred periprocedural.
He was started on Plavix and this statin. But it is felt by
neurology that he should not be anticoagulated at this time
as there is no further source of emboli. His cardiac status
was also compromised postoperatively by multiple episodes of
atrial flutter, which subsequently degenerated to atrial
fibrillation. Electrophysiology service was consulted for
assistance in management of this and initially had the
patient scheduled for ablation of his A-flutter. But as it
converted to atrial fibrillation, it is felt he should be
maintained on Coumadin and amiodarone. Will subsequently
follow up with electrophysiology as an outpatient.
He otherwise never evidenced any sort of ischemia or
congestive heart failure postoperatively, and had good
results from his surgery. Patient notably came in
hyperglycemic. Workup included a HBA1C which was found to be
8.3, which was consistent with history of diabetes mellitus.
He was seen by [**Hospital **] Clinic who started him on a regimen of
oral medications and insulin and continued to follow him
throughout his hospitalization. By the time of his discharge,
his blood sugars were well controlled on combination of oral
medications and glargine at night along with an insulin-
sliding scale.
Notably, patient's white blood cell count was elevated early
in the postoperative period on postoperative day 3 along with
low grade temperatures with occasional fevers to 101. He was
pancultured at that time and his urine and blood cultures
never evidenced any growth. His central line was changed and
removed. But the catheter tip also never evidenced any
growth. His sputum cultures consistently grew out
oropharyngeal flora and his chest x-ray showed what was left
pleural effusion process, but could not definitively rule out
a pneumonia. He was therefore treated empirically with
vancomycin and Zosyn for possible pneumonia versus aspiration
pneumonia. Was started on a 2-week course of this, which he
will finish at rehab.
By the time of his discharge, he had been afebrile with a
white blood cell count, which had been trending down. As
noted above, the patient was anticoagulated with Coumadin for
his atrial fibrillation with a Heparin drip used as a bridge.
He did have a formal swallow evaluation which showed that he
was able to take liquids and solids without difficulty or
risk for aspiration.
By postoperative day 13, patient was alert and mentating
well. He was moving all his extremities with a slight deficit
in the left upper and left lower extremity and the strength
each [**1-22**]. His lungs were essentially clear bilaterally. He
was in a sinus rhythm. His abdomen was otherwise soft. His
wound was healing well without significant drainage, and he
only had trace edema in the lower extremities. His white
blood cell count was 15.5 with a hematocrit of 29.5. His
platelets are 366. His INR was 1.5. His BUN and creatinine
were 27 and 1.6. His weight was 115 kg with a preoperative
weight of 107 kg.
As he had been afebrile, hemodynamically normal, and was just
receiving physical and occupational therapy, it is felt that
he can be discharged to rehabilitation in fair condition.
He was discharged to rehab on the following medications:
Lopressor 100 mg p.o. t.i.d., Lasix 20 mg p.o. q.12h.,
potassium chloride 20 mEq p.o. q.12h., Colace 100 mg p.o.
b.i.d., aspirin 82 mg p.o. once daily, Percocet 5-325 take 1-
2 tablets every 4-6 hours as needed for pain, Plavix 75 mg
p.o. once daily, Lipitor 10 mg p.o. once daily, Protonix 40
mg p.o. once daily, Norvasc 10 mg p.o. once daily, Glipizide
5 mg p.o. b.i.d., amiodarone 200 mg p.o. t.i.d. for 4 weeks,
Ambien 5 mg p.o. nightly as needed, Flomax 0.4 mg p.o.
nightly, lisinopril 10 mg p.o. once daily, Coumadin 4 mg p.o.
nightly with continued followup of his PT/INR for a goal of
2.0-2.5, insulin glargine 9 units subcutaneously nightly,
Humalog insulin-sliding scale, vancomycin 1 gram IV q.12h.
for 7 more days for a total course of 2 weeks, Zosyn 4.5
grams IV q.8h. for 7 more days for a total of 2 weeks.
He was to followup with Dr. [**Last Name (STitle) **] of electrophysiology in
clinic in 1 month and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of cardiology in 1
month. He is to followup with the [**Hospital **] Clinic with Dr.
[**Last Name (STitle) 174**] if possible upon discharge from rehab for management of
his blood sugars, and he was to followup with the Neurology
[**Hospital 4038**] Clinic in 2 weeks and Dr.[**Name (NI) 27686**] office in 4
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2101-3-3**] 10:46:03
T: [**2101-3-3**] 11:30:36
Job#: [**Job Number 60716**]
Admission Date: [**2101-2-15**] Discharge Date: [**2101-3-3**]
Date of Birth: [**2055-5-18**] Sex: M
Service: CSU
ADMISSION DIAGNOSES: Hypertensive urgency.
Rule out myocardial infarction.
DISCHARGE DIAGNOSES: Multivessel coronary artery disease -
status post cardiac catheterization, status post coronary
artery bypass grafting x6.
Postoperative atrial fibrillation, atrial flutter.
Hypertension.
Diabetes mellitus type 2 (new diagnosis).
Embolic cerebrovascular accident.
Blood loss anemia.
Pleural effusions.
Question of pneumonia versus aspiration pneumonia.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname **] was thought to be
a generally healthy 45-year-old gentleman who had not seen a
physician in over 20 years who presented to the ER with
complaints of increasing shortness of breath and was found at
[**Hospital1 **] to have significantly increased blood pressure to
180s-190s. He was transferred to the [**Hospital1 190**] for further workup. He was initially admitted
to the medical service for management of his hypertensive
urgency and further workup of his dyspnea.
On exam, he was afebrile. His pulse was in the 60s. His blood
pressure was between 180 and 190 systolic with a diastolic of
95-100. He is otherwise breathing at a rate of 22 and
saturating 96% on room air. His exam was notable for a few
crackles at the bases of his lungs. But otherwise, his heart
was regular and otherwise there was no rub. He had trace
edema in his extremities. His exam is otherwise essentially
unremarkable.
His admission white count was 10.3 with a hematocrit of 42.
His BUN and creatinine were notably 32 and 1.6 and his blood
sugar was 194. His CK, CK-MB, and troponins were normal.
Notably, a chest x-ray showed no evidence of failure. But his
EKG showed some T-wave inversion in the lateral leads. He was
therefore admitted to the medical service for rule out MI and
further cardiac workup.
HOSPITAL COURSE: Patient was admitted as noted above. His
cardiac enzymes were negative for evidencing any myocardial
infarction. But given his significant risk factors, it is
felt that he needed to be worked up somewhat further. He
continued to have significant elevations of his blood
pressure which were controlled with combination of various
nitrate drips along with beta-blockade, diuretics, and ACE
inhibitors.
During this time, he was monitored in the cardiac intensive
care unit. He subsequently underwent noninvasive cardiac
stress testing, which did not show any evidence of ischemia;
but he was quite symptomatic during this time. Therefore, he
subsequently underwent cardiac catheterization which in fact
showed 3 vessel coronary artery disease with elevated left-
sided filling pressures.
His cardiac catheterization from [**2101-2-17**] showed that
he had a left dominant system with a 90% stenosis at the
origin of the left anterior descending with an 80% distal
lesion. His left circumflex had a large trifurcating ramus
with an 80% lesion in all 3 branches and 99% OM-1 lesion,
which was intermittently occluded, and 90% lesion of the PDA.
He had an intra-aortic balloon pump placed periprocedural and
urgent cardiac surgical consultation was obtained at which
time it is felt that patient would most benefit from coronary
artery bypass grafting.
He was taken to the operating room on [**2101-2-18**] at which
time he had a 6-vessel coronary artery bypass grafting with
LIMA to LAD, SVG to PDA to OM, SVG to IR to IR, SVG to IR.
Cardiopulmonary bypass time was 97 minutes and the cross-
clamp time was 68 minutes. There were no intraoperative
complications. Patient was transferred to the cardiac surgery
recovery unit postoperatively intubated on Levophed,
propofol, insulin, and milrinone drips.
Postoperatively, patient's blood pressures were quite labile
requiring vigilant monitoring of his hemodynamic medications.
But we were able to stabilize his blood pressure and his
cardiac index. We removed his intra-aortic balloon pump on
postoperative day 2 without complication. He was difficult to
extubate initially secondary not to problems with
oxygenation, but problems with mentation. We minimized his
sedation and narcotics in order to allow him to clear, but
subsequently quite slow in clearing.
It was noted on postoperative day 4, the patient was having
significantly decreased movement of his left side and also
given his change in mentation, that there is concern that
neurologic process might be occurring. We attempted to rule
out any infectious and metabolic etiologies, which were
negative. Subsequently, a stat CT scan of the head showed no
evidence of major infarction, or mass, or hemorrhage. But a
neurology consultation was obtained, who recommended MR of
the brain, which showed diffuse multiple punctate infarcts
involving the white matter in both cerebral hemispheres, in
the frontal and parietal lobes, and also small left acute
cerebellar infarct. These were consistent with microembolic
CVA, which likely occurred periprocedural.
He was started on Plavix and this statin. But it is felt by
neurology that he should not be anticoagulated at this time
as there is no further source of emboli. His cardiac status
was also compromised postoperatively by multiple episodes of
atrial flutter, which subsequently degenerated to atrial
fibrillation. Electrophysiology service was consulted for
assistance in management of this and initially had the
patient scheduled for ablation of his A-flutter. But as it
converted to atrial fibrillation, it is felt he should be
maintained on Coumadin and amiodarone. Will subsequently
follow up with electrophysiology as an outpatient.
He otherwise never evidenced any sort of ischemia or
congestive heart failure postoperatively, and had good
results from his surgery. Patient notably came in
hyperglycemic. Workup included a HBA1C which was found to be
8.3, which was consistent with history of diabetes mellitus.
He was seen by [**Hospital **] Clinic who started him on a regimen of
oral medications and insulin and continued to follow him
throughout his hospitalization. By the time of his discharge,
his blood sugars were well controlled on combination of oral
medications and glargine at night along with an insulin-
sliding scale.
Notably, patient's white blood cell count was elevated early
in the postoperative period on postoperative day 3 along with
low grade temperatures with occasional fevers to 101. He was
pancultured at that time and his urine and blood cultures
never evidenced any growth. His central line was changed and
removed. But the catheter tip also never evidenced any
growth. His sputum cultures consistently grew out
oropharyngeal flora and his chest x-ray showed what was left
pleural effusion process, but could not definitively rule out
a pneumonia. He was therefore treated empirically with
vancomycin and Zosyn for possible pneumonia versus aspiration
pneumonia. Was started on a 2-week course of this, which he
will finish at rehab.
By the time of his discharge, he had been afebrile with a
white blood cell count, which had been trending down. As
noted above, the patient was anticoagulated with Coumadin for
his atrial fibrillation with a Heparin drip used as a bridge.
He did have a formal swallow evaluation which showed that he
was able to take liquids and solids without difficulty or
risk for aspiration.
By postoperative day 13, patient was alert and mentating
well. He was moving all his extremities with a slight deficit
in the left upper and left lower extremity and the strength
each [**1-22**]. His lungs were essentially clear bilaterally. He
was in a sinus rhythm. His abdomen was otherwise soft. His
wound was healing well without significant drainage, and he
only had trace edema in the lower extremities. His white
blood cell count was 15.5 with a hematocrit of 29.5. His
platelets are 366. His INR was 1.5. His BUN and creatinine
were 27 and 1.6. His weight was 115 kg with a preoperative
weight of 107 kg.
As he had been afebrile, hemodynamically normal, and was just
receiving physical and occupational therapy, it is felt that
he can be discharged to rehabilitation in fair condition.
He was discharged to rehab on the following medications:
Lopressor 100 mg p.o. t.i.d., Lasix 20 mg p.o. q.12h.,
potassium chloride 20 mEq p.o. q.12h., Colace 100 mg p.o.
b.i.d., aspirin 82 mg p.o. once daily, Percocet 5-325 take 1-
2 tablets every 4-6 hours as needed for pain, Plavix 75 mg
p.o. once daily, Lipitor 10 mg p.o. once daily, Protonix 40
mg p.o. once daily, Norvasc 10 mg p.o. once daily, Glipizide
5 mg p.o. b.i.d., amiodarone 200 mg p.o. t.i.d. for 4 weeks,
Ambien 5 mg p.o. nightly as needed, Flomax 0.4 mg p.o.
nightly, lisinopril 10 mg p.o. once daily, Coumadin 4 mg p.o.
nightly with continued followup of his PT/INR for a goal of
2.0-2.5, insulin glargine 9 units subcutaneously nightly,
Humalog insulin-sliding scale, vancomycin 1 gram IV q.12h.
for 7 more days for a total course of 2 weeks, Zosyn 4.5
grams IV q.8h. for 7 more days for a total of 2 weeks.
He was to followup with Dr. [**Last Name (STitle) **] of electrophysiology in
clinic in 1 month and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of cardiology in 1
month. He is to followup with the [**Hospital **] Clinic with Dr.
[**Last Name (STitle) 174**] if possible upon discharge from rehab for management of
his blood sugars, and he was to followup with the Neurology
[**Hospital 4038**] Clinic in 2 weeks and Dr.[**Name (NI) 27686**] office in 4
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2101-3-3**] 10:46:03
T: [**2101-3-3**] 11:30:36
Job#: [**Job Number 60716**]
Admission Date: [**2101-2-15**] Discharge Date: [**2101-3-3**]
Date of Birth: [**2055-5-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
CABGx6
Cardiac Catheterization with IntrAortic Balloon pump
History of Present Illness:
45yo non-smoking Male with family history of CAD who present to
OSH with progressive sob over one month. He reports antecedent
"flu" like symptoms including congestion, headache,
non-productive cough. The symptoms resolved after two weeks at
which point he noticed dyspnea on exertion and continued
non-productive cough. Symptoms are exacerbated at night when he
lies down and relieved by sitting up. Pt admits to PND but
denies orthopnea - stable 1 pillow. Pt denies chest pain, but
admits to some reproducible chest discomfort. He also denies le
swelling (thought he was just getting flabby). Although the
patient is not very active, he reports he could walk many miles
and walk up 1 flight of stairs (and maybe two flights with some
strain) without difficulty 6 months ago. Now though he admits
he can not walk up a flight of stairs without shortness of
breath.
The patient presented to Metowest ED with a BP of 194/138
with pulse 110 and 2+ piting edema. ECG was read as NSR with
LVH and non-specific anterior T and ST abnormalities. CXR
showed curly B-lines with redistribution consistent with CHF.
BNP was 1690, CK 74, troponin 0.05. He was given 40mg IV lasix
x1, 1 inch nitro past without change in his BP. Cardiology on
call recommended IV hydralazine, however this was never given as
they had difficulty obtaining hydralazine from the pharmacy at
the time. He was subsequently started on nitro gtt and
transferred to [**Hospital1 18**] ED.
At [**Hospital1 18**], the patient received ASA x1, SL NTG and metoprolol
5mg IV x1. He was then started back on the nitro gtt and
admitted to the CCU.
Past Medical History:
None (Has not seen a doctor since the 80s)
Social History:
Pt is a retired former desk worker. He has worked at med
records at [**Hospital1 **], desk clert at motel 6, etc in past. He
admits to occasional drug use but denies smoking, illicit drug
use.
Family History:
Father: 1st MI at 55, CA
Mother: [**Name (NI) 11964**]
Pt is the youngest of 9 children.
Brother: CABG at age 50
Brother: CVA ?age
Brother: gall bladder, pancreatitis
Physical Exam:
VS:
On admision to ED: T: 97.7 HR: 72 BP: 294/131 RR: 20
SaO2: 95% on RA
At time of transfer: T: 97.2 HR: 66 BP: 184/96 RR: 22
SaO2: 96% RA
Gen: middle aged caucasian male lying in bed asleep but easily
arousable to verbal stimuli. Conversing fluently in full
sentences. NAD
HEENT: EOMI, anicteric, PERRL 2mm bilaterally
Left fundoscopic exam: optic disc difficult to appreciate, no
obvious nicking of vessels, or flame hemorrhage.
Right fundoscopic exam: difficult to assess due to glare.
CV: RRR, S1, S2, no murmurs, rubs, gallops
Chest: CTA bilaterally
Abd: soft, NT, ND, BS+
Ext: trace to +1 pitting edema
Neuro: CN II-XII grossly intact
Pertinent Results:
[**2101-2-15**] 02:55AM GLUCOSE-194* UREA N-32* CREAT-1.6* SODIUM-138
POTASSIUM-3.1* CHLORIDE-98 TOTAL CO2-29 ANION GAP-14
[**2101-2-15**] 02:55AM WBC-10.3 RBC-5.12 HGB-14.2 HCT-42.0 MCV-82
MCH-27.7 MCHC-33.7 RDW-14.1
[**2101-2-15**] 02:55AM NEUTS-72.7* LYMPHS-21.7 MONOS-3.8 EOS-1.6
BASOS-0.2
[**2101-2-15**] 02:55AM PLT COUNT-206
[**2101-2-15**] 02:55AM PT-13.4 PTT-22.6 INR(PT)-1.1
[**2101-2-15**] 02:55AM CK(CPK)-63
[**2101-2-15**] 02:55AM CK-MB-NotDone
[**2101-2-15**] 02:55AM cTropnT-0.05*
.
[**2101-2-15**] CXR: Portable AP, min rotation, good inspiration and
penetration. No air under diaphragm, no obvious bony fractures,
possible vascular redistribution.
.
[**2101-2-15**] ECG: NSR at 70, Nml axis, widened P wave, TWI in I, aVL,
II, V2-V6, 0.5mm ST depression in I, 0.25mm ST depression in L,
0.5mm ST elevation in V1, V2, LVH.
.
[**2101-2-17**] ETT-MIBI:
"INTERPRETATION: 45 yo man was referred to evaluate his
shortness of
breath. The patient completed 3 minutes of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol
representing
a very poor functional exercise tolerance. The exercise test was
stopped
secondary to early-onset, progressive and marked shortness of
breath at
peak exercise. In the setting of the marked shortness of breath,
a drop
in systolic blood pressure was noted from baseline; 140/90 to
120/88
(taken twice). No chest, back, neck or arm discomforts were
reported
during the procedure. No lightheadedness of pre-syncopal
symptoms were
reported. In the presence of baseline LVH, the ECG is
uninterpretable.
The rhythm was sinus with no ectopy noted. As noted, an
asymptomatic
hypotensive response to exercise was noted.
IMPRESSION: Poor functional exercise tolerance limited by marked
dyspnea disproportionate to the level of exercise. Asymptomatic
hypotensive blood pressure response to exercise. No typical
anginal
symptoms with an uninterpretable ECG. Nuclear report sent
separatately."
.
.
"HISTORY: the new diagnosis of diabetes, hypercholesterolemia
and new onset congestive heart failure.
SUMMARY OF THE PRELIMINARY REPORT FROM THE EXERCISE LAB:
Exercise protocol: [**Doctor First Name **]
Resting heart rate: 61
Resting blood pressure: 140/98
Exercise duration: 3 minutes
Peak heart rate: 92
Percent maximum predicted heart rate obtained: 53%
Blood pressure at peak exercise: 120/88
Symptoms during exercise: progressive early onset shortness of
breath
Reason exercise terminated: progressive shortness of breath and
drop in systolic blood pressure
ECG findings: uninterpretable
INTERPRETATION:
Imaging Protocol: Gated SPECT
Resting perfusion images were obtained with Tl-201.
Tracer was injected 15 minutes prior to obtaining the resting
images. Exercise
images were obtained with Tc-[**Age over 90 **]m sestamibi.
This study was interpreted using the 17-segment myocardial
perfusion model.
The image quality is good.
Left ventricular cavity size is enlarged with a calculated
volume at end
diastole of 244 cc.
Gated images reveal severe global hypokinesis.
The calculated left ventricular ejection fraction is 27%.
There are no fixed or reversible perfusion defects.
IMPRESSION: Normal myocardial perfusion at the level of exercise
achieved with left ventricular dilatation, global hypokinesis,
and calculated ejection fraction of 27%."
.
.
[**2101-2-17**] Cardiac Catheterization:
"INDICATIONS FOR CATHETERIZATION:
Positive stress test, ongoing chest pain.
PROCEDURE:
Coronary Angiography: was performed in multiple projections
using a 6
French JL4, a 6 French JR4 catheter, and a 6 F AR2, with manual
contrast
injections.
Intra-aortic balloon counterpulsation: was initiated with an
introducer
sheath using a 8F 40 cc wire guided catheter, inserted via the
right
femoral artery.
Conscious Sedation: was provided with appropriate monitoring
performed by
a member of the nursing staff.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.32 m2
HEMOGLOBIN: 13.9 gms %
FICK
**PRESSURES
LEFT VENTRICLE {s/ed} 147/30
AORTA {s/d/m} 147/108/119
**CARDIAC OUTPUT
HEART RATE {beats/min} 65
RHYTHM SINUS
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD DISCRETE 80
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD DISCRETE 80
9) DIAGONAL-1 NORMAL
11) INTERMEDIUS DISCRETE 80
12) PROXIMAL CX DISCRETE 70
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 DISCRETE 99
17) LEFT PDA DISCRETE 90
17A) POSTERIOR LV NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 49 minutes.
Arterial time = 46 minutes.
Fluoro time = 17.9 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 120
ml, Indications - Hemodynamic
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 4000 units IV
Other medication:
Fentanyl 50 mcg IV
Heparin drip 1000 u/hr IV ggt
Nitroglycerine 140 mcg iv ggt
Versed 1 mg IV
Cardiac Cath Supplies Used:
8F ARROW, ULTRA 8, 40CC
200CC MALLINCRODT, OPTIRAY 200CC
COMMENTS:
1. Selective coronary angiography revealed a left dominant
system with
an anomalous takeoff of the LCX from the right cusp. The LAD had
a 80%
stenosis at the origin and a 80% very distal stenosis. There was
a large
trifurcating ramus with 80% stenoses in all three branches. The
LCX was
a large ectopic vessel coming off the right cusp with a 70%
proximal
stenosis. The OM1 was intermittently occluded during the
procedure, but
had a 99% stenosis at the end of the case. The PDA had a 90%
stenosis at
the origin. There was also a large posterolateral branch. The
RCA was a
small nondominant vessel with no significant disease.
2. Limited hemodynamics showed elevated LV filling pressures
with an
LVEDP of 30 mm Hg. There was no gradient across the aortic valve
on
pullback.
3. 8F 40 cc IABP was placed to help stablize the patient prior
to CABG
tomorrow.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Anomalous takeoff the the LCX.
3. Elevated left sided filling pressures."
.
.
Brief Hospital Course:
A/P: 45yo Male with no signficant PMH who presents with
hypertensive urgency.
.
1. CV:
A). CAD: The patient was initially admitted with hypertensive
urgency and given his LVH on ECG, the HTN was thought to be most
likely chronic. The patient was eventually placed on 4 oral
medication. The pt required metoprolol 100mg TID, lisinopril
40mg once daily, HCTZ 25mg once daily, and Norvasc 10mg once
daily to attain appropriate SBP control. As the patient had
several risk factors for CAD including family history of early
CAD, HTN, DM and hypercholesterolemia, he was taken for ETT-MIBI
for further risk stratification. Pt was found to have a
hypotensive response to exercise on ETT with transient ischemic
dilation and global hypokinesis with EF of 27% on MIBI. Almost
immediately after the ETT-MIBI, the patient developed an episode
of CP with new ST depressions in V3-V6 with deeper TWI in those
leads. At the time, the patient was found to be markedly
hypertensive with SBP in 170s. He was started on heparin gtt and
nitro gtt and sent for emergent cardiac catheterization. The
cardiac catheterization demonstrated 3VD with anomalous take off
of LCx (off Right cusp). 80% LAD at origin and distal, large
Ramus with 80% stenosis in all three branches, 70% proximal LCx,
intermittently occluded OM1. IABP was placed and the patient was
scheduled for CABG in the AM. The patient was cont. on the
nitro gtt, and beta blocker, however the ACEI was held pending
surgery and the CCB was held given the ongoing ACS. Please see
the additional d/c summary from cardiothoracic surgery team for
further details of his intra-op and post op course.
.
B). Pump: The patient had signs and sx of mild heart failure
with unknown EF. A TTE showed normal to low EF of 50% but the
MIBI demonstrated an EF of 27%. As he had clinical signs of mild
CHF on admission, he was gently diruesed. The etiology of the
CHF was unclear, however it was most likely multifactorial with
contribution from HTN, ischemia, and possibly even viral. In
the cath lab, he was given an IABP for additional inotropic
support.
.
C). Rhythm: The patient was in NSR with LVH and ?strain pattern.
He was monitor on tele in the CCU without events.
.
2. Renal: Pt with creatinine of 1.6 on admission to ED. It was
difficult to assess whether this was acute vs chronic -
secondary to recent devlopment of CHF versus chronic HTN. In
addition, the patient has some proteinuria (30 proteins in
urine) which was more suggestive of chronic HTN as the cause.
The creatinine did improve somewhat with improved cardiac
function and gentle diuresis. Recommend consideration of renal
US to assess for hydro and signs of chronic kidney disease and
if necessary MRA for renal artery stenosis as cause of both CRI
and HTN as outpatient.
.
3. DM: The patient does not carry a diagnosis of DM, however a
glucose of 194 on admission chem 7 was concerning. A Hgb A1c
returned with a value of 8 confirming our diagnosis of diabetes.
He was started on HISS with goal to obtain tight glycemic
control in the setting of ACS and impending surgery. .
.
4. FEN: diabetic, heart friendly low salt diet, replete lytes
.
5. PPx: The patient was continued on heparin sub Q TID or
heparin gtt for DVT prophylaxis during the duration of the
admission. He was also started on colace and senna for bowel
regimen as well.
.
6. Code: full code
.
7. The patient was sent to OR urgently for CABG, please see the
associated d/c summary from CT surgery team for the remainder of
the hospital course for this admission.
Medications on Admission:
As outpatient:
1. ASA 325mg once daily
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. 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*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
11. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
12. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 weeks.
Disp:*84 Tablet(s)* Refills:*0*
13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
14. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*0*
15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
16. Warfarin Sodium 4 mg Tablet Sig: Four (4) Tablet PO at
bedtime: check PT/INR once daily untl INR 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*0*
17. Insulin Glargine 100 unit/mL Solution Sig: Nine (9) units
Subcutaneous at bedtime.
18. Humalog 100 unit/mL Solution Sig: as per sliding scale units
Subcutaneous four times a day: dose per sliding scale.
19. Vancomycin HCl 10 g Recon Soln Sig: One (1) gm Intravenous
Q12H (every 12 hours) for 7 days.
Disp:*16 gm* Refills:*0*
20. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: 4.5 gm
Intravenous Q8H (every 8 hours) for 7 days.
Disp:*5 gm* Refills:*0*
21. Mycostatin 100,000 unit/g Powder Sig: One (1) Topical
[**Hospital1 **]/PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
CAD - s/p Cardiac Catheterization, s/p CABG x 6
Post-Operative Atrial Fibrillation, Atrial Flutter
HTN
Embolic Stroke
DM II (new diagnosis)
Blood loss anemia
Pleural Effusions
Discharge Condition:
Fair
Discharge Instructions:
No lifting over 10 pounds for 4-6 weeks.
Call if you experience worsening chest pain, shortness of
breath, or increasing redness/drainage from the wound.
You may shower, but no tub baths/swimming.
Followup Instructions:
-with Dr. [**Last Name (STitle) **] in [**Hospital **] clinic in [**11-21**] months ([**Telephone/Fax (1) 8793**]
-with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (cardiology) in 1 month ([**Telephone/Fax (1) 7437**]
[**Hospital 60717**] [**Hospital **] clinic ([**Telephone/Fax (1) 17484**] (Dr. [**Last Name (STitle) 174**] if possible)upon
discharge from rehab
-with neurology/stroke clinic in 2 weeks ([**Telephone/Fax (1) 2528**]
-Call Dr.[**Name (NI) 27686**] office and set up a follow up appointment
for mid [**Month (only) **] (in 4 weeks)
Completed by:[**2101-3-20**]
|
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"V17.3",
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"285.1"
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icd9cm
|
[
[
[]
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[
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"99.04",
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"37.61",
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icd9pcs
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[
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45168, 45313
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45533, 45539
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,190
| 141,990
|
8883
|
Discharge summary
|
report
|
Admission Date: [**2156-4-21**] Discharge Date: [**2156-4-26**]
Date of Birth: [**2101-7-13**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors / [**Last Name (un) **]-Angiotensin Receptor Antagonist / Precedex
Attending:[**First Name3 (LF) 2006**]
Chief Complaint:
Tongue Swelling
Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
History of Present Illness:
t is a 54 yo male with a h/o Hep C, currently on pegasys,
telaprevir and ribavirin (started on [**2156-2-3**]), HTN on lisinopril
and CKD who went to bed at midnight and woke up two hours later
with tongue swelling. According to the wife he had an uneventful
day prior to admission and went to bed about midnight. He woke
up around 2:30AM complaining of a funny sensation of his tonigue
and some swelling. He tried to go back to sleep but felt as if
his tongue was continuing to get swollen therefore he decided to
drive to the ED for further evaluation. He has never experienced
anything like this before. He has some pruritis associated with
Hep medications but no overt allergic reactions. The wife denies
any wheezing or difficulty breathing and did not note a rash. He
has previously had a reaction to hair dye where he broke out in
hives and ?pustules. Of note, he has been on lisinopril since at
least [**2152**] and does not appear to have ever had a reaction.
.
In the ED, initial VS were: Pulse: 100, RR: 18, BP: 142/84,
Rhythm: Sinus Tachycardia, O2Sat: 99%, O2Flow: RA, Pain: 4. He
was given epinephrine auto injector, methylprednisolone 125mg,
diphenhydramine 50mg and famotadine 20mg. His tongue swelling
was noted to be getting worse and it was decided to intubate the
patientfor airway protection. He was given midazolam, ketamine
and propofol.
.
On arrival to the MICU, he was sedated and intubated. He was
moving all extremities and appeared agitated therefore his
propofol was increased as was his fentanyl. He was noted to have
a large protruding tongue.
Past Medical History:
Hep C- currently being treated with telaprevir, peggylated
interferon and ribavirin ([**2156-2-3**])
Hypertension
CKD Stage III
Social History:
He lives in JP and is married. He worked as a personal care
attendant but is currenlty unemployed. No ETOH, alcohol or
illicit drug use. Pt. has 1 child with this partner, 2 others
with other partners.
Family History:
No h/o liver dz or CA. [**Name (NI) 1094**] Father had an MI at age 62. Mother
and 8 sibs in good health. No history of significant allergic
reactions.
Physical Exam:
Admission Exam:
Vitals: BP: 147/87 P: 79 18 O2: 100
Vent: 500/14/5/100 FiO2
General: intubated and sedated
HEENT: large edematous tongue that was protruding out of his
mouth
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Rhonchi noted bilaterally, no wheezes, good air movement
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Physical Exam on discharge:
General: AAOx3, NAD
HEENT: tongue normal in size, MM dry
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2156-4-21**] 05:50AM BLOOD WBC-2.4* RBC-3.08* Hgb-10.2* Hct-30.5*
MCV-99* MCH-32.9* MCHC-33.3 RDW-14.6 Plt Ct-234
[**2156-4-21**] 03:00PM BLOOD PT-11.4 PTT-27.7 INR(PT)-1.1
[**2156-4-22**] 03:15AM BLOOD Gran Ct-4190
[**2156-4-21**] 05:29PM BLOOD Ret Aut-1.8
[**2156-4-21**] 05:50AM BLOOD Glucose-135* UreaN-20 Creat-1.8* Na-124*
K-4.3 Cl-87* HCO3-24 AnGap-17
[**2156-4-21**] 03:00PM BLOOD ALT-38 AST-50* CK(CPK)-103 AlkPhos-69
TotBili-0.7
[**2156-4-23**] 01:45PM BLOOD CK-MB-1 cTropnT-<0.01
[**2156-4-23**] 08:12PM BLOOD CK-MB-1 cTropnT-<0.01
[**2156-4-21**] 03:00PM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.5 Mg-1.7
[**2156-4-21**] 05:29PM BLOOD Hapto-<5*
[**2156-4-22**] 03:15AM BLOOD Triglyc-87
[**2156-4-21**] 05:50AM BLOOD Osmolal-260*
[**2156-4-21**] 03:00PM BLOOD C3-105 C4-30
[**2156-4-21**] 09:20AM BLOOD Type-ART Temp-36.1 Rates-14/14 Tidal
V-500 PEEP-5 FiO2-100 pO2-505* pCO2-39 pH-7.43 calTCO2-27 Base
XS-2 AADO2-172 REQ O2-38 Intubat-INTUBATED
[**2156-4-21**] 09:20AM BLOOD Lactate-1.0
[**2156-4-21**] 10:24AM BLOOD TRYPTASE-3
CXR ([**2156-4-21**]):
As compared to the previous radiograph, the patient has been
intubated. The tip of the endotracheal tube projects 3 cm above
the carina. Relatively low lung volumes. Borderline size of the
cardiac silhouette, mild retrocardiac atelectasis. The presence
of a minimal left pleural effusion cannot be excluded.
.
TTE ([**2156-4-23**]):
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild mitral regurgitation.
.
DISCHARGE LABS:
[**2156-4-26**] 07:50AM BLOOD WBC-4.5 RBC-2.58* Hgb-8.5* Hct-26.2*
MCV-101* MCH-32.9* MCHC-32.5 RDW-15.0 Plt Ct-192
[**2156-4-26**] 07:50AM BLOOD Glucose-128* UreaN-13 Creat-1.4* Na-134
K-4.3 Cl-95* HCO3-30 AnGap-13
[**2156-4-26**] 07:50AM BLOOD Calcium-9.2 Phos-4.9* Mg-1.8
[**2156-4-25**] 01:37AM BLOOD ALT-28 AST-28 AlkPhos-57 TotBili-0.3
[**2156-4-25**] 01:37AM BLOOD VitB12-819 Folate-11.8
C1 esterase inhibitor assay: >100 (WNL)
Brief Hospital Course:
Primary Reason for Admisson: Pt is a 54 yo male with a h/o Hep
C, currently on pegasys, telaprevir and ribavirin, HTN (on
Lisinopril) and CKD who went to bed at midnight and woke up two
hours later with tongue swelling.
.
Active Problems:
.
Angioedema: His angioedema primarily affected his tongue.
Potential causes of his angioedema included lisinopril,
Hepatitis C treatment or food ingestion. Lisinopril is
certainly the most well known cause of angioedema and can occur
even many years after initiation of therapy. Peggylated
interferon is also a rare cause of angioedema. No reports of
ribivirin or telepravir causing angioedema, but telepravir is
newly on the market and could be a potential cause. No unusual
ingestions or new foods. Also on the differential includes
C1-inhibitor deficiency; an assay was sent for this and the
result was normal. Pt was intubated via fiber optic nasal scope
in the ED and upon arrival to the MICU was sedated and
paralyzed. He was started on Propofol/Fentanyl gtt with RASS
goal -5. The pt required high dose Propofol for sedation and
became bradycardic to the 30s, though he was never hypotensive.
His propofol was stopped and he was started on Dexmetetomidine.
Adequate sedation could not be achieved with Dexmetetomidine and
he was transitioned to a Versed gtt. He was given
Methlyprednisolone 80mg IV q8h, Benadryl 50mg IV q8h and
Famotidine 20mg IV q12h. All home medications were held. His
tongue swelling improved and he was extubated [**2156-4-24**] without
incident. He was transitioned to po prednisone, benadryl and
famotidine on the day of transfer to the medical floor. On the
floor he remained stable, so was discharged with a prednisone
taper and continued on fexofenadine while on the taper. Benadryl
was stopped due to complaints of somnolence. Outpatient follow
up arranged with allergy department.
.
# Pancytopenia: Present on admission, most likely drug effect,
would favor Telaprevir associated bone marrow suppression. There
are also rare reports of Captopril causing Angioedema and
Pancytopenia; unclear if this happens with Lisinopril. WBC and
platelets rebounded to normal limits after all medications were
held. Anemia persisted, unclear etiology, potentially [**3-4**] renal
disease. Haptoglobin was decreased raising concern for
hemolysis, but coombs test was negative, no schistocytes seen on
smear and t bili was normal. Recommend PCP follow up.
.
# Hyperkalemia: Pt had intermittent hyperkalemia (potassium
between 5.3 and 5.9). Renal consulted given hyperkalemia,
metabolic acidosis and hyponatremia intially on admission.
Renal recommended obtaining transtubular potassium gradient.
TTKG returned at 6.27, which was consistent with
mineralocorticoid deficiency. However, for this test to be
valid, UNa should be >25, and his was <10. As such, the test
characteristics are unclear. However, given the clinical
context, would favor mineralocorticoid deficiency and recommend
formal [**Last Name (un) 104**] stim testing once no longer on steroids (renal did
not recommend starting fludricortisone). Another potential
etiology of the hyperkalemia was heparin-induced type IV RTA, as
he developed hyperkalemia whenever SQ heaprin was re-started.
Electrolytes were stable and creatinine at baseline at the time
of discharge so he was given script for outpatient CHEM-7 to be
faxed to his PCP for continued outpatient follow up of renal
function.
.
# HTN: Pt has been hypertensive since weaning sedation and
d/c??????ing Lisinopril. On the day of transfer from the ICU we
started Amlodipine 10mg po qday and labetalol 100 mg tid. On
the floor pressures were well-controlled on this regimen,
ranging from SBP 130-160s. Due to concern that prednisone was
contributing to hypertension, anti-hypertensives were not
further uptitrated (as prednisone will be tapered on discharge)
and he will follow up with his PCP regarding further
hypertensive management. Pt instructed not to take ACE-I or ARBs
in the future. If down-titration of anti-hypertensives is
indicated in the future, recommend discontinuing labetalol in
favor of a once daily medication.
.
# NSVT: Had a small run of NSVT on [**2156-4-23**] which was self
limiting in the setting of precedex. Precedex was therefore
added to his allergy list.
.
Chronic Problems:
.
# CKD: Cr remained at baseline throughout the admission.
Lisinopril was discontinued [**3-4**] angioedema.
.
# Hepatititis C: Currently being treated with triple therapy.
We held all Hep C meds per liver. He will follow up with Dr.
[**Last Name (STitle) 10924**] in 2 weeks regarding further management of HCV.
Transitional Issues:
- outpatient follow up with Allergy; consider scratch testing
for interferon, ribavirin, or telaprevir
- pt at risk for recurrent episodes of angioedema in the near
future. Will complete prednisone taper as instructed per allergy
and take fexofenadine while on steroids as well.
- Severe reaction thought to be [**3-4**] lisinopril. NO ACE-I or ARBs
in the future
- question of heparin induced hyperkalemia (unsure of this was
incidental)
- follow up BP on new regimen of HCTZ, labetalol, amlodipine
- follow up repeat electrolytes on [**2156-4-29**]
- follow up anemia
Medications on Admission:
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day - No Substitution
LISINOPRIL - 30 mg Tablet - 1 Tablet(s) by mouth once a day
Ribavirin 600 mg [**Hospital1 **]
Telaprevir 750 mg tid
Pegasys 180 mcg weekly injections
Discharge Medications:
1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day
for 8 days: TAPER instructions:
4 tabs on [**4-27**]; 3 tabs on [**4-28**]; 2 tabs on [**5-7**]; 1 tab on
[**4-14**]; then stop.
Disp:*16 Tablet(s)* Refills:*0*
3. fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day
for 8 days: take while on steroids; can stop after steroid taper
is complete.
4. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
5. Outpatient Lab Work
CHEM-7
Diagnosis: Type IV RTA
Please fax results to PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11616**] (fax #[**Telephone/Fax (1) 13238**])
6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
angioedema
Secondary Diagnoses:
hypertension
hepatitis C cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you had swelling of your
tongue. You were admitted to the ICU and intubated to protect
your breathing. An Allergist was consulted and felt this was
likely an allergic reaction to lisinopril, though other causes
could also be possible. You were given steroids and the
swelling improved so you were extubated. You should never take
lisinopril again, and you should also avoid similar medications,
which includes all drugs called "ACE inhibitors" and
"Angiotension Receptor Blockers." These are drugs used to treat
hypertension. While you were in the hospital your kidney
function was found to be abnormal. Due to concerns that your HCV
medications could be related to your kidney dysfunction or to
your tongue swelling, these were stopped. Your kidney function
improved. Since your lisinopril was stopped, you were started on
two new medications to control your blood pressure in its place.
You should follow up with Dr. [**Last Name (STitle) 10924**] to determine when or if it
is safe to restart the HCV medication.
The following changes were made to your medications:
STOPPED lisinopril
STOPPED peggylated inferferon
STOPPED ribivirin
STOPPED telepravir
STARTED prednisone 10mg tablet - this will be tapered as
directed: take 4 tabs on [**4-27**]; take 3 tabs on [**4-28**]; take 2 tabs
on [**5-7**]; take 1 tab on [**4-14**]; then stop.
STARTED fexofenadine ([**Doctor First Name **]) 180 mg once a day while on
steroids; can stop after steroid taper is complete
STARTED amlodipine 10mg daily for hypertension
STARTED labetalol 100 mg three times a day for hypertension
Followup Instructions:
The following appointments have been made for you:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: THURSDAY [**2156-5-6**] at 9:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
*Please note, your appointment for [**4-27**] has been rescheduled to
the date above.
Department: LIVER CENTER
When: MONDAY [**2156-5-10**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 30913**], PA [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV OF ALLERGY AND INFLAM
When: TUESDAY [**2156-5-11**] at 11:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
|
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"458.9",
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icd9cm
|
[
[
[]
]
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[
"96.04",
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icd9pcs
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[
[
[]
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2024, 2154
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2170, 2375
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,726
| 136,738
|
27485
|
Discharge summary
|
report
|
Admission Date: [**2188-9-10**] Discharge Date: [**2188-9-12**]
Date of Birth: [**2116-10-30**] Sex: F
Service: MEDICINE
Allergies:
Proxy[**Name (NI) 67216**] / Caffeine / Butalbital / Barbiturates / Xanthines
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 2392**] is a 71yo female with PMH significant for ESRD on
HD, respiratory failure, who presents from HD with BRBPR.
Patient was at HD earlier this morning and was noted to have
400cc BRBPR. She was also hypotensive and HD was stopped. Her
blood pressure was 118/80 before her BP dropped. It is unclear
what her BP or how much fluid was removed at this time. Per NH
records, she had quaiac positive BM last night. While in
transport to the ED, she sounded extremely congested per EMS
reports.
In the ED, initial vitals were T 97.1 BP 80/70 AR 80 RR 24 O2
sat 70% on 50% flowmask. She was placed on 95% high flow mask
and her oxygen saturation increased to 99%. She was noted to
have thick, creamy looking secretions. Given improvement in her
O2 sat, the FIO2 was decreased to 0.50. She received Protonix
80mg IV and 1L NS bolus. She was then transferred to the MICU
for further management.
Past Medical History:
1)ESRD on HD of unclear etiology.
2)Respiratory failure s/p trach in [**2-11**], vent dependent until
[**1-11**] when she was successfully weaned
3)COPD
4)Chronic pleural effusions
5)Recurrent aspiration PNA
6)PVD, s/p R CEA, s/p bilateral iliac stents and gangrene of
toes bilaterally and autoamputating
7)HTN
8)Hypothyroidism
9)h/o GI bleeding
10)CHF no previous echo here, so unclear [**Name2 (NI) **]
11)h/o Cholesterol emboli syndrome
12)Paroxysmal AF
13)Anemia
14)s/p multiple embolic CVA
[**95**])Dementia
16)Adenocarcinoma of the colon s/p resection in [**2186**]
17)hx of C.diff colitis
18)Sepsis [**3-8**] to PNA d/c'd from MICU [**2188-6-25**]
Social History:
# Personal: Lives at [**Hospital 100**] Rehab MACU. Divorced. Three adult
children. [**Doctor Last Name **] id her HCP and is very involved
# Tobacco: Former smoker. 3 packs per day x 13 years.
# Alcohol: Occasional past use.
Family History:
Her parents lived until old age. One brother died of an MI in
his 60s. Another brother with schizophrenia. Son with
hypothyroidism.
Physical Exam:
Tcurrent: 35.4 (95.8 ) HR: 84 () bpm BP: 133/67 RR: 20 ()
SpO2: 89
General Appearance: Anxious, responds to verbal commands
Eyes / Conjunctiva: PERRL, Anicteric sclera
Lymphatic: Cervical WNL
Cardiovascular: RRR, distant heart sounds, no m,r,g
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Diminished), (Left
DP pulse: Diminished)
Respiratory / Chest: (Breath Sounds: Crackles : , Diminished: ),
CTA anteriorly, scattered crackles anteriorly and posteriorly
Abdomen: Soft, NT/ND, +BS; PEG tube in place
Extremities: Right: Absent, Left: Absent, Clubbing, Gangrenous
toes with evidence of auto-amputation
Skin: Not assessed, No rashes
Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
==================
ADMISSION LABS
==================
[**2188-9-10**] 10:15AM BLOOD WBC-10.9 RBC-3.30* Hgb-11.9* Hct-35.5*
MCV-108* MCH-36.1* MCHC-33.6 RDW-17.2* Plt Ct-304
[**2188-9-10**] 10:15AM BLOOD Neuts-74.5* Bands-0 Lymphs-12.6*
Monos-5.2 Eos-7.3* Baso-0.5
[**2188-9-10**] 11:13AM BLOOD PT-18.9* PTT-150* INR(PT)-1.7*
[**2188-9-10**] 10:15AM BLOOD Glucose-125* UreaN-53* Creat-3.0*# Na-142
K-5.4* Cl-97 HCO3-27 AnGap-23*
[**2188-9-10**] 10:15AM BLOOD cTropnT-0.58*
[**2188-9-10**] 04:05PM BLOOD Lactate-1.9
[**2188-9-10**] 10:24AM BLOOD Hgb-13.0 calcHCT-39
==============
RADIOLOGY
==============
CHEST X-RAY ([**2188-9-10**])
FINDINGS: There is a tracheostomy tube that terminates in the
standard
position. The cardiomediastinal silhouette is stable. There is a
left basal effusion with atelectasis in the left lower lobe. The
right lung does not show any focal consolidations. The tip of
the central venous line is projected over the right atrium.
CONCLUSION:
Left basal effusion with atelectasis in the left lower lobe,
though focal
consolidation cannot be excluded and followup is advised.
Brief Hospital Course:
Ms. [**Known lastname 2392**] is a 71yo female with PMH significant for ESRD on
HD, anemia, respiratory failure s/p tracheostomy who is being
transferred to the MICU for LGIB.
1)LGIB: Patient presented with approximately 400cc of BRBPR at
HD. Per her PMH, she has a history of GI bleeding. Differential
diagnosis for LGIB includes hemmoroids, diverticuliosis,
angiodysplasia, colitis (infectious, ischemia, IBD, and
neoplasm. No report of fevers, chills, or diarrhea to suggest an
infectious colitis or IBD. Most likely diverticulitis vs.
hemorrhoids. Per OMR, she has not had a colonoscopy here. Her
baseline Hct is between 25-30 but her Hct on admission today of
35.5. Her INR and PTT are elevated today. She is on Aspirin as
an outpatient but is not on any anti-coagulation (in light of
history of atrial fibrillation).
Patients hematocrit remained stable and she did not require any
transfusions. GI consult was obtained and given spontaneous
resolution of bleeding and low expectation for intervation,
colonoscopy was not pursued.
Aspirin was held given on clear indication for therapy was
found, defer further management to PCP.
Heparin prophylaxis dose was adjusted (reduced) from normal
amount, to 2500 SC BID.
2)Hypotension: Patient was noted to be hypotensive with SBPs in
80??????s, possibly lower at dialysis. Unclear how much fluid was
removed at dialysis. She also had 400cc of BRBPR which may be
accounting for her transient hypotension. She received 1L NS in
the ED and her BP quickly stabilized and remained at baseline.
No fevers or chills to suggest an underlying infectious process.
Lactate was elevated to 3.9 but quickly returned to [**Location 213**]. Her
hypotension also resolved upon tranfer to the MICU.
3)Respiratory: Patient has history of respiratory failure s/p
tracheostomy and was successfully weaned in [**1-11**]. Patient was
acutely hypoxic with O2 saturation between 50-70%. She was also
noted to have increased secretions; she likely mucous plugged
given acute desaturation. Her Upon transfer to the MICU, her
respiratory status stabilized. She is currently on 50%
trachmask. No evidence of a pneumonia on cxray. Patient had a
single, transient episode of desaturation wich resolved with
suctioning. She has remained with good oxygen saturation the the
trach mask per her baseline. We continued inhaler regimen as per
rehab.
4)Coagulopathy: Patient presented with elevated INR and PTT. She
is not on any anti-coagulation or blood thinners as outpatient.
These labs may have been draw via a line that was flushed with
heparin. This may also be due to heparin SQ she has been
receiving at home. Her labs were repeated and they normalized.
As above, SC heparin for prophylaxis was re-started at a reduced
dose.
5)ESRD on HD: Patient underwent dialysis prior to being
discharged to rehab.
6)COPD: Continue Atrovent and Albuterol
7)Anemia: Baseline Hct between 25-30. Hct on admission was 35,
which is slightly elevated from baseline. Her Hct remained
stable at 30 during her stay in the MICU. She also receives
Epogen at HD.
8)Hypothyroidism: Patient was continued on Levoxyl.
Medications on Admission:
Combivent 2 puffs Q6H
Aluminum hydroxide suspension
Aspirin 81mg PO daily
Chlorhexidine gluconate 5cc [**Hospital1 **]
Cyanocobalamin 1000 micrograms Q month
Docusate sodium liquid 100cc [**Hospital1 **]
Flovent [**Hospital1 **]
Folic acid 1mg PO daily
Heparin SQ [**Hospital1 **]
Levothyroxine 200micrograms PO daily
Lidocaine patich
Nystatin 5cc PO daily
Omeprazole 20mg PO BID
Oxycodone 2.5mg Q M,W,F at HD
Acetaminophen 650mg PO Q4H PRN
Discharge Medications:
1. Levothyroxine 100 mcg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
5. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Last Name (STitle) **]:
Two (2) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 2500 (2500)
units Injection [**Hospital1 **] (2 times a day).
9. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
10. Aluminum Hydroxide Gel 600 mg/5 mL Suspension [**Hospital1 **]: Thirty
(30) ML PO Q8H (every 8 hours).
11. Diphenhydramine HCl 25 mg Capsule [**Hospital1 **]: One (1) Capsule PO
Q6H (every 6 hours) as needed.
12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
PRIMARY:
HEMATOCHEZIA
Discharge Condition:
Hemodynamically stable, without bleeding
Discharge Instructions:
You were admitted to the hospital due to bleeding from your
gastrointestinal track during dialysis. We closely monitored you
and you did not need any blood transfusions. You did not require
a colonoscopy at this time.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
If you experience any further bleeding, or have any chest pain,
further desaturations or any other symptom that concerns you,
please seek medical attention.
Followup Instructions:
Please follow up with your rehab physician on arrival to MACU
|
[
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
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9328, 9394
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4351, 7482
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355, 361
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9460, 9503
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1995, 2223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,355
| 113,137
|
19931+19932+57103
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2159-5-4**] Discharge Date: [**2159-5-30**]
Date of Birth: [**2105-7-5**] Sex: M
Service: PURPLE SURGERY
ADMITTING DIAGNOSIS: Morbid obesity.
HISTORY OF PRESENTING ILLNESS: This patient is a 53-year-old
male, with Class 3 morbid obesity. He has a weight of 318.6
pounds, height of 5'[**65**]", and a body mass index of 46. He has
attempted numerous weight loss programs, as well as
medications in the past without significant long-term
success. He also has several co-morbidities associated with
his morbid obesity including dyslipidemia and
hypoandrogenemia. He now presents for surgical management of
his morbid obesity.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Dyslipidemia.
3. Hypoandrogenemia.
4. History of UTIs.
5. Status post arthroscopic knee surgery on the left.
6. Status post open appendectomy.
MEDICATIONS:
1. Lipitor 10 mg qd.
2. AndroGel topical qd.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION - VITAL SIGNS: Blood pressure 132/84,
heart rate 82.
GENERAL: No acute distress.
HEAD AND NECK: Anicteric, no lymphadenopathy.
CHEST: Clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm.
GI: Obese, soft, nondistended, and nontender.
EXTREMITIES: No edema.
HOSPITAL COURSE: This patient was admitted on [**2159-5-4**], and underwent a laparoscopic gastric bypass procedure.
The patient tolerated the procedure well, and there were no
immediate postoperative complications. Please see operative
note for further details. Following the operation, the
patient received a methylene blue test, and this did not
reveal any leakage. On postoperative day #2, the patient
underwent an upper GI series which did not demonstrate any
leakage or obstruction. The patient's pain was
well-controlled with a morphine PCA.
By postoperative day #3, the patient began developing
abdominal cramping along with severe nausea, vomiting and
diarrhea. His temperature climbed to as high as 105??????. An
Addison-like syndrome was suspected, and an endocrine consult
was obtained. The endocrinologist had a low suspicion for
Addison-like syndrome, but they recommended that the patient
be started on stress steroids.
Due to the rapid deterioration in the patient, the patient
was taken to the operating room for a laparoscopic
exploration. This was largely unremarkable. Following the
operation, the patient remained unstable. The patient
developed a septic-like picture, with the decreased blood
pressure and urine output. A Swan-Ganz catheter was placed,
and the patient remained intubated. He was started on
Levophed and vasopressin, as well as broad-spectrum
antibiotics including ampicillin, levofloxacin, Flagyl and
fluconazole. He was given aggressive fluid resuscitation.
On [**5-8**], an infectious disease consult was obtained, and
they suspected a toxic mediated process due to the rapid
sequence of events. A hematology consult was also obtained
for a left shift in the patient's white count differential.
They attributed this mostly due to stress response and had
low suspicion for any oncologic process. On [**5-8**], TPN
was started.
On [**2159-5-9**], the patient's antibiotics were changed to
vancomycin, linezolid, levofloxacin and Flagyl. He was given
APC for his sepsis-like syndrome, and IVIG to neutralize any
toxin. The patient was negative for heparin-induced
thrombocytopenia.
On [**2159-5-10**], the patient remained critically ill. The
patient was taken back to the OR for an exploratory
laparotomy. On gross examination in the operating room, the
bowels appeared largely unremarkable. Upon the request of
Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 1888**] performed a colonoscopy intraoperatively.
This revealed enterohemorrhagic colitis. The patient
received, over the course of 2 days, over 12 units of packed
red blood cells. The abdomen was left open, and the mesh
removed due to high intra-abdominal pressures and severe
fluid overload. The patient began to improve following the
colectomy and remained stable in the ICU. By [**5-12**],
cultures had returned for Methicillin resistant
Staphylococcus aureus from the rectum. This made a Staph
aureus toxic shock syndrome highly suspicious.
The patient was started on aggressive diuresis, and on [**2159-5-13**], the patient went back to the OR for further washout
and partial closure. The patient remained stable for the
most part, and was given a transfusion of platelets for
slightly low platelets. By [**5-16**], the patient's Swan-Ganz
catheter was discontinued. On [**5-17**], the patient's
vancomycin and levofloxacin were discontinued, and the
patient continued on linezolid and Flagyl for possible C.
diff infection and MRSA. The patient's hydrocortisone was
also discontinued.
On [**5-19**], the patient underwent a complete fascial
closure. His tube feeds were started on the following day,
and a physical therapy and occupational therapy consult were
obtained. On [**5-21**], the C. diff returned negative, and
the Flagyl was discontinued. The patient continued to have
persistent low-grade temps, and a chest x-ray was performed.
This revealed left lower lobe consolidation. Sputum cultures
also returned as Pseudomonas. The patient was then started
on ceftazidime.
By [**5-23**], the wound was again further closed, and a VAC
was placed on the areas that remained open. By [**5-26**], the
patient was extubated and off sedation. He appeared to make
significant progress during the ICU stay. His linezolid was
also discontinued upon recommendation by the infectious
disease consult. He was started on a stage 2 diet by [**5-27**], and advanced to stage 3 on [**5-28**]. He appeared to
tolerate his diet well.
The patient was transferred to the floor successfully on
[**2159-5-29**]. He remains stable while on the floor, and
tolerating a stage 3 diet. He was continued on TPN, and a
PICC line was placed for further IV antibiotics, and for
continued TPN following discharge. His total caloric intake
was decreased, but his protein intake was maximized. It was
felt that the patient was ready for discharge to rehab by
[**2159-5-30**].
DISCHARGE STATUS: Rehabilitation.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Morbid obesity, status post laparoscopic gastric bypass
procedure.
2. Staphylococcus aureus toxic shock syndrome.
3. Enterohemorrhagic colitis secondary to toxic shock
syndrome, status post total colectomy with ileostomy.
4. Pseudomonas pneumonia, treated with ceftazidime.
5. Sepsis.
FOLLOW-UP INSTRUCTIONS: The patient is to follow-up with Dr.
[**Last Name (STitle) **] within 2-3 weeks following discharge. The patient is to
continue on daily TPN with a caloric intake of 1,000
calories, 150 of amino acids, and 200 of dextrose. The
patient should receive a total of 2 weeks of ceftazidime
through his PICC line.
DISCHARGE MEDICATIONS:
1. Ceftazidime 2 gm IV q 8 x 2 weeks.
2. Lopressor 125 mg po tid.
3. Roxicet elixir 5-10 cc po q 4-6 h prn pain.
4. Testosterone 2.5 mg patch, 1 patch transdermal q 24 h.
5. Insulin sliding scale.
6. Heparin flush 100 U/cc, 1 cc IV qd prn. Instructions:
Ten cc normal saline followed by 1 cc of 100 U/cc heparin in
PICC line.
7. Loperamide 2 mg po qid for diarrhea.
8. Protonix 40 mg po bid.
9. Albuterol inhaler prn.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Name8 (MD) 3430**]
MEDQUIST36
D: [**2159-5-30**] 12:35
T: [**2159-5-30**] 12:37
JOB#: [**Job Number 53762**]
Admission Date: [**2159-5-4**] Discharge Date: [**2159-5-30**]
Date of Birth: [**2105-7-5**] Sex: M
Service:
ADMISSION DIAGNOSIS: The patient is a 53-year-old white male
with an admission diagnosis of morbid obesity.
HISTORY OF PRESENT ILLNESS: This is a 53-year-old male who
presents surgical management of his morbid obesity.
He has a current body weight of 318 pounds, a height of 5
feet 10 inches, and a body mass index of 46. He has
attempted numerous weight loss programs and medications but
without any long-term success. He also has other
comorbidities associated with his morbid obesity including
dyslipidemia and hypoandrogenemia. He now presents for a
laparoscopic Roux-en-Y gastric bypass procedure for his
morbid obesity.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Dyslipidemia.
3. Hypoandrogenemia.
4. History of urinary tract infections.
5. Status post left knee arthroscopic surgery.
6. Status post open appendectomy in [**2117**].
MEDICATIONS ON ADMISSION:
1. Lipitor 10 mg once per day.
2. AndroGel topically once per day.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a
heart rate of 82 and blood pressure of 132/84. In general,
in no acute distress. Head and neck examination revealed
anicteric. There was no lymphadenopathy. There were no
carotid bruits. The chest was clear to auscultation
bilaterally. Cardiac examination revealed a regular rate and
rhythm. Gastrointestinal revealed obese, soft, nontender,
and nondistended. The extremities were warm. There was
needed.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was admitted
on [**2159-6-4**] and underwent a laparoscopic gastric bypass
procedure performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient tolerated
the procedure well, and there were no immediate postoperative
complications. Please see the Operative Note for further
details. A methylene blue test was performed on the night of
the operation, and this was negative for any leakage.
On postoperative day two, the patient's was well controlled
with a morphine patient-controlled analgesia. He appeared to
be doing well. An upper gastrointestinal series did not
reveal any leakage or obstruction.
On postoperative day three, the patient started developing
abdominal cramping as well as severe nausea, vomiting, and
diarrhea. He also spiked temperatures that climbed as high
as 105 degrees. There was some concern for Addison disease,
and an Endocrine consultation was obtained. They had a low
suspicion for Addison disease, but recommended placing the
patient on stress-dose steroids of 100 intravenously q.8h.
Due to his worsening condition, the patient was taken back to
the operating room for a laparoscopic exploration. This was
largely unremarkable. The patient continued to remain
unstable and became septic with decreasing blood pressures
and urine output. A Swan-Ganz catheter was placed. The
patient remained intubated, and Levophed and vasopressin were
started. He was given vigorous fluid resuscitation and
started on broad coverage antibiotics including ampicillin,
levofloxacin, Flagyl, and fluconazole.
An Infectious Disease consultation was obtained, and they
suspected a toxic mediated process due to the acuity and
rapid sequence of events.
A Hematology consultation was obtained for a left shift in
white count, and they believed that the 55% bands that were
seen in the differential was attributable mostly to a stress
response. There was a low suspicion for any oncologic
process.
On [**5-8**], the patient was begun on total parenteral
nutrition. He was given APC for treatment of sepsis syndrome
and given intravenous immunoglobulin to neutralize any toxin
that was suspected in his pathology. He antibiotics were
changed to vancomycin, linezolid, and his levofloxacin and
Flagyl were continued.
On [**2159-5-11**], the patient went to the operating room for
re-exploration via a midline incision. On gross examination,
the bowels looked largely unremarkable.
Upon request by Dr. [**Last Name (STitle) **], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1888**] performed a
colonoscopy intraoperatively. Dr. [**Last Name (STitle) 1888**] found significant
enterohemorrhagic colitis, and a total colectomy with
ileostomy was performed. The patient remained critically ill
and received 7 units of packed red blood cells during the
operation. His abdomen was left open and packed, and the
mesh was removed. This was done because of severe fluid
overload and increase in intra-abdominal pressure.
On [**5-11**], rectal swabs returned with methicillin-resistant
Staphylococcus aureus, and a Staphylococcus toxic shock
syndrome was highly suspected. Clostridium difficile
cultures returned negative as well as a Clostridium difficile
B toxin which was also negative.
The patient began to stabilize by [**5-12**], and he was begun
on aggressive diuresis.
On [**5-13**], the patient was taken back to the operating room
for additional washout and partial closure. His platelets
remained slightly low, and the patient was given a platelet
transfusion.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Name8 (MD) 3430**]
MEDQUIST36
D: [**2159-5-30**] 12:10
T: [**2159-5-30**] 12:13
JOB#: [**Job Number 53763**]
Name: [**Known lastname 10003**], [**Known firstname 33**] Unit No: [**Numeric Identifier 10004**]
Admission Date: Discharge Date:
Date of Birth: [**2105-7-5**] Sex: M
Service:
This is an addendum to the dictation that was already done.
Patient stayed an additional two days regarding placement.
During the interim, the patient underwent a VAC change that
was performed on [**5-31**]. The wound was granulating very
well, with no signs of infection, and had shrunken in size
since the last dressing change.
Patient also was continued on his TPN making note that his
sodium was repleted for high ostomy output. Following
discharge, the patient should continue on TPN with a goal of
1000 calories, 200 of dextrose and 150 of amino acids. He
should have a VAC changed every three days until followup.
His last VAC change was performed on [**2159-5-31**]. In
addition, the patient will be going out on Imodium 1 mg p.o.
b.i.d.
His other medications remained unchanged. He should continue
ceftazidime 2 grams IV q.8 until [**2159-6-4**].
He will be going to [**Hospital3 1933**] in [**Hospital1 2314**], [**Location (un) 5299**].
[**First Name11 (Name Pattern1) 651**] [**Last Name (NamePattern4) 2749**], M.D. [**MD Number(1) 2750**]
Dictated By:[**Name8 (MD) 4548**]
MEDQUIST36
D: [**2159-6-1**] 11:23
T: [**2159-6-1**] 11:33
JOB#: [**Job Number 10005**]
|
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"584.9",
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] |
icd9cm
|
[
[
[]
]
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[
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"00.14",
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"96.04",
"96.72",
"89.61",
"46.20",
"54.11",
"00.11",
"45.23",
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icd9pcs
|
[
[
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6229, 6236
|
6257, 6546
|
6904, 7719
|
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|
1274, 6207
|
9220, 14508
|
7741, 7829
|
7858, 8353
|
167, 670
|
6571, 6881
|
8375, 8574
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,288
| 176,041
|
38843
|
Discharge summary
|
report
|
Admission Date: [**2130-9-23**] Discharge Date: [**2130-9-28**]
Date of Birth: [**2066-7-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD and variceal banding
History of Present Illness:
MICU admission: 64yoF with multifocal hepatocellular carcinoma
secondary to HepB cirrhosis, s/p RFA (clinical trial 08-256) of
right liver lesions, but persistence of left liver lesions, now
s/p TACE treatment with Doxorubicin on [**2130-5-29**], presented to the
ED and was womiting blood, with repeat of this while in triage.
She was admitted to MICU for an emergent upper endoscopy.
Vomitted BRB at home and vomited BRB here 100cc. Called for
emergency release blood, Hx of varices, getting pantoprazole,
octreotide, blood. Has 2 18g and a 16g PIV. CAlled for 2U PRBCs
and 2U FFP. T/C sent for 4 units.
.
Floor transfer: For full HPI please see MICU admission note. In
summary, Ms. [**Known lastname 86216**] is a 64 year old female w/ HBV cirrhosis
c/b varices, multifocal HCC s/p RFA (clinical trial 08-256) of
right liver lesions, but persistence of left liver lesions, now
s/p TACE treatment with Doxorubicin on [**2130-5-29**] who initially
presented w/ hematemesis and transferred to MICU for EGD.
She was treated w/ iv ppi and octreotide. She was intubated for
EGD ([**9-23**]) that was notable for grade III - IV esophageal
varices s/p banding. Patient was successfully extubated, and
switched to po ppi, and is also on cipro. She has received a
total of 3U pRBC. Her lamivudine was changed to tenofovir.
Currently, pt does not complain of any pain. She reports feeling
tired. Has had no bowel movements since admission. No abd pain
or cough.
Past Medical History:
Past Oncologic History:
- Hepatitis B, diagnosed in Nigera [**4-22**], when she presented
with ascites, has been on Lamivudine since.
- Moved to the US [**1-25**] and ultrasound at [**Hospital1 2177**] demonstrated two
lesions in the liver concerning for HCC.
- MRI [**2130-2-27**] showed a 5.6 x 4.3 cm lesion in segment VI that
demonstrated arterial enhancement and contrast washout and a 3.0
x 2.3 cm lesion in segment III, also with arterial enhancement
and contrast washout. Another 1.8x2.5 cm lesion was seen at the
dome of the liver suspicious for hepatoma as well as other
smaller lesions suspicious for hepatoma.
- Referred to [**Hospital1 18**] for evaluation in the liver center and was
found to have an AFP of 9508 ng/mL.
- Enrolled in clinical trial 08-256 and underwent radiofrequency
ablation on [**2130-4-26**] with some RUQ pain after that resolved,
with adequate treatment of R sided lesions
- Transarterial chemoembolization [**2130-5-29**] to treat the left
sided lesions.
.
Other Past Medical History:
1. History of hepatitis B cirrhosis, diagnosed 05/[**2127**].
2. Advanced multifocal hepatocellular carcinoma
3. Hypertension.
4. Chronic peripheral paresthesias. Her daughter states this
started decades ago before she was born and resulted from a trip
in [**Country 16573**] where she had to stand in the [**Doctor Last Name **] for 2-3 days (?)
5. Multinodular thyroid gland seen on [**2130-5-11**] ultrasound with
dominant right lobe nodule amenable for ultrasound-guided
biopsy, likely after Tx for HCC, per Heme Onc notes
Social History:
Originally from [**Country 16573**] and has been living in
United States with her daughter and her daughter's family since
[**1-25**]. She denies any history of tobacco, alcohol, or illicit
drug use. First language is Yoruba. Patient speaks English.
Family History:
No family history of malignancy.
Physical Exam:
VS - Temp 99.8F, BP 107/61, HR 73, R 18, O2-sat 100% RA
GENERAL - well-appearing woman in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric
NECK - supple, thryromegaly w/out nodules, + cervical LAD
LUNGS - poor respiratory effort and poor air entry to lower
lobes, mild crackles bibasilarly
HEART - PMI non-displaced, RRR, [**1-21**] holosystolic murmur at RUSB
ABDOMEN - soft, slightly distended, BS+, NT, no hepatomagelay
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake
Pertinent Results:
[**2130-9-28**] 05:25AM BLOOD WBC-3.0* RBC-3.32* Hgb-10.3* Hct-29.7*
MCV-89 MCH-30.9 MCHC-34.6 RDW-17.3* Plt Ct-PND
[**2130-9-27**] 05:10AM BLOOD WBC-3.5* RBC-3.33* Hgb-10.2* Hct-29.9*
MCV-90 MCH-30.6 MCHC-34.1 RDW-17.1* Plt Ct-56*
[**2130-9-26**] 07:05AM BLOOD WBC-4.0 RBC-3.40* Hgb-10.5* Hct-30.2*
MCV-89 MCH-30.8 MCHC-34.6 RDW-18.0* Plt Ct-44*
[**2130-9-24**] 05:22AM BLOOD WBC-2.9* RBC-3.33* Hgb-10.3* Hct-29.7*
MCV-89 MCH-30.8 MCHC-34.5 RDW-17.6* Plt Ct-44*
[**2130-9-23**] 04:12AM BLOOD WBC-6.0 RBC-3.05* Hgb-9.6* Hct-27.5*
MCV-90 MCH-31.6 MCHC-34.9 RDW-15.2 Plt Ct-49*#
[**2130-9-23**] 01:25AM BLOOD WBC-8.8# RBC-3.42* Hgb-11.2* Hct-32.0*
MCV-94 MCH-32.7* MCHC-34.9 RDW-15.0 Plt Ct-111*
[**2130-9-24**] 10:50AM BLOOD Neuts-80.6* Lymphs-11.8* Monos-4.2
Eos-2.9 Baso-0.4
[**2130-9-23**] 01:25AM BLOOD Neuts-71* Bands-0 Lymphs-23 Monos-3 Eos-3
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2130-9-28**] 05:25AM BLOOD PT-18.3* INR(PT)-1.7*
[**2130-9-23**] 01:25AM BLOOD PT-19.0* PTT-30.3 INR(PT)-1.7*
[**2130-9-28**] 05:25AM BLOOD Glucose-77 UreaN-10 Creat-0.7 Na-139
K-3.5 Cl-108 HCO3-27 AnGap-8
[**2130-9-27**] 05:10AM BLOOD Glucose-89 UreaN-12 Creat-0.8 Na-141
K-3.4 Cl-110* HCO3-26 AnGap-8
[**2130-9-26**] 07:05AM BLOOD Glucose-78 UreaN-15 Creat-0.9 Na-134
K-3.6 Cl-105 HCO3-26 AnGap-7*
[**2130-9-23**] 01:25AM BLOOD Glucose-126* UreaN-25* Creat-0.8 Na-137
K-6.5* Cl-106 HCO3-21* AnGap-17
[**2130-9-23**] 01:25AM BLOOD ALT-42* AST-135* AlkPhos-81 TotBili-1.7*
[**2130-9-25**] 04:22AM BLOOD TotBili-1.8*
[**2130-9-23**] 01:25AM BLOOD Lipase-77*
[**2130-9-28**] 05:25AM BLOOD Calcium-7.5* Phos-2.4* Mg-2.2
[**2130-9-23**] 01:25AM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.9 Mg-1.9
[**2130-9-23**] 04:12AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.7
[**2130-9-26**] 07:05AM BLOOD AFP-[**2052**]*
.
.
CXR - No acute intrathoracic abnormality.
.
EGD: Continue octreotide gtt for 48 hours.
Cipro 250 mg [**Hospital1 **] x 5 days
Continue ppi gtt for 48 hours total, then switch to oral.
Consider sorafenib for unresectable HCC. Recommend oncology
consult.
Patient will need further variceal banding as outpatient.
Okay to extubate.
Clear liquids for next 24 hours. Then soft diet after.
Carafate slurry 1g po qid for 5 days.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 86216**] is a 64-year-old woman with advanced multifocal
hepatocellular carcinoma occurring in the setting of hepatitis B
cirrhosis, s/p RFA p/w hematemesis from esophageal varices, s/p
banding on this admission.
.
# Esophageal varices- p/w hematemesis and melena, EGD showed
varices in the middle third of esophagus, s/p banding in 4
places on [**9-23**]. Pt was transferred from MICU the day following
banding and was hemodynamically stable throughout. BPs were SBP
110s-120s throughout admission. HCT was stable around 28-30 and
she did not require any blood transfusions. She completed 72-hr
course of octreotide, had IV PPI, 5 days of ciprofloxacin and 5
days of sucralfate. Prior to discharge, her PPI was transitioned
to oral omeprazole, she will follow up with Dr. [**Name (STitle) 23173**] in 2
weeks for repeat endoscopy and banding as outpatient. [**Month (only) 116**]
consider starting nadolol at that time.
.
# Ascites - prior to discharge, pt reported abdominal
distension, on exam mostly tympanitic with some dull areas, U/S
was done to evaluate for fluid and showed moderate ascites. Pt
was not uncomfortable with distension. We performed a diagnostic
tap which was negative for SBP. She was started on lasix 20mg
and aldactone was increased to 50mg from 25mg daily. She will
f/u in liver clinic for titration of these medications.
.
# Hepatocellular carcinoma: diagnosed in [**1-25**], s/p RFA and
transarterial chemoembolization in [**2130-5-16**], with lesions shown
to be improving on CT surveillance. Most recent CT showed no new
lesions, stable pulmonary nodule, and new PVT (see below).
Oncology was made aware of her admission, and recommended that
she follow up as outpatient for initiation of sorafinib for
unresectable HCC. She has f/u appt with Dr. [**Last Name (STitle) **] in 2 weeks.
.
# Hepatitis B cirrhosis: Lamivudine was changed to tenofovir to
prevent resistant, pt discharged with Rx.
.
# Portal venous thrombosis - new thrombus found on CT from
[**2130-9-15**] - complete occlusion of the posterior right portal vein,
partial occlusion of the proximal anterior right portal vein,
and near complete occlusion of the segmental left portal vein.
Last CT in [**Month (only) 205**] so not clear when PVT originated. Given this
chronicity and recent bleed, anticoagulation was not initiated.
.
# HTN: increased laxis to 20mg daily and aldactone 50mg daily,
will f/u in liver clinic.
Medications on Admission:
HOME MEDICATIONS:
LAMIVUDINE [EPIVIR] 150 mg daily
LISINOPRIL 2.5 mg once a day
SPIRONOLACTONE 25 mg daily
CALCIUM CARBONATE-VITAMIN D3 500 mg-400 unit [**Hospital1 **]
DOCUSATE SODIUM [COLACE] 50 mg prn
MULTIVITAMIN
.
TRANSFER MEDICATIONS:
Ciprofloxacin 250 mg [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Senna 1 tab [**Hospital1 **]
K/Mg sliding scale
Pantoprazole 40 mg Q12H
Tenofovir Disoproxil (Viread) 300 mg daily
Discharge Medications:
1. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aldactone 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Variceal bleed
Secondary:
HCC
HBV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a variceal bleed. Your
varices were banding during an endoscopy procedure. You were
stabilized in the MICU and then transferred to the floor. Your
blood counts remained stable and you were able to tolerate a
normal diet. We did an ultrasound of your abdomen which showed
some fluid, we took a sample of that fluid and it did not show
an infection. You should have another endoscopy in 2 weeks with
Dr. [**Name (STitle) 23173**] to make sure there is no more bleeding. Please
make sure to come for this procedure on [**2130-10-12**].
.
You should follow with Dr. [**Last Name (STitle) **] at the appointment date below
for your hepatocellular carcinoma.
.
We have made the following changes to your medications:
Take 20mg lasix once daily and 50mg aldactone once daily to keep
fluid out of your belly
We have changed your lamivudine to tenofovir
Take prilosec (omeprazole) to help reduce acid in your stomach
and prevent future GI bleeding
Followup Instructions:
Dr. [**Name (STitle) 23173**] will call you with the date/time of your
endoscopy (about 2 weeks from discharge)
.
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 86217**],MD
Specialty: Primary Care
When: Thursday, [**10-12**] at 10:10am
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2130-10-16**] at 4:00 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:[**2130-9-28**]
|
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65,359
| 199,672
|
39967
|
Discharge summary
|
report
|
Admission Date: [**2201-5-21**] Discharge Date: [**2201-5-29**]
Date of Birth: [**2119-3-25**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hematemasis
Major Surgical or Invasive Procedure:
Upper endoscopy : Two clips were unsuccessfully deployed in the
area of the bleeding lesion for the purpose of hemostasis. 2
cc.Epinephrine 1/[**Numeric Identifier 961**] injection was applied for hemostasis with
success. A gold probe was applied for hemostasis successfully.
History of Present Illness:
This is an 82 year old male with h/o Barrett's s/p EGD [**2201-5-1**]
with RFA of GEJ, atrial fibrillation on coumadin who woke up at
aprox 4:30 am on [**5-21**] with hematemasis. He did not tell anyone
and cleaned it up. He then had a second episode of hematemasis
and then some melana. His wife then became aware of the problem
and called an ambulance and he went to [**Hospital1 1562**] ED.
.
At falmough he had a HCT of 30 and INR of 3.3. He received 1
unit of PRBC, 2 ffp, 10 vit K. His potassium was noted to be 7,
he was given 5 U regular insulin and 1 amp of dextrose. He was
started on octreatide gtt at [**Hospital1 1562**]. He also recieved some
zofran.
In the ED initial vitals were: 36.4 90 114/59 18 100%. He had
about 400cc of hematemasis and an NG lavage with frank red
blood. He also had maroon stool/melana in ED. Two 16g IVs and
one 18g IV were placed and he was transfused 2 U of PRBC. He
then received another 2 of FFP for coagulopathy. The massive
transfusion protocol was activated. He was evaluated by GI who
felt that he needed to be scoped emergenty in the ICU. He was
hemodynamically unstable with BP dropping to 83/50 and
tachycardic to the low 100s. On transfer his vitals were:
97.8, 112/61, HR 90, 100% 2L.
.
On the floor, patient feels comfortable prior to EGD. He
continues to have some bright red blood from his NG tube. He
denies abdominal pain, nausea, vomiting. No chest pain,
shortness of breath.
.
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 constipation, abdominal pain. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.
Past Medical History:
1. CAD status post CABG in 03/84 with four grafts.
2. Hypertension.
3. Squamous cell carcinoma 03/[**2182**].
4. Atrial fibrillation.
5. Cardioversion [**7-/2191**] treated with Coumadin and
cardioversion.
6. Status post appendectomy.
7. Status post pacemaker placement.
8. Status post defibrillator in 09/[**2195**].
9. Status post right leg popliteal vein patch in 01/[**2197**].
Social History:
- Tobacco: None
- Alcohol: None
- Illicits: None
Married and lives with his wife.
Family History:
Noncontributory
Physical Exam:
Admission exam:
Vitals: T: 96.8 BP: 123/82 P: 88 R: 18 O2: 94% on RA
General: Alert, oriented, appears comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, NG tube in place
with bright red blood draining from it
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
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
.
.
.
Discharge exam:
General: Alert, oriented, appears comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2201-5-21**] 01:25PM BLOOD WBC-6.2 RBC-2.72* Hgb-9.5* Hct-27.1*
MCV-100* MCH-35.0* MCHC-35.1* RDW-14.7 Plt Ct-151
[**2201-5-21**] 01:25PM BLOOD Neuts-56.7 Lymphs-33.2 Monos-8.4 Eos-1.1
Baso-0.4
[**2201-5-21**] 01:25PM BLOOD PT-19.0* PTT-27.5 INR(PT)-1.7*
[**2201-5-21**] 01:25PM BLOOD Glucose-147* UreaN-56* Creat-1.0 Na-141
K-4.7 Cl-111* HCO3-25 AnGap-10
[**2201-5-21**] 01:25PM BLOOD ALT-15 AST-20 AlkPhos-34* TotBili-1.0
[**2201-5-21**] 01:25PM BLOOD cTropnT-0.03*
[**2201-5-21**] 01:25PM BLOOD Albumin-3.4* Calcium-7.9* Phos-3.3 Mg-2.0
EGD:
Blood in the middle third of the esophagus, lower third of the
esophagus and gastroesophageal junction. There was a hiatal
hernia that contained the distal esophagus and GEJ. Within the
hernia, at the most distal tip of the JEG there was a protruding
lesion with active arterial hemorrhage. (endoclip, injection,
thermal therapy). Because of the location of the lesion (within
the hiatal hernia), intervening upon the lesion was challenging.
Blood in the stomach body. Otherwise normal EGD to third part of
the duodenum
EKG:
Atrial fibrillation with a single ventricular premature beat.
Consider
lateral myocardial infarction. Intraventricular conduction delay
of left
bundle-branch block type. Since the previous tracing probably no
significant change.
Chest X-Ray:
Portable AP radiograph of the chest was reviewed with no prior
studies
available for comparison.
Severe cardiomegaly is noted. Mediastinum is dilated, chronicity
undetermined. The patient is in moderate-to-severe pulmonary
edema, accompanied by bilateral pleural effusions. Bibasilar
areas of atelectasis
are most likely present. Pacemaker leads terminate in right
atrium and right ventricle. There is no pneumothorax.
ECHO:
.
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.9 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *7.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *5.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 15% >= 55%
Left Ventricle - Stroke Volume: 81 ml/beat
Left Ventricle - Cardiac Output: 6.76 L/min
Left Ventricle - Cardiac Index: 3.35 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.06 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.03 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *27 < 15
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 3.0 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.7 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 18
Aortic Valve - LVOT diam: 2.4 cm
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - E Wave deceleration time: *269 ms 140-250 ms
TR Gradient (+ RA = PASP): *45 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness. Mildly dilated LV
cavity. Severely depressed LVEF. Cannot exclude LV
mass/thrombus. TDI E/e' >15, suggesting PCWP>18mmHg. No resting
LVOT gradient.
RIGHT VENTRICLE: Dilated RV cavity. Mild global RV free wall
hypokinesis. Abnormal septal motion/position consistent with RV
pressure/volume overload.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Focal calcifications in aortic root. Normal descending
aorta diameter. No 2D or Doppler evidence of distal arch
coarctation.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Severe
mitral annular calcification. Mild (1+) MR. Prolonged (>250ms)
transmitral E-wave decel time.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor subcostal
views. Echocardiographic results were reviewed by telephone with
the MD caring for the patient.
IMPRESSION: Biatrial enlargement. Severely depressed global left
ventricular systolic function with relative preservation of the
distal inferoseptal segment. Elevated left ventricular filling
pressures. Mild mitral regurgitation. Moderate to severe
tricuspid regurgitation. At least moderate pulmonary artery
systolic hypertension. EF%15
.
.
.
Labs on discharge:
[**2201-5-29**] 06:27
COMPLETE BLOOD COUNT
White Blood Cells 7.1 4.0 - 11.0 K/uL
Red Blood Cells 3.29* 4.6 - 6.2 m/uL
Hemoglobin 10.9* 14.0 - 18.0 g/dL
Hematocrit 31.9* 40 - 52 %
MCV 97 82 - 98 fL
MCH 33.2* 27 - 32 pg
MCHC 34.2 31 - 35 %
RDW 16.1* 10.5 - 15.5 %
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 197 150 - 440 K/uL
PERFORMED AT WEST STAT LAB
[**2201-5-29**] 06:27 901 23* 1.0 141 3.9 104 27 14
Other pertinent labs:
CKMB / CMBR index / Troponin
[**2201-5-23**] 03:27 16* / 9.8*/ 0.38*1
[**2201-5-22**] 18:09 24*/ 13.6*/ 0.39*1
[**2201-5-22**] 09:20 27*/ 16.6* /0.27*2
[**2201-5-22**] 01:31 13*/ 12.1*/ 0.09*
Brief Hospital Course:
This is an 82 yo M with h/o Barrett's esophagus with low-grade
dysplasia presenting with hematemesis s/p radiofrequency
ablation.
.
# Hematemasis: Mr. [**Known lastname 75589**] presented with hematemeis and melena
approximately three weeks following RFA of barrett's esophagus
at GEJ. At OSH and [**Hospital1 18**] patient was transfused a total of 6
units PRBC, 1 unit of platelets, and 4 units of FFP. The
massive transfusion protocol was activated in the emergency
department. Mr. [**Known lastname 75589**] was admitted to the ICU for urgent
endoscopy. On EGD seen to have protruding lesion with active
hemorrhage at JEG, s/p failed clipping but with cauterization
and epi injection.
.
Mr. [**Known lastname 75589**] was monitored in the ICU following intubation.
Surgery consulted and felt that it would be difficult to
surgically intervene distal esophagus as it was within hiatal
hernia. Serial HCTs were monitored. Following EGD patient did
not require any further transfusions in the ICU and his HCT
remained stable between 26 - 29. Patient was initially treated
with PPI gtt, which was transitioned to IV PPI [**Hospital1 **] and then
further transitioned to PO PPI on discharge. Over 4 days on the
floor he required only 1U pRBCs and his HCT stabalized around
28-30. His stool turned from tarry black to brown. on [**2201-5-26**] he
was started on 81mg aspirin without known rebleeding or drop in
hematocrit. He was not restarted on coumadin despite the risk of
afib-induced strokes given the significant risk of rebleed. He
will have follow up with his PCP on [**2201-6-1**] as well as GI
services on [**6-3**] at [**Hospital1 18**].
.
# NSTEMI: On admission, patient had slightly elevated troponin
at 0.03 felt to be secondary to demand in setting of acute GI
bleed. On Day 3 of admission patient became more tachycardiac
and cardiac enzymes peaked with troponin at 0.39, ECG changes
with V3-5 ST depressions. Likely in setting of demand from
massive bleeding vs. NSTEMI. Patient was asymptomatic. Started
patient on atorvastatin 80 mg daily and metoprolol (his
simvastatin was stopped). Aspirin and anticoagulation were
originally held given risk of further bleeidng. Aspirin 81mg
was started on [**2201-5-26**]. Coumadin was not restarted on this
admission.
.
Patient had ECHO showing severely depressed global left
ventricular systolic function with an EF of 15% (prior known EF
was 25%). Unclear if related to acute event or more
longstanding as patient with significant history of cardiac
disease. He did not exhibit any episodes of shortness of breath
or dyspnea on exertion during his admission to the floor. He was
continued on his home dose of lasix 40mg daily. His lisinopril
was decreased to 5mg daily given his borderline low systolic BP
(100-110). His metoprolol tartrate was increased to 50mg TID and
he was discharged on a higher dose of 150mg Toprol daily.
.
# Pulmonary edema ?????? On admissioni, Mr. [**Known lastname 75589**] had new oxygen
requirement and evidence of pulmonary edema on CXR. He was
believed to be volume overloaded in setting of massive
transfusions. Responded well to diuresis with Lasix 20 mg IV. He
was then continued on his home dose of 40mg lasix PO daily.
.
# A fib ?????? On Coumadin and digoxin prior to admission. Patient
has ICD. Had 39 beat run of v tach for which ICD did not fire.
EP interrogated pacer and was working well, threshold for firing
>180bpm, last recorded firing in [**2200-5-27**]. Patient was
tachycardic in a fib with RVR to 120s which was likely worsening
demand. Responded well to esmolol drip in the ICU with
improvement in rate control to 80s. Patient was transitioned
from esmolol gtt to metoprolol TID. Metoprolol was titrated up
to 50 mg TID. Digoxin was restarted in ICU and continued on the
floor. During his time on the floor, he had several runs of NSVT
(6-11 beats) during which he was asymptomatic.
.
# Hypertension: Antihypertensives were held during first several
days of admission given that patient was hypotensive in setting
to GI bleed. Prior to transfer from ICU, metoprolol was started
as above and lower dose lisinopril 5 mg daily was restarted. His
BP was borderline low with SBP 100-110. He did not exhibit
dizziness, lightheadedness or orthostasis at these blood
pressures.
.
######################
.
Transitional issues:
1. GI bleed: patient should have repeat Hematocrit as
outpatient. He was told to monitor his stool and to return to
the ED/call his doctor if he felt lightheaded or began seeing
dark tarry stool or frank blood. He will have follow up with GI
on [**6-3**] for further monitoring of his symptoms and of his
bleeding upper GI vessel. He might require further scope in the
future.
.
2. NTEMI/depressed EF: patient had echo showing very low EF 15%.
He did not exhibit clinical signs of volume overload and was not
dyspneic on exertion or at rest. He will have follow up with
Cardiology Dr. [**Last Name (STitle) **] on [**2201-6-1**] to further monitor and
treat his heart failure and possibly restart coumadin for afib.
.
3. Afib: patient on low dose aspirin but his CHADS score would
dictate that he would benefit from coumadin. Given the high risk
of rebleed from upper GI vessel, the GI service wanted to ensure
the patient was stabilized before starting aspirin. And low-dose
aspirin was only restarted on [**5-26**]. His coumadin should be
restarted at a later date once his risk for GI bleed decreases.
Medications on Admission:
Digoxin 125 mcg daily
Furosemide 40 mg dialy
Isosorbide dinitrate 30 mg daily
Lisinopril 10 mg daily
Nitro 0.3 mg SL PRN
Omeprazole 40 mg [**Hospital1 **]
Potassium chloride 40 mEq [**Hospital1 **]
Propranolol 80 mg daily
Simvastatin 40 mg daily
Sucralfate 1 gram QID PRN
Ascorbic acid 500 mg daily
Aspirin 81 mg daily
Omega 3 fatty acids
Coumadin
Discharge Medications:
1. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. isosorbide dinitrate 20 mg Tablet Sig: 1.5 Tablets PO DAILY
(Daily).
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. potassium chloride 20 mEq Packet Sig: Two (2) PO twice a
day.
8. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
11. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
12. Omega 3 Fish Oil Oral
13. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary:
Upper GI bleed
acute blood loss anemia
Secondary:
GERD with Barrett's esophagus
NSTEMI
acute on chronic systolic CHF
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the [**Hospital3 **] hospital for a
gastrointestinal bleed after undergoing radio-frequency ablation
of your Barrett's esophagus. You were transfused with blood and
had ongoing bleeding for several days. During that time you
unfortunately had a heart attack that resulted in further damage
to your heart. No intervention was performed during your
admission because of your Gastrointestinal bleeding risk. During
he course of your hospitalization your bleeding subsided and
your hematocrit remained stable. Your aspirin (which had been
held because of the bleeding) was reintroduced into your
medication regimen. We did not find evidence of bleeding on this
medication. We did not restart your coumadin given the risk of
bleeding and this should be discussed with your cardiologist Dr.
[**Last Name (STitle) **] during your next appointment. Your coumadin decreased your
risk of stroke while you have atrial fibrillation.
During your hospitalization, some of your medications have
changed, please note the following:
-START aspirin 81mg daily
-START Metoprolol 150mg daily
-START Atorvastatin 80mg daily
-DECREASE lisinopril to 5mg daily
-STOP Coumadin (you may restart this medication by your
cardiologist)
-STOP Simvastatin (you will be taking a similar drug
atorvastatin)
Followup Instructions:
Please note the following:
You have an appointment with Dr. [**Last Name (STitle) 52362**] on [**2201-6-1**] @ 10:00am
You have an appointment with Dr. [**Last Name (STitle) **] on [**2201-6-1**] @ 1:15pm
Also note following appointment:
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2201-7-3**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], 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) 1951**]
Campus: EAST Best Parking: Main Garage
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
16517, 16578
|
9563, 13883
|
315, 593
|
16761, 16761
|
4109, 4109
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2509, 2902
|
2918, 3004
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,693
| 198,481
|
29025
|
Discharge summary
|
report
|
Admission Date: [**2174-11-29**] Discharge Date: [**2174-12-5**]
Date of Birth: [**2130-5-18**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Phenergan
Attending:[**First Name3 (LF) 2167**]
Chief Complaint:
Abdominal pain x 2weeks
Major Surgical or Invasive Procedure:
PICC line placement [**12-2**]
History of Present Illness:
This is a 44yoF w/h/o etoh abuse and chronic pancreatitis c/b
pseudocysts and diminished endocrine/exocrine function, as well
as hepatic fibrosis who is transferred from OSH per family
request for management of pancreatitis. Pt initially presented
to OSH([**2174-11-22**]) w/2 weeks of N/V/D and epigastric abdominal
pain, dehydration, fatigue, and malaise.
.
At the OSH, she was initially on Ertrapenem but was then changed
to Zosyn/Vanc for coverage of pancreatitis vs. SBP vs.
aspiration PNA. Cardiac enzymes were negative x 3. Her HCT
trended down from 34.5 on presentation to 22.3 on day of
transfer during hospitalization, and she was noted to have guiac
+ stools. Per report was febrile on admission, last documented
fever Tm 101 on [**2174-11-26**].
.
Current ROS: The patient endorses [**8-14**] abdominal pain radiating
to her back; otherwise, denies any fevers, chills, weight
change, diarrhea, constipation, melena, hematochezia, chest
pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
-Chronic Pancreatitis c/b pseudocysts and decreased
endocrine/exocrine fxn per MRCP [**2173-1-25**] (PICC and TPN)
-likely pancreatic duct stricture per ERCP [**2173-1-19**]
- h/o etoh cirrhosis: Liver bx [**2173-2-3**]: hemosiderosis
w/increased portal fibrosis with focal portal septa (Stage 1-2)
- h/o EToh abuse c/b DTs
-Avascular necrosis and degenerative joint disease of both hips
-Hx of pneumonia
-Pulmonary embolism from right-sided blood clots
-Depression
-h/o stage 2 coccygeal pressure ulcer
-h/o obstructive lesion in the distal aspect of the stomach
-h/o normal colonoscopy
SURGICAL HISTORY
-s/p left THR
-DVT filter placement through her right groin.
-s/p CCY
Social History:
She lives at home with her parents. Notes that she hasn't drank
in "3 months" but has extensive h/o EtOH abuse (Vodka) hx.
Smoking - 20 pack years and quit "6 months ago".
Family History:
Pancraetic CA, Colon CA, Melanoma
Physical Exam:
Vitals: T: 99.8 BP: 114/59 HR: 103 RR: 17 O2Sat: 99% 2LNC
GEN: cachectic, NAD
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, dry MM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: tachy, RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: scar noted, distended, + epigastric tenderness, +BS, no
rebound/rigidity/guarding
EXT: No C/C/E, no palpable cords
NEURO: echolalia, not oriented to place/situation/year. CN II ??????
XII grossly intact. Moves all 4 extremities. Strength 5/5 in
upper and lower extremities. + tremulousness, difficult to
assess asterixis.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2174-11-29**] 08:28PM
PT-16.8* PTT-37.5* INR(PT)-1.5*
PLT SMR-VERY LOW PLT COUNT-70*# LPLT-1+
HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+
MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL SPHEROCYT-1+
OVALOCYT-OCCASIONAL BURR-1+ FRAGMENT-OCCASIONAL
NEUTS-86* BANDS-0 LYMPHS-3* MONOS-3 EOS-0 BASOS-0 ATYPS-8*
METAS-0 MYELOS-0
WBC-5.5 RBC-2.65* HGB-9.2* HCT-27.3*
MCV-103* MCH-34.7* MCHC-33.8 RDW-19.6*
TRIGLYCER-73
ALBUMIN-2.3* CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-1.5* LIPASE-44
ALT(SGPT)-7 AST(SGOT)-18 LD(LDH)-251* ALK PHOS-106 AMYLASE-30
TOT BILI-1.2
GLUCOSE-458* UREA N-10 CREAT-0.6 SODIUM-127* POTASSIUM-3.0*
CHLORIDE-98 TOTAL CO2-24 ANION GAP-8
[**2174-11-29**] 10:41PM URINE
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG
COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
UREA N-181 CREAT-18 SODIUM-96
CHEST (PORTABLE AP) Study Date of [**2174-11-29**] 8:29 PM
IMPRESSION:
1) Diffuse bilateral pulmonary edema.
2) Small right pleural effusion.
ECHO [**11-30**]
IMPRESSION: Normal global and regional biventricular systolic
function. No diastolic dysfunction, pulmonary hypertension or
significant valvular disease seen.
Radiology Report CT ABD W&W/O C Study Date of [**2174-11-30**] 9:15 AM
IMPRESSION:
1. Baseline changes in the pancreas with calcification and
pseudocysts,
largest one measuring 40 x 46 mm. Large amount of ascites.
Anasarca. Due to baseline changes and large amount of ascites,
it is difficult to evaluate for acute pancreatitis on the
current scan. Nodular cirrhotic liver.
2. Bilateral opacification in the lung, predominantly in the
upper lobes,
suggestive of possible aspiration. Bilateral large pleural
effusions.
Dependent small atelectasis at the lung bases.
[**2174-12-1**] 10:20 am PERITONEAL FLUID
GRAM STAIN (Final [**2174-12-1**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
[**2174-12-1**] 10:20AM ASCITES
WBC-110* RBC-90* Polys-60* Lymphs-11*
Monos-20* Eos-1* Mesothe-3* Macroph-5*
TotPro-0.7 Glucose-126 LD(LDH)-32 Albumin-LESS THAN
Brief Hospital Course:
This is a 44yoF with history of etoh abuse and chronic
pancreatitis w/multiple complications who is transferred from
OSH per family request for management of pancreatitis and fever.
.
# Chronic Pancreatitis: Patient's CT abdomen showed evidnece of
chronic pancreatitis and pancreatic pseudocyst. The patient was
continued on her home pancreatic enzyme supplementation, but was
not taking pos very well and was then started on TPN. She had
some diarrhea, which improved with uptitration of her pancreatic
enzymes, and this can be continued to be increased as her po
intake improves.
# Fever: Unclear etiology; possibly due to pancreatitis vs PNA,
as CXR and CT chest concerning for BL PNA. The patient was
covered broadly w/Vanc, Zosyn for presumed aspiration pneumonia
and will need to complete a 10 day course. Pt also had line
placed at OSH which was subsequently removed. Blood and urine
cultures were obtained and all cultures, including those from
OSH were negative.
# Anemia: Pt had guiac + stools at OSH. CT consistant with
esophageal varicies. Her hematocrit remained stable.
# Hyponatremia: Sodium was 127 on arrival but resolved with IV
fluid boluses.
# Thrombocytopenia: Likely due to cirrhosis. Stable
# Altered mental status: Patient oriented to self only on
arrival. A lactulose enema was given on admission with no
improvement. Possible infectious source rather than hepatic
encephalopathy. CT head was unremarkable.
# Cirrhosis: GI was consulted and CT of the abdomen was
obtained. Imaging with evidence of diffuse anasarca, large
amount of acites and chronic pancreatic changes. A u/s guided
paracentesis was obtained and cultures were sent. This was
negative.She was started on Lasix/aldactone.
# h/o ETOH abuse: Patient was initially placed on CIWA scale,
recieved minimal ativan. No evidence of acute withdrawal. Now
holding benzos due to mental status.
# Stage I coccygeal ulcer: wound care consulted.
# FEN: Patient severly cachetic and nutritionally depleted.
Speech/swallow evaluation cleared patient for nectar thick
liquids and purees. TPN was initiated and will need to continue
until patient is taking adequate po intake. Calorie counts will
need to be performed while at rehab for consideration of
discontinuation of TPN.
# PPx: PPI, heparin SC
# Code: Full
Discharge Medications:
1. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO Once Daily at
4 PM.
4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. Humalog 100 unit/mL Solution Sig: [**10-24**] Subcutaneous three
times a day.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever,ha,pain.
7. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection three times a day.
14. Amylase-Lipase-Protease 48,000-16,000- 48,000 unit Capsule,
Delayed Release(E.C.) Sig: Four (4) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS).
15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Insulin Lispro 100 unit/mL Solution Sig: One (1) dose
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
18. Vancomycin 1000 mg IV Q 12H
19. Piperacillin-Tazobactam Na 4.5 g IV Q8H
20. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
21. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for leg pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Aspiration pneumonia/pneumonitis vs HCAP
Chronic pancreatitis with pseudocysts with flare
Malnutrition, started on TPN
Mental status change, multifactorial
Discharge Condition:
FAIR
Discharge Instructions:
You were admitted to another hospital with
nausea/vomiting/abdominal pain secondary to your pancreatitis
flare.
While you were at the other hospital, you received pain meds
that caused you to be sedated and you may have aspirated and
developed a pneumonia.
On arrival to [**Hospital1 18**], you had low oxygen levels and you were
admitted to the intensive care unit. You were found to have a
pneumonia and were started on antibiotics, which you will
complete for 10 days.
Because you haven't tolerated food for a long time and are
severely malnourished, you were started on IV nutrition/TPN.
While you recovered, you tolerated some oral foods, so it is
possible that the TPN can be stopped in a short time if you can
take enough nutrition by mouth. You will be evaluated for this
by nutrition.
You have an appointment set up with Dr. [**Last Name (STitle) 2161**] in GI for your
pancreatitis. However, you need to also follow up with the liver
doctors at some [**Name5 (PTitle) **].
You were very deconditioned so you will go to a rehab for some
time for physical therapy.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2174-12-12**] 1:30
Please make an appointment with Dr. [**Last Name (STitle) 5456**] in 2weeks after
discharge.
|
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icd9pcs
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,915
| 146,974
|
41315
|
Discharge summary
|
report
|
Admission Date: [**2168-12-25**] Discharge Date: [**2169-1-26**]
Date of Birth: [**2120-8-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
acute liver failure
Major Surgical or Invasive Procedure:
L femoral hemodialysis line
Intubation
Tunneled HD line
Liver Biopsy
EGD by hepatology
Bolt Placement and Removal by neurosurgery
History of Present Illness:
48 year old female with COPD and alcohol abuse, who initially
presented to OSH with altered mental status. She has been having
5 days of fevers, chills, achiness, nausea, and weakness. She
was found at home with altered mental status by her friend and
was brought to OSH [**Name (NI) **]. At the OSH she was found to be in
multiorgan failure, with transaminitis in the 10,000s, INR 3.8,
ammonia 540, creatinine 3.6, and lactate of 13. She was
hypotensive initially to the 60's. Blood pressure was responsive
to 4L of IV fluids with improvement to the 90's. She was given
zosyn, protonix 40mg IV and D50 for hypoglycemia in the 20's.
She was transferred to [**Hospital1 18**] for further management.
.
In the ED, initial vs were: 96.8, 116, 92/41, 21, 100% 2L. Her
blood pressures remained low, as low as in the 70s, despite the
4L she was given at the OSH, was started on levophed. She had a
right IJ central line placed. She denied chills, pain, nausea,
vomiting, diarrhea, constipation, chest pain, some shortness of
breath. No
rash, no joint pain. Lactate was slightly improved at 8.1. ED
did not give any further IV fluids because of poor kidney
functions and low urine output despite IV fluid resuscitation at
OSH. Her mental status was noted to be somewhat more improved,
as she was not as lethargic as she had been. Awake and
conversive. She received vancomycin. Hepatology and transplant
surgery evaluated the patient in the ED. Patient was transferred
to the ICU for further workup. Vital signs on transfer were:
74/50, 123, 24, 100%RA
.
In the MICU, patient was alert and oriented. Having some nausea.
On presentation, had 250 cc of brown vomitus. She reports that
her last drink was yesterday. Takes tylenol 2 tablets at night,
this has been her habit for a long time. No recent travel, no
exotic foods. Last sexual activity was years ago, no unprotected
sex. Denies any IV drug use, illicit drug use.
.
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. Denies
diarrhea, dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
Alcohol abuse
COPD/Asthma
Depression
Lupus
Social History:
Works as a dental assistant and waitress. She is divorced with
19 yr old son. She smokes at least 1ppd. She drinks 10-12 beers
per day, and has been doing so for greater than 10 years. No
illicits. No Mushrooms.
Family History:
No FHx of liver disease
Physical Exam:
HEENT: No icterus, oropharynx dry, without exudate, no LAD, no
thyromegaly
Lungs: Poor Air movement
Cardiovascular: Tahcycardic, normal S1/S2, no rubs, murmurs or
gallops
Abdomen: Positive bowel sounds, nondistended, soft, mild
tenderness to palpation in RUQ, no splenomegaly, liver span
about
9-10 cm. Dullness to percussion in flanks.
Extremities: warm, well perfused, no edema
Skin: No spiders, no palmar erythema.
Neuro: Alert and oriented x 3. Subtle deficiency in cognition.
Pertinent Results:
OSH LABS:
144/5.4/97/8/24/3.6<22, Lactate - 13
CBC: 23>45<311, MCV-101, 95N, 1Band
INR-3.5, PT-46, PTT-31(normal)
Albumin-4.6, Amylase-89, Lipase-102 TP-7.6,
EtOH-62, Salicylate-9.3 (15-30), Tylenol-23
TB-4.4, DB-3.7, AlkPhos-179
ALT-10,300, AST-19,810, TB-4.4, DB-3.7
NH3-540
.
ADMISSION LABS:
[**2168-12-25**] 10:45PM BLOOD WBC-18.1* RBC-3.34* Hgb-10.9* Hct-33.1*
MCV-99* MCH-32.6* MCHC-32.9 RDW-13.4 Plt Ct-236
[**2168-12-25**] 10:45PM BLOOD Neuts-94.2* Lymphs-4.2* Monos-1.3*
Eos-0.2 Baso-0.2
[**2168-12-26**] 01:00AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2168-12-25**] 10:45PM BLOOD PT-63.8* PTT-44.9* INR(PT)-7.3*
[**2168-12-26**] 01:00AM BLOOD Fibrino-91*
[**2168-12-25**] 10:45PM BLOOD Glucose-159* UreaN-28* Creat-3.2* Na-141
K-5.5* Cl-108 HCO3-9* AnGap-30*
[**2168-12-25**] 10:45PM BLOOD ALT-7780* AST-[**Numeric Identifier 89939**]* CK(CPK)-319*
AlkPhos-117* TotBili-3.7*
[**2168-12-25**] 10:45PM BLOOD Lipase-164*
[**2168-12-27**] 04:06PM BLOOD Lipase-1237*
[**2168-12-25**] 10:45PM BLOOD cTropnT-<0.01
[**2168-12-27**] 04:06PM BLOOD CK-MB-8 cTropnT-0.03*
[**2168-12-27**] 08:29PM BLOOD CK-MB-8 cTropnT-0.05*
[**2168-12-28**] 07:35AM BLOOD CK-MB-5 cTropnT-0.06*
[**2168-12-25**] 10:45PM BLOOD Albumin-3.5 Calcium-6.8* Phos-9.5* Mg-2.0
[**2168-12-26**] 01:00AM BLOOD Albumin-3.6 Calcium-6.4* Phos-8.4* Mg-1.9
Iron-255* Cholest-100
[**2168-12-26**] 01:00AM BLOOD calTIBC-215 Ferritn-[**Numeric Identifier 89940**]* TRF-165*
[**2169-1-7**] 03:17AM BLOOD Hapto-<5*
[**2168-12-26**] 01:00AM BLOOD Triglyc-70 HDL-39 CHOL/HD-2.6 LDLcalc-47
[**2168-12-25**] 10:45PM BLOOD Ammonia-42
[**2168-12-26**] 11:10PM BLOOD Osmolal-315*
[**2168-12-26**] 01:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2168-12-27**] 04:06PM BLOOD HBcAb-NEGATIVE
[**2168-12-26**] 01:00AM BLOOD AMA-NEGATIVE
[**2168-12-26**] 01:00AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2168-12-26**] 01:00AM BLOOD CEA-2.7 AFP-3.4
[**2168-12-26**] 01:00AM BLOOD IgG-672* IgA-157
[**2168-12-26**] 01:00AM BLOOD HIV Ab-NEGATIVE
[**2168-12-25**] 10:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-19
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2168-12-25**] 10:49PM BLOOD Lactate-8.1*
[**2168-12-26**] 01:00AM BLOOD CA [**76**]-9 - 14 (nl <37 U/mL)
[**2168-12-26**] 01:00AM BLOOD CERULOPLASMIN- 18 (nl 18-53 mg/dL)
.
[**2168-12-26**] 01:00AM BLOOD HERPES SIMPLEX (HSV) 1, IGG
[**2168-12-26**] 01:00AM BLOOD HERPES SIMPLEX (HSV) 2, IGG
Test Result Reference
Range/Units
HSV 1 IGG TYPE SPECIFIC AB >5.00 H index
HSV 2 IGG TYPE SPECIFIC AB <0.90 index
Index Interpretation
<0.90 Negative
0.90-1.10 Equivocal
>1.10 Positive
.
[**2168-12-26**] 01:00AM BLOOD VITAMIN D 25 HYDROXY-
Test Result
Reference Range/Units
VITAMIN D, 25 OH, TOTAL <4 L 30-100 ng/mL
VITAMIN D, 25 OH, D3 <4 ng/mL
VITAMIN D, 25 OH, D2 <4 ng/m
.
DISCHARGE LABS:
[**2169-1-26**] 07:40AM BLOOD WBC-15.6* RBC-2.58* Hgb-9.0* Hct-26.6*
MCV-103* MCH-35.0* MCHC-33.9 RDW-20.1* Plt Ct-311
[**2169-1-26**] 07:40AM BLOOD Neuts-91* Bands-0 Lymphs-3* Monos-3 Eos-3
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2169-1-26**] 07:40AM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-3+ Microcy-1+ Polychr-NORMAL Ovalocy-1+
[**2169-1-25**] 05:10AM BLOOD PT-16.1* PTT-28.1 INR(PT)-1.4*
[**2169-1-24**] 04:50AM BLOOD Ret Man-5.1*
[**2169-1-26**] 07:40AM BLOOD Glucose-112* UreaN-32* Creat-6.2*#
Na-131* K-3.5 Cl-91* HCO3-27 AnGap-17
[**2169-1-26**] 07:40AM BLOOD ALT-50* AST-64* AlkPhos-165* TotBili-7.9*
[**2169-1-23**] 05:25AM BLOOD Lipase-678*
[**2169-1-26**] 07:40AM BLOOD Albumin-3.0* Calcium-9.0 Phos-4.3 Mg-2.9*
[**2169-1-24**] 04:50AM BLOOD VitB12-1538* Folate-GREATER TH
[**2169-1-24**] 04:50AM BLOOD PTH-45
MICROBIOLOGY:
Blood cultures from [**12-25**] (2 sets), [**12-27**] (2 sets), [**1-1**] (1 set),
[**1-3**] (2 sets), [**1-4**] (1 set), and [**1-5**] (1 set): NO GROWTH
.
Urine cultures from [**12-25**], [**12-26**], [**12-27**], [**1-5**]: NO GROWTH
.
Catheter Tip cultures from [**1-3**], [**1-4**]: No Growth
.
RAPID PLASMA REAGIN TEST (Final [**2168-12-28**]):
NONREACTIVE.
Reference Range: Non-Reactive.
.
Rubella IgG/IgM Antibody (Final [**2168-12-27**]):
POSITIVE by Latex Agglutination.
This test should be used to screen for immunity to
Rubella. A
positive test result indicates immunity. Note, this test
should not
be used to diagnose acute Rubella infection.
.
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2168-12-27**]):
POSITIVE BY EIA.
A positive IgG result generally indicates past exposure
and/or
immunity.
.
CMV IgG ANTIBODY (Final [**2168-12-27**]):
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
< 4 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2168-12-27**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA
.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2168-12-26**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2168-12-26**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2168-12-26**]):
NEGATIVE <1:10 BY IFA.
.
[**2168-12-27**] 8:28 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2168-12-29**]**
GRAM STAIN (Final [**2168-12-27**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2168-12-29**]):
Commensal Respiratory Flora Absent.
YEAST. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
.
[**2169-1-1**] 11:28 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2169-1-3**]**
GRAM STAIN (Final [**2169-1-1**]):
THIS IS A CORRECTED REPORT ([**2169-1-2**]).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2169-1-2**] 1:25PM.
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): YEAST(S).
.
PREVIOUSLY REPORTED AS ([**2169-1-1**]).
>25 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 [**2169-1-3**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES.
.
[**2169-1-2**] 7:45 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2169-1-4**]**
GRAM STAIN (Final [**2169-1-2**]):
<10 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2169-1-4**]):
Commensal Respiratory Flora Absent.
YEAST. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
.
[**2169-1-3**] 10:19 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2169-1-5**]**
GRAM STAIN (Final [**2169-1-3**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2169-1-5**]):
Commensal Respiratory Flora Absent.
YEAST. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
.
[**2169-1-8**] 4:43 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2169-1-9**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2169-1-9**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
[**2169-1-15**] 4:07 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2169-1-16**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2169-1-16**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
IMAGING:
RUQ US ([**2168-12-26**]):
1. Patent hepatic and portal veins; limited assessment of
hepatic artery.
2. No intra- or extra-hepatic biliary dilatation.
.
TTE ([**2168-12-27**]):
Grossly preserved biventricular systolic function. No pulmonary
hypertension or clinically-significant valvular disease seen.
Limited study.
.
CT head without contrast ([**2168-12-27**]):
No evidence of acute intracranial hemorrhage or cerebral
swelling.
.
CT chest/abdomen/pelvis without contrast ([**2168-12-27**]):
1. No retroperitoneal hematoma
2. Diffuse soft tissue anasarca, free fluid in the mesentery,
retroperitneum, and pelvis.
3. Fatty liver
4. Diffuse enlargment of the pancreas which can be seen with
pancreatitis.
5. Small R>L pleural effusion. Diffuse ephysematous changes.
.
CT Brain Perfusion : No large area of increased MTT or
perfusion deficit in the imaged portions of the brain.
Evaluation of the imaged posterior fossa structures is limited
due to artifacts. The study is somewhat suboptimal due to
slightly suboptimal quality of the perfusion maps for the
posterior fossa.
.
EEG ([**2168-12-31**]): This EEG continues to show a moderately severe to
severe diffuse encephalopathy although some of the frequencies
now appear to be slightly faster suggesting there may be some
reversibility. Also, two events occurred that appeared, in one
case, to be a focal sustained seizure from the right frontal
region and the other a more generalized discharge, neither
associated with a clear clinical accompaniment.
.
MRI Brain ([**2169-1-2**]): 1. Status post right frontal bolt removal
with a small amount of residual blood products, but no large
intracranial hemorrhage.
2. No evidence of acute infarct.
3. Paranasal mastoid sinus or air-fluid levels, most likely the
sequela of recurrent intubation.
.
BIPOSY of L flank ([**2169-1-3**]): Skin, left flank; punch biopsy (A):
Extravasation of red blood cells into dermis and subcutis.
No occlusive small vessel vasculopathy identified in this
sample.
Multiple levels have been examined.
.
Abdominal U/S ([**2169-1-9**]): 1. No biliary obstruction identified.
2. Moderate amount of ascites and bilateral pleural effusions
noted.
3. Collapsed gallbladder with a thickened gallbladder wall,
likely due to
underlying liver disease.
.
LIVER CORE BX (1 JAR) Study Date of [**2169-1-18**]: Pending
.
EGD ([**2169-1-25**]): Impression: Varices at the lower third of the
esophagus
Mosaic appearance in the fundus, stomach body and antrum
compatible with portal hypertensive gastropathy. Rotated
duodenal anatomy- likely secondary to pancreatitisOtherwise
normal EGD to third part of the duodenum
Successful placement of Dobhoff 10-French nasojejunal feeding
tube
Brief Hospital Course:
48 y/o F w/ COPD and alcohol abuse who presented from an outside
hospital with altered mental status, found to have fulminant
hepatic failure and renal failure, initially requiring
intubation and pressor support, then extubated with improving
mental status, improvement in liver function, but interval
development of pancreatitis, spontaneous bacterial peritonitis,
and ongoing volume overload due to persistent renal failure
requiring dialysis.
.
# Fulminant Liver Failure - Patient with no known underlying
liver disease except history of alcohol abuse presents with
altered mental status and abnormal liver enzymes ALT 7780, AST
[**Numeric Identifier 89939**], LDH 319, Alk Phos 117, TBili 3.7) and elevated INR (peak
of 8.9)suggestive of acute liver failure. She does report using
standing tyelnol but no overdose. Likely etiology tylenol
toxicity in setting of alcohol abuse as the cause of her liver
failure. Hepatitis serologies and autoimmune work-up (including
[**Doctor First Name **] and AMA) were negative. RUQ U/S with Dopplers showed patent
vasculature and no evidence of obstructive disease (stones).
She completed N-acetyl cysteine protocol for tylenol
hepatotoxicity and supportive care. A bolt was placed on
[**2168-12-30**] and labs/mental status exams closely followed out of
concern for cerebral edema. She was treated prophylactically
with hypertonic saline and mannitol. Her ICP's remained within
normal range, and the bolt was pulled on [**1-2**]. Follow-up MRI did
not show evidence of infarct or hemorrhage. She was treated
empirically with Vancomycin/Levofloxacin/Zosyn on [**2168-12-26**] and
transitioned to Vanco/Cefepime/Flagyl for hepatobiliary
infection from [**2168-12-30**] to [**2169-1-8**]. Transplant surgery and
hepatology evaluated her for liver transplant. She was
initially listed, but as she improved she was eventually
delisted. She experienced hepatic encephalopathy which was
quite subtle at times (only recognizable to family) but
completely improved with lactulose and rifaximin which she will
continue. The length of her course suggested more profound
underlying liver disease than was apparent on admission so liver
biopsy was obtained, which was pending at the time of discharge
and the hepatologist (Dr. [**Last Name (STitle) **] will follow up. An EGD was
performed that showed 2 cords of grade 1 esophageal varices. As
she was unable to take in greater than [**2157**] calories daily
witout vomiting, a post-pyloric Dobhoff was placed and bridled
for nutrition to improve recovery.
.
#. Acute kidney injury: Differential includes acute tubular
necrosis from hypotension versus hepatorenal syndrome type 1.
Urine lytes consistent with prerenal etiology which could be any
of the latter two. She has been oliguric and course complicated
by hyperkalemia. Renal placed a left femoral dialysis catheter
and started CVVH on [**2168-12-27**] to help for clearance. She was
converted to intermitted HD about one week later which she
tolerated well. She is discharged with a tunneled HD line on a
Tu/Th/Sa dialysis schedule. She continues to be anuric. The
prognosis of her renal failure is still unclear; most likely she
will be on hemodialysis permanently, but she still requires
closely monitoring of intra-dialysis creatinine given that she
may recover some kidney function. She should not be aggresively
hemodialysed given history of labile BP during HD.
.
#. Respiratory distress: The patient developed increased work of
breathing on [**2168-12-26**] to compensate for her metabolic acidosis
due to elevated lactate from acute liver and kidney failure.
She was intubated electively on [**2168-12-26**]. Extubated [**2169-1-5**].
Sputum cultures persistently showed yeast and she was treated
with fluconazole from [**12-29**] to [**1-3**] and transitioned to
micafungin from [**1-3**] to [**1-7**]. At the time of discharge she was
breathing comfortably with excellent oxygen saturations on room
air.
.
# Alcohol use - The patient drinks up to 12 beers daily. Last
drink was on the day prior to admission. She was initially
placed on a CIWA scale. She showed no evidence of alcohol
withdrawal or DT's and the CIWA scale was discontinued. She was
seen by social work for alcohol cessation counseling and for
support coping with acute illness. She will need to join a
relapse prevention program.
.
# Pancreatitis: The patient was noted to have a chemical
pancreatitis on admission (lipase 164 on admission and 1237 on
HD 2) which appeared to resolving by HD 9, however over the next
few days the lipase was noted to be in the 1000s again. She
developed Grey [**Doctor Last Name 27210**] sign (flanks biopsied showing
extravasation of red blood cells into dermis, consistent with
pancreatitis). Patient largely denied abdominal pain but did
experience some nausea with po intake. A CT Abdomen on [**12-27**]
showed the pancreas to be diffusely enlarged with surrounding
stranding consistent with pancreatitis, but no evidence of
necrosis or pseudocyst. The lipase remained elevated. She had
a Dobhoff placed post-pyrlorically and bridled as she was not
tolerating a full diet and will require > [**2157**] calories per day
for recovery from fulminant hepatitis. Her diet should be
advanced as tolerated. If she vomits she should simply decrease
her intake and then slowly advance.
.
# Spontaneous Bacterial Peritonitis: On the day of liver
biopsy, the patient underwent paracentesis. She later spiked a
fever to 100.6 and developed increased epigastric tenderness.
Cell Count from the paracentesis showed 975 WBCs (70% PMNs).
She was treated with Ceftriaxone for a 7 day course. She did
not receive albumin as she was already anuric. She is
discharged on ciprofloxacin for sbp prophylaxis.
.
# COPD/Asthma: The patient has underlying COPD/Asthma. She was
initially placed on standing albuterol and ipratropium nebs.
After transfer from the MICU to the hepatology service, she did
not require any nebulizer treatments as she was breathing well
on room air without wheezing, shortness of breath, or
desaturations.
.
# Liver transplant workup - Patient was seen and examined by
transplant team and psych/social work. After extensive
discussion, the patient was listed for Status One liver
transplant. A bolt had been placed on [**2168-12-30**] and labs/ mental
status exams closely followed. Her ICP's were always within
normal range, and it was pulled on [**1-2**]. Follow-up MRI did not
show evidence of infarct or hemorrhage. Her liver function tests
(ALT/AST and Alk phos) improved significantly, however the
bilirubin remains quite elevated. However given her improvement
following extubation and lab value improvement, she was removed
from the liver transplant list on [**2169-1-6**].
.
# Depression/Anxiety: Given fulminant hepatic failure, anuric
renal failure, and concern for hepatic encephalopathy, the
patient's mirtazapine, wellbutrin, and ativan were held for much
of her inpatient stay. Her mirtazapine and wellbutrin were
restarted prior to discharge. Given her hepatic encephalopathy
her ativan was held and should continue to be held until she
recovers completely from liver insult.
.
# Lupus: The patient's plaquenil was held during her
hospitalization. It should be restarted as an outpatient.
.
# Communication: Patient, [**Name (NI) **] (sister) [**Telephone/Fax (1) 89941**], [**Doctor Last Name **]
(son) [**Telephone/Fax (1) 89942**]
Medications on Admission:
remeron 15mg QHS
wellbutrin XL 300mg QAM
Singulair 10mg daily
spiriva inhaled capsule 1 QAM
fexofenadine 180mg daily
plaquenil 200mg daily
ativan 1mg up to 5x/day
albuterol inhaler PRN
Discharge Medications:
1. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Wellbutrin XL 300 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
4. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) inhalation (capsule) Inhalation once a day.
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): please titrate to [**1-12**] bowel movements daily.
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
10. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
11. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Ondansetron 4 mg IV Q4H PRN nausea/vomitting
14. Prochlorperazine 10 mg IV Q6H:PRN nausea
15. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
16. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for sbp < 100, hr < 60.
17. Liver follow up
Dr. [**Last Name (STitle) **] (Gastroenterologist)
Please follow up in 2 weeks (they will call with appointment)
Office Location:LMOB 8E
Office Phone:([**Telephone/Fax (1) 89943**]
Office Fax:([**Telephone/Fax (1) 4409**]
18. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week for 8 weeks.
19. Zemplar 2 mcg/mL Solution Sig: One (1) mcg Intravenous With
HD.
20. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary Diagnoses: Fulminant Liver Failure, Hepatic
Encephalopathy, Grade I Esophageal Varices, Acute Renal Failure
requiring Hemodialysis, Hepatorenal Syndrome, Cholangitis,
Septic Shock, Spontaneous Bacterial Peritonitis, Malnutrition,
Pancreatitis, Increased Intracranial Pressure, Respiratory
Distress
.
Secondary Diagnoses: COPD, Asthma, Depression, Anxiety, SLE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital for liver failure due to
alcohol and tylenol use. As a consequence of your severe liver
disease, your kidneys were injured and began to require
dialysis. There was concerned that you had swelling in your
head, so a bolt was placed to reduce the pressure. The bolt was
later removed. Your course was complicated by infections which
were treated with antibiotics. Prior to discharge, your liver
function was improving but your kidneys continued not to work
properly. You will need to continue dialysis.
Followup Instructions:
Dr. [**Last Name (STitle) **] (Gastroenterologist)
Please follow up in 2 weeks (they will call with appointment)
Office Location:LMOB 8E
Office Phone:([**Telephone/Fax (1) 89943**]
Office Fax:([**Telephone/Fax (1) 4409**]
.
.
Follow up with your kidney doctor [**First Name (Titles) **] [**Last Name (Titles) **].
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
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icd9cm
|
[
[
[]
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[
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[
[
[]
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24230, 24330
|
14654, 22094
|
325, 456
|
24743, 24743
|
3621, 3900
|
25491, 25916
|
3080, 3105
|
22330, 24207
|
24351, 24660
|
22120, 22307
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24926, 25468
|
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|
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|
266, 287
|
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3916, 6711
|
24758, 24902
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2791, 2835
|
2851, 3064
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,101
| 196,763
|
7040
|
Discharge summary
|
report
|
Admission Date: [**2137-2-27**] Discharge Date: [**2137-3-4**]
Date of Birth: [**2065-2-27**] Sex: F
Service: MEDICINE
Allergies:
Azithromycin / Ace Inhibitors / Codeine
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Allergic reaction.
Major Surgical or Invasive Procedure:
Nasotracheal Intubation
History of Present Illness:
Mrs. [**Known lastname **] is a 71 year old woman with a history of hypertension
and diabetes who recently presented with bronchitis and now
presents with tounge swelling after a dose of azithromycin. She
initially complained 11 days of cough which was productive for
about 5 days. She denied any fevers, chills, nausea or vomiting.
She presented to her PCP on the day of admission and was
prescribed azithromycin. Around 3pm, she took the first dose of
azithromycin and by about 4pm, she noticed a tingling sensation
in her tongue. At 5pm, the left side of her tongue became
swollen. She was concerned that her throat might close off so
she presented to the ED.
.
In the ED, ENT was consulted and a fiberoptic intubation was
performed given the rapidity of her airway compromise. She was
given 0.3mg 1:1000 epinephrine sc, afrin, bendaryl 50mg iv,
solumedrol 125mg iv, and was sedated with propafol.
.
She was monitored overnight in the ED and initially staffed with
west ICU team, but a bed became avaliable in [**Hospital Unit Name 153**]. ENT
suggested following cuff-leak throughout intubation and possible
allergy consult. On arrival to [**Hospital Unit Name 153**], nursing noted some
decreased breath sounds on the left side. She had a temp of 94,
was placed on warming blanket.
Past Medical History:
1. Hypertension
2. Diabetes
3. Obesity
Social History:
No history tobacco abuse, [**1-11**] alcoholic beverages per day.
Family History:
Daughter with history of allergic reaction to fish.
Physical Exam:
VS: T 96 BP 120/80 HR 73 RR 12 Sat 98-100%
VENT: CPAP 10/5 0.5 572-588
GEN: Intubated/sedated
HEENT: Protruding, swollen tongue, peri-oral edema
CV: Normal s1/s2, RRR
PUL: CTA bilaterally anteriorly, decreased breath sounds on Left
side.
ABD: Soft, obese, nontender, NABS
EXT: 1+ UE edema bilaterally, no LE edema
NEURO: Sedated, unarousable
Pertinent Results:
[**2137-2-27**] 11:47PM TYPE-ART PEEP-5 O2-.5 PO2-88 PCO2-43 PH-7.33*
TOTAL CO2-24 BASE XS--3 -ASSIST/CON INTUBATED-INTUBATED
[**2137-2-27**] 05:59AM GLUCOSE-228* UREA N-32* CREAT-1.2* SODIUM-134
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-19* ANION GAP-17
[**2137-2-27**] 05:59AM CALCIUM-8.3* PHOSPHATE-4.0 MAGNESIUM-1.9
[**2137-2-27**] 05:59AM WBC-10.5 RBC-4.10* HGB-12.7 HCT-36.7 MCV-90
MCH-31.0 MCHC-34.6 RDW-13.5
[**2137-2-27**] 05:59AM PLT COUNT-248
[**2137-2-26**] 07:35PM GLUCOSE-123* UREA N-37* CREAT-1.3* SODIUM-134
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-21* ANION GAP-21*
[**2137-2-26**] 07:35PM WBC-12.8* RBC-4.67 HGB-14.3 HCT-41.3 MCV-89
MCH-30.6 MCHC-34.6 RDW-13.5
[**2137-2-26**] 07:35PM NEUTS-62.4 BANDS-0 LYMPHS-27.5 MONOS-7.4
EOS-1.7 BASOS-0.9
[**2137-2-26**] 07:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2137-2-26**] 07:35PM PT-11.9 PTT-22.1 INR(PT)-1.0
============
STUDIES:
CXR [**2137-2-26**]
INDICATION: Intubation.
An endotracheal tube has been placed, terminating at
approximately the thoracic inlet level. The lung volumes are
quite low accentuating the cardiac silhouette and
bronchovascular structures. There is a patchy area of opacity in
the right retrocardiac region which likely reflects atelectasis,
although aspiration is an additional consideration. The
remainder of the lungs are grossly clear.
.
CXR [**2137-2-26**]
Lungs are clear. Heart size normal. No pleural abnormality or
evidence of central adenopathy. Right heart border is obscured
by mediastinal fat, as before. The thoracic aorta is very
tortuous and moderately calcified but not definitely aneurysmal.
.
CXR [**2137-2-27**]
IMPRESSION:
1. Endotracheal tube in appropriate position with tip
approximately 6 cm above the carina.
2. Bilateral right and left retrocardiac opacities, which may
represent atelectasis or aspiration.
.
Brief Hospital Course:
71 year old woman with obesity, diabetes, hypertension who
presents with tongue swelling after taking a dose of
azithromycin for bronchitis as well as cough syrup containing
codeine.
.
# Angioedema: As described in the HPI, ENT was consulted and
performed a fiberoptic nasal intubation in the ED and pt was
sent to the [**Hospital Unit Name 153**]. Her reaction was thought to be due to either
the azithromycin or the codeine but it was heard the tell as she
took both at the same time. There was a question of whether the
ACE-I was the culprit as it can cause angioedema at any time.
All three of these medications are now listed as allergies. She
was treated initially with decadron, benadryl, and zantac. Her
tongue swelling slowly improved and she was extubated on
hospital day #2. Fiberoptic scope by ENT the next day revealed
persistent laryngeal edema, mild erythema of nasal pharynx,
moderate supraglottis edema, fair glottic airway but the
following day this had all improved. She will follow up with
Dr. [**Last Name (STitle) 2603**] as an outpatient. She will continue the benedryl and
zantac for 5 days and begin a prednisone taper over 7 days. She
was given a prescription for an epi-pen.
.
# Hypertension: The pt's HCTZ and ACE-I were initially held
given her sedation. Once she was extubated, her HCTZ was
restarted. As above, pt's ACE-I was not restarted given concern
for the possible etiology of her angioedema.
.
# Bronchitis/Sinusitis: Pt remained afebrile but was noted to
have excessive nasal secretions on fiberoptic exam by ENT. She
was started on a course of levofloxacin on [**3-1**]. Levofloxacin
was started as it was hoped to be the least allergenic of
potential antibiotics. She will continue this for a 10-day
course.
.
# Diabetes: Metformin was restarted once pt started eating.
.
# Dispo: PT evaluated the patient and recommended rehab and pt
was agreeable.
.
# Code: Full.
Medications on Admission:
Metformin 500mg [**Hospital1 **]
Vasotec 20mg [**Hospital1 **]
aspirin 325
ranitidine 150mg [**Hospital1 **]
HCTZ 25mg QD
Tylenol prn
lipitor 20mg qd
guaituss/codine syrup 1teaspoon q3h prn
mucinex
Discharge Medications:
1. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Atorvastatin 20 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. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. EpiPen 0.3 mg/0.3 mL Syringe Sig: One (1) injection
Intramuscular ONCE as needed for anaphylactic reaction.
Disp:*1 pen* Refills:*1*
7. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day:
Take 3 pills for 3 days, 2 pills for 2 days and 1 pill for 2
days.
Disp:*15 Tablet(s)* Refills:*0*
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q
8H (Every 8 Hours) for 5 days.
Disp:*15 Capsule(s)* Refills:*0*
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: per insulin
sliding scale Injection ASDIR (AS DIRECTED).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6692**] Nursing & Rehabilitation - [**Location (un) 38**]
Discharge Diagnosis:
Primary Diagnosis:
1. Anaphylactic reaction
2. Bronchitis and Sinusitis
Secondary Diagnosis:
1. Hypertension
2. Diabetes
Discharge Condition:
good, oxygenating 90% on ambulation on room air
Discharge Instructions:
Resume all prior medications except:
- we have stopped your ACE-I given concern for throat swelling
- do NOT take azithromycin or codeine until cleared by the
allergist
Call Dr. [**Last Name (STitle) 1007**] or return to the ER if you experience any throat
swelling, difficulty speaking, trouble breathing, chest pain,
wheezing or anything else that concerns you
Followup Instructions:
You should see an allergist. We have made you an appointment to
see Dr. [**Last Name (STitle) 2603**] tomorrow, [**3-5**], at 9am. The clinic is on [**Hospital Ward Name 23**]
7.
You should also make an appointment to see Dr. [**Last Name (STitle) 1007**] in the next
1-2 weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
Completed by:[**2137-3-4**]
|
[
"272.0",
"E930.8",
"E849.8",
"250.00",
"518.81",
"466.0",
"519.8",
"401.9",
"278.00",
"995.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
7652, 7753
|
4184, 6105
|
319, 345
|
7919, 7969
|
2258, 4161
|
8381, 8824
|
1827, 1880
|
6356, 7629
|
7774, 7774
|
6131, 6333
|
7993, 8358
|
1895, 2239
|
261, 281
|
373, 1665
|
7868, 7898
|
7793, 7847
|
1687, 1727
|
1743, 1811
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,652
| 175,910
|
20054
|
Discharge summary
|
report
|
Admission Date: [**2123-10-12**] Discharge Date: [**2123-10-14**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
female with a history of rheumatoid arthritis, hypertension,
and questionable colon cancer who has been ill for months.
The patient has been having multiple syncopal episodes at
home times months. They have been unwitnessed. She
experienced fracture of left arm and right arm during falls.
Earlier this year, worked up at [**Hospital **] Medical Center for
a questionable large gastrointestinal bleed. A colonoscopy
with multiple polyps; unclear if cancer or not. Has been
requiring blood transfusions every three months.
In [**2123-7-19**] the patient was admitted to
[**Hospital3 1196**] status post fall. Had delirium and
a 5[**Hospital 15386**] hospital course there.
Last week, she was treated with ciprofloxacin for a urinary
tract infection. On the night of admission, she was found
passed out on the floor by her nephew who called Emergency
Medical Service. Found the patient with heart rate of 33 and
a blood pressure of 80/palp. Taken to [**Hospital 4068**] Hospital. In
the Emergency Department, blood pressure there was 66/palp,
heart rate was 33, respiratory rate was 22, and 97%. Weight
was 60 kilograms. Electrocardiogram with questionable
complete heart block. Was started on dopamine and intubated
for hypotension. When stabilized, was med-flighted to [**Hospital1 1444**] for further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Anemia; no clear etiology, requires blood transfusions
every two to three months.
3. Hypothyroidism.
4. Gastroesophageal reflux disease.
5. Colonic polyps; diagnosed at [**University/College **] in [**2122**] (unsure if
cancer).
6. Rheumatoid arthritis.
7. Chronic renal failure.
8. Falls.
ALLERGIES: CODEINE (unknown reaction).
MEDICATIONS ON ADMISSION:
1. Plaquenil 200 mg by mouth once per day.
2. Risperdal 0.5 mg by mouth twice per day.
3. Protonix 40 mg by mouth once per day.
4. Iron sulfate 325 mg by mouth once per day.
5. Synthroid 0.125 mg by mouth once per day.
6. Toprol-XL 50 mg by mouth once per day.
7. Procrit 10,000 units every week.
8. Lasix (unsure of dose).
FAMILY HISTORY: Family history is unknown.
SOCIAL HISTORY: She lives alone but nephew often visits at
night. Health aide during the day.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature was too low to record rectally, her heart rate
was 65, her blood pressure was 109/84, her respiratory rate
was 14, and her oxygen saturation was 97% on ventilator. In
general, lying in bed, minimally responsive to voice. Head,
eyes, ears, nose, and throat examination revealed jugular
venous pressure was flat. The oropharynx was dry.
Cardiovascular examination revealed a regular rate and
rhythm. No murmurs, rubs, or gallops. The lungs were clear
to auscultation bilaterally. The abdomen was soft,
nontender, and nondistended. Bowel sounds were present.
Extremities revealed 1+ lower extremity edema. Neurologic
examination revealed the patient was intubated and sedated.
Responded minimally to voice. Responded to pain.
PERTINENT RADIOLOGY/IMAGING: Bedside echocardiogram revealed
no wall motion abnormalities, normal ejection fraction, no
valvular abnormalities.
An electrocardiogram at the outside hospital showed sinus
bradycardia at 33, left axis deviation, T wave inversions in
III.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
an outside hospital revealed sodium was 134, potassium was
3.5, chloride was 98, bicarbonate was 25, blood urea nitrogen
was 42, creatinine was 2.9, and her blood glucose was 85.
Protein was 5.7. Albumin was 2.6. Calcium was 9. Total
bilirubin was 0.18. Alkaline phosphatase was 108,
alanine-aminotransferase was 34, aspartate aminotransferase
was 29. Creatine kinase was 161. MB was 18. Troponin was
less than 0.01. White blood cell count was 4.4, her
hematocrit was 31, and her platelets were 171. Differential
with neutrophils of 81, lymphocytes of 13, and monocytes of
5.2.
Laboratories at [**Hospital1 69**] revealed
her white blood cell count was 6.6, her hematocrit was 39.8,
and platelets were 211. Differential with neutrophils of
88.7. INR was 1.1. Prothrombin time was 12.9 and partial
thromboplastin time was 37.3. Urinalysis was unremarkable.
Sodium was 134, potassium was 3.2, chloride was 97,
bicarbonate was 23, blood urea nitrogen was 44, creatinine
was 3.1, and blood glucose was 100. Her
alanine-aminotransferase was 31, her aspartate
aminotransferase was 31, alkaline phosphatase was 115, and
her total bilirubin was 0.3. CK/MB was 45. Troponin was
0.13. Calcium was 9.6, magnesium was 2.2, and her phosphate
was 5.1. Arterial blood gas revealed pH of 7.4, PCO2 was 35,
PO2 was 454 on 100% assist control. Total volume 500.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. HYPOTENSION ISSUES: The patient was admitted to the
Coronary Care Unit. Presumably at the time of presentation
we thought that the patient might have been septic as her
numbers were more consistent with a septic physiology as
opposed to a cardiogenic shock physiology.
The patient had an elevated white blood cell count and a left
shift. She was hypothermic and had evidence of a recent
urinary tract infection for which she was being treated.
However, we could not completely exclude a myocardial
infarction given recent ongoing myocardial infarction;
although less likely. Other things on our differential that
we were including were adrenal insufficiency and hypothermia
with which she presented.
A sepsis workup was sent off which included blood cultures,
urine cultures, and sputum culture. The urine culture was
unremarkable. The sputum culture was unremarkable as well as
blood cultures. There was one bottle that showed a likely
contaminant. A chest x-ray showed a left lower lobe
collapse and questionable consolidation. No evidence of
congestive heart failure; thus bringing the likelihood that
the patient was in cardiogenic shock.
The patient had a triple lumen placed for access and
aggressive intravenous fluid hydration. The patient was
started on dopamine and later on was changed to Levophed for
blood pressure support. Despite one pressor, the patient
required pressors for blood pressure support. Hence, we
added on Neo-Synephrine and vasopressin. The patient was
covered with broad-spectrum antibiotics; vancomycin,
levofloxacin, and Flagyl with one dose of gentamicin for a
presumed infection. Cortisol was checked and was
unremarkable. Metoprolol was held. The patient was
eventually stabilized on three pressors with an attempt to
wean off pressors and see if the patient would be able to
maintain her own blood pressure.
A conversation with the family was held, and it was their
wishes that the patient not any have further aggressive
measures or attempts of resuscitation such as pacing,
cardiopulmonary resuscitation, or cardioversion. They did,
in the interim, wish to continue with the intubation and
mechanical support as well as intravenous antibiotics. The
family brought in the health care proxy, ([**Name (NI) **] [**Name (NI) 53995**])
assigned her son [**First Name5 (NamePattern1) **] [**Name (NI) 53995**]) as her decision maker.
Despite out continued efforts in attempts to stabilize the
patient and wean off pressors, the patient was not going to
be able to tolerate being off mechanical ventilation or
pressor support. Per family, the patient was made comfort
measures only and comfortable on a morphine sulfate drip.
The family was at bedside at all times. The patient expired
on [**2123-10-14**] at 12:08 a.m. The family declined
autopsy, and the attending was notified.
The patient was admitted to the Unit from an outside hospital
with an external pacemaker, heart beating at 60, and a blood
pressure of 100/60. Pacing wires were subsequently no longer
needed as the patient's heart rate had returned to a regular
rate without any further need for intervention. The
patient's family had also declined any further cardiac
measures such as external pacing.
2. HYPOTHERMIA ISSUES: Likely secondary to sepsis. We
were unable to record any rectal temperatures. The patient
was started on a warming blanket and concurrent antibiotics;
vancomycin, levofloxacin, and Flagyl with one dose of
gentamicin to treat the possible sepsis. Cortisol was
unremarkable. On the second day of her admission,
temperature was improved.
3. BRADYCARDIA ISSUES: At outside hospital, the patient
was recorded as having sinus bradycardia up to 33. On
admission, her bradycardia has resolved, and she had a
regular rate. Most likely secondary to ischemia and
consequent hypothermia.
4. NON-ST-ELEVATION MYOCARDIAL INFARCTION ISSUES: It was
likely that the patient had a non-ST-elevation myocardial
infarction secondary to demand given her hypotension.
Unlikely acute coronary syndrome. Heparin was held, and the
patient was given supportive measures such a blood pressure
support on three pressors; Levophed, Neo-Synephrine, and
vasopressin.
Given the patient's elevated cardiac enzymes with a troponin
of 0.15 in the setting of renal insufficiency, the troponin
leak was attributed to demand ischemia and not acute coronary
syndrome.
5. CHRONIC RENAL INSUFFICIENCY ISSUES: The patient's
baseline creatinine was unknown, but chronic renal
insufficiency may have been attributed to hypotension or
rheumatoid arthritis. Her electrolytes were followed on a
daily basis, and medications were renally dosed.
6. ANEMIA ISSUES: The patient's hematocrit was followed on
a daily basis. Her hematocrit dropped secondary to large
intravenous fluid hydration and volume given. No evidence of
acute blood loss noted on examination. The patient was
stable.
7. SEIZURE ISSUES: The patient had an episode of seizure.
Her blood sugar was checked and noted to be 37. One ampule
of dextrose 50 was administered and consequent Dilantin
loading was also done. The patient's seizure activity
resolved, and no further seizure activity was noted
throughout the remainder of her stay. Likely etiology was
hypoglycemic seizure.
8. PROPHYLAXIS ISSUES: The patient was maintained on
heparin subcutaneously.
9. CODE STATUS ISSUES: The patient was made do not
resuscitate/do not intubate and subsequently comfort measures
only.
10. ACCESS ISSUES: The patient had a right internal jugular
and left arterial line placed on [**10-12**].
CONDITION AT DISCHARGE: The patient expired on [**2123-10-14**] at 12:08 a.m.
DISCHARGE STATUS: None.
FINAL DIAGNOSES:
1. Hypotension.
2. Hypothermia.
3. Bradycardia.
4. Anemia.
5. Hypothyroidism.
6. Gastroesophageal reflux disease.
7. Colon polyps.
8. Rheumatoid arthritis.
9. Chronic renal failure.
10. Falls.
11. Seizure.
MEDICATIONS ON DISCHARGE: None.
DISCHARGE INSTRUCTIONS/FOLLOWUP: None.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5214**]
Dictated By:[**Last Name (NamePattern1) 9622**]
MEDQUIST36
D: [**2124-1-18**] 08:30
T: [**2124-1-18**] 21:00
JOB#: [**Job Number 53996**]
|
[
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"785.51",
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"285.9",
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"530.81"
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icd9cm
|
[
[
[]
]
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[
"96.6",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2237, 2265
|
10901, 10908
|
1887, 2220
|
10943, 11193
|
10648, 10874
|
4919, 10534
|
10549, 10630
|
118, 1479
|
1501, 1861
|
2282, 4884
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,059
| 118,636
|
35477
|
Discharge summary
|
report
|
Admission Date: [**2163-5-21**] Discharge Date: [**2163-5-25**]
Date of Birth: [**2088-12-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Levaquin in D5W
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Tracheostomy change with bronchoscopy and biopsy
.
PICC placement
History of Present Illness:
Ms. [**Known lastname **] is a 74yo F with history of COPD and recent
respiratory distress due to COPD exacerbation and pneumonia
requiring chest tube, VATS and eventual trach at [**Location (un) 620**] earlier
this month who presented to the ER from LTAC with respiratory
distress and vent dyssynchrony.
.
Patient was recently hospitalized at [**Hospital1 **] [**Location (un) 620**] from [**Date range (1) 80824**]
with complicated hospital course. She presented with
respiratory distress and given concern for pneumothorax, she
underwent needle decompression. Patient eventually underwent
VATS and trach with pleural fluid cultures from the VATS
revealing VRE, Proteus, coag-negative staph and [**Female First Name (un) 564**].
Initial sputum cultures revealed Pseudomonas. Her hospital stay
was also complicated by sepsis requiring brief pressor support.
Her antibiotics were tailored to fluconazole, imipenem and
linezolid with plans for additional 10 day course (to end approx
[**5-25**]), and she was discharged to [**Hospital1 100**] LTAC on these through a
subclavian central line.
.
At the rehab, she was continued on these antibiotics. Patient
developed vent discordance and was sent to [**Hospital1 18**] ER for further
evaluation.
.
In the ED, initial vs significant for hypotension with SBP<90.
She was started on levophed. Patient was also given stress dose
steroids, home dose linezolid, 2L of NS and had CXR which showed
bilateral pleural effusions and bibasilar atelectasis. CT of
her head was remarkable for encephalomalacia and CT torso showed
resolving pneumonia, stable AAA and large ventral hernia
containing bowel without signs of incarceration. Surgery was
consulted but felt there was no acute surgical need. Patient
was unable to have ABG drawn and VBG was significant for extreme
hypoxemia with gas 7.21/66/29/28. She was admitted to the MICU
for further treatment. Vitals on transfer were 77, 158/81 with
levo at 0.06, 94% AC 450x20, 5, 50% Fi02.
.
In the ICU, patient is intubated and not following commands or
responding to questions.
.
Review of systems: Unable to obtain
Past Medical History:
- MI
- DM
- recent respiratory distress s/p trach replacement earlier this
month, [**5-9**]
- COPD s/p ruptured diverticulum with prolonged resp failure and
trach in rehab for approximately 1 year and removed in [**11-5**]
- HTN
- CHF [**3-2**] diastolic dysfunction
- Prior CVA
- Depression and anxiety
- colostomy [**3-2**] to multiple hernia repair(?)
- h/o MRSA, C. Diff, pseudomonas, VRE
Social History:
The patient is a nursing home resident, a former smoker.
Family History:
Per records, Positive for CAD.
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T:99.8rectal BP:154/99 P:64 R:26 O2: 96%
General: opens eyes to voice, will not follow commands
HEENT: mucous membranes dry, no LAD, PERRLA
Neck: JVP not elevated,
Lungs: harsh upper airway sound from trach with cough leak,
clear to auscultation bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, colectomy site non tender/non
erythematous, large right sided pannus with evidence of multiple
abdominal surgeries. bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU: foley in place, macerated area under right sided pannus that
is erythematous
Ext: slightly cool extremities, well perfused, 1+ pedal pulses,
no palpable radial or ulnar pulses. Bilateral clubbing in feet.
No cyanosis or edema
.
DISCHARGE PHYSICAL:
General: opens eyes to voice, follows commands
HEENT: mucous membranes dry, no LAD, PERRLA
Neck: JVP not elevated,
Lungs: no audible leak, no rhonchi, no rales, no wheezes
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, colectomy site non tender/non
erythematous, large right sided pannus with evidence of multiple
abdominal surgeries. bowel sounds present and visible
peristalsis, no rebound tenderness or guarding, no organomegaly
GU: foley in place, macerated area under right sided pannus that
is erythematous
Ext: slightly cool extremities, well perfused, 1+ pedal pulses,
no palpable radial or ulnar pulses. Bilateral clubbing in feet.
No cyanosis or edema
Pertinent Results:
ADMISSION LABS:
[**2163-5-20**] 08:00PM BLOOD WBC-12.3* RBC-4.32 Hgb-11.1* Hct-36.1
MCV-84 MCH-25.7* MCHC-30.7* RDW-19.7* Plt Ct-570*
[**2163-5-20**] 08:00PM BLOOD Neuts-85.7* Lymphs-9.7* Monos-3.4 Eos-0.7
Baso-0.5
[**2163-5-20**] 08:00PM BLOOD Plt Ct-570*
[**2163-5-20**] 08:00PM BLOOD Glucose-133* UreaN-23* Creat-0.5 Na-136
K-5.6* Cl-104 HCO3-24 AnGap-14
[**2163-5-20**] 08:00PM BLOOD ALT-18 AST-19 LD(LDH)-266* AlkPhos-153*
TotBili-0.2
[**2163-5-20**] 08:00PM BLOOD cTropnT-0.05*
[**2163-5-21**] 03:22AM BLOOD CK-MB-5 cTropnT-0.02*
[**2163-5-21**] 12:12PM BLOOD CK-MB-4 cTropnT-<0.01
[**2163-5-20**] 08:00PM BLOOD Albumin-3.7
[**2163-5-21**] 03:22AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
[**2163-5-20**] 09:17PM BLOOD Type-ART Tidal V-450 PEEP-5 FiO2-50
pO2-29* pCO2-66* pH-7.21* calTCO2-28 Base XS--4 -ASSIST/CON
Intubat-INTUBATED
.
DISCHARGE LABS:
[**2163-5-25**] 04:30AM BLOOD WBC-7.4 RBC-3.91* Hgb-10.1* Hct-31.8*
MCV-81* MCH-25.8* MCHC-31.8 RDW-19.7* Plt Ct-512*
[**2163-5-24**] 03:28AM BLOOD WBC-10.3 RBC-4.22 Hgb-10.7* Hct-34.5*
MCV-82 MCH-25.3* MCHC-30.9* RDW-20.3* Plt Ct-652*
[**2163-5-23**] 03:03AM BLOOD WBC-10.0# RBC-4.03* Hgb-10.4* Hct-32.5*
MCV-81* MCH-25.8* MCHC-32.0 RDW-19.9* Plt Ct-585*
[**2163-5-22**] 03:52PM BLOOD Hct-32.5*
[**2163-5-22**] 04:48AM BLOOD WBC-6.2 RBC-3.78* Hgb-9.7* Hct-30.8*
MCV-81* MCH-25.6* MCHC-31.4 RDW-20.4* Plt Ct-562*
[**2163-5-25**] 04:30AM BLOOD Plt Ct-512*
[**2163-5-25**] 04:30AM BLOOD PT-13.4 PTT-22.3 INR(PT)-1.1
[**2163-5-24**] 03:28AM BLOOD Plt Ct-652*
[**2163-5-24**] 03:28AM BLOOD PT-17.8* PTT-24.3 INR(PT)-1.6*
[**2163-5-23**] 03:03AM BLOOD Plt Ct-585*
[**2163-5-23**] 03:03AM BLOOD PT-40.0* PTT-31.7 INR(PT)-4.1*
[**2163-5-22**] 04:48AM BLOOD Plt Ct-562*
[**2163-5-25**] 04:30AM BLOOD Glucose-95 UreaN-8 Creat-0.3* Na-142
K-4.1 Cl-100 HCO3-32 AnGap-14
[**2163-5-24**] 03:28AM BLOOD Glucose-108* UreaN-12 Creat-0.3* Na-140
K-4.2 Cl-97 HCO3-32 AnGap-15
[**2163-5-23**] 02:36PM BLOOD Glucose-100 UreaN-14 Creat-0.4 Na-143
K-5.2* Cl-102 HCO3-31 AnGap-15
[**2163-5-23**] 03:03AM BLOOD Glucose-97 UreaN-13 Creat-0.3* Na-142
K-3.3 Cl-105 HCO3-29 AnGap-11
.
STUDIES:
CXR [**2163-5-20**]:
IMPRESSION: Tubes and lines positioned appropriately.
Cardiomegaly with
bilateral pleural effusions and bibasilar atelectasis.
.
CXR [**2163-5-22**]:
IMPRESSION: Limited study demonstrating no definite change.
.
CXR [**2163-5-24**]:
FINDINGS: The right PICC line extends to the mid-to-lower
portion of the SVC. Otherwise little change.
.
CT TORSO [**2163-5-20**]:
IMPRESSION:
1. Resolving bibasilar pneumonia, with trace residual pleural
effusions.
2. Large left ventral hernia, with simple ascites and mild
stranding of the fat and thickening of the omentum within the
hernia. Consider and element of fat necrosis in the right
clinical setting.
3. No evidence of bowel pathology.
4. Unchanged suprarenal aortic ectasia and infrarenal AAA.
.
IP study [**2163-5-24**]: read pending
.
MICRO:
URINE CULTURE (Final [**2163-5-21**]): NO GROWTH.
.
BCX [**2163-5-20**]: PENDING
.
[**2163-5-21**] 9:08 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2163-5-25**]**
GRAM STAIN (Final [**2163-5-21**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2163-5-25**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R R
CEFTAZIDIME----------- 32 R =>64 R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 8 I <=1 S
MEROPENEM------------- =>16 R <=0.25 S
PIPERACILLIN/TAZO----- =>128 R 16 S
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S
BAL:
[**2163-5-24**] 3:30 pm BRONCHOALVEOLAR LAVAGE RIGHT MIDDLE LOBE.
GRAM STAIN (Final [**2163-5-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.
Brief Hospital Course:
HOSPITAL COURSE:
Ms. [**Known lastname **] is a 74yo F with history of COPD and recent
respiratory distress requiring VATS and trach here with vent
dyssynchrony and respiratory distress. Pt was continued on broad
spectrum abx, and continued course with completed date on [**5-25**].
Pt had trach changed with IP on [**5-24**], without complications.
.
ACTIVE ISSUES:
.
# Respiratory failure: Patient has been vent dependent at the
rehab facility since trach replacement earlier this month in
setting of COPD exacerbation and pneumonia. Her CT here shows
resolving pneumonia, and she has been treated with broad
spectrum antibiotics - linezolid, imipenem and fluconazole based
on her prior sensitivities from her pleural fluid. Once pt
admitted, did well on vent without dysynchrony. Respiratory
distress there attributed Bubona trach. She was continued on
MDIs on the ventilator. IP was consulted regarding change of her
trach. The patient had her trach changed on [**5-24**] in the OR to a
long (130mm) flexible trach. The patient afterwards did not have
any dyssynchrony. Otherwise was not having any respiratory
distress. Her lung sounds improved and her oxygen saturations
were consistent after the trach was replaced.
Of note, pt had sputum cultures here growing pseudomonas &
klebsiella. However, these were thought to be [**3-2**] colonization,
as pt remained afebrile without leukocytosis or secretions to
suggest pneumonia.
.
# Hypotension: Most likely [**3-2**] continued VAP, vs. auto-PEEP,
some sedation. Pt required brief levophed in the ED. She was
continued on broad spectrum abx with
Linezolid/Meropenem/Fluconazole per previous regiment with end
date [**2163-5-25**]. ACS was ruled-out with CE's. Auto-PEEP considered
as well, but did not appear to be auto-PEEPing on vent. C. diff
was sent as well, but was negative. BPs improved. After the
procedure on [**5-24**] the patient became hypotensive into the high
70s however quickly resolved with pressures in the 90s after a
500 cc bolus. The hypotension completely resolved 4 hours after
the procedure with blood pressures in the 120s. Pt has
hemodynamically stable at time of discharge.
Home atenolol 50mg [**Hospital1 **] and amlodipine 10mg daily were held
during this admission. These should be restarted as needed per
her physicians at the LTAC.
.
# Diastolic dysfunction: She has known diastolic dysfunction
with suggestion of cardiomegaly on CXR. No signs of volume
overload on exam but she has received 2 liters of NS in the ER.
Maintained euvolemic volume status with gentle hydration for
hypotension as above. Appeared euvolemic at discharge.
.
# h/o hyperglycemia: She had history of glucose intolerance
while on steroids at [**Location (un) 620**]. While here, will have her on FSBS
QID with insulin sliding scale while on steroids. Her BG were
normal on discharge, and insulin was not continued on discharge.
This should be followed up further at rehab to assess insulin
needs.
.
INACTIVE ISSUES:
.
# h/o CVA: INR Supratherapeutic on admission, and Warfarin held.
The patient was not restarted on her warfarin given that the
reason was for her previous CVA and with no history of embolic
disease. She was started on an ASA 325mg daily.
.
# Large hernia: She has a large ventral hernia containing bowel
without signs of incarceration. The patient's PCP was notified
and will follow up with general surgery clinic for elective
repair.
.
TRANSITIONAL CARE:
1. CODE: FULL
2. FOLLOW-UP:
- with physicians at LTAC
3. Medical management:
- STOP Warfarin
- Completed Linezolid/Vanc/Fluconazole
- Complete one more day of Prednisone 5mg
- START Aspirin, Lansoprazole, Chlorhexidine oral care
- Increase dose of prn Ativan
- Held Amlodipine, Atenolol - should be restarted as needed at
LTAC
Medications on Admission:
Medications: per rehab notes
Linezolid 600 mg IV bid
Imipenem 500 mg IV q. 6 hours
Fluconazole 400 mg PO daily
Albuterol 6puffs q4 MDI
Albuterol nebs q4
Amlodipine 10mg qdaily
Atenolol 50mg [**Hospital1 **]
Clonazepam 1mg [**Hospital1 **]
Senna daily
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 10711**]/mg hydro/simeth 30mL q6 NG PRN
Guaifenesin 300mg q4 NG PRN
Ativan 1mg q4 IV PRN
Morphine 2mg SL q4 PRN
Nitro 0.3mg SL PRN
Prochlorperazine 25mg PR PRN
Clotrimazole 1% cream [**Hospital1 **]
Eucerin [**Hospital1 **]
Flucinolone 0.025% ointment qHS
Acetaminophen 650mg q6 NG PRN
Miconazole [**Hospital1 **] topically and vaginally
Zinc oxide 40% [**Hospital1 **]
Discharge Medications:
1. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Six (6) Puff Inhalation Q4H (every 4 hours).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Six (6) Puff Inhalation Q4H (every 4 hours).
3. acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
4. clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
5. lorazepam 2 mg/mL Syringe [**Hospital1 **]: Two (2) mg Injection Q4H
(every 4 hours) as needed for anxiety.
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. clotrimazole 1 % Cream [**Last Name (STitle) **]: One (1) Topical twice a day.
8. nitroglycerin 0.3 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Sublingual ONCE as needed for chest pain.
9. prochlorperazine 25 mg Suppository [**Last Name (STitle) **]: One (1) Rectal once
a day as needed for nausea.
10. Eucerin Cream [**Last Name (STitle) **]: One (1) Topical twice a day.
11. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
12. heparin, porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
13. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day as
needed for constipation.
14. prednisone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 1 days.
15. Maalox Advanced 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty
(30) ml PO every six (6) hours as needed for heartburn.
16. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
17. zinc oxide 40 % Ointment [**Hospital1 **]: One (1) Topical twice a day.
18. miconazole Powder [**Hospital1 **]: One (1) Miscellaneous twice a
day.
19. morphine 2 mg/mL Syringe [**Hospital1 **]: Two (2) mg Injection every
four (4) hours as needed for chest pain, tachypnea.
20. docusate sodium 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a
day.
21. guaifenesin 200 mg/5 mL Liquid [**Hospital1 **]: Three Hundred (300) ml
PO every four (4) hours as needed for cough.
22. fluocinolone 0.025 % Cream [**Hospital1 **]: One (1) Topical at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis
Trach leak
.
Secondary Diagnoses:
CAD
DM
COPD
HTN
dCHF
Prior CVA
Depression and anxiety
Colostomy [**3-2**] to multiple hernia repair(?)
h/o MRSA, C. Diff, pseudomona, VRE
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - always.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of respiratory
distress. You were found to have an ill fitting tracheostomy.
You had this replaced on [**2163-5-24**]. Your symptoms improved.
.
MEDICATION CHANGES:
STOP Linezolid
STOP Meropenem
STOP Fluconazole
Continue prednisone 5mg for one more day
DO NOT RESTART Coumadin
START Aspirin 325mg daily
START Colace 100mg twice daily
START Lansoprazole 30mg by mouth daily
START Chlorhexidone oral rinse 15mL twice daily
Change the dose of Lorazepam from 1mg to 2-4mg IV every 4 hrs as
needed for anxiety
Discuss restarting Amlodipine and Atenolol with your doctors (we
held both of these here given low blood pressures)
Followup Instructions:
Please follow up with the rehab physicians.
Completed by:[**2163-5-25**]
|
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"401.9",
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icd9cm
|
[
[
[]
]
] |
[
"31.99",
"33.24",
"38.97",
"96.71",
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icd9pcs
|
[
[
[]
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|
9762, 9762
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310, 378
|
16951, 17027
|
4637, 4637
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17042, 17063
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2544, 2940
|
2956, 3015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,814
| 127,288
|
29684
|
Discharge summary
|
report
|
Admission Date: [**2149-3-9**] Discharge Date: [**2149-3-14**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
86 yo F w/PMHx sx CHF, HTN who presented from a nursing home
with altered mental status after being found unresponsive, with
frothy secretions. Initial VS were HR 39, BP 100/60 O2sat 91%
RA, and RR 22. Patient was initially DNR/DNI, and was hypoxic to
the 80s, and was placed on a face mask to mid-90s. Patient's BPs
90/60s, with HR 70s, and T 100.0. She received vancomycin,
levofloxacin, and metronidazole. Her code status was then
changed to full code prior to admission to the ICU.
.
Her CXR showed an effusion vs. pneumonia, and her CT head showed
communicating hydrocephalus. Her first set of CE were negative.
.
MICU COURSE:
[**3-9**]: Admitted.
[**3-10**]: Mental status much improved. CTA r/o PE, showed
atelectasis, no clear pna. Echo showed. Mild LV dysfunction and
small pericard effusion.
[**3-11**]: Alert, talkative. Back on home dose beta blocker.
Vancomycin d/c'd. Plan to continue levo for 7 days.
Past Medical History:
CHF
HTN
Failure to thrive
Thyroid mass
Pancreatic mass
Social History:
Lives in a nursing home. Chinese speaking only. Nonverbal on
arrival. Has 5 sons.
Family History:
Noncontributory
Physical Exam:
VS: 94.6 122/97 HR 86 O2sat 94% on 15L face tent
Gen: disoriented. Unable to follow commands.
HEENT: MM dry. No oral ulcers or lesions.
Hrt: Irreg irreg. No MRG.
Lungs: Poor inspiratory effort. Decreased BS at bases.
Expiratory wheezing at right base. No rales or rhonchi
anteriorly.
Abd: Soft, nontender, nondistended. Guaiac negative per ED
report
Ext: WWP.
Neuro: Pupils equally round and reactive to light. Able to move
all extremities. Unresponsive to verbal stimuli. 2+DTRs
symmetric bilaterally.
Pertinent Results:
Labs on admission:
[**2149-3-9**] 01:15PM BLOOD WBC-6.1 RBC-4.56 Hgb-13.8 Hct-42.4 MCV-93
MCH-30.4 MCHC-32.6 RDW-13.6 Plt Ct-186
[**2149-3-10**] 02:03AM BLOOD Neuts-73.5* Lymphs-20.8 Monos-4.1 Eos-1.4
Baso-0.2
[**2149-3-10**] 04:00AM BLOOD PT-18.4* PTT-150* INR(PT)-1.7*
[**2149-3-9**] 01:15PM BLOOD UreaN-25* Creat-1.0
[**2149-3-9**] 01:15PM BLOOD CK(CPK)-39 Amylase-68
[**2149-3-10**] 02:03AM BLOOD CK(CPK)-46
[**2149-3-10**] 09:43AM BLOOD CK(CPK)-52
[**2149-3-9**] 01:15PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-3544*
[**2149-3-10**] 02:03AM BLOOD CK-MB-3 cTropnT-0.02*
[**2149-3-10**] 09:43AM BLOOD CK-MB-3 cTropnT-0.02*
[**2149-3-9**] 01:15PM BLOOD TSH-0.27
[**2149-3-9**] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2149-3-10**] 01:55AM BLOOD Type-ART pO2-177* pCO2-47* pH-7.41
calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2149-3-9**] 01:25PM BLOOD Glucose-141* Lactate-2.0 Na-142 K-4.4
Cl-100 calHCO3-32*
.
Imaging:
CT head ([**3-9**]): IMPRESSION: No acute hemorrhage. Regions of
hypodensity in the right cerebellum and both parietal lobes
could represent prior hemorrhage or infarct. There is dilatation
of the ventricles in a pattern suggesting communicating
hydrocephalus. Correlation with clinical findings may be
helpful.
.
CXR ([**3-9**]): 1. Left basilar and retrocardiac opacity, likely
secondary to a combination of effusion and atelectasis, but
denser areas of consolidation medially with peribronchial
thickening are more suggestive of consolidation secondary to an
infectious process. If possible, lateral radiographs would be
helpful in further evaluating this region.
.
CTA chest ([**3-10**]): 1. No evidence of pulmonary embolism. 2. Left
lower lobe of collapse. No definite endobronchial lesion
identified. 3. Mild CHF/fluid overload with a small left pleural
effusion. 4. Cardiomegaly with secondary signs of ventricular
dysfunction.
.
CXR ([**3-10**]): Persistent left lower lobe consolidation and pleural
effusion, consistent with the history of pneumonia. Prominent
left hilum, which could be further evaluated on a PA and lateral
radiograph when feasible.
.
ECHO ([**3-10**]): The left atrium is normal in size. The right atrium
is moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
probable inferior/inferolateral hypokinesis (views suboptimal).
Overall left ventricular systolic function is mildly depressed.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**1-14**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion with no echocardiographic evidence of tamponade.
.
Microbiology:
blood culture ([**3-9**]): no growth to date
sputum culture ([**3-9**]): contaminated
Brief Hospital Course:
84F Chinese-speaking with PMH dementia, CHF, HTN, goiter, and
large mass involving pancreatic tail with unresponsive episode
while at Nursing Home, likely precipitated by hypoxia/infection
in setting of LLL pneumonia/lung collapse. Improved with
antibiotics/supportive care in ICU. Newly-recognized atrial
fibrillation with satisfactory rate control on once-daily
atenolol. Remains approximately euvolemic.
PLAN:
# LLL PNEUMONIA, COMMUNITY-ACQUIRED
1. Continue levofloxacin x total of 14 days
# ATRIAL FIBRILLATION
1. Coumadin 5 mg daily, will need INR checked in [**2-15**] days.
2. Continue beta-blocker at current dose
# DIASTOLIC HEART FAILURE
1. Continue furosemide 50 [**Hospital1 **]
# PRESUMED CAD
1. ASA, BB
# DEMENTIA/DELIRIUM
1. Avoid benzos, anticholinergic agents
2. Ambulate with assist as tolerated
# PANCREATIC MASS
1. History confirmed per [**Hospital1 336**] records as above; no further
evaluation at this time for presumed incurable neoplasm.
REVIEW OF [**Hospital1 336**] RECORDS: DISCHARGE SUMMARY [**2147-12-5**]
CHEST CT WITH CONTRAST [**2147-12-4**]:
IMPRESSION:
1. Bilateral pleural effusions with accompanying compression
atelectasis and/or consolidation.
2. Narrowed airway at the level of the vocal cords as well as
thyroid with possible mass at the level of the left vocal cord,
laryngoscopic examination is recommended.
3. Multiseptated hypodense likely cystic neoplasm of the
pancreatic tail (6.1 x 5.9cm in largest dimension). There is a
concern for a malignant neoplastic process, further evaluation
is
recommended.
4. Possible clot vs masses in left atrium, right atrium and
right
atrium/IVC junction, echocardiogram is recommended.
5. Ground-glass opacities in lungs.
6. Cardiomegaly.
Airway narrowing was attributed to longstanding goiter.
Echocardiogram did not confirm intracardiac clot/masses, LVEF
40%
with mild global hypokineses as awell as 2+MR/2+TR.
Regarding pancreatic mass, "There was a family meeting including
the patient herself and the decision was made not to pursue
further workup as the patient was feeling well and did not wish
to pursue invasive testing."
Medications on Admission:
Aspirin 325 mg qd
Furosemide 60 mg qd
Lopressor 50 mg [**Hospital1 **]
KCl 20 meq qd
Colace 1 tab qd
Trazadone 75 mg qhs
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**] Center
Discharge Diagnosis:
Left lower lobe pneumonia
Delirium, resolved
Atrial fibrillation
Systolic heart failure
Dementia
Goiter
Pancreatic mass
Discharge Condition:
Stable.
Discharge Instructions:
Complete course of antibiotics.
Check INR on [**3-16**] to determine appropriate coumadin dose, goal
INR [**2-15**].
Followup Instructions:
Follow-up with Dr [**First Name (STitle) **] at [**Hospital **] Health Center.
Completed by:[**0-0-0**]
|
[
"427.31",
"157.2",
"294.8",
"486",
"518.81",
"240.9",
"401.9",
"428.30",
"428.0",
"293.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8026, 8080
|
5105, 7233
|
283, 291
|
8244, 8254
|
1988, 1993
|
8419, 8525
|
1432, 1449
|
7405, 8003
|
8101, 8223
|
7259, 7382
|
8278, 8396
|
1464, 1969
|
222, 245
|
319, 1238
|
2007, 5082
|
1260, 1317
|
1333, 1416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,186
| 107,894
|
20327
|
Discharge summary
|
report
|
Admission Date: [**2199-1-14**] Discharge Date: [**2199-2-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
84 yo M c significant h/o CAD, atrial fibrillation, s/p
pacemaker placement for Sick Sinus Syndrome with recent
admission in [**Month (only) **] for STEMI found to have increasing SOB and
tachypnea at Rehab hospital. He was admitted in [**Month (only) **] for
STEMI after bilateral knee replacement. Catherization at that
time showed 100% proximal stent restenosis, diffuse RCA disease,
and a patent Left Circumflex stent. A PTCA [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] was
successfully placed in LAD. The catherization was complicated
by the development of wide complex tachycardia and hypotension
(SBP 80s). As a result, the patient was defibrillated once,
given IV lopressor, IV Amiodarone,
Dopamine pressor, an Intraaortic Balloon Pump, and intubated to
protect airway. He was treated in the CCU, stabilized, and
discharged to [**Hospital **] Rehab. There he was doing well until he
developed a PNA, found to have RLL infiltrate on CXR. He was
started on Cefuroxime. He had increasing SOB over several days,
on [**2198-12-14**] had increased SOB and was given Lasix and Ativan. He
had no chest pain, N/V. He was found down at rehab and then
transferred to [**Hospital1 18**] for further care. In the ED he was found
to have severe CHF with complicating PNA, he was sent to the CCU
for further care.
Past Medical History:
Past Medical History:
CAD
-s/p PCI to L circ and LAD in [**2-12**]
-s/p MI [**04**] years ago
-[**9-12**]: pMIBI showed a small fixed inferior defect with slight
apical redistribution suggestive of ischemia.
-[**12-13**] Echo showed EF 20% with regional left ventricular
systolic dysfuntion, HK basal septum, AK distal septum, lat wall
and basal ant. wall
[**Month/Year (2) **]
[**Month/Year (2) **]
Atrial Fibrillation on coumadin
Sick sinus syndrome, s/p pacer
s/p bilateral total knee replacement
s/p umbilical hernia repair
Social History:
Denies tobacco, ETOH, Italian speaking
Family History:
No history of CAD
Physical Exam:
VS. T 99.6 BP 101/69 Pulse 100s a.fib RR 20-30s 92% NRB
GEN: Alert and oriented X3 in NAD
HEENT: PERRLA, MMM, OP clear
Neck: No elevated JVP apreciated
Lungs: Crackles [**4-12**] way up bilaterally
CV: Irregularly irregular, tachycardic, difficult to assess
rhythm
Abd: Soft, NT/ND, +BS
Ext: 2+ Edema, no clubbing or cyanosis
Neuro: A &O X 3in NAD, CN II-XII intact, strenght grossly
intact, no change in sensation
Pertinent Results:
[**2199-1-14**] 11:09PM TYPE-ART RATES-16/4 TIDAL VOL-650 PEEP-10
O2-100 PO2-127* PCO2-48* PH-7.49* TOTAL CO2-38* BASE XS-12
AADO2-566 REQ O2-90 INTUBATED-INTUBATED
[**2199-1-14**] 08:15PM TYPE-ART PO2-62* PCO2-56* PH-7.41 TOTAL
CO2-37* BASE XS-8
[**2199-1-14**] 06:40PM TYPE-ART PO2-55* PCO2-60* PH-7.42 TOTAL
CO2-40* BASE XS-11
[**2199-1-14**] 06:40PM LACTATE-2.2*
[**2199-1-14**] 06:08PM ALT(SGPT)-31 AST(SGOT)-37 CK(CPK)-146 ALK
PHOS-94 TOT BILI-1.1
[**2199-1-14**] 06:08PM CK-MB-6 cTropnT-0.16*
[**2199-1-14**] 05:25PM TYPE-ART O2-100 PO2-56* PCO2-75* PH-7.30*
TOTAL CO2-38* BASE XS-7 AADO2-610 REQ O2-96 INTUBATED-NOT INTUBA
VENT-SPONTANEOU
[**2199-1-14**] 01:30PM GLUCOSE-152* UREA N-22* CREAT-0.8 SODIUM-139
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-32* ANION GAP-14
[**2199-1-14**] 01:30PM CK(CPK)-156
[**2199-1-14**] 01:30PM CK-MB-6 cTropnT-0.12*
[**2199-1-14**] 01:30PM CALCIUM-6.7* PHOSPHATE-3.1 MAGNESIUM-1.6
[**2199-1-14**] 06:51AM GLUCOSE-153* UREA N-22* CREAT-0.9 SODIUM-135
POTASSIUM-4.7 CHLORIDE-92* TOTAL CO2-31* ANION GAP-17
[**2199-1-14**] 06:51AM CK(CPK)-146
[**2199-1-14**] 06:51AM CK-MB-6 cTropnT-0.16*
[**2199-1-14**] 06:51AM CALCIUM-8.3* PHOSPHATE-3.9 MAGNESIUM-1.7
[**2199-1-14**] 06:51AM WBC-15.3* RBC-3.72* HGB-11.4* HCT-35.6*
MCV-96 MCH-30.6 MCHC-31.9 RDW-15.5
[**2199-1-14**] 06:51AM PLT COUNT-518*
[**2199-1-14**] 06:51AM PT-19.0* PTT-32.9 INR(PT)-2.3
[**2199-1-14**] 02:06AM COMMENTS-GREEN TOP
[**2199-1-14**] 02:06AM LACTATE-1.3
[**2199-1-14**] 01:30AM URINE HOURS-RANDOM
[**2199-1-14**] 01:30AM URINE GR HOLD-HOLD
[**2199-1-14**] 01:30AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2199-1-14**] 01:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-1-14**] 01:30AM URINE RBC-[**4-13**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-<1
[**2199-1-14**] 01:20AM GLUCOSE-161* UREA N-22* CREAT-0.9 SODIUM-136
POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-32* ANION GAP-15
[**2199-1-14**] 01:20AM CK(CPK)-123
[**2199-1-14**] 01:20AM cTropnT-0.15*
[**2199-1-14**] 01:20AM CK-MB-5
[**2199-1-14**] 01:20AM MAGNESIUM-1.7
[**2199-1-14**] 01:20AM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.6
[**2199-1-14**] 01:20AM DIGOXIN-0.7*
[**2199-1-14**] 01:20AM WBC-13.5*# RBC-3.68* HGB-11.3* HCT-34.9*
MCV-95 MCH-30.8 MCHC-32.5 RDW-15.5
[**2199-1-14**] 01:20AM HYPOCHROM-1+ POIKILOCY-1+ MACROCYT-1+
[**2199-1-14**] 01:20AM PLT COUNT-469*#
[**2199-1-14**] 01:20AM PT-18.6* PTT-30.7 INR(PT)-2.2
CT OF THE CHEST WITHOUT IV CONTRAST: Prominent right
paratracheal lymph node is present. This is non-pathologically
enlarged by CT criteria and is most likely reactive. There are
dense multifocal coronary artery calcifications as well as
cardiac enlargement. Previously evident small pericardial
effusion has slightly decreased in size since the prior study.
Assessment of lung fields again demonstrates findings of
congestive heart failure, with evidence of ground-glass
opacities and smooth thickening of septal lines. Small to
moderate bilateral pleural effusions slightly increased in size
in the interval. There has been development of areas of
organizing fibrosis peripherally with associated bronchiectasis
and bronchiolectasis. The airways are patent to the level of the
subsegmental bronchi bilaterally. Imaged portions of the upper
abdomen are notable for vascular calcifications and a left renal
cyst. IMPRESSION:
1) Cardiomegaly, coronary artery calcifications, and evidence of
congestive heart failure as above, with persistent ground-glass
opacities, smooth thickening of septal lines, and small to
moderate bilateral pleural effusions.
This process appears to be superimposed upon underlying ARDS as
described below
2) Progressive development of areas of organizing fibrosis along
the periphery of both lungs. The appearance is consistent with a
history of ARDS with an element of organizing fibrosis.
INTERPRETATION:
Findings:
This study was compared to the prior study of [**2198-12-21**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing
wire is seen in the RA and/or RV.
LEFT VENTRICLE: Mild symmetric LVH. Top [**Doctor First Name **]/borderline dilated
LV cavity
size.
LV WALL MOTION: Regional LV wall motion abnormalities include:
mid anterior -
akinetic; mid anteroseptal - akinetic; basal inferior - hypo;
basal
inferolateral - hypo; anterior apex - akinetic; septal apex-
akinetic;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Mildly dilated aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**2-10**]+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate
[[**2-10**]+] TR. Moderate PA systolic [**Month/Day (2) **].
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: Small pericardial effusion. No echocardiographic
signs of
tamponade.
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated.
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is top normal/borderline dilated. Resting regional
wall motion
abnormalities include anteroseptal, anterior and apical
hypokinesis and basal
inferior and inferolateral hypokinesis. Right ventricular
chamber size and
free wall motion are normal. The aortic root is mildly dilated.
The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly
thickened. Mild to moderate ([**2-10**]+) mitral regurgitation is seen.
The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery
systolic [**Month/Day (2) **]. There is a small pericardial effusion.
There are no
echocardiographic signs of tamponade.
Compared with the prior study (tape reviewed) of [**2198-12-21**],
left ventricular
systolic function appears slightly more vigorous.
Brief Hospital Course:
1. Pulmonary - This 85 year old male with history of CAD, s/p
recent STEMI with cardiac catheterization was admitted with SOB
and hypoxia. It was felt these symptoms were most likely
secondary to PNA and CHF exacerbation based upon history,
examination, and his admission CXR. He was admitted to the CCU
for continued care. His enzymes were cycled to rule out
ischemia as a cause of his CHF exacerbation. There was no
evidence of ischemia on EKG. He was treated with antibiotics
for presumed infection, he was initially started on
levofloxacin. He was also diuresed with Lasix. The day after
admission Vancomycin and Flagyl were added for additional
antibiotic coverage. On the evening after admission he
developed increased respiratory distress. Agressive diuresis,
morphine, nitro, and BIPAP were tried with no sucess. He was
intubated for respiratory distress, a SWAN was placed and a Head
CT was obtained. His SWAN numbers indicated that he was fluid
overloaded so he was diuresed.
He continued to spike temperatures despite being on Levo,
Vanco, and Flagyl. He was diuresed agressively with Lasix and
developed a metabolic alkalosis secondary to contraction. He
was treated with Bumex for a few days. Then his alkalosis was
treated with a tight KCl sliding scale. He continued to spike
fevers and sputum cultures revealed MRSA. His lines were
changed. Since he continued to spike and have positive cultures
despite Vanco he was changed to Linezolid and the Levofloxacin
and Flagyl were dcd. His WBC count continued to trend down from
admission. His respiratory status improved, his WBC count
improved, and his CXR improved. Based upon good response to a
pressure trial he was extubated on hospital day #9. He did well
post extubation. He had some diarrhea the evening following
extubation which was found to be c.diff positive. He was
restarted on Flagyl.
Based upon his improved respiratory status and lack of fevers
it was felt he was stable to be discharged from the CCU and sent
to the floor. We continued to diurese him but with much less
close monitoring than had been occuring in the unit. On
hospital day #14 he was found to be very crackly on exam with
marked respiratory distress. His antibiotics were broadened to
Zosyn, Flagyl, Linezolid. He was transferred up to the CCU with
concern that he had become fluid overloaded again. His lt IJ
was removed and a rt IJ placed with SWAN. The SWAN indicated
that he was fluid overloaded and he was aggressively diuresed
with Lasix. He was noted to have a swollen wrist and ankle on
arrival to the CCU. An attempt was made to remove fluid from
his ankle which was unsucessful. That evening he became
increasingly hypoxic with SOB, he also became hypotensive. He
was tried on BIPAP and given Neo then Dopamine for BP support.
He did not tolerate BIPAP and was intubated.
He continued to require Neo for BP support, which was weaned off
slowly. He was diuresed with Lasix based upon CXR which
indicated that he was fluid overloaded. A repeat Echo was
performed which indicated an improvement in his EF to 30-35%.
On hospital day 18 a bronchoscopy was performed and sample sent
for culture. He was was eventually exubated in the CCU after
aggresive diuresis. BAl results came back positive for
STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA which was sensitive
for bactrim. However at that point patient looked much improved
with no recent spike in temperature, respiratory decompensation,
or increase in WBC. It was agreed upon to hold off on treating
with Bactrim and if patient decomensated in future we would
treat. However patient never showed any evidence of furter
active infection. Linezolid and Zosyn course were completed
while patient was in hospital. Patient was transferred back to
the floor out of the unit. Patient still had crackles on lung
exam but based on exam and swan numbers (before swan taken out)
patient was dry. A CT Chest was ordered which showed resolving
ARDS and fibrosis. Patient should have repeat CT scan in [**7-17**]
weeks. While on floor patient was slowly transitioned from IV
lasix dose to PO lasix with close monitoring of fluid status.
2. CAD - He had a history of CAD, on this admission further
ischemia was ruled out by enzymes. He was continued on Aspirin,
Lipitor, and Plavix throughout his hospital stay. He was
started on Beta-blocker and ACE-I once BP could tolerate. His
EKGs remained unchanged.
3. Pump - His EF prior to admission was documented as 20%. On
admission a CXR showed evidence of CHF most likely due to PNA
c/b a.fib with RVR. He was agressively diuresed as mentioned
above. He was continued on his Digoxin. His ACE-I was given
when his pressure was able to tolerate it. A repeat Echo on
[**2199-1-30**] showed and EF of 30-35%. It also showed:
"anteroseptal, anterior and apical hypokinesis and basal
inferior and inferolateral hypokinesis, mild (1+) aortic
regurgitation, mild to moderate ([**2-10**]+) mitral regurgitation."
4. Rhythm - He had a history of A.fib with pacer placed for
SSS. On admission his rhythm was a.fib with lots of PVCs and
short runs of NSVT on telemetry. He was initially continued on
beta-blocker and Amiodarone. His beta-blocker was held when his
blood pressure could tolerate it, and then restarted once he
improved. His Amiodarone was discontinued on [**2199-1-28**] with
concern for Amiodarone induced lung toxicity. He was
anticoagulated throughout his hospital stay with Heparin IV or
Coumadin.
2. ID - He was treated for PNA with various antibiotics as
mentioned above. He had a c.diff positive stool for which he
was treated with Flagyl. Sputum cultures grew MRSA treated with
Vancomycin then Linezolid. BAL samples were sent for culture
and results mentioned above. Repeat c. diff toxin came back
negative. Patient was kept on flagyl until other antibiotic
courses were completed and he should continue on flagyl for two
more days since his zosyn was discontinued on the day of
discharge.
4. S/P Fall - He had a fall at the nursing home prior to coming
to the hospital. His neuro exam showed no deficits on arrival.
Head CT showed old lt temporal infarct, no new infarcts. He had
some increased confusion after sedation but had no focal
neurologic deficits.
5. Psych - All out-patient psych medications were held.
Medications on Admission:
Haloperidol 0.5 mg q 1700
Lorazepam 0.25 mg po q 8hrs prn
Aceotminophen 650 mg po q 4 hours prn
Furosemide 40 mg IV
Metop 50 mg po
Lansoprazole 30 mg ppo q d
Insulin
Digoxin 0.125 mg qd
Quetaiapine fumarate 25 mg po qhs
Haloperidol 1 mg p q4h PR IM
Haloperiodl 1 mg po q 4 hrs
Coumadin 1 dose?
Bisacodyl 10 mg qd
MgOH 30 mg
Laactulose 20 mg qd
Senna
Colace
Lisinopril 5 mg qd
Atorvastatin 80 mg qd
Amiodrarone 400 mg qd
Clopidogrel 75 mg qd
Aspirin 325 mg qd
Cefuroxime 500 mg po bid
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
Pnemonia-MRSA
Congestive heart failure (EF 30 to 35%)
C difficile colitis
Questionable amiodarone pulmonary induced toxicity.
Secondary:
Coronary Artery Disease
[**Hospital1 **]
[**Hospital1 **]
Atrial Fibrillation on coumadin
Sick sinus syndrome, s/p pacer
s/p bilateral total knee replacement
s/p umbilical hernia repair
Discharge Condition:
Good, afebrile, tolerating po intake and sating comfortably on
3L NC.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: 1500 cc
Please return to the emergency room or your PCP if you
experience shortness of breath, chest pain or light headedness
or increasing weight gain not relieved by lasix. It is very
important to weigh yourself every day and call your physician if
you experience any weight gain.
Followup Instructions:
Please call your PCP doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 54533**] at [**Telephone/Fax (1) 54534**]
to make a follow up appointment in one week.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2199-3-14**]
12:45
Provider: [**Name10 (NameIs) 1571**] EXAM ROOM IS (NO CHARGE) Where: IS (NO
CHARGE) Date/Time:[**2199-3-14**] 1:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2199-3-14**] 1:00
Please have your son accompany you to assist in translation.
You have an appointment for a chest CT the morning of [**2199-3-14**].
You will be called about the time.
|
[
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"250.00",
"008.45",
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"719.03",
"427.31",
"401.9",
"V58.67",
"V45.01",
"482.41",
"410.72",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"00.17",
"38.93",
"00.14",
"96.6",
"00.13",
"89.64",
"96.04",
"96.72",
"99.04",
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icd9pcs
|
[
[
[]
]
] |
15774, 15853
|
8895, 15239
|
282, 295
|
16228, 16299
|
2753, 8872
|
16752, 17609
|
2283, 2302
|
15874, 16207
|
15265, 15751
|
16323, 16729
|
2317, 2734
|
223, 244
|
323, 1655
|
1699, 2211
|
2227, 2267
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,437
| 182,999
|
11722
|
Discharge summary
|
report
|
Admission Date: [**2190-1-13**] Discharge Date: [**2190-1-16**]
Date of Birth: [**2125-1-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
maroon stool
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
History of Present Illness:
65 y.o male with neuroendocrine pancreatic tumor s/p Whipple
[**2179**], transfered from OSH w/lower GI bleed. Experienced
yesterday and today, 1 BM per day, maroon/dark brown well formed
stool, with non associated abdominal pain. Presented to pcp
today complaining of worsening weakness and lightheadedness,
found to have a hematocrit of 18 and sent to [**Hospital 16843**] Hosp.
Was HD stable, received 1U PRBC prior to transfer. Denies chest
pain,abdominal pain,fevers /chills, shortness of breath or
actual syncope. Reports h/x 2 episodes of BRBPR [**10-7**] and [**12-7**]
with normal colonoscopy [**10/2188**](although h/o polypectomy
previously), attributed to internal hemorrhoids via anoscopy at
that time. Last Hct was [**9-/2189**] and Hct was 40. Has recieved
radiation treatments for peripancreatic mass which was initially
being followed with serial octreotide scans and MRI of the
abdomen. Last radiation treatment was in [**9-/2189**], he recieved a
total of 5 treatments to the whole abdomen over 2 weeks ending
late 10/[**2188**]. He recieves his cancer care in [**Hospital 37090**] clinic at
[**Location (un) 8985**].
.
In the ED, initial VS were: 99.1 82 108/64 16 100% RA . GI was
consulted and recommended to hold ASA for now, and if
hemodynamically stable to start GI prep for colonoscopy
tonight.Recieved 1 Liter NS. Given PPI IV bolus and denied NG
lavage.Started on Mag Citrate for colonoscopy prep down in the
ED.
.
On arrival to the MICU, afebrile, BP-104/72, P-80.He denied any
pain and the above hx was obtained. Last BM morning of admission
which was maroon in 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:
Nephrolithiasis
Whipple Procedure in [**2179**]
Neuroendocrine tumor of the Pancreas
Social History:
denies smoking illciit drug abuse or alcohol abuse.
Family History:
NC
Physical Exam:
Admission Exam:
Vitals: afebrile, BP-104/72, P-80
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
Rectal:Maroon/Black stool , no external hemmrrhoids visualized.
Discharge Exam:
T 96.6 BP 127/75 HR 67 RR 18 O2 Sat 99% RA
GENERAL - Well appeaing man in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
LUNGS - CTAB, no increased WOB, no wheezes, rales, rhonchi
HEART - RRR, normal s1/s2, no s3/s4, no m/r/g
ABDOMEN - NABS, NTND, no rigidity, rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - A/Ox3, CN II-XII intact, non focal.
Pertinent Results:
Admission Labs:
[**2190-1-13**] 08:20PM BLOOD WBC-6.1 RBC-2.37*# Hgb-6.8*# Hct-21.8*#
MCV-92 MCH-28.8 MCHC-31.2 RDW-15.5 Plt Ct-228
[**2190-1-13**] 08:20PM BLOOD Glucose-158* UreaN-16 Creat-0.7 Na-140
K-3.9 Cl-104 HCO3-28 AnGap-12
[**2190-1-14**] 05:14AM BLOOD Albumin-3.3* Calcium-7.8* Phos-2.3*
Mg-3.1*
[**2190-1-14**] 12:29AM BLOOD Hgb-7.0* Hct-22.2*
[**2190-1-14**] 05:14AM BLOOD WBC-4.5 RBC-2.38* Hgb-7.0* Hct-22.2*
MCV-93 MCH-29.3 MCHC-31.5 RDW-15.5 Plt Ct-212
[**2190-1-14**] 02:44PM BLOOD Hct-16.4*#
[**2190-1-14**] 04:02PM BLOOD WBC-7.3# RBC-2.28* Hgb-6.9* Hct-21.5*#
MCV-94 MCH-30.2 MCHC-32.0 RDW-15.5 Plt Ct-232
Discharge Labs:
[**2190-1-16**] 06:40AM BLOOD WBC-4.9 RBC-2.80* Hgb-8.3* Hct-25.7*
MCV-92 MCH-29.7 MCHC-32.4 RDW-15.2 Plt Ct-217
[**2190-1-15**] 05:11AM BLOOD Glucose-150* UreaN-8 Creat-0.8 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11
[**2190-1-15**] 05:11AM BLOOD Calcium-7.4* Phos-3.2 Mg-2.3
EGD ([**2190-1-15**]):
Esophagus: Normal esophagus.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Other findings: The anastomosis was intact without evidence of
ulceration. Both loops of bowel were intubated and no evidence
of blood, ulceration or other cause of bleeding was seen.
Impression: The anastomosis was intact without evidence of
ulceration. Both loops of bowel were intubated and no evidence
of blood, ulceration or other cause of bleeding was seen.
Otherwise normal EGD to third part of the duodenum
Colonoscopy ([**2190-1-15**]):
Lesions Medium internal hemorrhoids were noted.
Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Brief Hospital Course:
Primary Reason for Admission: 65 y.o male with neuroendocrine
pancreatic tumor s/p Whipple [**2179**], transfered from OSH with GIB
.
Active Problems:
.
# GIB: Over the past several months the patient has noted
recurrent episodes of BRBPR associated with fatigue. Pt was
initially admitted to the MICU for monitoring. 18g PIV x2 were
established and he was given IV Protonix. He was transfused 2U
pRBCs with appropriate response in HCT 16->21->27 and prepped
for EGD/Colonoscopy. He remained hemodynamically stable and
underwent EGD/Colonoscopy without incident and was subsequently
called out to the floor. Endoscopy showed grade 1 internal
hemorrhoids and was otherwise normal. On the floor, the
patient's HCT remained stable x24 hours and he required no
additional blood transfusions. He was monitored on telemetry. He
had a normal BM on the day of discharge that was negative for
BRB. Follow up with his PCP for HCT check and GI for ongoing
workup of his GIB was arranged. The cause of the patient's
recurrent GIBs is unclear at this time. Hemorrhoids are likely
contributing to his BRBPR, but it is unlikely that his
substantial HCT drop can be attributed [**Last Name (un) 7245**] to a hemorrhoidal
bleed in the absence of significant anticoagulation. As such,
would suspect an occult Dieulafoys lesion vs small bowel source.
.
Chronic Problems:
.
# DM: Pt has iatrogenic DM due to subtotal pancreatic resection
(s/p Whipple). His home Metformin was held and he was started on
ISS and his home Lantus dose. He was given a diabetic diet. His
BG was well controlled throughout his course and his home
Metformin was restarted at the time of discharge.
.
# Exocrine Pancreatic Insufficiency: Pt has iatrogenic exocrine
pancreatic insufficiency s/p Whipple. His home Pancrease enzyme
replacement therapy was continued throughout his course.
.
Transitional Issues: Pt was discharged home with PCP follow up
in 1 week for HCT check as well as GI follow up for ongoing
workup of his recurrent GIBs. Warning signs were discussed at
length with the patient.
Medications on Admission:
Insulin- Lantus 15 units nighttime
Metformin 1000mg [**Hospital1 **]
Pancrease w/ meals
Baby ASA 81mg daily
Iron [**Hospital1 **]
Vit B12
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Eight (8) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS).
3. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
4. insulin glargine 100 unit/mL Solution Sig: One (1) 15 units
Subcutaneous at bedtime.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
6. Iron (ferrous sulfate) 325 mg (65 mg iron) Tablet Sig: One
(1) Tablet PO twice a day.
7. B-12 DOTS 500 mcg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
GI Bleed
Secondary Diagnosis:
Neuroendocrine tumor of the Pancreas s/p Whipple Procedure in
[**2179**]
Diabetes II
Pancreatic Insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 37091**],
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for a GI bleed. You were given
blood transfusions and evaluated by GI specialists, who
performed upper and lower endoscopies. These studies showed only
hemorrhoids and no other cause for your bleeding. You blood
levels were monitored and because they were stable, we feel you
are safe to return home.
No changes were made to your medications. Thank you for allowing
us to participate in your care.
Followup Instructions:
Name: [**Last Name (un) 37092**],ZBIGNIEW
Address: [**Street Address(2) 37093**] [**Apartment Address(1) 37094**], [**Location (un) **],[**Numeric Identifier 37095**]
Phone: [**Telephone/Fax (1) 37096**]
***Its recommended you follow up with Dr [**Last Name (STitle) **] next week for
follow up from your hospital stay. Please call Dr [**Last Name (STitle) **] [**Name (STitle) 766**]
morning to arrange an appt for that week.
Department: DIV. OF GASTROENTEROLOGY
When: WEDNESDAY [**2190-1-27**] at 11:00 AM
With: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], 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
|
[
"285.1",
"455.2",
"577.8",
"V13.01",
"V15.3",
"251.3",
"V10.91",
"578.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8199, 8205
|
5330, 7175
|
316, 334
|
8408, 8408
|
3708, 3708
|
9098, 9896
|
2534, 2539
|
7577, 8176
|
8226, 8226
|
7413, 7554
|
8559, 9075
|
4350, 5307
|
2554, 3262
|
3278, 3689
|
7196, 7387
|
1985, 2340
|
263, 278
|
362, 1966
|
8275, 8387
|
3725, 4333
|
8245, 8254
|
8423, 8535
|
2362, 2449
|
2465, 2518
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,928
| 154,188
|
46452
|
Discharge summary
|
report
|
Admission Date: [**2101-3-15**] Discharge Date: [**2101-3-29**]
Date of Birth: [**2060-8-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
shortness of breath, pain in right lower extremity
Major Surgical or Invasive Procedure:
PICC line placement
History of Present Illness:
History of Present Illness (mostly from prior note and OMR,
including sign out from MICU):
Mr. [**Known lastname 4300**] is a 49 year old diabetic with CHF (20-30% in [**2097**])
who presented with SOB on [**2101-3-14**]. SOB was worse over the last 3
days prior to admission, present both at rest and with exertion.
It began subacutely. He sleeps on 2 pillows chronically,
recently has had to sleep more upright. He does endorse PND. He
says he has been taking all of his medications at home, though
he is not sure of all of the names. He does not watch his sodium
intake carefully, but says that his diet hasn't really changed
recently. Denies any CP or palpitations. Pt also notes RLE
erythema with some associated pain over the last several days
prior to admission. He has had a mild productive cough with
green phlegm and rhinitis no fevers/chills/sweats.
.
In the ER, vitals were 97.4 83 157/100 22 93% (?on RA).
Admission labs notable for BNP of 2595. EKG showed RBBB, new
from [**2098**]. CXR poor quality but without clear infiltrate. RLE
lenis were negative for clot. ER did not want to do CTA given
report of shellfish allergy and felt VQ would not be feasible
given habitus. He was given 1g vancomycin for ?RLE cellulitis
and levofloxacin 750mg. Also received carvedilol 12.5mg, lasix
80mg PO, KCL 20meq, nitro SL, and furosemide 40mg IV. ER course
notable for hypertension up to 201/128. Vitals prior to transfer
afebrile 83 177/117 20 92% on 3L
Past Medical History:
* CHF/dilated cardiomyopathy with EF 20-30% on last TTE [**2097-3-30**].
Trivial MR, [**2-5**] TR and moderate pulmonary hypertension
* Type 2 DM,
* Hypercholesterolemia
* Morbid obesity
* Crack abuse
* OSA (new diagnosis)
Social History:
Lives with his mother. Is on disability. Most recent crack use 3
weeks prior. Formerly smoked cigarettes. Drinks 40oz beer
occasionally. Denies any IVDA of any kind. Reports prior
negative HIV test but says he thinks "he's due for another"
.
Family History:
Family History: +HTN, DM
Physical Exam:
Vitals 97.2 81 177/106 22 94% on 4L
General Morbidly obese pleasant man, mildly tachypneic but no
acute distress.
HEENT Anicteric, conjunctiva pink, MMM
Neck Large neck, JVP appears to be at least 10cm
Pulm Lung exam very challenging due to his habitus but no rales
appreciated
CV Regular S1 S2 no m/r/g appreciated
Abd Large pannus, +bowel sounds, nontender
Extrem 2+ bilateral edema, hand-sized area of erythema R shin
with warmth slightly tender
Neuro Alert awake, not somnolent, moving all extremities
Pertinent Results:
ADMISSION LABS:
.
CBC 6.8>46.4<179 N 70 no bands
Chem 138/4.3/97/34/11/1.1<266 gap=7
CK 183 MB 3 Tropn 0.01
INR 1.2, PTT 28
.
EKG SR @87, left axis with LAFB, RBBB with secondary ST/T
changes, qtc 461. LAA.
compared to [**7-/2098**] EKG the RBBB is new.
[**2101-3-15**] 06:25PM cTropnT-0.01
[**2101-3-15**] 06:25PM CK(CPK)-183
.
DISCHARGE LABS:
.
[**2101-3-28**] 05:39AM BLOOD WBC-4.2 RBC-4.61 Hgb-13.0* Hct-40.8
MCV-89 MCH-28.2 MCHC-31.9 RDW-14.5 Plt Ct-242
[**2101-3-29**] 06:38AM BLOOD Glucose-149* UreaN-10 Creat-0.8 Na-137
K-4.4 Cl-96 HCO3-36* AnGap-9
[**2101-3-27**] 05:41AM BLOOD ALT-12 AST-19 AlkPhos-70 TotBili-0.4
[**2101-3-23**] 06:16AM BLOOD proBNP-925*
[**2101-3-28**] 05:39AM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0
[**2101-3-16**] 10:15AM BLOOD HIV Ab-NEGATIVE
[**2101-3-22**] 06:58AM BLOOD INSULIN-LIKE GROWTH FACTOR-1- within
normal limits
.
MICROBIOLOGY:
[**2101-3-23**] WOUND CULTURE (Final [**2101-3-25**]) - from RLE draining
cellulitis
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
IMAGING/STUDIES:
TTE [**2101-3-16**]: The left atrium is markedly dilated. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = 25 %). No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is dilated with moderate
global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve is not well seen. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
.
CXR for 57cm RUE PICC placement [**2101-3-19**]: There has been interval
placement of a right-sided PICC, which on initial film
demonstrated coiling in the supraclavicular region and
terminated within the mid SVC. Subsequently, this was advanced
with tip at the cavoatrial region, in good position.
There is severely limited inspiration. Cardiopericardial
silhouette is not
well assessed. Focal airspace consolidation is evident. No
evidence of
pneumothorax.
.
Bilateral LE Ultrasound [**2101-3-23**]:
IMPRESSION:
1. No evidence of DVT.
2. Prominent inguinal lymph nodes, likely hyperplastic.
.
Inpatient Bedside Sleep study [**2101-3-25**]:
RESPIRATORY EVENTS: ETCO2 measurements varied between 41-47cm
throughout the course of the night while on PAP. NV mask alone
was used and no EERS was added. BIPAP SV Auto pressures of EEP
10
PS min 5 PS max 10 to BIPAP SV Auto EPAP 12 PS min 7 PS max 13
with 4L O2 to 6L O2 was titrated throught the course of the
night. The entire night was spent in the supine position. In
supine NREM BIPAP Auto SV pressures of EPAP 12 PS min 5 PS max
10
with 4L O2 resulted in sats greater than 91% with occasional
flow
limitation and occasional microarousals. In supine REM higher
pressures were clearly needed. In supine REM BIPAP SV auto
pressures of EPAP 12 PS min 7 PS max 13 and 6L O2 resulted in
sats 88% and occasional respiratory events but while in NREM
sats
stayed at 95% or greater. There was no evidence of periodic
breathing with the addition of NV mask.
ASSESSMENT: The patient must avoid supine sleep. BIPAP Auto SV
EPAP 12 PS min 7 PS max of 13 with 6L O2 results in very good
control of SDB in supine NREM and acceptable control in supine
REM. There was no evidence of periodic breathing, albeit with
the
aid of a NV mask, on tonights PSG. Continued efforts must be
made
towards weight loss. A formal outpatient split night study will
be performed to identify optimal settings upon discharge from
the
hospital.
ABGS DURING SLEEP STUDY:
[**2101-3-25**] 01:39AM BLOOD Type-ART pO2-63* pCO2-66* pH-7.38
calTCO2-41* Base XS-10
[**2101-3-25**] 05:44AM BLOOD Type-ART pO2-78* pCO2-66* pH-7.38
calTCO2-41* Base XS-10
Brief Hospital Course:
#Dyspnea / Hypoxia / CAP - Etiology presumed to be
multifactorial including an acute decompensation of his chronic
heart failure, a possible viral URI, underlying pulmonary HTN in
setting of uncontrolled OSA, as well as compressive atelectasis
secondary to body habitus. CXR on admission was without evidence
of pneumonia; noted to have some hilar fullness in a very
limited study due to body habitus. LENIs negative for DVT, BNP
2595. (no prior). Cardiac enzymes remained negative, however
Repeat ECHO showed persistant EF 25% (unchanged from prior). PE
was also considered but felt to be less likely. Unfortunately,
patient was unable to fit in CT scanner to better evaluate for
the possibility of PE or a primary pulmonary airspace disease.
However, given persistently hazy appearance of lung fields and
hypoxia, patient was treated for community acquired pneumonia
with 7 days of Levofloxacin. Patient was diuresed and
medications for heart failure optimized. Additionally, he was
treated with aggressive pulmonary toilet including incentive
spirometry, physical and occupational therapy. At the time of
discharge he continued to require supplemental oxygen; SaO2 low
90s on 3L nasal cannula.
.
# Obstructive Sleep Apnea: After admission to the medicine
floor, the patient had witnessed apneic events, loud snoring and
gasping/choking episodes with significant daytime fatigue. His
nocturnal PaCO2 was 79, and he was noted to have severe
obstructive apneas with desats down to 50%. Pt was transferred
to MICU for initiation of BIPAP, which he tolerated poorly at
first due to mask discomfort. Patient required pressures of up
to 18/12, however still noted to have desaturations to 80s and
even 70's when laying flat. Patient was transferred to the
floor after initiation of Bipap, but continued to have
difficulty tolerating secondary to mask discomfort. On [**2101-3-25**]
he underwent bedside inpatient sleep study and was provided with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 98692**] large NV with large head gear. This machine is the
property of the patient, and should remain with him at all
times. The patient tolerated Bipap titration with the
better-fitting mask and was continued on BIPAP with good effect
on the following settings: Auto SV EPAP 12 PS min 7 PS max of 13
with 6L O2. At discharge, he was given an appointment to follow
up in sleep disorders clinic as an outpatient. He will need a
formal sleep study as an outpatient following pulmonary rehab.
.
# CHRONIC SYSTOLIC HEART FAILURE: Patient with dilated
cardiomyopathy, possibly secondary to chronic prior crack
cocaine use, last EF 25%. Patient initially persistantly
hypertensive, started on maximum medical therapy with
Lisinopril, and beta blocker, however remained hypertensive.
Started combination Hydralazine / Isosorbide per A-Heft trial,
with significant improvement in status. Patient was also
diuresed agressively, with 4.5L negative length of stay in MICU.
Patient tolerated this regimen well on the floor, with
significant improvement in blood pressure control.
Additionally, the patient was continued on furosemide and
started on spironolactone for improved diuresis during this
admission.
.
# HTN, benign: As noted above, patient with difficult to control
blood pressure, that has improved significantly on aggressive
regimen with lisinopril, labetolol, hydralazine, and isosorbide.
This regimen should be continued at discharge.
.
# Cellulitis, LLE: On admission, noted to have increasing
warmth/erythema on right lower extremity. Patient started on
Augmentin intially however with progression of lesion requiring
initiation of Vancomycin. Small collection was noted over the
medial aspect of the right leg and ultrasound was obtained to
evaluate for potential abscess formation, however none was
found. Patient was continued on Vancomycin from
[**3-18**] to [**3-25**]. On [**3-25**], wound culture grew MSSA and the patient
was changed to Nafcillin. He should continue for a total 14 day
course to end on [**2101-3-31**]. He was evaluated by wound care
specialists, who recommended the following treatment:
Cleanse openings in the skin with wound cleanser then pat dry,
apply thin layer of aloe vesta moisturizer to leg, cover weeping
area with softsorb and wrap with conform, change daily and prn
strike-through, Elevate legs whenever possible, Place spiral ace
wrap to right leg from above toe to below knee and remove at bed
time. Additionally, patientt may benefit from vascular clinic
evaluation for venous stasis
disease as outpatient.
.
# Intertriginous Tinea: Patient was started on miconazole
powder [**Hospital1 **] to inguinal area on [**2101-3-28**]. This should continue
for a minimun of 2 weeks, and may be continued thereafter for
persistent pruritus.
# Morbid obesity: Patient was seen by nutrition and provided
with significant diet and weight loss education during this
admission. She was also seen by physical therapy who
recommended continued ambulation with supervision and oxygen
supplementation at least three times per day.
.
# DM, type 2 poorly controlled: Patient was poorly controlled on
metformin as an outpatient. During this hospitalization, he was
well controlled on Lantus 14 units at bedtime and a Humalog
sliding scale. This should be continued at discharge. Patient
also continued on ASA 81 mg daily.
.
# Hyperlipidemia: Continued on home statin.
.
# FEN: Low Na/diabetic diet, 1500 ml fluid restriction
.
# ACCESS: Rt PICC line in place
FULL CODE
Medications on Admission:
Aspirin 325mg daily
Carvedilol 12.5mg [**Hospital1 **]
Simvastatin 80mg daily
Lasix 80mg [**Hospital1 **]
Lisinopril 40mg daily
Metformin 500 mg [**Hospital1 **]
Kcl 40meq [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Multivitamin daily
Miralax prn
Viagra prn
Ibuprofen [**Hospital1 **]
Discharge Medications:
1. Nafcillin 2 gram Recon Soln Sig: One (1) Intravenous every
six (6) hours for 2 days: To end on [**2101-3-31**].
2. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO Q 8H (Every 8
Hours).
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Please discontinue when patient
more ambulatory.
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) for 2 weeks: Continue twice daily for two weeks.
[**Month (only) 116**] continue thereafter if patient continues to have rash in
inguinal region.
11. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
12. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
13. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
15. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
16. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: [**6-13**]
MLs PO Q6H (every 6 hours) as needed for cough.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
19. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-5**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
20. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
21. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
22. Lantus 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous at bedtime.
23. Humalog 100 unit/mL Solution Sig: as directed Subcutaneous
four times a day: Please dispense as directed by sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
RLE cellulitis
Obstructive and central sleep apnea
Hypertension
Cardiomyopathy with Low EF
Tinea corporis infection
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital for shortness of breath and
pain in your right leg. The pain in your right leg was thought
to be due to infection, and you were treated with antibiotics.
Your shortness of breath was felt to be multifactorial; a
combination of excess fluid, infection and obstructive sleep
apnea. You were started on a Bipap machine during sleep and
initiated on oxygen therapy to help with your shortness of
breath.
.
We made the following changes to your home medications:
- STOP Carvedilol and START Labetolol; continue at 1000 mg three
times daily
- START hydralazine and Isosorbide Dinitrate for your high blood
pressure
- Decrease furosemide to 60 mg twice daily
- Start spironolactone; this is a medication to help with your
heart failure
- Start Bipap at night for sleep apnea; please keep your Bipap
machine with you from now on. This machine was extremely
expensive and it is unlikely your health insurance will replace
it if lost or stolen.
- START Miconazole powder and apply to the groin twice daily for
at least 2 weeks
- START IV Nafcillin for your leg infection; this should
continue for another two weeks
- STOP Metformin and start insulin; 12 units Lantus in the
evening and Humalog insulin as directed by sliding scale four
times daily.
Followup Instructions:
Patient should follow-up with PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) **] 1-2 weeks
after discharge. Call [**Telephone/Fax (1) 250**] to schedule.
.
Patient should also follow-up in Sleep Disorders Center on
Thursday [**4-21**] at 3pm with Dr. [**First Name (STitle) **] [**Name (STitle) **]. This is
located on the [**Hospital Ward Name 23**] building, [**Location (un) **]. Tel([**Telephone/Fax (1) 9525**]
.
You have an appointment to follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on
Monday [**4-25**], 1 pm in Cardiology clinic. Tel ([**Telephone/Fax (1) 3942**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
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[
[
[]
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367, 389
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16135, 16135
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1900, 2125
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2141, 2385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,690
| 152,449
|
5235
|
Discharge summary
|
report
|
Admission Date: [**2194-9-17**] [**Year (4 digits) **] Date: [**2194-9-28**]
Date of Birth: [**2148-7-12**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 45-year-old female
with a past medical history significant for coronary artery
disease, status post myocardial infarction in [**2178**], status
post cardiac catheterization in [**2191**] which revealed 2-vessel
disease. The patient is also status post renal transplant in
[**2185**]. She presented with complaints of substernal chest pain
radiating to the neck and jaw with minimal activity. The
patient denied claudication, stroke, syncope in the past
secondary to hypoglycemia.
PAST MEDICAL HISTORY: (The patient's past medical history is
significant for)
1. Type 1 diabetes with a history of diabetic ketoacidosis.
2. Renal failure, status post renal transplant in [**2185**] with
a baseline creatinine of 1.6 to 2.2.
3. Coronary artery disease, status post myocardial
infarction in [**2178**].
4. Hypertension.
5. Hypercholesterolemia.
6. Peptic ulcer disease, status post upper gastrointestinal
bleed.
7. History of deep venous thrombosis.
8. Status post left toe amputation.
9. Peripheral vascular disease.
10. Status post left groin bypass.
11. Diverticulitis.
12. Gout.
13. History of pancreatitis in [**2194-6-29**].
ALLERGIES: The patient's allergies include NARCOTICS which
cause nausea and vomiting. No other drug allergies.
HOSPITAL COURSE: The patient underwent coronary artery
bypass graft times five; saphenous vein graft to the distal
left anterior descending artery and diagonal sequential,
saphenous vein graft to obtuse marginal, left internal
mammary artery to the left anterior descending artery, and
saphenous vein graft to the posterior descending artery.
The patient was stable and transferred to the unit on
propofol, Milrinone at 0.5, Neo-Synephrine at 0.02, and
phenylephrine at 1.5. The operation was performed on
[**2194-9-23**].
On postoperative day one the patient was still on
Neo-Synephrine and Milrinone which was eventually turned off.
The patient was extubated, afebrile, heart rate of 79 in
sinus rhythm, blood pressure 142/52, output of 5.5, index
of 2.9, with an systemic vascular resistance of 897,
pulmonary artery pressure 34/17, with a central venous
pressure of 11. Chest tubes put out 214 cc over the shift.
On physical examination the patient was neurologically
intact. Lungs had bilateral wheezes. Heart was regular.
The abdomen was soft. Extremities were warm with no edema.
The patient was on an insulin drip at 4 and Nipride at 1.
The plan was to continue Lopressor, keep the Foley in, and
discontinue the chest tubes and transfer to the floor.
On postoperative day two the patient had no acute events over
the last 24 hours. Temperature maximum of 101.1, temperature
current of 99.3, heart rate 79 in sinus rhythm, blood
pressure 155/62, respirations 19, satting at 95% on 2 liters
nasal cannula. On physical examination the patient was
neurologically intact. Lungs with bilateral wheezes. Heart
was regular. Abdomen was soft. Extremities revealed the left
foot was somewhat cooler than the right. Laboratories were
pending. The plan was to continue pulmonary toilet, wean the
Nipride which was on at 1, increase Lopressor, continue the
Foley, and to transfer to the floor.
On postoperative day three the patient was afebrile at 97.6,
heart rate of 71 in sinus rhythm, blood pressure 152/67,
satting at 94% on 3 liters. On physical examination lungs
had crackles at both bases, heart was regular, the sternum
was stable and dry. The abdomen was soft. Extremities were
warm. The patient had a white blood cell count of 14,
hematocrit of 30.2, and a platelet count of 245. Sodium 135,
potassium 4.5, blood urea nitrogen 77, creatinine 2.2, with a
glucose of 130. The plan was to continue the Lopressor and
aspirin.
Renal came by to see the patient. They recommended to not
use nonsteroidal antiinflammatory drugs in transplant
patients. It was written as p.r.n., but the patient had not
received any anyway, and they recommended to follow up with
her renal doctor [**First Name (Titles) **] [**Last Name (Titles) **].
On postoperative day four the patient remained afebrile,
heart rate of 74, blood pressure 112/55, satting at 95% on 2
liters. On physical examination the chest was clear to
auscultation bilaterally, heart was regular, sternum was
stable and dry. The abdomen was soft. Extremities were
warm. White blood cell count of 11.7, blood urea nitrogen
and creatinine of 86 and 2.8. The plan was to [**Last Name (Titles) **]
home.
On postoperative day five the patient remained afebrile,
heart rate of 85 in sinus rhythm, blood pressure 145/74,
respirations 18, satting at 94% on 2 liters. Fingersticks
ranged between 170 and 240. On physical examination the
patient was conversational. The lungs were clear to
auscultation bilaterally. Heart was regular. Sternum was
dry with a positive click. The abdomen was soft.
Extremities were warm. The plan was to [**Last Name (Titles) **] the patient
home.
[**Last Name (Titles) 894**] STATUS: The patient was discharged home on
[**2194-9-28**].
MEDICATIONS ON [**Year (4 digits) 894**]:
1. Imuran 100 mg p.o. q.d.
2. Elavil 100 mg p.o. q.d.
3. Albuterol meter-dosed inhaler.
4. Norvasc 10 mg p.o. q.d.
5. Neoral 125 mg p.o. b.i.d.
6. Diovan 80 mg p.o. q.d.
7. Colace.
8. Lopressor 50 mg p.o. b.i.d.
9. Lasix 40 mg p.o. b.i.d.
10. Potassium chloride 20 mEq p.o. b.i.d.
11. Aspirin 81 mg p.o. q.d.
12. NPH 14 units b.i.d.
13. Protonix 40 mg p.o. q.d.
14. Nystatin p.r.n.
15. Tylenol p.r.n.
[**Year (4 digits) 894**] FOLLOWUP: The plan was also to follow up with
nephrologist and to follow up with Dr. [**Last Name (STitle) 70**] in two to
four weeks.
[**Last Name (STitle) 894**] DIAGNOSES: Coronary artery disease.
CONDITION AT [**Last Name (STitle) 894**]: The patient's condition on [**Last Name (STitle) **]
was good/stable.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 15735**]
MEDQUIST36
D: [**2194-12-18**] 12:42
T: [**2194-12-21**] 11:27
JOB#: [**Job Number 21387**]
|
[
"443.9",
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icd9cm
|
[
[
[]
]
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[
"37.23",
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icd9pcs
|
[
[
[]
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1490, 6331
|
193, 687
|
710, 1471
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,138
| 143,955
|
50268
|
Discharge summary
|
report
|
Admission Date: [**2128-11-4**] Discharge Date: [**2128-11-9**]
Date of Birth: [**2067-6-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
S/p fall, AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 61 year old female with a history of metastatic renal ca
w/ mets to L3-L5 and abnormal vaginal bleeding [**3-11**] to mass, and
recent PE in [**10-13**]. Prior to admission the pt was in her USOH.
The morning of admission she woke up and her husband found her
confused and lying on the floor at the side of the bed. She did
not remember getting up at the time and felt weak. She later
complained of right sided back pain and right upper quadrant/rib
pain. She denies recent infection,sore throat, cough, dysuria or
diarrhea. She is known to have L LE weakness for the last
month, and was receiving XRT to the L-spine.
.
When the EMS arrived, her VS was 110/70 P 64 RR 16. She was
following command and oriented. On arrival to the ED, her VS was
T 98 P 104, BP 96/54 RR 16 O2 96 on RA
.
ED course: pt was found to be hypotensive to 70s-80s and sinus
tachy to 130-140s. IVF was started and eventually received 4 L
NS. Other notable PE finding included lethargic, slurried,
decreased dorsiflexion strength of left feet, tenderness of
T12-L3. EKG (no significant arrthymia or ischemic changes, but
sinus tachy 120s). WBC 14.9 lactate 4.4. Femoral line was placed
( as u/s was not working). Vanco/zosyn was started. 10 mg
dexamethason was given empirically for ?spinal cord trauma. CXR
prelim showed diffuse interstitial opacities. CT scan was held
up initally due to delay on [**Location **]. Her vs stablized w/ BP
100-110, P 110. Lactate improved to 1.6 after IVF.
Past Medical History:
- post-menopausal vaginal bleeding
- renal cell CA: left renal mass dx [**2128-8-11**] after painless
hematuria, w/ multiple lung nodules and possible met in L5
vertebral body (admitted in [**7-26**] for left renal mass
and underwent Left radical nephrectomy and excision of tumor
thrombus from left renal vein and IVC.
-history of PE in [**9-1**]-> heparin-> coumadin
- DM type 2
- Hypertension
- Hypercholesterolemia
- Anxiety
- Left breast lumpectomy X 2 (benign lesions)
- s/p open cholecystectomy
- s/p low back surgery
- guiac positive stool
Social History:
lives with husband and 35-[**Name2 (NI) **] daughter; smoked 60 pack-years but
quit 25 years; no alcohol, cocaine, or IV drug use.
Family History:
Mother had a stroke at 73, father died at 48 from diabetes
Physical Exam:
Vitals: (on arrival to [**Hospital Unit Name 153**]) p 111, BP 98/51 RR 14 O2 96 RA
Gen: lying flat in bed, speaking in full sentences, pleasant and
conversational in NAD
HEENT: NC/AT, anicteric, PERRL, EOMI, OP clear w/ MMM, no JVD
CVR: RRR, nl s1, s2, no r/m/g
Chest: decreased BS over RLL, good inspiratory effort
Pulm: CTA B/L w/ good air movement
Abdomen: soft, previous surgical site,
no erythema. tender over R flank, + bowel sounds
EXT: warm, no edema, +2 distal pulses, right fem line in place
Neuro: a/o x 3, CN II-XII intact, upper motor strength 4-5/5,
RLE motor 4-5/5, LLE 2-3/5, intact touch and pain sensory
throughout, lower ext reflexes equivocal, decreased rectal tone
Pertinent Results:
[**2128-11-4**] 10:00AM WBC-14.9* RBC-4.20 HGB-11.9* HCT-35.1* MCV-84
MCH-28.3 MCHC-33.8 RDW-17.5*
[**2128-11-4**] 10:00AM PLT COUNT-219
[**2128-11-4**] 10:00AM MAGNESIUM-1.7
[**2128-11-4**] 10:00AM LIPASE-13
[**2128-11-4**] 10:00AM ALT(SGPT)-277* AST(SGOT)-346* CK(CPK)-29 ALK
PHOS-365* AMYLASE-21 TOT BILI-0.7
[**2128-11-4**] 10:00AM GLUCOSE-164* UREA N-30* CREAT-1.3* SODIUM-134
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-24 ANION GAP-20
[**2128-11-4**] 10:21AM PT-32.9* PTT-39.7* INR(PT)-3.5*
[**2128-11-4**] 10:47AM LACTATE-4.4*
[**2128-11-4**] 12:29PM LACTATE-1.6
[**2128-11-4**] 12:40PM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2128-11-4**] 12:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2128-11-4**] 01:03PM O2 SAT-99
[**2128-11-4**] 01:03PM GLUCOSE-169* LACTATE-1.3
[**2128-11-4**] 01:03PM TYPE-ART PO2-219* PCO2-29* PH-7.32* TOTAL
CO2-16* BASE XS--9 INTUBATED-NOT INTUBA
[**2128-11-4**] 03:42PM CALCIUM-6.4* PHOSPHATE-3.9 MAGNESIUM-1.3*
.
CXR [**11-4**]-
Cardiac size is normal. Mediastinal contour is unremarkable.
There has been interval progression of pulmonary abnormalities.
Multiple new pulmonary nodules are seen throughout both lungs.
Interval increase in size in the right upper lobe and right
lower lobe lung nodules measuring, the largest in the right
upper lobe, 5.5 cm, wich appear to be cavitated. There is no
pleural effusion.
.
R Rib Xray-
Consolidative opacities within the right lung have worsened
compared to yesterday, raising the possibility of worsened
infection and/or metastatic disease. No definite rib fracture is
visualized
Brief Hospital Course:
61 year old w/ metastatic renal cell carcinoma, PE on Coumadin,
was found on floor by her husband, and s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 153**] stay for
hypotension.
.
#Fall- No apparent injuries, etiology unknown. Neurology was
consulted and there was concern for seizure secondary to
possible brain metastasis. MRI of head recommended but pt
refused due to inability to lie flat. CT head also recommended
but pt and her family decided that goals of care would be
palliative, and did not wish to pursue further imaging. Her
mental status was clear, and her neurological exam remained
stable (known L LE weakness). She was discharged home w/hospice
as per patient wishes.
.
# Hypotension- The patient was admitted to the ICU was treated
with IVFs and pressors (Levophed). ABX were not continued as pt
had no clear source of infection. SHe was continued on stress
dose steroids. On the floor she remained normotensive. Blood
and urine cultures remained negative.
.
#Metastatic renal carcinoma- Prior to admission, the patient was
receiving radiation to her pelvic mass and spine. She did not
wish to continue with this treatment after discharge. Her lung
metastases have increased in size on chest x-ray, and the pt was
more short of breath, now requiring constant O2. Her pain was
managed with fentanyl patch and oral dilaudid for breakthrough.
After discussion with patient and family, her code status was
changed to DNR/DNI, and care directed to alleviate symptoms. As
per patient wishes, she was discharged home with hospice.
.
#Anemia- The patient's anemia is likely due to a combination of
dilution from fluids and bleeding from pelvic mass. Her stool
was guiac negative. Hemolysis labs were negative. She was
given 2 units PRBCs prior to discharge. Due to higher risk of
bleeding over risk of clot, her coumadin was stopped.
.
#Elevated LFTs- RUQ ultrasound was considered to evaluate for
cholestatsis, but patient/family did not want further imaging.
Her LFTs had trended down to near normal valued by the time of
discharge.
.
#Renal insuffiency-Initially noted on admission. Her creatinine
normalized with IV hydration.
.
#DM- She was continued on Lantus and covered with regular
insulin sliding scale.
.
# h/o PE- The patient had a PE in [**10/2128**], and was
supratherapeutic on coumadin upon admission. Her coumadid was
held. She had a small amount of hemoptosis, and was given Vit K
to reverse anti-coagulation. After discussion with the primary
oncology team, it was decided her risk of bleeding was greater
than her risk of clot. She will not re-start anti-coagulation.
.
# FEN- Diabetic/consistent carbohydrate
.
#PPx-PPI, supratherapeutic INR, bowel regimen
.
#Code-DNR/DNR
Medications on Admission:
1. Pravastatin 80mg po daily
2. Oxycodone-Acetaminophen 1-2 tabs Q4-6H PRN
3. Quinapril 10mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Pantoprazole 40 mg PO Daily
6. Warfarin 3mg PO QHS
7. Lantus 28 units QHS
8. Dexamethasone 4 mg PO Q6H
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.
Disp:*60 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:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2-4H (every
2 to 4 hours) as needed for pain.
Disp:*180 Tablet(s)* Refills:*0*
5. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
6. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
7. Insulin Glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous at bedtime.
Disp:*qs bottles* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: 1-14 units
Injection as directed.
Disp:*qs bottles* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Hospice Care
Discharge Diagnosis:
Primary: 1. Renal Cell Carcinoma 2. hypotension 3. Anemia [**3-11**]
Vaginal bleeding
Secondary: 1. DM 2. Anxiety
Discharge Condition:
Stable
Discharge Instructions:
1. Take all medications as prescribed
2. You have elected to pursue home hospice care for further
management of your health care needs. Please contact them if any
issues arise.
3. Call your doctor if you have confusion, uncontrolled pain or
SOB, fever/chills, weakness, or any other concerns.
Followup Instructions:
Please contact your oncologist, Dr. [**Last Name (STitle) **] as needed.
Completed by:[**2128-11-10**]
|
[
"V10.52",
"280.0",
"780.39",
"276.52",
"401.9",
"272.0",
"198.3",
"V58.61",
"197.0",
"198.82",
"198.7",
"250.00",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9201, 9244
|
5051, 7793
|
330, 336
|
9404, 9413
|
3363, 5028
|
9755, 9860
|
2577, 2638
|
8085, 9178
|
9265, 9383
|
7819, 8062
|
9437, 9732
|
2653, 3344
|
277, 292
|
364, 1840
|
1862, 2411
|
2427, 2561
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,380
| 150,243
|
44113
|
Discharge summary
|
report
|
Admission Date: [**2150-12-31**] Discharge Date: [**2151-1-18**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea of Exertion
Major Surgical or Invasive Procedure:
[**2151-1-1**] Off-Pump Coronary Artery Bypass Graft x 2 (LIMA->LAD,
SVG->PDA)
History of Present Illness:
88 yo M with worsening DOE x 6 months. Cath at MWMC on [**12-31**] with
3VD.
Past Medical History:
syncope
PVD
paroxysmal afib
chronic renal insufficiency
anemia
s/p PPM
s/p R carotid endarerectomy
s/p AV fistula L arm
Social History:
lives alone
retired
Family History:
None
Physical Exam:
60 18 130/50 99% RA NAD
Lungs CTAB
Heart RRR No M/R/G
Abd protuberent
1+edema to LE, cool
Left DP/PT by doppler only
Left AV fistula +thrill/bruit
Pertinent Results:
[**2151-1-1**] CNIS: 1. Widely patent right common and internal carotid
artery. 2. Calcific plaque involving the left common and
internal carotid artery, unassociated with any stenosis,
however.
[**2151-1-1**] Echo: There is mild global left ventricular hypokinesis.
Overall left ventricular systolic function is mildly depressed.
Mild inferior and apical hypokinesis noted. Right ventricular
free wall motion is normal. There are simple atheroma in the
ascending aorta. There is diffuse calcification of the ascending
aorta. There are complex (>4mm) atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. Mild to moderate ([**11-24**]+)
mitral regurgitation is seen. There is no pericardial effusion.
There is a left pleural effusion. Post procedure: Mild global
and inferior and apical focal abnormalities persist. MR remains
2+. Aortic contours remain unchanged.
[**1-2**] Abd U/S: 1. Gallbladder wall thickening and edema with
multiple stones within the gallbladder with no evidence of
gallbladder distension. Since fluid accumulation is also noted
within the abdominal cavity, gallbladder wall edema is most
likely secondary to underlying medical problem. HIDA scan is
recommended for further evaluation if strong clinical suspecion
of cholecystitis exists. 2 The doppler fiondings are a little
difficult ot interpret-The vessels are all patent, but the
findings suggest right sided heart failure. There is one clear
image with hepatofugal main portal flow, which would also
suggest bidirectional portal venous flow indicating or at least
suggesting portal hypertension. A physician directed repeat
examination may help to resolve these findings [**2151-1-14**] CXR:
Persistent bilateral small layering effusions and bibasilar left
retrocardiac atelectasis.
[**2150-12-31**] 07:23PM BLOOD WBC-7.1 RBC-4.31* Hgb-12.5* Hct-39.6*
MCV-92 MCH-29.1 MCHC-31.7 RDW-17.2* Plt Ct-216
[**2151-1-3**] 10:09PM BLOOD WBC-16.5*# RBC-4.31*# Hgb-12.8*#
Hct-38.1* MCV-88 MCH-29.8 MCHC-33.7 RDW-17.3* Plt Ct-109*
[**2151-1-15**] 04:43AM BLOOD WBC-8.8 RBC-3.71* Hgb-11.0* Hct-34.4*
MCV-93 MCH-29.7 MCHC-32.1 RDW-19.6* Plt Ct-118*
[**2150-12-31**] 07:23PM BLOOD PT-14.9* PTT-28.3 INR(PT)-1.3*
[**2151-1-4**] 04:14AM BLOOD PT-36.5* PTT-133.7* INR(PT)-4.0*
[**2151-1-13**] 02:36AM BLOOD PT-14.9* PTT-30.0 INR(PT)-1.3*
[**2150-12-31**] 07:23PM BLOOD Glucose-105 UreaN-68* Creat-2.4* Na-146*
K-4.1 Cl-108 HCO3-24 AnGap-18
[**2151-1-5**] 01:42AM BLOOD Glucose-136* UreaN-45* Creat-2.5* Na-143
K-4.5 Cl-101 HCO3-28 AnGap-19
[**2151-1-15**] 04:43AM BLOOD Glucose-85 UreaN-66* Creat-2.1* Na-147*
K-3.3 Cl-112* HCO3-29 AnGap-9
[**2151-1-11**] 01:04AM BLOOD ALT-272* AST-61* LD(LDH)-324* AlkPhos-91
Amylase-143* TotBili-1.7*
[**2151-1-13**] 02:36AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.5
Brief Hospital Course:
Mr. [**Known lastname 94685**] was taken to the operating room on [**2151-1-1**] where
he underwent a CABG x 2. Please see operative report for
surgical details. Following surgery he was transferred to the
CSRU for invasive monitoring in stable condition. Later that day
he was weaned from sedation, awoke neurologically intact and was
extubated. He was also seen by renal services that day and
throughout hospital course for his history of kidney disease. On
post-op day one, he was found to have cardiogenic shock and a
respiratory acidosis for which he was re intubated and started
on Epinephrine, Levophed and Vasopressin. He was seen in
consultation by surgery for metabolic acidosis, rising LFTs and
lactate, that was felt to be shock liver and mesenteric ischemia
likely secondary to cardiogenic shock. No surgery was indicated.
His liver enzymes trended down throughout hospital course
following initial rise on first several post-op days. He did
require Inotropic support for several more days and remained
intubated until post-op day six. On post-op day seven speech and
swallow eval was performed and his diet was eventually advanced
to regular. Chest tubes and epicardial pacing wires were removed
per protocol. Beta blockers and diuretics were initiated and he
was diuresed towards his pre-op weight. He remained in the CSRU
for several more days requiring Neo-synephrine gtt at times d/t
hypotension and also needed aggressive pulmonary toilet. He
eventually was transferred to the telemetry floor on post-op day
twelve. The remainder of his hospital course was uneventful and
he was discharged on post-op day thirteen to rehab with the
appropriate follow-up appointments.
Medications on Admission:
Lasix 120 mg qAM and 80 mg qPM, Atenolol 50mg qd, Digoxin 0.125
mg qd, Cozaar 100mg qd, Aspirin 81mg qd, Colchicine 0.6mg qd,
FeSO4 [**Hospital1 **], Fish Oil 4x/wk, Epogen once weekly, Vit B12 q2wks,
Hyodroxyzine 25mg qd
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) 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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
8. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
PMH: Paroxysmal Atrial Fibrillation, PPM '[**41**], Chronic Renal
Failure w AV fistua on [**10-28**] (HD not started), s/p RCEA 02,
anemia
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 or while taking narcotics.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**Last Name (STitle) 8605**] 2 weeks
Dr. [**First Name (STitle) 1075**] 2 weeks
Completed by:[**2151-1-18**]
|
[
"411.1",
"570",
"428.0",
"557.1",
"585.4",
"276.0",
"440.0",
"V45.01",
"427.31",
"785.51",
"414.01",
"276.2",
"707.03",
"443.9",
"584.9",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"36.15",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
6487, 6632
|
3773, 5461
|
289, 369
|
6876, 6882
|
859, 3750
|
7207, 7360
|
671, 677
|
5733, 6464
|
6653, 6855
|
5487, 5710
|
6906, 7184
|
692, 840
|
230, 251
|
397, 475
|
497, 618
|
634, 655
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
510
| 166,097
|
24455
|
Discharge summary
|
report
|
Admission Date: [**2150-11-11**] Discharge Date: [**2150-11-13**]
Date of Birth: [**2099-3-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
found unresponsive at home
Major Surgical or Invasive Procedure:
Endotrachial Intubation
History of Present Illness:
51 y/o female with PMH significant for seizures who per notes
was found down at home by her daughter. [**Name (NI) **] report, pt had been
lying on the couch all day. She then went to the restroom. When
her daughter went to check on her, she was laying on the
bathroom and had been incontinent of urine. Her daughter was
concerned that she could be postictal so she called EMS who
brought her to the [**Hospital1 18**] ED for further evaluation.
.
In the field, the EMS FS was 147. The pt received 1 of narcan
with little response. On arrival to the ED, her VS were 98 111
142/73 20 100% NRB. There was a concern that the pt was in
nonconvolsive status and a STAT neuro consult was obtained.
Speaking to the neuro resident, they did not feel she was in
nonconvolsive status. Her eyes were not deviated on exam. The pt
became very agitated with noxious stimuli. Pt was then intubated
for airway protection as she was nonresponsive. In the ED, the
pt received 10 mg of narcan with some response but she did not
wake up entirely or for any prolonged period of time. Her
toxicology screen was positive for tricyclics and ETOH.
Amphetimines were also seen in her urine. A toxicology consult
was obtained. The pt's QRS on her ECG was >100 but other ECG
findings and her clinical picture were not felt to be consistent
with a tricyclinc overdose. The pt was given bicarb with no
change in her ECG or clnical status. Pt was then sent to the
[**Hospital Unit Name 153**] for further care.
.
Past Medical History:
1. CAD (MIBI [**2147**] with small reversible defect)
2. HTN
3. Hypercholesterolemia
4. ? h/o Sz (? related to EtOH)
5. depression (possible suicide attempt [**4-30**])
6. substance abuse (EtOH)
Social History:
Lives with husband and 3 kids. Occ ETOH. 3 cig/d x 4 months. No
IVDU/no illicit drug use. Does not work.
Family History:
DM
Physical Exam:
98.0 140/83 90 14 100%
AC 600/14/.50
Gen- Sedated and intubated. Unresponsive.
HEENT- NC AT. PERRL. Anicteric sclera. MMM. Intubated.
Cardiac- RRR. S1 S2. No m,r,g.
Pulm- CTA anteriorly and laterally.
Abdomen- Obese. Soft. NT. ND. Positive bowel sounds.
Extremities- Warm. No c/c/e.
Neuro- Sedated. Intubated. Downgoing toes bilaterally.
Pertinent Results:
CXR [**11-11**]- Low lung volumes. No definite infiltrate. Per
radiology, ETT tube in place.
.
Head CT [**11-11**] - Very limited due to pt motion. No gross evidence
for hemorrhage, mass effect, shift of normally midline
structures, or hydrocephalus. Density values of the brain
parenchyma are grossly within normal limits. [**Doctor Last Name **]-white matter
differentiation is grossly intact. Visualized osseous structures
show no evidence for fracture.
.
ECG [**11-11**] - Pt with multiple ECGs in the ED. Sinus rhythm. QRS
about 125 in all.
..
[**2150-11-11**] 06:00PM WBC-9.5 RBC-3.56* HGB-9.3* HCT-28.2* MCV-79*
MCH-26.2* MCHC-33.0 RDW-18.4*
[**2150-11-11**] 06:00PM PLT COUNT-333
[**2150-11-11**] 06:00PM PT-12.9 PTT-24.6 INR(PT)-1.1
[**2150-11-11**] 06:00PM ASA-NEG ETHANOL-107* CARBAMZPN-<1.0*
ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS
[**2150-11-11**] 06:00PM ALT(SGPT)-28 AST(SGOT)-28 CK(CPK)-424* ALK
PHOS-72 AMYLASE-150* TOT BILI-0.2
[**2150-11-11**] 07:57PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-POS mthdone-NEG
[**2150-11-11**] 11:05PM GLUCOSE-123* UREA N-11 CREAT-0.8 SODIUM-140
POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-28 ANION GAP-9
[**2150-11-11**] 11:05PM ALT(SGPT)-29 AST(SGOT)-27 LD(LDH)-273*
CK(CPK)-389* ALK PHOS-67 AMYLASE-146* TOT BILI-0.3
[**2150-11-11**] 11:05PM LIPASE-20
[**2150-11-11**] 11:05PM CK-MB-5 cTropnT-<0.01
Brief Hospital Course:
51 y/o female with PMH significant for EtOH abuse, ? EtOH
withdrawal seizures, and ? suicide attempt who was found down at
home by her daughter.
.
1. Mental status changes: Pt was found down at home per her
daughter with a change in mental status. Per report, she was
basically unresponsive but would respond to noxious stimuli. We
considered a wide differential including seizure, ingestion,
metabolic, and infection. Neuro was consulted but did not
believe she was in non-convulsive status. An EEG on [**11-12**] showed
no seizure activity in the morning. After contacting her PCP, [**Name10 (NameIs) **]
was unclear if she had a true seizure disorder. Per PCP's
history, her seizures have only been related to withdrawal from
ETOH. Pt was found to have multiple ingestions on her tox
screens. Her serum tox screen was positive for tricyclics in
addition to ETOH. Pt's urine tox was positive for amphetamines.
Toxicology was consulted and did not feel her clinical picture
was consistent with a tricyclic overdose. They were concerned
that she could have taken another depressive medication which is
not detected on tox screen. Patient was monitored closely.
Serial EKGs checked. Patient's clinical picture was less
concerning for infection; she had a very abrupt onset of
symptoms, was afebrile during her stay, and her WBC was WNL. A
lumbar puncture was not done. Patient was extubated soon after
arriving in the ICU and she was maintaining her O2 sats without
difficulty. As patient became more alert, she was able to
provide more history. She had a history of depression and EtOH
use; per patient she was not trying to commit suicide. She would
like to enroll in a dual diagnosis program to work on her
depression and anxiety as well as her alcoholism. We were
unable to discharge patient directly to such a program. She will
follow up with her PCP next week and enroll in the Partial Dual
Diagnosis Program on Monday [**2150-11-14**] at 9AM.
[**Hospital3 8063**] in [**Location (un) **], MA.
.
2. Seizure disorder- Per report, pt has a history of seizures in
the setting of EtOH withdrawal. Neurology evaluated the patient
and an EEG showed no evidence of seizure activity. Patient was
monitored closely for signs and symptoms of EtOH withdrawal. On
discharge no evidence of withdrawal.
.
3. Depression - Psychiatry was consulted. Patient not suicidal.
She was discharged to enroll in a dual diagnosis to address her
ongoing depression and substance abuse.
.
4. CAD - Patient was continued on a beta blocker, [**Last Name (un) **], and ASA.
.
5. HTN - Continued on outpatient regimen of Toprol, Avapro and
Procardia.
.
6. Anemia. Unclear etiology, appears to be iron deficient.
Likely related to EtOH use. B12 and Folate WNL in [**4-30**]. Stools
were guaiac negative. Continued on iron supplements. She have
anemia follow-up by her PCP next week.
Medications on Admission:
1. Toprol XL 200 daily
2. Lipitor 80 daily
3. Niferex 150 [**Hospital1 **]
4. Ultram 50 tid prn
5. procardia XL 120 daily
6. NTG prn
7. neurontin 300 daily
8. lactulose prn constipation
9. hctz 50 daily
10. ambien 10 qhs prn
11. Amytriptyline 125 qhs
12. avapro 300 daily
13. colace
14. compazine
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
2. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
3. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Hydrochlorothiazide 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed.
10. Procardia XL 60 mg Tab, Sust Release Osmotic Push Sig: Two
(2) Tab, Sust Release Osmotic Push PO once a day.
11. Neurontin 300 mg Capsule Sig: One (1) Capsule PO once a day.
12. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Anxiety
Mental Status Changes requiring Intubation
Secondary Diagnosis:
Coronary Artery Disease
Hypertension
Depression
History of EtOH abuse
Discharge Condition:
Good
Discharge Instructions:
Please call your primary care physician or return to the
hospital if you experience confusion, shortness of breath, chest
pain, or have any other concerns. Please come to the emergency
room if you have any thougths of harming yourself.
Please resume all your previous medications, except
Amitriptyline and Klonopin.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 35975**] next week.
([**Telephone/Fax (1) 24731**])
2. Please follow up at the Partial Dual Diagnosis Program on
Monday [**2150-11-14**] at 9AM. Contact [**Name (NI) 19447**] - [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 54752**] ([**Telephone/Fax (1) 61855**])
Located at: [**Hospital3 8063**]
[**Street Address(2) **]
[**Location (un) **], MA
|
[
"401.9",
"518.81",
"788.39",
"278.00",
"980.0",
"272.4",
"E853.2",
"305.1",
"305.00",
"E860.0",
"780.39",
"724.2",
"280.9",
"969.4",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"94.62",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8262, 8268
|
4049, 6915
|
344, 370
|
8474, 8481
|
2621, 4026
|
8847, 9293
|
2243, 2247
|
7263, 8239
|
8289, 8289
|
6941, 7240
|
8505, 8824
|
2262, 2602
|
278, 306
|
398, 1885
|
8381, 8453
|
8308, 8360
|
1907, 2104
|
2120, 2227
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,155
| 106,584
|
53425
|
Discharge summary
|
report
|
Admission Date: [**2172-12-4**] Discharge Date: [**2172-12-11**]
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
[**2172-12-5**]: Right hip hemiarthroplasty
History of Present Illness:
The patient is a 88 year old male who fell sustaining a right
femoral neck fracture. He was initially seen at [**Hospital3 635**]
hospital. There he was seen by cardiology for elevated
troponins. He was found to be a moderate high risk for surgery.
At the request of the patient's daughter, he was transferred to
[**Hospital1 18**] for fixation of his fracture.
Past Medical History:
CAD, s/p CABG [**2145**]
CVA
HTN
h/o SBO
CHF
PVD
s/p appy
s/p ccy
s/p hernia repair
Social History:
Lives alone
Family History:
NC
Physical Exam:
Upon arrival:
NAD
RRR, 2/6 systolic murmur
CTA b/l
S/NT/ND +BS
RLE: shortened, externally rotated
NVI distally
Pertinent Results:
[**2172-12-9**] 10:12AM BLOOD WBC-10.6 RBC-3.64* Hgb-12.0* Hct-34.6*
MCV-95 MCH-32.9* MCHC-34.6 RDW-13.5 Plt Ct-393
[**2172-12-8**] 09:38AM BLOOD WBC-15.8* RBC-3.52* Hgb-11.6* Hct-33.4*
MCV-95 MCH-32.9* MCHC-34.7 RDW-13.5 Plt Ct-366
[**2172-12-7**] 06:05AM BLOOD WBC-15.8* RBC-3.53* Hgb-11.6* Hct-33.2*
MCV-94 MCH-32.7* MCHC-34.8 RDW-13.6 Plt Ct-297
[**2172-12-6**] 03:09AM BLOOD WBC-15.2* RBC-4.02* Hgb-13.9* Hct-37.2*
MCV-93 MCH-34.5* MCHC-37.2* RDW-14.1 Plt Ct-326
[**2172-12-5**] 11:01AM BLOOD WBC-15.8* RBC-4.19* Hgb-13.8* Hct-39.5*
MCV-94 MCH-33.0* MCHC-35.0 RDW-13.7 Plt Ct-317
[**2172-12-5**] 06:30AM BLOOD WBC-13.1* RBC-4.66 Hgb-15.3 Hct-43.8
MCV-94 MCH-33.0* MCHC-35.1* RDW-13.8 Plt Ct-314
[**2172-12-4**] 03:00PM BLOOD WBC-13.5* RBC-4.68 Hgb-15.5 Hct-44.3
MCV-95 MCH-33.1* MCHC-35.0 RDW-13.9 Plt Ct-279
[**2172-12-9**] 10:12AM BLOOD Neuts-82.1* Lymphs-10.8* Monos-6.1
Eos-0.9 Baso-0.2
[**2172-12-9**] 10:12AM BLOOD PT-14.3* INR(PT)-1.3*
[**2172-12-7**] 06:05AM BLOOD PT-15.8* PTT-38.8* INR(PT)-1.4*
[**2172-12-5**] 06:30AM BLOOD PT-13.9* PTT-34.1 INR(PT)-1.2*
[**2172-12-4**] 03:00PM BLOOD PT-14.6* PTT-34.1 INR(PT)-1.3*
[**2172-12-8**] 09:38AM BLOOD Glucose-148* UreaN-19 Creat-0.7 Na-138
K-4.1 Cl-102 HCO3-27 AnGap-13
[**2172-12-7**] 06:05AM BLOOD Glucose-134* UreaN-17 Creat-0.7 Na-135
K-4.1 Cl-101 HCO3-27 AnGap-11
[**2172-12-6**] 03:09AM BLOOD Glucose-143* UreaN-16 Creat-0.9 Na-134
K-4.3 Cl-101 HCO3-23 AnGap-14
[**2172-12-5**] 11:01AM BLOOD Glucose-167* UreaN-21* Creat-0.9 Na-134
K-4.5 Cl-104 HCO3-22 AnGap-13
[**2172-12-5**] 06:30AM BLOOD Glucose-140* UreaN-22* Creat-0.9 Na-134
K-4.5 Cl-102 HCO3-24 AnGap-13
[**2172-12-4**] 03:00PM BLOOD Glucose-141* UreaN-24* Creat-0.9 Na-136
K-4.9 Cl-101 HCO3-24 AnGap-16
[**2172-12-6**] 10:15AM BLOOD CK-MB-8 cTropnT-0.15*
[**2172-12-6**] 03:09AM BLOOD CK-MB-7 cTropnT-0.19*
[**2172-12-5**] 08:47PM BLOOD CK-MB-6 cTropnT-.30*
Brief Hospital Course:
The patient was transferred to [**Hospital1 18**] on [**2172-12-4**] and admitted to
the orthopedic service. He was seen by both medicine and
cardiology for pre-operative risk assessments. On [**2172-12-5**] he
was taken to the operating room for a right hip
hemiarthroplasty. Intra-operatively the patient had a NSTEMI.
He was brought to the SICU post-operatively. His troponins
trended down from 0.3 to 0.15 and he was stable enough to be
transferred to the floor. On the floor he was evaluated by
physical therapy and progressed well. Cardiology saw the
patient daily and adjusted his lopressor to control his heart
rate adequately. On [**2171-12-9**] his incision was found to have
increased erythema and warmth. Ancef was started for this
cellulitis and the erythema improved. A repeat echocardiogram
was done which was unchanged from previous. His hospital course
was otherwise without incident. His pain was well controlled.
His labs and vital signs remained stable. He is being
discharged today to rehab in stable condition.
Medications on Admission:
nitro 0.4mg SL prn
isosorbide 60mg PO daily
digitek 0.025mg PO daily
citalopram 20mg PO daily
propranolol 20mg PO daily
lisinopril 7.5mg PO daily
lasix 20mg PO every other day
lipitor 10mg PO daily
Vitamin B complex daily
Imodium prn
Discharge Medications:
1. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 7 days.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
8. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
11. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg syringe
Subcutaneous DAILY (Daily) for 4 weeks.
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day): hold for SBP<100, HR<55.
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for standing.
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Right femoral neck fracture
NSTEMI
Cellulitis
Discharge Condition:
Stable
Discharge Instructions:
Pleae continue with the weight bearing as tolerated on your
right leg.
Please keep incision clean and dry. Dry sterile dressing daily
as needed. If you notice any increased redness, swelling,
drainage, temperature >101.4, or shortness of breathe please
[**Name8 (MD) 138**] MD or report to the emergency room.
Please take all medications as prescribed. You need to take the
lovenox shots for 4 weeks to prevent blood clots. You may
resume any normal home medication.
Please follow up as below. Call with any questions.
Physical Therapy:
Activity: Activity as tolerated
Right lower extremity: Full weight bearing
Treatment Frequency:
Dry sterile dressing daily as needed.
Staples may be removed 2 weeks post-op ([**2172-12-20**])
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital1 18**] orthopedic clinic
in 4 weeks. Please call [**Telephone/Fax (1) **] to make an appointment.
Please follow up with your cardiologist Dr. [**Last Name (STitle) 20948**] soon after
your discharge.
Completed by:[**2172-12-11**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,231
| 101,216
|
50417
|
Discharge summary
|
report
|
Admission Date: [**2121-12-18**] Discharge Date: [**2122-1-6**]
Date of Birth: [**2043-2-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Heparin Agents / Levofloxacin
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Ongoing hypotension, hypothermia, anasarca, and inability to
tolerate HD for fluid removal
Major Surgical or Invasive Procedure:
Tunnelled Left Internal Jugular Hemodialysis Catheter
Left Femoral Hemodialysis Catheter
Right Femoral Triple Lumen Catheter
Left PICC line
Debridement of Sacral Decubitus
History of Present Illness:
Ms. [**Known lastname **] was admitted on [**2121-12-18**] for [**Date Range 1106**] surgery
evaluation of right heel ulcer. She was started on
vanco/cipro/flagyl on admission to cover an infection. On
hospital day 2 ([**2121-12-19**]), she underwent right peroneal
angioplasty on [**2121-12-19**] and was put on an argatroban drip for 24
hours following the procedure. On [**12-20**], she was noted to be
hypotensive to 72/37 and hypothermic to 94.6. Cardiac enzymes
were checked and were noted to be positive. She was transfused 2
units packed red blood cells on [**12-20**]. Plastic surgery was
consulted for evaluation of sacral decubuti, but declined to
debride wound due to aspirin/plavix/argatroban use. She
underwent HD on [**2121-12-21**], but they were unable to remove fluid
due to low blood pressures. When renal evaluted her on that day,
there was concern that her mental status was not at baseline and
her words were not well enunciated. They recommended sending
blood cultures and broadening antibiotics but no intervention
was undertaken at this time. Cardiology was consulted on [**12-21**]
for bradycardia, hypotension, and elevated cardiac enzymes and
recommended discontinuation of beta-blockers. An echo was
performed on [**12-22**] which showed new regional wall motion
abnormalities. Given hypotension, anasarca, and inability to
tolerate HD due to low blood pressures, patient was transfered
to MICU for CVVHD.
.
Upon arrival to the MICU, patient reports right hand pain. She
denies any other complaints. No abdominal pain, nausea,
vomiting, diarrhea, fevers, chills, shortness of breath, chest
pain.
Past Medical History:
Type 2 DM
ESRD on HD Tue/Thurs/Sat
CAD s/p MI in [**2103**] and [**2113**], s/p CABG x 2
Diagstolic CHV (EF 60-65%0
PAF (not anticoagulated due to GI bleeds)
HTN
Hypothyroidism
Anemia of chronic disease
Thrombocytopenia
HIT in [**2116**]
H/o MRSA endocarditis
Chronic GI bleeds due to AVMs
PUD, Barrett's
Asthma
PSH:
CABG x 2
Cholecystectomy
BSO -- patient with uterus on CT scan 11/08
L BKA [**2121-12-2**]
Social History:
The patient is primarily Spanish speaking but does speak fair
English.
She is wheelchair bound and lives in a [**Hospital1 1501**]. The patient is
widowed, a retired factory worker.
Tobacco: None
ETOH: None
Illicits: None
Family History:
CAD, HTN, and DM
Physical Exam:
Tcurrent: 36.2 ??????C (97.2 ??????F)HR: 66 bpm BP: 72/28(38)RR: 22 SpO2:
92% RA
Physical Examination
General Appearance: Well nourished, obese, anasarcic
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral [**Hospital1 **]: (Right radial pulse: dopplerable), (Left
radial pulse: dopplerable), (Right DP pulse: dopplerable), (Left
DP pulse: Not assessed)
Respiratory / Chest: (Breath Sounds: Clear : anteriorly)
Abdominal: Soft, Non-tender, Bowel sounds present, obese
Extremities: Right: 3+, Left: 3+, Right heel ulcer, Left BKA
Skin: Sacral decub, bilaterial ischial decubiti, right heel
ulcer, RUE erythema/warmth
.
On discharge
Tcurrent: 36.6 ??????C (97.8 ??????F)HR: 69 bpm BP: 80/40 mmHg RR: 21
insp/min, SpO2: 96% RA
Wgt (current): 79.5 kg (admission): 112.5 kg, DRY 78.5 KG
General Appearance: Well nourished, Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: No(t) Systolic)
Peripheral [**Hospital1 **]: (Right radial pulse: Diminished), (Left
radial pulse: Diminished), (Right DP pulse: Diminished), (Left
DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Bowel sounds present, No(t) Tender:
Extremities: Right: Trace, Left: Trace
Musculoskeletal: Unable to stand
Skin: Warm, Rash: right arm remains with ischemic blisters,
less tender. Sacral and ischial decubiti - stage III
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Oriented (to): self, location, Movement:
spontaneous
Pertinent Results:
TRANSFER TO UNIT:
[**2121-12-24**] 06:00AM BLOOD WBC-27.7*# RBC-3.33* Hgb-10.5* Hct-30.9*
MCV-93 MCH-31.4 MCHC-33.9 RDW-18.5* Plt Ct-173
[**2121-12-24**] 06:00AM BLOOD Neuts-89.7* Lymphs-4.0* Monos-5.5 Eos-0.4
Baso-0.3
[**2121-12-24**] 06:00AM BLOOD PT-19.7* PTT-38.1* INR(PT)-1.8*
[**2121-12-24**] 06:00AM BLOOD Glucose-81 UreaN-24* Creat-2.9* Na-130*
K-4.0 Cl-96 HCO3-24 AnGap-14
[**2121-12-24**] 06:00AM BLOOD ALT-13 AST-25 LD(LDH)-247 AlkPhos-212*
TotBili-1.1
[**2121-12-24**] 05:06PM BLOOD Calcium-8.2* Phos-1.7* Mg-1.6
.
IRON STUDIES
[**2121-12-19**] 08:20AM BLOOD calTIBC-113* Ferritn-488* TRF-87*
Iron-26*
[**2121-12-20**] 09:00AM BLOOD calTIBC-104* TRF-80* Iron-39
.
CARDIAC MARKERS
[**2121-12-20**] 03:37AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2121-12-20**] 09:00AM BLOOD CK-MB-NotDone cTropnT-0.20*
[**2121-12-20**] 04:30PM BLOOD CK-MB-NotDone cTropnT-0.15*
.
TFTs
[**2121-12-25**] 12:23AM BLOOD TSH-3.7
[**2121-12-25**] 12:23AM BLOOD T4-3.4*
.
CORTISOL STEM TEST
[**2121-12-25**] 07:43AM BLOOD Cortsol-17.0
[**2121-12-25**] 08:54AM BLOOD Cortsol-24.8*
.
INFLAMMATORY MARKERS
[**2121-12-24**] 11:48AM BLOOD ESR-55*
[**2122-1-4**] 04:07AM BLOOD ESR-109*
[**2121-12-21**] 03:00AM BLOOD CRP-177.2*
[**2122-1-4**] 04:07AM BLOOD CRP-55.2*
[**2121-12-25**] 06:39AM BLOOD Lactate-4.0*
[**2122-1-2**] 05:07AM BLOOD Lactate-2.3*
.
RADIOLOGY
ECHO [**2121-12-22**]: EF 55%, Normal left ventricular cavity size with
regional systolic function most c/w CAD. Mildly dilated RV with
mild global hypokinesis. Mild pulmonary arterial systolic
hypertension. Mild mitral regurgitation.
.
RIGHT HEEL [**2121-12-24**]: FINDINGS: Comparison is made to prior
radiographs from [**2116-3-19**]. There is no soft tissue gas
or large ulceration within the right posterior heel. There are
large plantar spur which is unchanged since [**2116**] study.
Extensive [**Year (4 digits) 1106**] calcifications are seen. There is no bony
destruction to indicate acute osteomyelitis. There is overall
demineralization of the bony structures.
.
RIGHT UE VEINS 11/25,[**12-24**]
No evidence of deep venous thrombosis. Patent AV fistula, right
antecubital fossa.
.
RIGHT ARM ARTERIAL DOPPLERS [**2121-12-29**]: Findings as stated above
which indicate poor right radial artery flow with improvement
with compression. Note of radial artery calcification.
Calcifications are new when compared to a prior AV fistula study
performed in [**2116**].
.
RIGHT FOREARM [**12-26**] Interstitial edema. No evidence of abscess.
.
CT ABDOMEN/PELVIS [**12-26**]: IMPRESSION:
1. Soft tissue wound inferior to the coccyx, with induration and
inflammatory changes within the subcutaneous fat extending to
the rectum, with inflammatory changes involving the posterior
wall of the rectum.
2. 4.3 cm fat-containing anterior abdominal wall lesion,
consistent with a
fat-containing hernia, not significantly changed in size
compared to [**2117-1-1**] with a focus of central hyperdensity which
may represent an engorged vessel.
3. Fractures of the right lateral ninth and eighth ribs.
4. A 15 mm cystic lesion inferior to the pancreatic head, which
may represent a side branch IPMN or other mucinous lesion, for
which further evaluation with MRCP is recommended.
5. Nodular appearance of the liver surface, consistent with
cirrhosis.
6. Anasarca and ascites.
7. Left inguinal lymphadenopathy, with a single prominent node
measuring up to 11 mm in short axis diameter.
.
TRANSVAGINAL ULTRASOUND [**2121-12-31**]: The patient is post-menopausal.
Transabdominal examination is significantly limited due to large
patient body habitus and poor echo penetration. Transvaginal
examination was attempted; however, due to the patient's
condition she had difficulty complying with endovaginal
ultrasound probe maneuvers.
.
PICC [**2122-1-2**]:Uncomplicated ultrasound and fluoroscopically
guided 5 French
double-lumen PICC line placement via the left brachial venous
approach. Final internal length is 41 cm, with the tip
positioned in SVC. The line is ready to use.
.
Non-Tunneled LIJ HD [**2121-12-26**]: Uncomplicated placement of
left-sided 12-French 20-cm triple lumen temporary hemodialysis
catheter via the left internal jugular vein.
.
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2122-1-6**] 03:48AM 13.6* 2.75* 8.9* 25.8* 94 32.3* 34.4
20.1* 74*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2122-1-6**] 03:48AM 115* 28* 3.9* 127* 4.7 90* 25 17
Brief Hospital Course:
Ms. [**Known lastname **] is a 78 year old female with type 2 DM, ESRD on HD,
PVD s/p BKA, CAD s/p MI with septic shock, volume overload.
.
1. Septic Shock: Due to MDR Acinetobacter line infection and
RESOLVED. Had initially been treated empirically with
Daptomycin, Colistin, Flagyl and Unasyn. Daptomycin and Flagyl
were discontinued as there were no gram positive bacteria in
blood cultures, and negative C. difficile x 3. Acinetobacter
coverage narrowed to high dose Unasyn to complete a 14-day
course from the date of the first negative blood culture.
Unasyn day 1=[**12-25**], to complete [**1-7**].
.
2. Hypotension: Baseline SBP 70s-80s per the renal team that
follows her as an outpatient; suspect bad PVD preventing
accurate measurement of true BP. The patient mentates well at
this blood pressure. We initiated midodrine and this was
continued for discharge.
.
3. Sacral /ischial decubiti: Plastic Surgery debrided the sacral
ulcer. Given rise in ESR from 55 to 109, were are treating for
now for presumptive osteomyelitis. She should continue
Vancomycin and Ceftazidine for a two-week course and monitor
ESR. If ESR persists high, discuss continuation of antibiotics
with Plastics. The patient has follow-up scheduled with Plastic
Surgery.
.
5. End-stage renal disease on hemodialysis: Patient negative 30L
on CVVHD during her admission to the MICU, and she is felt to be
near her dry weight. Patient is tolerating HD. Continuing
midodrine as above.
.
6. Right Arm Pain: There is some steal from her AV fistula, but
no current change in management is recommended at this time
after consultation with the Hand Surgeons. Her neuropathic pain
is improved. She has a good radial pulse currently. Further
consideration of neurontin or other treatments may be
appropriate after discharge.
.
7. Anemia: History of chronic GI bleed from AVMs. We targeted a
Hct of 25 for transfusion and recommend follow-up monitoring for
signs of GI bleeding.
.
8. Heel ulcer/peripheral [**Month/Year (2) 1106**] disease: Status post right
peroneal angioplasty on [**2121-12-19**]. Continued weight-sparing
boot. The patient has follow-up scheduled with [**Date Range 1106**]
surgery.
.
8. Thrombocytopenia: She has a history of thrombocytopenia and
her counts are stable at discharge. The patient has a history
of heparin-induced thrombocytopenia and therefore heparin was
avoided and heparin-free lines only were used.
.
9. Type 2 diabetes: We continued sliding scale insulin and
stopped her fixed dose 70/30 in setting of hypoglycemia.
.
11. Elevated INR: Likely nutritional and somewhat improved with
vitamin K 5 mg PO x 3 days.
.
12. Vaginal bleeding: The patient had a small amount of vaginal
bleeding during admission. She has a uterus and cervix, but CT
scan and transvaginal ultrasound with limited views show no
pathologic features. Further evaluation is deferred to the
outpatient setting.
Medications on Admission:
Home Meds:
1. Acetaminophen
2. albuterol MDI
3. ASA
4. colace
5. advair diskus (250/50)
6. synthroid
7. metoprolol XL
8. neutra-phos
9. pantoprazole
10. simvastatin
.
Medications on Transfer:
Carbamide Peroxide ear drops
Vancomycin D1 = [**2121-12-22**]
Insulin SS
Toprol 12.5 XL
Silver sulfadiazine
Hydromorphone prn
Aspirin 81 mg daily
Plavix 75 mg daily
Flagyl 500 q 8, D1 = [**12-18**]
Cipro 500 mg daily, d1 = [**12-18**]
Colace
Fluticasone/Salmeterol [**Hospital1 **]
Simvastatin 40 mg daily
Pantoprazole 40 mg daily
Levothyroxine 175 daily
Albuterol prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Severe Sepsis d/t Acinetobacter Bacteremia
Sacral Decubitus, Stage III
Bilateral Ischial Decubiti, Stage II
End stage renal disease requiring CVVHD
Osteomyelitis of Sacrum
Discharge Condition:
Stable, afebrile, 98% RA, SBPs 80/40
Discharge Instructions:
You were admitted for revascularization of your right leg. You
developed a blood infection that is being treated with
antibiotics. For a time you required medications to support your
blood pressure. You underwent continuous hemodialysis to remove
30 liters of extra fluid.
You also came in with a dead tissue covering an ulcer that
needed to be removed. The dead tissue and fat were removed from
your sacrum and you were started on antibiotics to treat a
potential bone infection related to your ulcer. You improved on
antibiotics and have resumed normal hemodialysis.
You are ready to go to a rehabilitation facility to continue
your recovery. You will need to complete all your antibiotics.
You have a special intravenous line called a PICC to allow you
to receive these antibiotics. You will continue to receive
hemodialysis at your rehabilitation facility. You have been
started on a new medication MIDODRINE to help support your blood
pressure.
If you experience temperature < 95.0 F, or > 101.5, chest pain,
inability to breath, or any other concerning symptoms please go
to the Emergency Department.
Followup Instructions:
You will receive hemodialysis on Monday/Wednesday/Friday.
Follow-up with plastic surgery: Provider: [**Name10 (NameIs) **] SURGERY CLINIC
Phone:[**Telephone/Fax (1) 4652**] Date/Time: [**2122-1-16**] 02:30pm Location: [**Hospital1 18**],
[**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building [**Location (un) 470**].
Follow-up with [**Location (un) 1106**] surgery: [**Last Name (LF) 1111**],[**Name8 (MD) 1112**], MD Phone:
[**Telephone/Fax (1) 3121**] Date/Time:[**2122-2-5**] 12:50pm Location: [**Hospital1 18**], [**Hospital Ward Name 12837**], [**Hospital **] Medical Building, [**Location (un) 442**].
Follow-up with Primary Care: [**Name6 (MD) **] [**Name8 (MD) 1447**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2122-2-19**] 02:00pm Location:
[**Hospital3 **], [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Building [**Location (un) **].
|
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icd9cm
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icd9pcs
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[
[
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12603, 12669
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411, 585
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4636, 8818
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14091, 14995
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2929, 2948
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12018, 12185
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8834, 9063
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2963, 4617
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281, 373
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613, 2240
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12210, 12580
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2262, 2673
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2689, 2913
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,581
| 123,885
|
37382
|
Discharge summary
|
report
|
Admission Date: [**2173-11-6**] Discharge Date: [**2173-11-23**]
Date of Birth: [**2104-5-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**11-8**] - 1. Mitral valve repair, triangular resection of the
posterior leaflet and mitral valve annuloplasty with a
32-mm Future CG annuloplasty ring.
2. Ascending aortic replacement with 28-mm Gelweave graft
under deep hypothermic circulatory arrest.
History of Present Illness:
69 year old male who underwent colonoscopy 5 days prior, and
started to complain of progressive fatigue and cough without
hemoptysis since then. Denies SOB or CP or any neuro symptoms.
Went to outside hospital today where Echocardiogram showed sever
mitral regurgitation with flail posterior leaflet with no
vegetation, but noted for fever. Transferred for cardiac workup
Past Medical History:
s/p appendectomy
s/p R cholesteatoma
Social History:
Occupation: allergy doctor works in industry
Tobacco: no
ETOH: no
Lives alone
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Pulse:112 Resp: 25 O2 sat: 94 on FM
B/P Right: 90/55 Left:
General: mild distress
Skin: Dry [x] intact []. No evidence of septic emboli to skin.
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur / tacchy. [**12-11**]+ systolic MR
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds
+ []
xtremities: Warm [], well-perfused [x] Edema Varicosities: None
[]
Neuro: Grossly intact. moves 4 ext
Pulses:
Femoral Right: Left:palp
DP Right:dop Left:palp
PT [**Name (NI) 167**]: Left:
Radial Right:palp Left:palp
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2173-11-21**] 05:30AM BLOOD WBC-12.5* RBC-3.59* Hgb-10.9* Hct-32.3*
MCV-90 MCH-30.4 MCHC-33.8 RDW-14.5 Plt Ct-505*
[**2173-11-19**] 05:20AM BLOOD WBC-12.7* RBC-3.66* Hgb-11.0* Hct-33.6*
MCV-92 MCH-30.2 MCHC-32.9 RDW-14.8 Plt Ct-517*
[**2173-11-6**] 08:11PM BLOOD WBC-11.8* RBC-3.98* Hgb-12.6* Hct-35.8*
MCV-90 MCH-31.7 MCHC-35.2* RDW-13.1 Plt Ct-178
[**2173-11-7**] 02:00AM BLOOD WBC-8.7 RBC-3.78* Hgb-12.2* Hct-34.0*
MCV-90 MCH-32.3* MCHC-35.8* RDW-13.2 Plt Ct-182
[**2173-11-21**] 05:30AM BLOOD Glucose-107* UreaN-18 Creat-0.8 Na-141
K-4.5 Cl-108 HCO3-24 AnGap-14
[**2173-11-6**] 08:11PM BLOOD Glucose-108* UreaN-15 Creat-0.9 Na-131*
K-4.0 Cl-100 HCO3-21* AnGap-14
[**2173-11-13**] 01:01AM BLOOD ALT-21 AST-31 AlkPhos-147* TotBili-0.5
[**2173-11-12**] 12:42AM BLOOD ALT-22 AST-42* AlkPhos-166* Amylase-55
TotBili-0.6
[**2173-11-6**] 08:11PM BLOOD ALT-14 AST-16 CK(CPK)-77 AlkPhos-66
TotBili-1.6*
[**2173-11-12**] 12:42AM BLOOD Lipase-42
[**2173-11-7**] 02:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2173-11-21**] 05:30AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.1
[**2173-11-6**] 08:11PM BLOOD Albumin-3.6
[**2173-11-7**] 02:00AM BLOOD %HbA1c-5.7
[**Known lastname **],[**Known firstname **] [**Medical Record Number 84045**] M 69 [**2104-5-22**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2173-11-18**] 1:36
PM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2173-11-18**] 1:36 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 84046**]
Reason: Eval for effusion
[**Hospital 93**] MEDICAL CONDITION:
69 year old man s/p MVR
REASON FOR THIS EXAMINATION:
Eval for effusion
Provisional Findings Impression: SP [**Doctor First Name **] [**2173-11-18**] 3:12 PM
Stable chest findings. No pneumothorax has developed. Pleural
density and
atelectasis unchanged.
Final Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: Status post mitral valve replacement, evaluate for
effusion.
FINDINGS: AP single view of the chest has been obtained with
patient in
sitting semi-upright position. Analysis is performed in direct
comparison
with the next preceding similar study of [**2173-11-15**]. The
patient
remains extubated. The next previous examination still present
right-sided
central venous line has been removed. No pneumothorax has
developed. The
accessible portion of the pulmonary vasculature does not
demonstrate increased
congestion and no new infiltrates are identified. The left-sided
diaphragmatic contour remains obliterated by a mostly linear
density
suggestive of atelectasis and some pleural effusion. This
finding has not
undergone any significant interval change. Heart size appears
unaltered, and
the same holds for the appearance of annuloplasty.
IMPRESSION: Stable findings.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2173-11-18**] 4:40 PM
Neurophysiology Report EEG Study Date of [**2173-11-14**]
OBJECT: Bedside ltm video ekg [**Date range (1) 84047**]. THERE WAS ONE
PUSHBUTTON ACTIVATION. ROUTINE SAMPLING AND SPIKE AND SEIZURE
DETECTION
PROGRAMS WERE UTILIZED.
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 900**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
FINDINGS:
ROUTINE SAMPLING: Showed a slow background in the theta and
delta range
with additional bursts of generalized slowing in the delta
range. There
were no areas of prominent focal slowing or epileptiform
features seen.
SPIKE DETECTION PROGRAMS: Showed no epileptic activity.
SEIZURE DETECTION PROGRAMS: There were 40 entries in these files
for
muscle artifacts, chewing artifacts, as well as electrode
artifacts.
There was no ongoing seizure activity seen in these files.
PUSHBUTTON ACTIVATIONS: There was one for unclear reasons.
However,
there was no epileptic activity correlated with this pushbutton
activation.
SLEEP: There were no normal sleep patterns seen in this
recording.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured one pushbutton activation
for an
unclear reason with no EEG correlate. There were no ictal or
interictal
epileptiform features seen in this recording. The background
activity
was slow suggestive of encephalopathy. There were no areas of
prominent
focal slowing.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) 7495**] B.
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2173-11-13**]
10:18 AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2173-11-13**] 10:18 AM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 84048**]
Reason: assess for cva
[**Hospital 93**] MEDICAL CONDITION:
69 year old man s/p mvr/asc ao replacement
REASON FOR THIS EXAMINATION:
assess for cva
CONTRAINDICATIONS FOR IV CONTRAST:
elevated creat
Provisional Findings Impression: AFSN SAT [**2173-11-13**] 12:19 PM
PFI:
Bilateral predominantly cortical frontal, parietal and occipital
lobe as well
as right caudate head areas of restricted diffusion, suggestive
of _____
global hypoxic event. No midline shift or hydrocephalus. Soft
tissue changes
both mastoid air cells, likely secondary to intubation.
Final Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with status post MVR and ascending
aorta
replacement, assess for CVA.
TECHNIQUE: T1 sagittal and FLAIR T2 susceptibility and diffusion
axial images
of the brain were acquired.
FINDINGS: There are bilateral diffuse predominantly cortical
areas of
restricted diffusion seen in both frontal, parietal and
occipital lobes with
restricted diffusion in the right caudate head. There is no
midline shift,
mass effect, or hydrocephalus seen. There is no evidence of
acute or chronic
blood products.
IMPRESSION: Bilateral predominantly cortical frontal, parietal
and occipital
lobe as well as right caudate head areas of restricted
diffusion, suggestive
of global hypoxic event. No midline shift or hydrocephalus. Soft
tissue
changes both mastoid air cells, likely secondary to intubation.
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: SAT [**2173-11-13**] 3:26 PM
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84049**]Portable TEE
(Complete) Done [**2173-11-7**] at 12:07:59 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 11063**] Cardiology
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Street Address(2) 8667**], [**Hospital Ward Name **] 4
[**Location (un) 86**], [**Numeric Identifier 718**]
[**Last Name (LF) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2104-5-22**]
Age (years): 69 M Hgt (in): 72
BP (mm Hg): 90/54 Wgt (lb): 175
HR (bpm): 100 BSA (m2): 2.01 m2
Indication: Mitral Regurgitation. Flail MV Posterior leaflet.
Endocarditis.
ICD-9 Codes: 428.0, 424.90, 799.02, 424.0
Test Information
Date/Time: [**2173-11-7**] at 12:07 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]: Cardiology
Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W004-1:06 Machine: Vivid i-3
Sedation: Versed: 2 mg
Fentanyl: 25 mcg
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 60% >= 55%
Findings
LEFT ATRIUM: No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: No atheroma in ascending aorta. No atheroma in aortic
arch.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or vegetations on aortic valve. No AR.
MITRAL VALVE: Myxomatous mitral valve leaflets. Partial mitral
leaflet flail. No mass or vegetation on mitral valve. Torn
mitral chordae. Eccentric MR jet. Severe (4+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. No TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No vegetation/mass on pulmonic valve. No PR. Physiologic
(normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. Local anesthesia was provided by
benzocaine topical spray. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). The posterior pharynx was anesthetized with 2% viscous
lidocaine. No TEE related complications. Echocardiographic
patient. An intra-aortic balloon pump was placed. The proximal
balloon tip is positioned distal to the takeoff of the left
subclavian.
Conclusions
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are myxomatous
with torn mitral chordae and partial flail of the posterior
mitral leaflet. No mass or vegetation is seen on the mitral
valve. An eccentric, posteriorly directed jet of Severe (4+)
mitral regurgitation is seen. No masses or vegetations are seen
on the tricuspid valve. No vegetation/mass is seen on the
pulmonic valve. There is no pericardial effusion. An
intra-aortic balloon pump is seen in the descending throacic
aorta.
IMPRESSION: Myxomatous mitral leaflets with partial flail of the
posterior mitral leaflet with severe mitral regurgitation. A
torn chord can be seen at the distal end of the flail segment of
the posterior leaflet. No obvious valvular vegetation, mass or
abscess seen, but cannot exclude a very small valvular
vegetation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2173-11-8**] 09:49
Cardiology Report Cardiac Cath Study Date of [**2173-11-6**]
BRIEF HISTORY: This 69 year old healthy male referred to the
lab for
severe mitral regurgitation, chest discomfort, hypotension, and
acute
decompensated heart failure.
INDICATIONS FOR CATHETERIZATION:
Hypotension. Acute mitral regurgitation. Chest pain.
PROCEDURE:
Left Heart Catheterization: was performed by percutaneous entry
of the
right femoral artery, using a 5 French angled pigtail catheter,
advanced
to the left ventricle through a 5 French introducing sheath.
Coronary Angiography: was performed in multiple projections
using a 5
French JL4 and a 5 French JR4 catheter, with manual contrast
injections.
Intra-aortic balloon counterpulsation: was initiated with an 8
French
introducer sheath using a 40cc balloon catheter, inserted via
the right
femoral artery.
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.02 m2
HEMOGLOBIN: 13.8 gms %
ENTRY
**PRESSURES
LEFT VENTRICLE {s/ed} 110/39
AORTA {s/d/m} 110/82/97
**CARDIAC OUTPUT
HEART RATE {beats/min} 114
RHYTHM SINUS
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA NORMAL
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA NORMAL
4) R-PDA NORMAL
4A) R-POST-LAT NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN NORMAL
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD NORMAL
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 NORMAL
12) PROXIMAL CX NORMAL
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 NORMAL
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 26 minutes.
Arterial time = 25 minutes.
Fluoro time = 4.4 minutes.
IRP dose = 701 mGy.
Contrast injected:
Non-ionic low osmolar (isovue, optiray...), vol 55 ml
Premedications:
Midazolam 0.5 mg IV
Fentanyl 25 mcg IV
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Heparin 5000 units IV
Other medication:
Heparin 1000 IV units/hr
Cardiac Cath Supplies Used:
8FR ARROW, IABP ULTRA FIBEROPTIX CATHETER 40CC
- ALLEGIANCE, CUSTOM STERILE PACK
- [**Company **], LEFT HEART KIT
- [**Company **], RIGHT HEART KIT
5FR [**Company **], MULTIPACK
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated no
significant coronary disease in the LMCA, LAD, LCx, and RCA.
2. Hemodynamics revealed severely elevated left ventricular
filling
pressures with LVEDP 39 mmHg.
3. Insertion of 40 cc IABP with good augmentation and afterload
reduction.
FINAL DIAGNOSIS:
1. Coronary arteries are normal.
2. Severely elevated left ventricular filling pressures.
3. Successful intraaortic balloon pump placement.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
REFERRING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CARDIOLOGY FELLOW: [**Last Name (LF) 39562**],[**First Name3 (LF) **] G.
[**Last Name (LF) **],[**First Name3 (LF) 640**] A.
ATTENDING STAFF: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] J.
Electronically signed by: [**Last Name (LF) 2052**],[**First Name3 (LF) 2053**] on MON [**2173-11-8**]
6:29 PM
Brief Hospital Course:
Transferred into hospital for evaluation of mitral
regurgitation, with acute systolic heart failure. He underwent
cardiac catheterization that revealed no coronary disease and
intra aortic balloon pump placed for hemodynamics. He underwent
preoperative workup and was brought to the operating [****]
and underwent mitral valve repair and ascending aorta
replacement. See operative report for further details. He
received vancomycin for perioperative antibiotics. He was
transfered to the intensive care unit for post operative
management.
Neuro: Early post op there was concern for potential seizure
activity, neurology was consulted, he was loaded with dilantin,
CT scan, and EEG. It was noted as slowing but no seizure
activity, dilantin was discontinued. MRI revealed bilateral
predominantly cortical frontal, parietal and occipital lobe as
well as right caudate head areas of restricted diffusion. No
midline shift or hydrocephalus. His neuro status progressively
improved with ability to lift and hold bilateral lower
extremities and left upper extremity, however right arm only
able to use fingers. Oriented to family and will interact only
when asked questions.
Cardiovascular: Acute systolic heart failure with EF 30% s/p
mitral valve replacement, remains hemodynamically stable
requiring medication adjust post operatively for blood pressure
management
Respiratory: Prolonged intubation post operatively due to neuro
status and ability to protect airway, remains extubated on RA to
2 liters NC.
Gastrointenstinal: received nutritional support with tube feeds
while intubated, after extubation has been tolerating diet with
1:1 supervision
Renal: Aggressively diuresed for volume overload post
operatively with good response. Creatinine on admission 0.9,
peak creatinine 1.2 with diuresis and IV dye for cardiac
catheterization and CT scan. He is now normovolemic off all
diuretics.
He was ready for discharge to acute neuro rehab on [**2173-11-23**]
Medications on Admission:
Lipitor
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Date Range **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Date Range **]: One (1) ml
Injection TID (3 times a day).
3. Atorvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: Three (3) ml Inhalation Q6H (every 6 hours) as
needed for wheezing.
7. Clonidine 0.1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
8. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for sleep.
9. Lisinopril 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
10. Cephalexin 500 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours) for 10 days: sternal wound .
11. Carvedilol 6.25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO BID (2
times a day): continue to titrate for heart rate ^ [**11-23**] to
18.75 [**Hospital1 **] .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Mitral Regurgitation s/p Mitral Valve Repair and aortic
replacement
Acute systolic heart failure
CVA
s/p appendectomy
s/p removal right cholesteatoma
Discharge Condition:
Responds to verbal stimuli
Oriented to family, at times unable to answer doping better with
answering questions when giving choices
Able to lift and hold bilateral lower extremities and left upper
extremity not bearing weight, right arm only movement in hand
and fingers
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] at [**Hospital1 **] heart center [**Telephone/Fax (2) 6256**] in
[**1-12**] weeks
Primary Care Dr. [**Last Name (STitle) 349**] after discharge from rehab
([**Telephone/Fax (1) 7401**])
Cardiologist Dr. [**Last Name (STitle) 1655**] 2-3 weeks [**Telephone/Fax (1) 6256**]
Dr [**Last Name (STitle) 1693**] in 1 month [**Telephone/Fax (1) 1694**]
Completed by:[**2173-11-23**]
|
[
"E936.1",
"796.2",
"997.1",
"441.01",
"424.0",
"E878.8",
"458.29",
"V12.72",
"518.5",
"428.0",
"041.86",
"790.4",
"276.1",
"348.1",
"344.40",
"997.01",
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icd9cm
|
[
[
[]
]
] |
[
"35.12",
"96.6",
"39.61",
"37.22",
"37.61",
"88.72",
"96.72",
"39.57",
"88.56",
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] |
icd9pcs
|
[
[
[]
]
] |
19713, 19783
|
16330, 18306
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342, 612
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19977, 20250
|
2014, 3517
|
20790, 21242
|
1186, 1301
|
18364, 19690
|
6701, 6744
|
19804, 19956
|
18332, 18341
|
15655, 16307
|
20274, 20767
|
1316, 1995
|
14633, 15638
|
13284, 14614
|
283, 304
|
6776, 13251
|
640, 1015
|
1037, 1075
|
1091, 1170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,011
| 141,073
|
16363
|
Discharge summary
|
report
|
Admission Date: [**2156-1-19**] Discharge Date: [**2156-2-4**]
Date of Birth: [**2080-11-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Premarin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Acute myocardial infarction, NON STEMI
Major Surgical or Invasive Procedure:
[**2156-1-19**] emergent coronary artery bypass grafts x4 (LIMA to LAD,
SVG to PDA, SVG to DIAG , Y grafted to SVG to OMI)
[**2156-1-20**] mediastinal re-exploration
left heart catheterization, coronary angiogram,attempted
angioplasty, insertion of intra aortic balloon [**2156-1-19**]
History of Present Illness:
This 75 year old [**Location 7972**] female presented to the ED with
acute onset of epigastric pain. She had ST elevation in aVL,II
and reciprocal depressions. She went emergently to the cath
lab.
Past Medical History:
osteoporosis
jhypertension
hyperlipidemia
s/p endovascular repair of abdominal aortic aneurysm
noninsulin dependent diabetes mellitus
Social History:
SOCIAL HISTORY
She exercises three times a week at her adult day center. She is
a nonsmoker. She does not drink alcohol or use illicit drugs.
Family History:
.
FAMILY HISTORY:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T=98 BP= 135/60 HR= 70 intubated O2 sat= 100
GENERAL: Prior to intubation, spanish speaking only, in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of *** 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. Both femoral arteries are cannulated.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT -
[**Name (NI) 2325**]: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT -
.
Pertinent Results:
[**2156-1-19**] Cardiac Catheterization
1. Selective coronary angiography in this right dominant system
demonstrated three vessel CAD. The LMCA was patent. The LAD was
totally
occluded proximally without collateral filling. The LCx was
retroflexed
and gave off a high OM1 (functionally a ramus) that had a hazy
60%
lesion proximally (OM2, on a curve). The RCA was a large
dominant vessel
diffusely calcified with 80% proximally.
2. Limited resting hemodynamics revealed initial normal systemic
arterial pressures with an SBP of 100 mmHg. Over the course of
the
case, systemic arterial systolic pressures declined to SBPs in
the
70s-80s requiring initiation of dopamine gtt and levophed gtt.
3. Initially successful PTCA alone of totally occluded proximal
LAD with
ultimate shutdown of LAD. Unsuccessful rescue of LAD.
4. Successful IABP.
CTA [**2156-1-20**]:
1. No evidence of aortic dissection.
2. Aortobiliac stent is in place, which appears intact. There is
no evidence of an endoleak. Excluded aneurysmal sac is slightly
decreased in size from [**2153-8-22**] exam.
3. Multiple focal hypodensities, too small to characterize, most
likely cysts or hamartomas.
4. An hypodense lesion centered within the uncinate process of
the pancreas, stable in size and appearance from [**2153-8-22**] exam,
which likely represents an IPMN or alternatively, serous
cystadenoma.
ECHO [**2156-1-19**]
Pre-CPB:
The patient is on IABP at 1:1, on dopamine and levophed.
No spontaneous echo contrast is seen in the left atrial
appendage.
There is moderate regional left ventricular systolic dysfunction
with intact basal motion but hypokinesis of the mid-anterior and
antero-septal walls. The apex is akinetic.
There is mild global free wall hypokinesis.
The ascending aorta is mildly dilated.
There are simple atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen.
There is no pericardial effusion.
An IABP is seen in the descendiing aorta 9 cm. beyond the arch.
Surgeons advised to move it more proximally.
Brief Hospital Course:
Ms. [**Known lastname 2470**] was admitted to the [**Hospital1 18**] on [**2156-1-19**] for further
management of her chest pain. A cardiac catheterization was
performed showing a totally occluded left anterior descending
artery which was incompletely opened with angioplasty. There was
significant concomittant disease and emergent surgical
revascularization was undertaken after an intra aortic balloon
was placed for stabilization.
In the Operating Room the LV was very impaired with an ejection
fraction of 20-25%. She left the operating room on Epinephrine,
levophed, and Neo Synephrine. She was very unstable and bleed
profusely having received Integrilin preoperatively. There was a
large apical hematoma on the left lung and echocardiographic
evidence of a mediastinal hematoma. She was returned to the
operating room on [**2156-1-20**] for a reexploration for bleeding.
Hemostasis was acheived and vasopressin was added with improved
hemodynamics. Multiple blood products were administered and
coagulation parameters gradually corrected. Pressors were weaned
significantly, however, they were required for another week and
a half. She required a right chest tube for a pneumothroax.
The balloon was removed on POD 3 without incident and aggressive
diuresis undertaken. She was neurologically intact and extubated
on POD 10, all pressors were off at that point.
On POD 14 she transferred to the floor and Coreg was given due
to her severe LV dysfunction. Gentle diuresis was continued and
she was screened for rehabilitation. She worked with physical
therapy daily. She developed atrial fibrillation which was
treated with amiodarone. She converted back into a normal sinus
rhythm. She developed some drainage from the lower pole of her
sternotomy. Ancef was started intravenously which was switched
to keflex on discharge. She continued to make steady progress
and was discharged home on [**2156-2-4**]. She will follow-up with Dr.
[**Last Name (STitle) **] and Dr. [**First Name (STitle) **] as an outpatient. Dr. [**Last Name (STitle) **] will refer her
to a cardiologist. An ace inhibitor should be started at some
point given her diminished ejection fraction and preoperative
myocardial infarction. She did not have adequate room with her
blood pressure (90's/50-60's) to add an ace and thus it will
need to be addressed as an outpatient.
Medications on Admission:
Atorvastatin 20 mg daily
Calcium carbonate-vit D3-min 600 mg-400 unit [**Hospital1 **]
Carboxymethylcell-glycerin(PF) [Refresh Optive Sensitive (PF)]
0.5 %-0.9 % 1 to 2 drops each eye(s) 4 times a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 months: take one tablet twice daily for 7 days then
decrease to once daily.
Disp:*40 Tablet(s)* Refills:*1*
5. ipratropium-albuterol 18-103 mcg/actuation Aerosol Sig: [**12-29**]
Puffs Inhalation Q4H (every 4 hours).
Disp:*1 MDI* Refills:*1*
6. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
8. Refresh Optive Sensitive (PF) 0.5-0.9 % Dropperette Sig: [**12-29**]
Drops Ophthalmic four times a day: 1-2 drops each eye 4 times
per day.
9. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day for 10 days.
Disp:*10 Capsule, Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
coronary artery disease
chronic systolic heart failure
s/p emergent coronary artery bypass grafts
myocardial infarction
Dyslipidemia
s/p endovascular repair of abdominal aortic aneurysm
Osteopenia
Pancreatic cyst
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema small amount serosang
drainage
Leg Left - healing well, no erythema or drainage.
Edema: trace bilat.
Discharge Instructions:
1) 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.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Take amiodarone 200mg twice a day for 1 week then decrease
dose to 200mg once daily therafter.
7) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
*Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1504**] Thursday [**2156-2-26**] at 1:45p
Cardiologist: You should be referred to one by Dr. [**Last Name (STitle) **]. An
appointment has been made with Dr. [**Last Name (STitle) **] on [**2155-2-18**] at 2:00pm
who will refer you to a cardiologist. [**Telephone/Fax (1) 7976**]
**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:[**2156-2-4**]
|
[
"998.31",
"E878.2",
"285.1",
"272.4",
"512.1",
"287.5",
"998.11",
"998.09",
"733.90",
"518.51",
"410.91",
"250.00",
"428.23",
"414.01",
"272.0",
"785.51",
"560.1",
"428.0",
"427.31",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.03",
"37.61",
"36.15",
"00.66",
"96.6",
"39.61",
"36.13",
"34.04",
"96.72",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
8606, 8677
|
4524, 6881
|
314, 603
|
8934, 9188
|
2266, 4501
|
10260, 10842
|
1185, 1301
|
7133, 8583
|
8698, 8913
|
6907, 7110
|
9212, 10237
|
1316, 2247
|
236, 276
|
631, 832
|
854, 989
|
1005, 1150
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,929
| 171,608
|
15394
|
Discharge summary
|
report
|
Admission Date: [**2140-9-19**] Discharge Date: [**2140-9-22**]
Service: CCU
CHIEF COMPLAINT: Acute inferior myocardial infarction status
post stenting of the saphenous vein graft to the right
coronary artery.
HISTORY OF PRESENT ILLNESS: This is an 85 year-old man with
a history of coronary artery disease status post coronary
artery bypass graft times six in [**2122**], status post stent
times two three years ago who had a laminectomy about two
weeks ago prior to admission. He presented to the [**Hospital3 1280**]
Hospital with bilateral arm pain and profound weakness. He
also complained of jaw and neck pain. He took some
nitroglycerin with some relief, but had persistent discomfort
at [**Hospital3 1280**] Hospital. His electrocardiogram there showed
ST elevation inferiorly with reciprocal ST depression. He
was given aspirin, nitroglycerin and heparin drip there. He
was flighted to [**Hospital1 69**] for
percutaneous transluminal coronary angioplasty. Intracath
during the placement of the ventricular pacer wire he
developed an episode of V fibrillation, which was
successfully shocked back to sinus rhythm with 200 jewels.
Otherwise he tolerated the procedure well and had successful
thrombectomy and stenting of the saphenous vein graft to the
right coronary artery. He was admitted to Coronary Care Unit
for overnight observation.
PAST MEDICAL HISTORY: Coronary artery disease status post
coronary artery bypass graft times six in [**2122**], status post
stent times two three years ago. Status post laminectomy two
to three weeks ago. Hypertension. No history of diabetes.
MEDICATIONS: Hydrochlorothiazide 25 q.d., Metoprolol 25
b.i.d., aspirin 81 q.d., vitamin E, vitamin D, eye drops,
stool softeners.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father died of pancreatic cancer.
SOCIAL HISTORY: The patient lives with wife at home.
Retired Abian salesman. No tobacco, alcohol or drugs.
PHYSICAL EXAMINATION ON ADMISSION TO CORONARY CARE UNIT:
Temperature 96.7. Blood pressure 131/70. Pulse 78.
Respirations 13. O2 sat 100% on 3 liters nasal cannula.
Weight 95 kilograms. In general the patient is awake, alert
and oriented times three, conversant. No acute distress.
Head and neck, no JVP. Cardiovascular normal S1 and S2.
Lungs clear to auscultation bilaterally. Abdomen soft,
nondistended, nontender. Extremities no edema. Distal
pulses bilaterally.
LABORATORY: At [**Hospital6 3872**] white count 11.3.
Differential 74% neutrophils, 1% bands, 13% lymphocytes,
hematocrit 42.7, platelet 172, PTT 28.1, INR 0.97, sodium
138, potassium 4.0, chloride 101, bicarb 28, BUN 24,
creatinine 1.2, glucose 221, calcium 9.9, total protein 6.8,
albumin 3.5, total bilirubin .6, ALT 43, AST 28, alkaline
phosphatase 75, troponin 0.74, CK 69. Electrocardiogram
number one sinus rate, ST elevation in 3, AVF, ST depression
with T wave inversion in 1, AVL and V1 to V3. Q wave in 3.
At [**Hospital1 69**] white blood cell
count 11.2, hematocrit 36.7, platelet 144, PT 13.2, PTT 41.2,
INR 1.2, sodium 139, potassium 4.4, chloride 103, bicarb 24,
BUN 20, creatinine 1.0, glucose 151, calcium 8.3, magnesium
1.7, phosphate 3.1. CK 1301, CKMB 120.
Catheterization, three vessel coronary artery disease with
total occlusion of three of four grafts, successful
thrombectomy and stenting of the saphenous vein graft to the
right coronary artery. Left main coronary severe diffuse
disease. Left anterior descending coronary artery total
occlusion proximally, left circumflex total occlusion
proximally, right coronary artery total occlusion proximally.
Saphenous vein graft to obtuse marginal one and two total
occlusion proximally, previously stented, but no refills.
Saphenous vein graft to diagonal one total occlusion
proximally. Saphenous vein graft to left anterior descending
coronary artery patent with mild disease. Diagonal one with
retrograde from left anterior descending coronary artery 50
to 60% occlusion, distal to the supraventricular tachycardia
to left anterior descending coronary artery anastomosis.
Saphenous vein graft to right coronary artery total occlusion
at mid segment with thrombus. The patient had successful
thrombectomy and stenting of the saphenous vein graft to
right coronary artery.
Echocardiogram ejection fraction 50%, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5660**] dilated,
left ventricular size normal with systolic function mildly
depressed, three aortic valve mildly thickened, mitral valve
mildly thickened with 2+ MR.
HOSPITAL COURSE: Post catheterization Integrilin was held
secondary to the recent surgery, but aspirin and Plavix was
continued. He remained chest pain free in the hospital and
had no more events on telemetry. His episode of ventricular
fibrillation in the catheterization laboratory was likely due
to the ventricular irritation. His cardiac enzymes trended
downward in the hospital with a peak CK of 1301. His
echocardiogram showed an ejection fraction of 50% with 2+ MR
[**Name13 (STitle) **] was evaluated by physical therapy on the day of discharge
and deemed stable to go home.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES:
1. Status post acute inferior myocardial infarction.
2. Status post saphenous vein graft to right coronary
artery.
3. Status post ventricular fibrillation in catheterization
laboratory.
DISCHARGE MEDICATIONS: Plavix 75 q.d. for thirty days,
aspirin 325 q.d., Lisinopril 5 mg q.d., Metoprolol 25 b.i.d.,
sublingual nitroglycerin prn.
OUTPATIENT FOLLOW UP: The patient will be followed by his
cardiologist Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1968**] in [**Hospital3 1280**], phone number
[**Telephone/Fax (1) 20223**]. Outpatient cardiac rehab will be arranged by
Dr. [**Last Name (STitle) 1968**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 44692**]
MEDQUIST36
D: [**2140-9-24**] 21:03
T: [**2140-9-28**] 06:06
JOB#: [**Job Number **]
|
[
"401.9",
"427.41",
"414.01",
"V45.82",
"414.02",
"997.1",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.62",
"36.01",
"88.42",
"37.78",
"36.06",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
5154, 5189
|
1807, 1842
|
5210, 5400
|
5424, 5560
|
4561, 5132
|
5572, 6110
|
105, 222
|
251, 1371
|
1394, 1790
|
1859, 4543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,051
| 113,012
|
240
|
Discharge summary
|
report
|
Admission Date: [**2194-1-7**] Discharge Date: [**2194-2-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered Mental Status and hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]F Russian-speaking h/o refractory nodular sclerosing Hodgkins
Lymphoma was brought in by EMS and admitted after her home
health care aide noted she was hypotensive to 88/40 and
confused.
In the ED, T 98.4 (rectal), HR 101, BP 102/53, RR 20, O2Sat 98%
on 3L. Incontinant of guaiac-positive stool. Treated with 4 L
NS, vanco 1g IV, ceftazadime 1g IV, and flagyl 500mg IV.
Received 0.5 mg ativan and 2mg IV morphine for agitation.
Pt was admitted to [**Hospital Unit Name 153**] where she completed a 10-day course of
ceftazadime and vancomycin for urosepsis. A 7-day course of
metronidazole was also completed for empiric treatment of C.
Diff given loose stools in the setting of an elevated WBC count,
although all C. Diff assays were negative. Pt was stabilized and
was transferred to the floor for further care. At the time of
transfer, active issues were poor nutritional status,
thrombocytopenia and anemia.
On the floor, however, pt experienced an episode of new Afib
with RVR to 160s and hypotension to SBP 90-100s, as well as
respiratory distress after she received fluid resuscitation.
There was also a concern for tachy-brady syndrome because she
had pauses up to 4 sec on telemetry; EP curbside, however, felt
digoxin was not recommended.
Pt was therefore readmitted to the MICU. While in the MICU, she
was started on vancomycin and piperacillin-tazobactam as she had
(1) sites of possible infection at the erosions under her
breasts and on her right hip, as well as question of PNA, (2)
rising WBC, reaching a high of nearly 17. MICU course was also
marked by (1) hypotension, which responded to gentle NS boluses;
(2) low UOP believed to be [**2-22**] both hypovolemia and a low
baseline nitrogenous load/obligate urine output; and (3)
recurrent Afib, for which she was transitioned to amiodarone
400mg PO daily, to run for 7 days before titrating downward.
Past Medical History:
# Nodular sclerosing Hodgkins Lymphoma ([**3-/2188**])
--Presentation: Inguinal lymphadenopathy, treated with local
radiotherapy initially with good results.
--CT [**8-23**]: Progression, treated with Cytoxan, Velban and
Prednisone with a good response
--Eroding mass at sacrum, treated with radiation therapy
--[**3-/2191**]: Severe hypoxemia, somnolence, and generalized edema,
with anasarca responsive to diuresis and oxygen supplements, and
discharged on constant oxygen
--[**3-/2191**]: CVVP trial, stopped in [**10-28**] because of low blood
counts
--Low-dose modified regimen: Chlorambucil 4mg daily for days
[**1-27**], Procarbazine 50mg daily for days [**1-27**], Velban 10 mg IV on
day 1 only, Neulasta 6mg on day 8.
--[**9-/2192**]: Chemotherapy discontinued given poor response
--[**1-/2193**]: L sided chest pain with lytic lesions in the thoracic
vertebrae; received radiation therapy to T6-T8 including the
right 7th rib
--CT [**8-/2193**]: Interval decrease in vertebral lesions.
# Lower extremity cellulitis
# GERD
# Arthritis
# Chronic BLE edema
# Hypothyroidism
# Hypertension
# Constipation
Social History:
Lives at home with health care aide. Son [**Name (NI) **] very involved in
her care. Three children. No tobacco, alcohol, and illicit drug
use.
Family History:
Noncontributory
Physical Exam:
Initial Physical Exam
GENERAL: Elderly female in no acute distress. Minimally
reponsive to verbal stimuli but very responsive to tactile
stimulation.
VITALS: T 98.8 Rectal HR 79 BP 104/67 RR 15 SAT 97%4L NC
HEENT: Sclera anicteric. Moist mucous membranes.
NECK: 2+ carotid pulses. No LAD.No JVP elevation.
CHEST: Lungs Clear Anteriorly and laterally. No axillary LAD.
HEART: Regular. No murmurs.
ABD: Soft, non distended, quiet bowel sounds, non tender to
percussion.
EXT: Pitting edema of feet bilaterally. Nonpalpable pulses. Feet
cool. Reasonable capillary refill bilaterally.
NEURO: Sleepy but arousable. Pupils 1-2mm bilaterally. Withdraws
from painful stimuli. Good strength. Increased Tone. Mute
reflexes bilaterally. Toes mute bilaterally.
Physical Exam at Time of Transfer to Medical Floor
VITALS: T 97.1 P 96 R 24 100/60 94% 2L NC
GENERAL: Elderly female in no acute distress. Minimally
reponsive to verbal stimuli but arousable with tactile
stimulation.
HEENT: Sclera anicteric. Dry mucous membranes.
NECK: 2+ carotid pulses. No LAD. No JVP elevation.
CHEST: Diminished breath sounds at bases bilaterally. No
axillary LAD.
HEART: Regular. No murmurs.
ABD: Soft, distended, active bowel sounds, non tender to
percussion.
EXT: Pitting edema of all extremities bilaterally. Nonpalpable
pulses. Feet cool. Reasonable capillary refill bilaterally.
NEURO: Sleepy but arousable. Pupils 3-4mm bilaterally. Withdraws
from painful stimuli. Diminished reflexes bilaterally
throughout.
Physical Exam upon transfer to MICU:
VS: Temp: 98.1 BP: 87/35 HR: 102 RR: 31 O2sat 94% 2 LNC
GEN: pleasant, comfortable, NAD, somewhat somnolent (falling
asleep during the exam)
HEENT: PERRL, EOMI, anicteric, tachy MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: occ. crackle at bases, though difficult to assess b/c
patient not cooperative during the exam
CV: RR, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: warm, + anasarca with involvement of upper limbs
SKIN: no rashes, no jaundice
NEURO: somewhat somnolent. Cn II-XII grossly intact. Difficult
to complete full neuro exam given somnolence
Pertinent Results:
[**1-8**] - CXR - IMPRESSION: Persistent right-sided effusion. No
definite consolidation. Routine PA and lateral films are
recommended for evaluation when feasible.
[**1-10**]. Echo.
The left atrium is normal in size. 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 normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (probably 3) are mildly thickened. There
is no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Physiologic
mitral regurgitation is seen (within normal limits). There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Based on [**2193**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Compared with the report of the prior study (images unavailable
for review) of [**2190-12-22**], there is no definite change.
Brief Hospital Course:
[**Age over 90 **]F with Nodular Sclerosing Hodgkin's Lymphoma initially
admitted for urosepsis, and who was transferred to the ICU with
hypotension and AFib with RVR.
# Goals of Care: The patient had a long hospital course with
many family meetings reagarding goals of care. On [**2194-1-21**] the
patient was made DNR/DNI but the family continued to want ICU
transfers and pressors if needed, regardless of comfort to the
patient. The patient was tranferred to the unit on [**2194-1-30**].
She was started on levophed for hypotension but eventually a
decision was made that it was medically futile to escalate care.
Care was not escalated and she expired at 14:26 on [**2194-2-2**].
The family declined autopsy.
# Afib with RVR: Pt experienced transient episodes of Afib to
150's controlled with diltiazem and metoprolol, with spontaneous
conversion but with multiple episodes of up to 4 second pauses
and bradycardia to 40, likely junctional escape. Digoxin
considered unfavorable in this patient. In the MICU, pt was
started on amiodarone gtt, and converted to amiodarone PO. When
the patient was readmitted to the ICU on [**2194-1-30**], she was having
increased pauses up to 20 seconds. Her amiodarone was stopped.
# Thrombocytopenia/Anemia: The patient was anemia and
thrombocytopenic throughout the admission thought to be
secondary to marrow infiltration of lymphoma. Was transfused
total of 3 units PLT (1 unit each on [**1-14**] and [**1-19**])
with a transfusion threshold of 10. Will continue to trend
platelets, transfuse for bleeding or platelet count < 10.
Transfused 1 unit platelets with good bump on [**1-25**]. Also, the
patient has been receiving pRBC transfusions for HCT <24 (total
of four units since [**2194-1-12**]).
# Hypotension: Early on in the admission, she was having
hypotensive episodes after furosemide but was responsive to
fluid blosues of 250 cc. ECHO demonstrated impaired LV
relaxation and given elevated WBC, there was concern for
distributive shock. Once no longer fluid responsive, she was
started on phenylephrine gtt, which was weaned off. She was
again hypotension later in her admission thought to be secondary
to systemic vasodilation. She was started on levophed but a
decision was then made to not escalate care.
# Infection: WBC elevated with multiple possible infectious
sources which could contribute to hypotension (ie, skin erosions
under breasts, course breath sounds with ?PNA). Vanc and piptaz
started on [**1-22**]; cultures of blood and urine pending; sputum not
obtainable at this point. CDiff repeated with toxin B. C Diff
neg, thus D/C flagyl [**1-24**]. Now with GNR from skin swab.
# Hypernatremia: Noted to be periodically hypernatremic since
admission (Na 148-150), due to free water defecit. She has been
getting slow infusions of D5W as she has poor po intake and have
not been able to keep up her free water intake.
# Altered Mental Status: Increased lethargy compared to baseline
on admission most likely [**2-22**] metabolic encephalopathy due to
infection and acute renal failure, with slight improvement after
resolution of urosepsis. Head CT negative for acute process.
Thyroid studies show elevated TSH but this may be c/w sick
euthyroid syndrome.
# Respiratory Distress: Early in her admission, the patient
developed labored breathing after receiving 1 L NS for
hypotension c/w flash pulmonary edema. Diuresis with furosemide
gtt lead to hypotension; albumin resuscitation lead to repeated
respiratory distress. On [**2194-1-30**] she was on the floor and had a
witnessed aspiration event and needed 100% Hi Flow mask. While
in the ICU her O2 was weaned but again aspirated and had
increasing O2 requirements.
# Acute renal failure: Pt noted to have Cr up to 1.7 on
admission from presumed baseline of 1.0, returned to baseline of
0.9. Likely was pre-renal due to dehydration and hypotension due
to sepsis. Later in her hospital course, the patient was
hypotensive and her creatinine again began to rise thought
secondary to ATN.
# Hypothyroidism: Initially treated with levothyroxine 12.5 mcg
IV daily (half home dose). T3 low. TSH elevated. Resumed home
dose 1/4.
# Anasarca: Pt has diffuse edema and large bilateral pleural
effusions likely third-spacing from malnutrition given low
albumin (2.8 on admission, then 2.2) and poor po intake.
Diuresis has been difficult due to hypotension as detailed
above. Continue to monitor.
# Urosepsis: Admitted with hypotension due to urosepsis
requiring pressor support. Urine cultures from [**1-9**] were
positive for E.coli, and pt completed treated with vancomycin
and ceftazidime x10 days. Repeat UCx [**2194-1-19**] grew out yeast,
which was not treated. Another repeat UCx [**1-22**] final again grew
out yeast.
# Right Hip pain: Pain due to destruction of the right
acetabulum consistent with progressive lymphoma on CT scan.
There is dramatic medial displacement of the right femoral head
secondary to lack of remaining osseous support. Stable
destruction of the right posterior sacroiliac joint and
surrounding right sacral ala and iliac bone. The patient's pain
is being controlled with fentanyl and lidocaine patches.
# Bilateral pleural effusion: R>L, thought most likely due to
agressive hydration in the setting of sepsis and
hypoalbuminemia. Was difficult to effect a significant diurese
in MICU due to development of hypotension in response to
furosemide. Appears slightly improved on CXR from [**2194-1-17**],
unchanged on [**1-20**] CXR.
# Nodular Sclerosing Hodgkin's Lymphoma: Seen by oncology, no
interventions at this time. Likely with bone marrow infiltration
causing anemia and thrombocytopenia above, as pt with low retic
count and no evidence of hemolysis. No further treatment per
oncology.
# Coagulopathy: Mild, likely due to nutritional deficiency.
Encourage PO intake and trend LFTs, coags.
Medications on Admission:
Medications on Admission:
1. Levothyroxine 25 mcg daily
2. Docusate Sodium 100 mg [**Hospital1 **]
3. Omeprazole 20 mg daily
4. Oxycodone-Acetaminophen 5-325 mg Q4H PRN
5. Ferrous Sulfate 325mg daily
6. Tylenol-Codeine #3 300-30 mg QID PRN
7. Ultram 50 mg every 4-6 hours
8. Lasix 20 mg daily
9. Senna 8.6 mg [**Hospital1 **] prn
10. Aspirin 81 mg daily
11. Potassium Chloride
12. Multivitamin
.
Medications on Transfer
1. Acetaminophen 325-650 mg PO/PR Q6H:PRN
2. Miconazole Powder 2% 1 Appl TP TID apply to affected area
3. FoLIC Acid 1 mg PO DAILY
4. Multivitamins 1 CAP PO DAILY
5. Ipratropium Bromide Neb 1 NEB IH Q6H
6. Bisacodyl 10 mg PO/PR DAILY:PRN
7. Senna 1 TAB PO BID constipation
8. Docusate Sodium 100 mg PO BID
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/cough
10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
11. Fentanyl Patch 25 mcg/hr TP Q72H
12. Lidocaine 5% Patch 1 PTCH TD QD apply to right hip. One per
day, on for 12 hours then remove
13. Sarna Lotion 1 Appl TP TID:PRN
14. Levothyroxine Sodium 12.5 mcg IV DAILY
15. Pantoprazole 40 mg IV Q24H
Discharge Medications:
The patient expired at 14:26pm on [**2194-2-2**]
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Urosepsis
Aspiration Pneumonitis
Atrial Fibrillation with RVR
Lymphoma
Discharge Condition:
The patient expired at 14:26pm on [**2194-2-2**]
Discharge Instructions:
The patient expired at 14:26pm on [**2194-2-2**]
Followup Instructions:
The patient expired at 14:26pm on [**2194-2-2**]
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"201.58",
"785.52",
"682.2",
"038.42",
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"401.9",
"511.9",
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"008.45",
"530.81",
"286.9",
"349.82",
"718.28",
"244.9",
"287.4",
"995.92",
"507.0",
"584.5",
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icd9cm
|
[
[
[]
]
] |
[
"99.21",
"38.93",
"99.04",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
14056, 14071
|
6975, 9894
|
305, 311
|
14185, 14235
|
5756, 6952
|
14332, 14519
|
3549, 3566
|
13983, 14033
|
14092, 14164
|
12914, 13960
|
14259, 14309
|
3581, 5737
|
228, 267
|
339, 2234
|
9909, 12862
|
2256, 3369
|
3385, 3533
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,074
| 133,219
|
10157
|
Discharge summary
|
report
|
Admission Date: [**2158-7-24**] Discharge Date: [**2158-8-3**]
Date of Birth: [**2081-11-19**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Percocet / Hydromorphone
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
wound infection, sepsis
Major Surgical or Invasive Procedure:
Right internal jugular central line placement
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname **] was a 76 year old woman with stage IV
breast cancer with spinal metastases s/p /p L1 posterior
decompression of mass at T11-L3 on [**2158-7-2**] and L1 corpectomy on
[**2158-7-11**] by Ortho Spine Service at [**Hospital1 18**]. Post operative course
was complicated by Afib with RVR. She was discharged to rehab on
[**7-17**] and presented for concern of wound infection. She had a
PICC line placed and was started on vancomycin and ceftazadime
at [**Hospital **] Hospital [**Hospital1 8**] on [**7-21**] for concern for UTI due
to fevers. Her fevers resolved but erythema and drainage was
noted around her first surgical site on her spine and she was
brought to the Emergency Department.
.
In ED VS were T 98.2 HR 78 BP 107/70 RR 18 SpO2 98% RA. She was
found to have significant tenderness over her wound Ortho-spine
team was consulted and accepted the patient to their service.
She was taken to the OR by the Ortho Spine Service who washed
out her wound and placed a wound vac. She received a dose of
vancomycin intraoperatively as well as 900 cc NS. Given her
history of atrial fibrillation and post-op tachycardia in the
operating room she was admitted to the MICU for further
monitoring.
.
Past Medical History:
1) CAD s/p LAD and RCA angioplasty in [**2139**], then BMS to RCA in
[**2147**]
ECHO - [**2154**] with normal LV function and PA pressure 40mmg Hg
2) Metastatic breast cancer, s/pbilateral breast mastectomy ,
s/p
XRT and chemotherapy with implant reconstructive surgery
3)Restless leg syndrome
4)Osteopenia
5)H/o esophageal stricture
6)Gastritis
7)Abnormal liver function tests
8)Atrial fibrillation with RVR in post op setting
Social History:
Resided at [**Hospital3 **]. Previous lived at home alone.
Drank socially. No history of tobacco use.
Family History:
Noncontributory.
Physical Exam:
Patient expired.
Pertinent Results:
Patient was made CMO and labs were no longer checked.
Brief Hospital Course:
76 year old woman with stage IV breast cancer with spinal
metastases s/p L1 posterior decompression of mass at T11-L3 on
[**2158-7-2**] and L1 corpectomy on [**2158-7-11**] who presented from rehab
with an MSSA wound infection and was found in the MICU to have
MSSA bacteremia as well as an E.coli/Klebsiella UTI. Given her
deteriorating clinical condition, she was made comfort measures
only and transferred to the floor for comfort care and hospice.
She expired on the afternoon of [**8-3**].
Medications on Admission:
1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain, temp, headache.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for wheezing.
12. Calcium Carbonate 500 mg daily
13. Pantoprazole 40 mg daily
14. Miconazole nitrate apply topically [**Hospital1 **]
15. Bumex 1 mg IV bid
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis:
sepsis from wound infection
metastatic breast cancer
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2158-8-7**]
|
[
"730.08",
"401.9",
"V45.82",
"427.89",
"324.1",
"038.11",
"428.0",
"584.9",
"198.3",
"E878.1",
"V10.3",
"996.67",
"995.92",
"041.4",
"599.0",
"276.1",
"041.3",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"77.49",
"77.69",
"83.32"
] |
icd9pcs
|
[
[
[]
]
] |
4070, 4079
|
2379, 2875
|
318, 365
|
4194, 4204
|
2301, 2356
|
4260, 4419
|
2231, 2249
|
4029, 4047
|
4100, 4100
|
2901, 4006
|
4228, 4237
|
2264, 2282
|
255, 280
|
393, 1643
|
4119, 4173
|
1665, 2094
|
2110, 2215
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,089
| 189,156
|
8539
|
Discharge summary
|
report
|
Admission Date: [**2156-1-16**] Discharge Date: [**2156-1-30**]
Date of Birth: [**2115-11-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Fevers and Rash
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
History of Present Illness:
40 yo male with an unremarkable past medical history except for
ulcerative colitis which has been very well controlled with no
recent flares, presents to the ED with a 4 day history of
myalgias and low temperature, along with a temperature spike to
102 and chest pain on the day of admission. During that same
time, he noticed increase swelling and erythema on his R shin
but denies any trauma or insect bites. He describes his chest
pain as being inspirational but not exertional. Never had
symptoms like this before. Also noticed a 1 day swelling of his
L neck / supraclavicular area. He was seen in the ED and had
blood cultures sent and started on IV Oxacillin for presumed
cellulitis and admitted for further evaluation. He was also
found to have EKG changes consistent with pericarditis.
Past Medical History:
1. Ulcerative Colitis
Social History:
He works as a consultant and is married and has 2 children.
Occasional, social EtOH intake but completely denies any tobacco
use or IV recreational drug use.
Family History:
Non contributory
Physical Exam:
VS: Temp 101.2, Pulse 104, BP 110/68, RR 18-20, O2 sat 98% room
air
GEN: mild to moderate respiratory distress
HEENT: PERRLA, EOMI, dry mucous membranes
NECK: no JVD, supple, small swelling around the L
supraclavicular area, tender, and slightly erythematous, non
mobile
LUNGS: CTA bilateral
HEART: tachycardic, distant heart sounds
ABD: soft, ND, NT, no HSM, + bowel sounds
EXTREM: RLE erythema and edema, small petechiae, tender to
palpation - located on the anterior shin with some surrounding
erythema extending to the sides and at the back of his calf
NEURO: AAO x 3
Pertinent Results:
[**2156-1-16**] 02:05PM WBC-11.6*# RBC-4.98 HGB-15.6 HCT-43.9 MCV-88
MCH-31.3 MCHC-35.5* RDW-12.9 NEUTS-44* BANDS-45* LYMPHS-4*
MONOS-6 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 PLT SMR-NORMAL
PLT COUNT-183
[**2156-1-16**] 02:05PM GLUCOSE-132* UREA N-12 CREAT-1.0 SODIUM-138
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13
[**2156-1-16**] 02:05PM CK(CPK)-220* CK-MB-8 cTropnT-0.14*
[**2156-1-16**] 09:05PM CK(CPK)-210* CK-MB-7 cTropnT-0.26*
[**2156-1-17**] 06:50AM CK(CPK)-619* CK-MB-39* MB Indx-6.3*
cTropnT-1.86*
[**2156-1-18**] 04:35AM CK(CPK)-312* CK-MB-12* MB Indx-3.8*
cTropnT-1.37*
US of R LE: No evidence of DVT.
CT Angio: No evidence of acute pulmonary embolus. Multifocal
nodular densities, some of which are patchy and ill defined.
Given the history of fever, these findings are suggestive of an
infectious etiology. A follow up chest CT is advised after
treatment, to confirm resolution.
CT Abdomen / Pelvis: New moderate/large pericardial effusion and
new small bilateral pleural effusions. Progression of disease
within the left upper lobe and right lower lobe with worsening
peripheral opacities, some of which have a wedge-shaped
configuration. These findings raise the question of progression
of septic emboli. Possible peripheral wedge-shaped area of
hypoattenuation/hypoperfusion within the posterior spleen as
well as multiple peripheral areas of possible infarction within
both kidneys. New small amount of ascites. No clear source for
the patient's suspected septic emboli identified within the
chest, abdomen, and pelvis with no abscesses or definite thrombi
identified.
MRI Neck: Abnormal enhancement surrounding the distal
sternocleidomastoid muscle with perhaps a minute central area of
nonenhancing. No drainable collection is present. The
radiological differential diagnosis includes infectious
etiolgies and a myositis.
MRI Abdomen: No deep venous thrombus in the pelvic veins or
inferior vena cava.
Echo [**1-21**]: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricle is borderline dilated with preserved systolic free
wall motion. The aortic valve leaflets (3) are mildly thickened.
The mitral valve appears structurally normal with trivial mitral
regurgitation. The left ventricular inflow pattern suggests a
restrictive filling abnormality, with elevated left atrial
pressure. There is a slight interventricular septal bounce.
These findings are suggestive of an element of pericardial
constriction. There is mild pulmonary artery systolic
hypertension. There is a partially echo dense small pericardial
region consistent with residual pericardial effusion and
possible thickened pericardium. There are no echocardiographic
signs of tamponade.
Brief Hospital Course:
40 year old male who presents to the ED with fever, chills, and
R lower extremity cellulitis and found to be bacteremic now and
developed abscess on R shin and is s/p I and D by the surgical
team.
1. Bacteremia - patient initially presented with fever and
chills and started on IV Oxacillin. His blood cultures grew
Staph Aureus Coag + (2/4 bottles from admission day) and so
switched to IV Vancomycin and also received IV Clindamycin for
toxic syndrome coverage. Given his bacteremia and his fever, it
was concerning for endocarditis, and he had a TTE that showed no
vegetations but some pericardial effusion. Had a repeat TEE
which was negative for vegetations or any abscess formation. The
sensitivities returned and it was MSSA and so he was wtiched to
Gentamicin and Oxacillin. However, soon his pericardial effusion
progressed and he went into tamponade leading to emergent
drainage with a pericardial drain. His fluid from the
pericardial effusion was unremarkable in terms of bacterial
infections. His blood cultures and fungal cultures from
subsequent blood has been negative or no growth to date. He was
switched to cefazolin because he developed a presumed drug rash.
His gentamycin was discontinued once it was clear that the
bacteremia had cleared and the patient was discharged on
cefazolin to complete a 6 week course of iv antibiotics, ending
[**2156-3-1**]. The patient will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17444**] from
infectious diseases just prior to stopping the antibiotics.
2. RLE Cellulitis/Abscess - initially he was on oxacillin and
then switched to Vanco, and then switched back to Oxacillin once
his blodo cultures were found to be MSSA. However, given his
drug rash, he was switched to Cephazolin but despite being on it
and Gentamicin, his leg continued to swell and become more
localized and erythematous. He was seen by the Dermatology team
who biopsied the lesion and the prelim results on that was that
it was a resolving cellulitis. He Had an MRI that showed a
large 15 x 6 cm fluid filled abscess which was immediately seen
by the Ortho team and he was taken to the OR for an I and D. He
tolerated the procedure well and significant amount of purulent
fluid was drained and sent for cultures. He had a Hemovac drain
attached to his wound at that time. The drain was left in place
for nearly 72 hours with minimal drainage. One day prior to
discharge, the drain was removed and the wound was inspected and
found to have subcutaneous edema but no abscess. The patient
was ambulating with crutches (non-weight bearing on right leg).
He was maintained on oxycontin and oxycodone for pain control
and was given a 2 week supply. The patient will follow up with
Dr. [**Last Name (STitle) 2719**] next Tuesday, [**2156-2-3**].
3. Pericarditis / Tamponade - initially it was felt that he had
pericarditis and so was started on Indomethacin and Colchicine.
His pain was well controlled but he developed the effusion
leading to ? tamponade and was drained. After the procedure, he
was restarted on colchicine as per Cardiology who recommended
that it would minimize the risk of constriction and it should be
continued for 1-2 years. He had repeat TTEs that was unchanged
and it was recommended that he have another one in about 4
months. The patient was asked to call Dr. [**Last Name (STitle) 696**] to set up a
follow up appointment as an outpatient.
4. Elevated LFTs - patient had elevated LFTs which was thought
to be secondary to high dose Oxacillin. He had a CT abdomen that
showed no evidence of liver abscess or any other abnormalities
in the liver. Once the antibiotic was changed to Cephazolin, his
LFTs began to trend down and returned to [**Location 213**] prior to
discharge. He was asymptomatic in terms of nausea or vomiting
throughout the hospital course
5. Ulcerative colitis: Patient was maintained on mesalamine
enemas and had no flares during his hospital course.
Medications on Admission:
1. Rowasa Enemas prn (usually 3-4 times per week)
Discharge Medications:
1. Cefazolin Sodium 10 g Recon Soln Sig: Two (2) grams Injection
Q8H (every 8 hours) for 32 days.
Disp:*192 grams* Refills:*0*
2. Mesalamine 4 g Enema Sig: One (1) enema Rectal 3X/WEEK
(MO,WE,FR).
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Oxycodone HCl 10 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO Q12H (every 12 hours) for 2
weeks.
Disp:*28 Tablet Sustained Release 12HR(s)* Refills:*0*
5. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for 2 weeks.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Endocarditis
Bacteremia
septic emboli
Pericarditis
Pericardial effusion
right leg abscess
Transaminitis
Ulcerative colitis
Discharge Condition:
good, ambulating with crutches, afebrile with decreased WBC
Discharge Instructions:
Follow up with Dr. [**Last Name (STitle) 2719**] next Tuesday, [**Telephone/Fax (1) **].
Follow up with Dr. [**Last Name (STitle) 17444**] from Infectious Disease in 4 weeks.
Call [**Telephone/Fax (1) 457**] on Monday to set up an appointment.
Follow up with Dr. [**Last Name (STitle) 4127**] within 2 weeks.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 2719**] next Tuesday, [**Telephone/Fax (1) **].
Follow up with Dr. [**Last Name (STitle) 17444**] from Infectious Disease in 4 weeks.
Call [**Telephone/Fax (1) 457**] on Monday to set up an appointment.
Follow up with Dr. [**Last Name (STitle) 4127**] within 2 weeks.
Follow up with Dr. [**Last Name (STitle) 696**] from cardiology [**Telephone/Fax (1) 10464**] to set
up an appointment within 1-2 months
Completed by:[**2156-1-30**]
|
[
"682.6",
"729.4",
"415.19",
"423.9",
"995.91",
"556.9",
"421.0",
"276.5",
"038.11",
"041.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.14",
"88.72",
"83.45",
"37.0",
"86.11",
"37.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9610, 9668
|
4904, 8875
|
331, 363
|
9835, 9896
|
2048, 4881
|
10253, 10733
|
1422, 1440
|
8975, 9587
|
9689, 9814
|
8901, 8952
|
9920, 10230
|
1455, 2029
|
276, 293
|
391, 1186
|
1208, 1231
|
1247, 1406
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,822
| 179,873
|
3074
|
Discharge summary
|
report
|
Admission Date: [**2103-8-26**] Discharge Date: [**2103-10-11**]
Date of Birth: [**2054-6-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Epistaxis and petechiae on lower extremities
Major Surgical or Invasive Procedure:
s/p splenectomy
History of Present Illness:
49 y/o male with HIV/AIDS, CD4 8, on ART, and diagnosed with
DLBCL in [**2103-6-13**], was just discharged home after a lengthy
hospitalization during which his lymphoma was diagnosed, and he
was started on [**Hospital1 **], received 2 cycles of chemotherapy,
finished 2nd cycle (per patient) on [**2103-8-24**]. Since Friday
([**8-24**]), he noticed intermittent episodes of small amounts of
epistaxis from his left nostril which was followed by appearance
of petechiae on bilateral lower extremities involving inner
aspect of thigh and on shin. Labs in his rehab showed platelet
count of 1. He was then transferred to ED. In ED, his wbc was
found to be 0.6 and plt of 7. He was admitted for observation.
ROS: Patient denies fevers, chills, chest pain, SOB, diarrhea,
constipation, hematochezia/melena, blurry vision, abdominal
pain, tingling numbness in extremities, dizziness. He reports
malaise, early satiety. Rest of ROS unremarkable.
Past Medical History:
#HIV/AIDS--CD4-57/4%, VL [**Numeric Identifier 14614**] on [**2101-10-5**], not on meds since
then; Nadir CD4 57 prior to [**5-/2103**] admit, no documented thrush
or CMV in past
Prior treatment includes: LAM/ZDV/EFV, ?NFV; TDF/FTC with FD
LPV/r (started [**2096-11-26**], stopped [**2096-12-19**] due to diarrhea but
restarted by [**1-3**], discontinued by [**7-/2097**]); TDF/FTC and ATV/r
(started [**7-/2098**], self-discontinued [**12/2098**])
RPR non-reactive [**2099-5-5**].
Toxo IgG negative [**2097-6-11**].
HCV Ab negative [**2094-8-10**].
#pneumonia [**11/2096**] (Admitted [**Hospital1 112**]) thought to be viral
#History of anorectal HPV. Last High resolution anoscopy
[**2099-6-30**], path with AIN I x 2. Last anal pap done on that day.
Social History:
Patient lives alone. Patient works with [**Hospital1 14615**], processing donations.
Tobacco: 1 ppd x 12 years, quit in [**2103-6-13**]
ETOH: Heavy drinking in the past, quit in [**2103-6-13**]
Recreational drugs: cocaine and marijuana years ago
Family History:
No family history of cancer, neurological issues, heart disease.
Physical Exam:
VS: Tc 98.1 HR: 82 BP: 104/56 RR: 16 02: 99% RA
GEN: pleasant, A&Ox3, NAD
HEENT: NCAT, PERRL, mildly injected conjunctivae b/l, EOMI,
sclerae anicteric, neck supple, MMM, poor dentition, no LAD
CV: RRR, normal S1, S2, no M/G/R
PULM: good air movement, no wheezes, no rales
BACK: no focal tenderness, no CVAT, has a small healing ulcer in
coccyx measuring 0.5 x 0.5 cm.
GI: normoactive BS, soft, non-tender, non-distended, no HSP
MSK: no joint swelling or erythema
EXT: warm and well perfused, no edema, 2+ DP pulses palpable
bilaterally, small area of skin breakdown on R knee
LYMPH: no cervical, axillary LAD;
SKIN: no rashes, no jaundice. + petechiae on b/l LE on inner
aspect of thigh and over the shin
NEURO: AAOx3, 4/5 strength in bil UE, [**5-17**] in RLE, [**4-17**] in L LE;
CN
intact.
Pertinent Results:
[**2103-8-26**] 07:20PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2103-8-26**] 07:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2103-8-26**] 05:50PM LACTATE-1.2
[**2103-8-26**] 05:42PM GLUCOSE-100 UREA N-21* CREAT-0.4* SODIUM-133
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-10
[**2103-8-26**] 05:42PM WBC-0.6*# RBC-2.63* HGB-7.8* HCT-21.9* MCV-83
MCH-29.6 MCHC-35.6* RDW-16.2*
[**2103-8-26**] 05:42PM NEUTS-68.2 LYMPHS-28.3 MONOS-0.3* EOS-1.7
BASOS-1.5
[**2103-8-26**] 05:42PM PLT COUNT-7*#
[**2103-8-26**] 05:42PM PT-14.3* PTT-29.8 INR(PT)-1.2*
[**2103-8-25**] 06:18AM ALT(SGPT)-22 AST(SGOT)-11 LD(LDH)-168 ALK
PHOS-71 TOT BILI-0.9
[**2103-8-25**] 06:18AM ALBUMIN-2.2* CALCIUM-7.3* PHOSPHATE-2.9
MAGNESIUM-2.0 URIC ACID-2.2*
[**2103-8-25**] 06:18AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL
TARGET-1+ BURR-OCCASIONAL
[**2103-8-25**] 06:18AM FIBRINOGE-158
.
[**2103-8-18**] Chest X Ray: No evidence for active cardiopulmonary
disease.
.
[**2103-8-7**] CT chest:
1. Dramatic interval improvement in multiple bilateral
ground-glass opacities with minimal if any residual opacities
remaining.
2. Moderate bilateral effusions with associated atelectasis are
non-hemorrhagic.
3. Splenomegaly.
.
[**2103-7-19**]: MR head: Prominence of ventricles and sulci consistent
with global
cerebral atrophy given the history of HIV/AIDS. Few T2 and FLAIR
hyperintensities in the subcortical and periventricular white
matter
consistent with chronic small vessel ischemic disease.
.
[**2103-7-11**] BM biopsy: DIFFUSE INVOLVEMENT BY NON-HODGKIN'S LYMPHOMA
(DIFFUSE LARGE B-CELL LYMPHOMA).
[**2103-9-6**] 7:42 am [**Month/Day/Year **] Source: Induced.
**FINAL REPORT [**2103-9-21**]**
GRAM STAIN (Final [**2103-9-6**]):
[**11-6**] 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 [**2103-9-6**]):
TEST CANCELLED, PATIENT CREDITED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2103-9-6**]):
SPECIMEN NOT PROCESSED DUE TO: QUANTITY NOT SUFFICIENT.
Less than 2 ml received.
Reported to and read back by [**First Name8 (NamePattern2) 5557**] [**Last Name (NamePattern1) **] RN @1005,
[**2103-9-6**].
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Final [**2103-9-21**]):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
[**2103-9-16**] 4:57 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2103-9-16**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2103-9-18**]):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2103-9-17**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Final [**2103-10-1**]):
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2103-9-18**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
[**2103-9-29**] 12:30 am IMMUNOLOGY Source: Line-picc.
**FINAL REPORT [**2103-10-1**]**
HIV-1 Viral Load/Ultrasensitive (Final [**2103-10-1**]):
HIV-1 RNA is not detected.
[**2103-10-4**] 10:15 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2103-10-7**]**
Blood Culture, Routine (Final [**2103-10-7**]):
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin MIC = 1.5 MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 1 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Aerobic Bottle Gram Stain (Final [**2103-10-5**]):
Reported to and read back by DR. [**First Name (STitle) **] BINDER PAGER # [**Numeric Identifier 14623**]
@ 0708 ON
[**2103-10-5**].
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Anaerobic Bottle Gram Stain (Final [**2103-10-5**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2103-10-11**] 06:10AM BLOOD WBC-12.2* RBC-2.11* Hgb-6.1* Hct-19.7*
MCV-93 MCH-29.0 MCHC-31.2# RDW-17.6* Plt Ct-13*
Brief Hospital Course:
Mr. [**Known lastname 14619**] is a 49 y/o M with AIDS, DLBCL, discharged from
[**Hospital1 18**] (treated for AIDS dementia, cerebral histoplasmosis,
DLBCL) on [**2103-8-25**], returned from nursing home on [**2103-8-26**] with
petechiae, epistaxis and thrombocytopenia (plt count at 1), s/p
open splenectomy on [**9-13**] for refractory ITP, complicated by
hypoxemic respiratory failure requiring intubation, now s/p
extubation and received ICE chemotherapy for DLBCL complicated
by persistent VRE bactermia which resulted in his death.
.
#.thrombocytopenia/ITP- The patient presented with petechiae,
epistaxis and a platelet count at 1. During the patient prior
hospitalization, he became refractory to platelet transfusions,
and an anti-platelet antibody screen was found to be positive.
He was therefore administered a five-day course of IVIG to
neutralize
the anti-platelet antibodies. Splenomegaly was also thought to
contribute to his thrombocytopenia. Since he had failed IVIG
therapy, he received once weekly dose of romiplostim. After an
initial response, he started to respond poorly to romiplostim.
Concurrently, he received platelets transfusions to maintain a
platelet count above 10. Given his refractory thrombocytopenia,
a splenectomy was performed on [**2103-9-13**]. The splenectomy was
complicated post-op by a large incision hematoma and hypoxemic
respiratory failure requiring intubation (see below). For
treatment of the hematoma, a large abdominal binder was place,
and the patient received thrice daily transfusion of platelets
for approximately 1 week, responding well to each unit, but
consumed quickly. Romiplostim was re-initiated 23 days
post-op. By the time of the patient's death, he was requiring
once daily units of platelet to maintain platelet count greater
than 10.
.
#.DLBCL- A bone marrow on [**2103-9-6**] demonstrated hypocellular
regenerating marrow, but no diagnostic morphologic nor
immunophenotypic evidence of lymphoma. Yet, circulating
atypical lymphoma cells were present on peripheral blood smears.
A splenectomy was performed on [**2103-9-13**] due to ITP and a biospy
of the spleen demonstrated extensive involvement of DLBCL. On
[**2103-9-22**], he was treated with ICE and bortezomib given without
complication. Standard anti-emetic were given. A peripheral
smear on [**2103-10-8**] demonstrated findings consistent with
involvement by previously diagnosed CD5 positive large B-cell
lymphoma. The patient died on [**2103-10-11**].
.
#.Hypoxemic Respiratory Failure- On [**2103-9-15**] (post op day 2), the
patient was transferred to the ICU for altered mental status,
fever, and hypoxemic respiratory failure. Initially, BI-PAP was
placed, but the patient continued to de-sat to high 80's and
required intubation. A CXR was concerning for LLL
infiltrate/pneumonia, and a BAL was performed, which grew only
normal respiratory flora. A repeat [**Date Range **] culture on [**9-19**] grew
the same. Blood and Urine cultures also were negative. Empiric
antibotics were continued (vancomycin/ Ambisome / Meropenem /
Acyclovir). The patient was palliatively extubated on [**9-22**] and
his mental status improved. The patient desired to continue
treatment for DLBCL (see above)
.
#.Fever/Bactermia- The patient was neutropenic after receiving
ICE therapy on [**9-22**]. Neupogen was given. Start on [**10-4**] VRE grew
daily in blood cultures. A catheter was removed on [**10-4**] and
grew VRE. A new catheter was placed and then removed on [**10-7**],
and was culture negative. Linezolid therapy was initiated on
[**10-4**]. The patient decided to not undergo more invasive
treatment to control the VRE bactermia and died on [**10-11**]. (see
below regarding the patient death).
.
#.HIV/AIDS- The patient was maintained on his home HAART
medications. A CD4 count was 39, and a viral load was
undetectable. Atovaquone for PCP [**Name9 (PRE) **] was continued throughout
the hospitalization.
.
#.Histoplasmosis- The patient was diagnosed during his previous
hospitalization with cerebral histoplasmosis. Antifungal
antibotics were continued throughout the entire hospitalization
until his death.
.
#. Anemia- The patient was anemic throughout the
hospitalization. The patient recieved blood transfusion for
HCT<25.
.
#. Adrenal Insufficiency- The patient received prednisone for
adrenal insufficiency, and was tappered multiple times after
each round of chemotherapy that contained steroids.
.
#.[**Name (NI) 14624**]
Pt found to be persistently bacteremic with VRE despite
linezolid therapy. Unclear source. Culture of PICC tip was
negative and pt remained bacterimic. Bicarbonate decreased to
10 and pt became increasingly tachypneic. Pt did not want
further invasive testing and pt would not likely survive any
aggressive intervention. Pt wanted to keep being treated
symptomatically with antibiotics and transfusion. Pt's blood
pressure dropped, breathing worsened, and pt was unresponsive to
painful stimulus or verbal cues by the afternoon of [**2103-10-11**].
The pt passed away at approximately 3:15pm.
Medications on Admission:
Medications (D/C Summary [**8-25**]):
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(MO).
Disp:*60 Tablet(s)* Refills:*2*
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
Disp:*450 ML(s)* Refills:*2*
6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
7. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. itraconazole 100 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours).
Disp:*90 Capsule(s)* Refills:*2*
11. oral wound care products Gel in Packet Sig: One (1) ML
Mucous membrane TID (3 times a day).
Disp:*90 ML(s)* Refills:*2*
12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
Disp:*30 * Refills:*2*
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
15. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day) as needed for constipation.
Disp:*90 Capsule(s)* Refills:*0*
17. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a
day as needed for constipation.
Disp:*500 ML(s)* Refills:*0*
18. filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H
(every 24 hours) for 15 days.
Disp:*15 * Refills:*0*
19. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO once a
day.
Disp:*60 * Refills:*2*
21. Lidocaine Viscous 2 % Solution Sig: One (1) Mucous membrane
three times a day as needed for mouth pain.
Disp:*60 * Refills:*0*
22. miconazole nitrate 2 % Powder Sig: One (1) Topical three
times a day as needed: apply to groin, other fungal skin rash as
needed.
Disp:*qs * Refills:*0*
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
diffuse large b-cell lymphoma
thrombocytopenia
anemia
vancomycin-resistant Enterococcal bacteremia
hypoxemic respiratory failure
idiopathic thrombocytopenic purpura
splenectomy with subsequent incisional hematoma
HIV/AIDS
death
Discharge Condition:
death
Discharge Instructions:
none
Followup Instructions:
none
|
[
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
"41.31",
"41.5",
"99.25",
"96.72",
"00.14",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
16604, 16613
|
8815, 13909
|
350, 367
|
16884, 16891
|
3311, 6802
|
16944, 16951
|
2410, 2476
|
16575, 16581
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16634, 16863
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13935, 16552
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16915, 16921
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2491, 3292
|
6838, 8792
|
266, 312
|
395, 1342
|
1364, 2126
|
2142, 2394
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,340
| 106,221
|
30868
|
Discharge summary
|
report
|
Admission Date: [**2179-8-19**] Discharge Date: [**2179-8-19**]
Date of Birth: [**2114-7-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
fevers, hypotension
Major Surgical or Invasive Procedure:
R IJ line placed; d/c'ed prior to discharge
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname **] is a 65-year-old woman with
advanced pancreatic cancer undergoing systemic palliative
chemotherapy with weekly gemcitabine initiated on [**2179-7-22**] who
presented to the ED complaining of fevers/chills, dysuria and
cough 24 hours following treatment. She had been tolerating the
chemo well, aside from reports of significant weakness and
tiredness over the last few weeks as well as a possible skin
reaction to the chemo. Her third dose was held secondary to
ANC-740, plt-43,000. Her pain has been under control with
OxyContin 40 mg b.i.d. She
reports a fair appetite and her weight is stable. Her energy
level has been her chief complaint until now.
.
In the ED, she was found to be febrile to 105, slightly
disoriented, with a SBP in the 80's and sats in the low 90's.
She was fluid resuscitated with 3L of NS which brought her
pressure back up to the 110's and in the meantime, she was given
a dose of empiric stress dose steroids and a central line was
placed under ultra sound guidance. Her lactate was 1.1, she was
given doses of CTX and vanco. CXR, CTA and CT head were negative
for acute processes. Since being fluid resuscitated initially,
she has remained hemodynamically stable with sats in the mid
90's. She is admitted to the [**Hospital Unit Name 153**] for further management.
.
On ROS, the patient denies chest pain, shortness of breath,
abdominal pain. She denies having fevers, chills currently. She
notes having an episode of n/v after taking compazine yesterday,
prior to chemo, and afterwards, does not recall much of what
happened. She was told by her daughter that she was "shaking
like a leaf" and after waking from a nap, she was disoriented
and not making much sense. The patient also notes that she is
sleeping more and not taking in much PO as a result.
Past Medical History:
Metastatic Pancreatic Ca with multiple mets in liver and lungs
Hypercholesterolemia
?Lupus
AAA (incidentally picked up on a CT scan 3 years ago)
h/o Zoster
Social History:
The patient smoked for several years but has quit recently and
she also is a recovering alcoholic.
Family History:
Her mother died of lung cancer, although she was a smoker. She
also suffered from stroke and required a triple vessel CABG.
She has 3 children, all of whom are healthy. No remarkable
history of malignancies in her family.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION
Vitals: T 97.3 HR 70 BP 133/64 R 20 Sat 95% RA
General: 65 yo F, NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric, MMM, OP clear
Neck: supple, JVP @ 7cm
Chest: RRR II/VI SEM at LLSB radiating across precordium. No
rub.
Lungs: bibasilar rales. No wheeze/rhonchi
Abd: soft, NT/ND +BS
Ext: No e/c/c, warm and well perfused.
Neuro: CN II-XII in tact bilaterally. A&Ox3. Strength 5/5
bilaterally.
Skin: warm and well perfused, no lesions/rashes
Access: RIJ, PIV
foley in place
Pertinent Results:
LABS:
WBC RBC Hgb Hct MCV MCH MCHC
RDW Plt
[**2179-8-19**] 05:01AM 4.1 3.29* 10.6* 30.4* 92 32.1* 34.8
13.7 279
[**2179-8-18**] 08:20PM 6.2 3.44* 11.0* 30.6* 89 32.0
36.0*14.4 334
[**2179-8-18**] 09:50AM 6.3# 3.41* 11.0* 31.4* 92 32.2* 35.0
13.8 368
.
Neuts Bands Lymphs Monos Eos Baso Atyps
Metas
[**2179-8-19**] 05:01AM 85.3* 12.6* 1.9* 0.1 0.1
.
Glucose UreaN Creat Na K Cl HCO3
AnGap
[**2179-8-19**] 05:01AM 164* 11 0.6 141 4.1 107 25
13
.
Lactate
[**2179-8-19**] 05:29AM 0.9
.
CARDIAC ENZYMES:
-CK 40; 38
-Tn-T <0.01 x2
.
MICRO:
-Blood cultures x4-pending
-Urine cultures pending
.
IMAGING:
-[**8-18**] CTA:
1. No pulmonary embolism or aortic dissection is noted.
2. Multiple bilateral pulmonary nodules are noted, the largest
nodules are seen within the left upper lobe and measure up to 7
mm in the short axis. These nodules could represent an atypical
or fungal infection. Followup is recommended to ensure
resolution.
3. Pathologically enlarged mediastinal nodes likely reactive.
.
-[**8-18**] HEAD CT:
IMPRESSION: No acute intracranial pathology including no
intracranial hemorrhage.
.
-[**8-18**] CXR:
IMPRESSION:
No acute intrathoracic process.
.
Brief Hospital Course:
1. Hypotension: It was responsive to fluid resusitation,
received a total of 3L in the ED. Initial episode of hypotension
was likely [**3-5**] recent poor po intake and insensible losses from
high fevers. On arrival to the [**Name (NI) 153**], pt's SBP 140's & she had
bibasilar rales with O2sats on RA in mid 90's. Recieved total of
Lasix 40mg IV for fluid overload, and maintained adequate BP
while in the [**Hospital Unit Name 153**].
.
2. Fevers: Most likely [**3-5**] chemotherapy; although infection is
certainly on the differential; however pt. remained afebrile
while admitted. Other etiologies include drug reaction, although
patient was premedicated with benadryl, decadron could also have
helped shut down a hypersensitivity reaction. CXR was
unremarkable for any infectious process. CTA done was negative
for PE. On-call covering heme-onc physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] was
paged & agreed that this was most likely Gemcitabine reaction
since all work up was negative so far. Blood & urine cultures
were done and need to be followed up by outpt. PCP or
oncologist.
.
3. Dysuria: UA unremarkable. Foley was placed & d/c'ed prior to
discharge. Pt. denied further complaints.
.
4. Pancreatic Cancer: Pt of Dr. [**Last Name (STitle) **]; receiving weekly
gemcitabine. Continued supportive care of pt with anti-emetics &
anti-diarrheal agents. No new interventions for pt.
.
5. Code: DNR/DNI, confirmed with patient
.
Medications on Admission:
CHOLESTYRAMINE LIGHT 4 gram--1 packet by mouth before meals
COMPAZINE 10 mg--1 tablet(s) by mouth three times a day
LOMOTIL 2.5 mg-0.025 mg--1 tablet(s) by mouth 3-4 times a day as
needed for diarrhea
LORAZEPAM 0.5 mg--one tablet(s) by mouth every 6 hours as needed
MS CONTIN 30 mg--1 tablet(s) by mouth twice a day
OXYCONTIN 40 mg--1 tablet(s) by mouth twice a day
PANCREASE 20,000 unit-[**Unit Number **],500 unit-[**Unit Number **],000 unit--1 capsule(s) by
mouth three times a day
PERCOCET 5 mg-325 mg--[**2-2**] tablet(s) by mouth every 4-6 hours as
needed for pain
Discharge Medications:
1. Medications
Please resume all your home medications. We have not added or
changed any of your prior medations.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Fever
- Hypotension
.
Secondary Diagnosis:
- Pancreatic cancer
Discharge Condition:
Stable, afebrile, ambulating & tolerating po
Discharge Instructions:
1. Please take your medications as directed
.
2. Return to emergency department if you have fever greater than
101.5F, nausea, vomiting, lightheadedness, difficulty breathing,
chest pain or any other worrisome symptoms.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2179-8-25**] 10:30
Provider: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2179-9-1**] 9:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2179-9-15**]
1:30
|
[
"710.0",
"788.1",
"E933.1",
"197.0",
"197.7",
"458.9",
"272.0",
"157.8",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6892, 6898
|
4668, 6131
|
335, 380
|
7026, 7073
|
3324, 3967
|
7341, 7767
|
2559, 2784
|
6753, 6869
|
6919, 6919
|
6157, 6730
|
7097, 7318
|
2799, 3305
|
3984, 4488
|
276, 297
|
408, 2247
|
6983, 7005
|
4497, 4645
|
6938, 6962
|
2269, 2426
|
2442, 2543
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,985
| 132,537
|
14467
|
Discharge summary
|
report
|
Admission Date: [**2172-6-3**] Discharge Date: [**2172-6-14**]
Date of Birth: Sex:
Service: TRAUMA
HISTORY OF THE PRESENT ILLNESS: This 73-year-old man with a
history of syncopal episodes now status post a fall after a
syncopal episode. He was noted to be conversant at an
outside hospital. On transfer, he had markedly decreased
mental status. He was intubated on arrival. A CT scan
showed a left subarachnoid bleed with intraparenchymal
hemorrhage.
PAST MEDICAL HISTORY:
1. Syncopal episodes.
2. Anemia.
3. Diabetes.
4. COPD.
5. Questionable diagnosis of cancer of the prostate.
ALLERGIES: The patient is allergic to codeine and
erythromycin.
ADMISSION MEDICATIONS: Inhalers.
PHYSICAL EXAMINATION ON ADMISSION: The [**Location (un) 2611**] Coma Scale
was 3T. Vital signs: The blood pressure was 154/87, heart
rate 100, respiratory rate 28. Chest: Clear. Abdomen:
Soft and nontender. Extremities: Without obvious trauma.
ADMISSION LABORATORY DATA: Hematocrit 26, white blood cells
10,000. Creatinine 1.5.
C-spine films were negative to C7. The chest x-ray was
negative. The head CT showed the above mentioned findings
with some cerebral edema.
The EKG showed no ischemic changes.
HOSPITAL COURSE: The patient was admitted with the diagnosis
of head injury with subarachnoid bleed. The patient was
admitted to the Intensive Care Unit with Neurosurgical
consultation. He was observed closely and he was supported
with blood pressure management to avoid hypertension and
hypotension.
The patient was given nitroprusside p.r.n. for hypertension
and fluids for short periods of hypotension. The patient was
transfused for blood loss anemia. He seemed to have some
improvement in his mental status. Diabetes was controlled
with insulin.
The patient, on follow-up CT scans, was noted to have a
nondisplaced pedicle fracture of C2 and he was placed in a
hard collar for six weeks at the recommendation of the
Orthopedic Service.
The patient was then discharged to the floor where he opened
eyes to stimulation. He moved his extremities but did not
follow commands. He was given some physical therapy. The
patient then spiked a fever and developed some respiratory
difficulties. He was transferred to the Intensive Care Unit
and antibiotics were begun. The patient was intubated and
appropriately monitored. A CT of the head was performed
which showed no change.
The patient then improved to some degree from a respiratory
perspective. However, mental status did not improve a great
deal. At this time, he opened his eyes only with minimal
reflexes and did not follow any commands whatsoever.
There was a discussion with the family and due to his poor
prognosis, it was decided to make him comfort measures only.
Support was withdrawn and the patient expired.
FINAL DIAGNOSIS:
1. Severe head injury with subarachnoid hemorrhage.
2. Respiratory failure.
3. Pneumonia.
4. Diabetes.
5. Chronic obstructive pulmonary disease.
6. Anemia.
SURGICAL PROCEDURES: None.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern4) 9706**]
MEDQUIST36
D: [**2173-2-3**] 10:48
T: [**2173-2-5**] 09:58
JOB#: [**Job Number 42767**]
|
[
"E888.9",
"805.02",
"496",
"250.00",
"996.62",
"276.1",
"851.41",
"518.5",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"89.64",
"96.6",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1258, 2831
|
2848, 3291
|
710, 742
|
757, 1240
|
506, 686
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,690
| 113,682
|
52267+52268+59416
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2192-5-4**] Discharge Date: [**2192-6-12**]
Date of Birth: Sex: M
This Dictation Summary will discuss the patient's course in
hospital. There will be an addendum detailing his initial
presentation.
1. Operative: The patient was taken to the Operating Room
hemicolectomy. Following his operation, his postoperative
course was complicated by a prolonged ileus which prohibited
the patient from taking p.o. Additionally, he was delirious.
He was started on TPN for nutrition on [**2192-5-14**].
from probable aspiration. He required intubation and
displayed septic physiology with hypotension, abnormal
cultures ultimately grew E. coli and Klebsiella. The source
was felt to be urinary, however, the patient also had
Methicillin sensitive Staphylococcus aureus in his sputum
along with copious thick secretion. He was treated initially
with Vancomycin, Ceftazidime and Levofloxacin and later
switched to Oxacillin and Levofloxacin when sensitivities
revealed that his organisms were sensitive to these
medications. He was extubated on [**2192-5-21**].
Following this, he had been slow to interact with others and
displayed continued inability to take oral feedings and
medications due to his sedation. This was initially
attributed to morphine and Propofol infusion received while
in the Surgical Intensive Care Unit. However, on [**2192-5-29**], the patient continued to exhibit poor interaction with
others and an inability to tolerate p.o. and at this point
the Geriatrics Team was consulted.
On [**2192-6-1**], the patient was transferred to the Medical
Service for further management.
2. Renal: At the time of transfer to the Medical Service,
the patient's creatinine had markedly increased. Concern was
raised for another septic episode given hypernatremia as well
as rising creatinine and hypotension and mild fevers. As
discussed initially, a septic picture was considered and the
patient was started on broad-spectrum antibiotics, however, a
Foley catheter was placed and the patient exhibited a large
post obstructive diuresis. He was diagnosed with
post-obstructive uropathy and was followed closely. He had
no further rises in creatinine throughout the remainder of
his hospital course.
3. Infectious Disease: As discussed, it was initially felt
that the patient was septic at the time of the rise in
creatinine. He was covered with Vancomycin, Ceftazidine, and
Clindamycin. When cultures remained negative over 48 hours,
those antibiotics were discontinued. However, on [**6-4**], the
patient spiked a temperature to 102.0 F. Cultures were sent
by Venipuncture and off of his central line. An Infectious
Disease consultation was obtained.
They recommended that Clindamycin and Vancomycin be
discontinued. Liver functions were checked and these were
mildly elevated. An abdominal ultrasound was obtained which
was mainly negative. Please see separate report for full
details.
The patient also had yeast growing in his urine, which they
recommended not to be treated by the Infectious Disease
Service. Throughout the remainder of the hospitalization,
the patient remained afebrile. Surveillance cultures were
checked and remained mainly negative with the exception of
one set of blood cultures taken off of the patient's central
line which grew Staphylococcus aureus, coagulase negative,
felt to be a contaminant, given no other blood cultures grew
this. This was not treated with any antibiotics. The
patient remained afebrile throughout the remainder of the
course of the hospitalization.
Access: His central line was changed and replaced with a
PICC line.
4. Cardiovascular: The patient had tachycardia which was
treated off and on with Lopressor. This was occasionally
held given concerns for hypotension and at this time is off
Lopressor.
5. Pulmonary: The patient had worsening O2 needs and
developed tachypnea on [**2192-6-5**]. An arterial blood gas
was consistent with respiratory alkalosis and chest x-ray was
negative. A VQ scan was obtained which revealed a pulmonary
embolism. Although the study was poor, the patient was felt
to be high probability for pulmonary embolism and he was
treated with heparin. It was also known that he had a
thrombus in the right internal jugular from an old central
line which could also be the source of his embolus. Hypoxia
resolved, and at the time of this dictation, he is on room
air with no oxygen needs. He was ultimately changes to
Lovenox 60 mg subcutaneously q. 12. Coumadin was not started
because of fluctuating nutritional status.
6. Endocrine: Although he had no prior history of diabetes
mellitus, the patient was noted to be hyperglycemic while on TPN
and was managed with a regular insulin sliding scale, and insulin
in his TPN.
7. Gastrointestinal: On rounds on [**2192-6-6**], the patient
was found to be distended and tympanitic. An abdominal x-ray
was obtained which revealed a partial small bowel obstruction
versus ileus. An NG tube was placed and over the course of
the next several days, the patient's distention resolved
slowly. His NG tube was removed on [**6-9**], and the patient
remained stable since. Repeat abdominal x-ray showed
resolution of his small bowel obstruction/ileus.
Given his past history, it was felt that the most likely
cause of this was ileus as opposed to obstruction.
8. Fluids, Electrolytes and Nutrition: When initially
transferred to the Medical Service, the patient was
hypernatremic. This was repleted with free water and
adjustments in his TPN. Ultimately, the patient became
hyponatremic and required further TPN adjustments. At the
time of this dictation, his hyponatremia and hypernatremia
are both controlled and he has normal natremic and continues
to receive TPN. The patient was not started on enteral feedings
given his profound delirium and ileus problems. Since he had
not yet "woken up" and continued to be somnolent much of the
time, even after about a month after surgery, the prognosis was
quite guarded, so the decision for a PEG tube in this elderly
confused gentleman was deferred. At this time, he continued on
TPN.
9. Prophylaxis: The patient received Zantac in his TPN on
[**2192-6-11**]. This was changed to Protonix as Zantac can
interfere with mental status in the elderly.
ADDITIONAL STUDIES: During the course of this
hospitalization:
1. Abdominal ultrasound: Which revealed a simple cyst in
the liver and a small amount of pleural effusion on the right
(please see full report).
2. CT scan of the neck on [**2192-6-5**]: Revealed a filling
defect in the right internal jugular vein consistent with
non-occlusive thrombus and a left subclavian line which was
felt to be coiled upon itself. Following discovery of this,
his line was discontinued and changed to a PICC line.
3. CT scan of the abdomen and pelvis on [**2192-5-19**]: Full
transit of oral contrast through the GI tract; not unchanged
from the [**5-18**] CT scan of the abdomen which revealed no
evidence for pulmonary embolism in the main pulmonary
arteries and intussusception and small bowel obstruction.
4. Echocardiogram on [**2192-5-18**], ejection fraction greater
than 55%, left atrium moderately dilated; left ventricular
wall thickness, cavity size, and systolic function normal; an
left ventricular ejection fraction of greater than 55%; right
ventricular cavity dilated, right ventricular systolic
function appears depressed; aortic root moderately dilated.
Aortic leaflets three and mildly thickened, or at least mild
aortic regurgitation, mitral leaflets mildly thickened.
Presence/absence of mitral valve prolapse cannot be
determined. There is at last mild mitral regurgitation.
There is moderate pulmonary hypertension and no pericardial
effusion.
DISCHARGE STATUS: Stable for discharge to rehabilitation
facility.
DISCHARGE INSTRUCTIONS:
1. He should follow-up with his primary care physician upon
discharge.
2. Routine PICC line care with heparin and saline flushes.
3. Continue total parenteral nutrition.
DISCHARGE MEDICATIONS:
1. Lovenox 60 mg subcutaneously q. 12.
2. Regular insulin sliding scale.
3. Protonix 40 mg p.o. q. day.
4. Total parenteral nutrition as directed.
FINAL DIAGNOSES:
1. Colon cancer status post right hemicolectomy.
2. Sepsis.
3. Urosepsis.
4. Pulmonary embolus.
5. Obstructive uropathy.
6. Diabetes mellitus.
7. Ileus.
8. Small bowel obstruction.
9. Hypernatremia.
10. Hyponatremia.
11. Delirium.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 45008**]
Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36
D: [**2192-6-12**] 09:57
T: [**2192-6-12**] 10:03
JOB#: [**Job Number 37508**]
Admission Date: [**2192-5-4**] Discharge Date: [**2192-6-13**]
ADDENDUM: Of note, this is an addendum to detail the
patient's initial presentation prior to hospitalization.
HISTORY OF PRESENT ILLNESS: This is an 85-year-old white
hematocrit down to 22 which was normal one year prior to
admission.
A workup including colonoscopy on [**2192-4-4**] revealed a
large fungating cecal mass with question of involvement of
the ileocecal valve, though there was no evidence of
obstruction. Pathology was highly suspicious for cancer, but
gastrointestinal symptoms with the exception of decreased
exertional tolerance secondary to easy fatigue. He has had
some fecal and urinary incontinence develop over the past
several years. No weight loss was noted.
PAST MEDICAL HISTORY: Mild dementia with decreased
short-term memory.
MEDICATIONS ON ADMISSION: Medications at home included
aspirin (stopped in [**2192-3-16**]) and Niferex 100 mg p.o.
t.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He never smoked. No alcohol. No drugs.
Married times 55 years with one daughter. [**Name (NI) **] is a retired
hospital pharmacist.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on [**2192-4-19**] preoperatively revealed a neurologically
pleasant and cooperative white male with minimal
comprehension and recall of short-term events, but able to
follow commands. A shuffling stable gait. No focal defects.
Head, eyes, ears, nose, and throat examination revealed 4+
carotids. No bruits. Decreased range of motion.
Cardiovascular was a regular rate and rhythm without murmurs,
rubs or gallops. Chest was clear to auscultation and
percussion. The abdomen was soft and nontender, with no
masses, no organomegaly, and a well-healed hernia scar.
Extremities revealed 4+ pulses bilaterally, 1+ edema to the
ankles.
HOSPITAL COURSE: The patient was admitted on [**2192-5-4**]
for surgical removal of fungating mass. Please see the prior
dictation for details of the [**Hospital 228**] hospital course.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 45008**]
Dictated By:[**Name8 (MD) 2665**]
MEDQUIST36
D: [**2192-6-12**] 17:25
T: [**2192-6-12**] 17:48
JOB#: [**Job Number **]
Name: [**Known lastname 17670**], [**Known firstname 448**] Unit No: [**Numeric Identifier 17671**]
Admission Date: [**2192-5-4**] Discharge Date: [**2192-6-18**]
Date of Birth: Sex: M
Service:
ADDENDUM: This is an addendum to his discharge summary
detailing his stay from [**2192-6-13**] through [**2192-6-18**].
Due to nutritional concerns, a G tube was placed on [**2192-6-13**]. Tube feedings were started on [**2192-6-14**]. He
remained afebrile and stable from and infectious disease
standpoint, and required no antibiotics. His pulmonary
status also remained stable. His cognitive status slowly
improved and he became more alert and interactive each day,
able to speak in short sentences. His PICC line was finally
discontinued and his fingersticks and regular insulin sliding
scale was also discontinued after he was started on tube
feeds.
He was finally discharged to an acute rehab facility on [**2192-6-18**] for increasing strength, mobility, and general
reconditioning.
DISCHARGE INSTRUCTIONS:
1. G tube feeding at 75 cc an hour.
2. Follow-up with primary M.D. after discharge.
3. Consider swallowing study as the patient's delirium
improves.
DISCHARGE MEDICATIONS:
1. Lovenox 60 mg subcutaneously q. 12 hours.
2. Protonix 40 mg p.o. q.d.
DR.[**Last Name (STitle) **],[**Doctor First Name 1658**] 12-847
Dictated By:[**Name8 (MD) 17380**]
MEDQUIST36
D: [**2193-3-27**] 07:38
T: [**2193-3-27**] 20:22
JOB#: [**Job Number 17672**]
|
[
"038.3",
"599.6",
"996.74",
"293.0",
"250.00",
"153.6",
"518.82",
"560.1",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"43.11",
"99.15",
"96.71",
"50.12",
"38.93",
"45.73",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12238, 12535
|
9595, 9731
|
10600, 12038
|
12062, 12215
|
8258, 8916
|
8945, 9496
|
9519, 9568
|
9748, 10581
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,169
| 116,296
|
45405
|
Discharge summary
|
report
|
Admission Date: [**2130-2-9**] Discharge Date: [**2130-2-21**]
Date of Birth: [**2071-10-16**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Altered mental status, respiratory failure
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Bronchoscopy
Central Venous Cannulation
Arterial Line Placement
History of Present Illness:
58 yo female who at [**Hospital3 **] facility was noted to have
changes in mental status, eye rolling, gait instability at home.
Had also reported to outside providers that she was coughing
and low grade temps for several weeks -> started on augmentin
[**1-12**]. Call to PCP reported some pain from abdominal incision,
fatigue and depression. Brought to ED on [**2130-2-9**] and was found
to have fever and hypoxia and respiratory distress. She was
started on NIPPV. She was eventually intubated upon transfer to
ICU for somnolence and no significant improvement in terms of
respiratory status. Started on levo, vanco, cefepime. [**Hospital **] facility reported [**1-4**] pills missing from trazadone
bottle. Toxicology consult obtained but it turned out the
facility was mistaken and was referring to another patient, so
erroneous. MICU course ([**Date range (1) 33280**]) was significant for mucus
plugging s/p bronchoscopy on [**2-10**] showing thin secretions,
sputum cx growing H flu, oliguria responsive to IVF, bradycardia
from Precedex, development of HTN while on steroids. Was
extubated on [**2-16**]. HCT also showed frontal lobe hypodensities of
unclear chronicity, family declined MRI for now. At this point,
leukocytosis, hypercapnia, mild transaminitis have all improved.
She has some paranoid thoughts about her health care which are
new. Denies any suicidal or homicidal thoughts. Reports that
breathing is "at 100%" and reports no pain.
Past Medical History:
- COPD/asthma
- "throat disorder" ("not GERD or Barrett's...throat closes if I
don't take protonix")
- depression with suicide attempts in past
- sleep apnea
- colonic polyps
- no h/o HTN, no anti-HTN meds in OMR
Past Surgical History:
- cholecystectomy [**2124**] c/b subsequent incarcerated hernia with
bowel compromise requiring small bowel resection with primary
anastamosis @ OSH
- ventral hernia repair
Social History:
- Tobacco: still actively smoking up until admission per niece
(per patient quit 2 weeks ago)
- Alcohol: negative
- Illicits: negative
Family History:
HTN diffusely in family
Physical Exam:
Admission Exam (in MICU):
General Appearance: Intubated, sedated. Wakes up when
stimulated, starts choking on tube. Can occasionally squeeze
hands
Eyes / Conjunctiva: left pupil s/p cataract surgery. 5 mm L, 2
mm R pupil. ERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Lymphatic: Cervical WNL
Cardiovascular: RRR, normal S1,S2. No m/g/r
Respiratory / Chest: Good bilateral air entry, coarse upper
respiratory sounds/rhonchi, but no wheezes or crackles.
Significant sputum production.
Abdominal: Soft, Non-tender, Obese, mid-line ventral hernia
scar, well-healed
Extremities: Warm, well perfused. 2+ peripheral pulses. No
edema
Exam on transfer ([**2-17**] PM):
Gen well appearing female in NAD
VS afebrile 170/90 95 95% 2L
Neck JVD unable to be appreciated
CV RR no mrg
Pul poor air movement, scant end-inspiratory wheezes, no rales
Abd soft NT ND, midline scar well healed, no palpable hernia
Ext without edema, cold but not cyanotic
Neuro "[**Hospital1 18**]," "you're a doctor," "I'm here for pneumonia."
Could only do 4 digits immediate recall. CN 2-12 intact, VFFTC,
sensation intact to light touch, DTRs present and symmetric in
upper extremities and knees.
Psych reported "someone is trying to download files about that
person who died in the ICU" and "they are after me"
Exam on discharge
AVSS with SBPs 110-120s. Desaturation to 88% transiently on
ambulation on room air.
NAD, hoarse voice
No wheezes, good air movement
CNII-XII intact, normal gait, normal affect.
Pertinent Results:
====================
LABORATORY RESULTS
===================
On Admission:
WBC-18.4*# RBC-4.89 Hgb-12.6 Hct-40.2 MCV-82 RDW-15.1 Plt Ct-271
--Neuts-87.1* Lymphs-6.9* Monos-5.6 Eos-0.2 Baso-0.2
PT-11.4 PTT-25.3 INR(PT)-1.1
Glucose-157* UreaN-19 Creat-0.9 Na-133 K-4.4 Cl-97 HCO3-24
ALT-105* AST-133* CK(CPK)-100
Calcium-8.2* Phos-3.7 Mg-2.1 Albumin-4.1 Lactate-1.1
VitB12-802 Osmolal-280 TSH-0.48
Blood Tox: ASA-NEG EtOH-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Urine: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013 RBC-1 WBC-2
Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 CastGr-2* CastHy-30*
bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG
mthdone-NEG
On Discharge:
[**2130-2-21**] 07:24AM BLOOD WBC-7.8 RBC-4.91 Hgb-12.8 Hct-39.4
MCV-80* MCH-26.0* MCHC-32.4 RDW-16.3* Plt Ct-503*
[**2130-2-21**] 07:24AM BLOOD Glucose-146* UreaN-21* Creat-0.6 Na-133
K-3.9 Cl-99 HCO3-23 AnGap-15
[**2130-2-19**] 06:05AM BLOOD %HbA1c-6.2* eAG-131*
Other Significant Labs:
[**2130-2-9**] 04:48PM BLOOD CK-MB-7 cTropnT-0.06*
[**2130-2-9**] 11:45PM BLOOD CK-MB-6 cTropnT-0.02*
==============
MICROBIOLOGY
==============
Urine Culture [**2130-2-9**]:
URINE CULTURE (Final [**2130-2-10**]):
PROBABLE ENTEROCOCCUS. ~1000/ML.
Sputum Culture [**2130-2-9**]:
GRAM STAIN (Final [**2130-2-9**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2130-2-11**]):
SPARSE GROWTH Commensal Respiratory Flora.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE.
MODERATE GROWTH.
BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN.
All blood cultures negative
==============
OTHER STUDIES
==============
EKG on Presentation [**2130-2-9**]:
NSR, NI, LAD, TWI in V1-V3, transition point V5. Similar to
prior dated [**2128-8-31**].
CXR [**2130-2-9**]:
Impression:
1. Pulmonary vascular congestion.
2. Area of increased opacity lateral right upper lung could be
due to
overlying vascular and osseous structures, although underlying
consolidation may be present, due to infection or aspiration.
CT Head [**2130-2-9**]:
Impression:
1. Loss of [**Doctor Last Name 352**]-white matter differentiation and subtle
hypodensities in the left frontal lobe, inferior putamen, and
subinsular region . The etiology is unclear. Would recommend MRI
for further evaluation.
2. Small air-fluid levels in the right maxillary sinus and
sphenoid sinuses may be related to intubation.
TTE [**2-13**]:
The left atrium is elongated. The left ventricular cavity size
is normal. Regional wall motion abnormalities could not be
excluded due to suboptimal imaging. However, overall left
ventricular systolic function is probably normal (LVEF>55%). The
number of aortic valve leaflets cannot be determined. There is
no aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Regional wall motion
abnormalities could not be excluded due to suboptimal imaging.
However, overall left ventricular systolic function is probably
normal. No significant valvular regurgitation/stenosis.
CXR [**2-17**]:
FINDINGS: In comparison with the study of [**2-15**], the endotracheal
tube and
nasogastric tube have been removed. Continued hyperexpansion of
the lungs
with substantial decrease in opacification at the right base.
Pulmonary
vascularity is within normal limits, and there is no definite
pneumonia. Mild atelectatic changes at the bases.
CT Head [**2130-2-18**]:
IMPRESSION: Previously seen vague hypodensities in the left
insular region
are less apparent on today's examination. No acute hemorrhage
detected.
MRI Head/ MRA Head/ MRA Neck [**2130-2-18**]:
IMPRESSION:
1. Findings involving the parieto-occipital subcortical white
matter,
bilaterally, without significant mass effect or associated
diffusion
abnormality or hemorrhage. These findings are most suggestive of
so-called
PRES (posterior reversible encephalopathy syndrome) and should
be closely
correlated with history of significant hypertension (including
"relative"
hypertension) and/or implicated pharmaceutical agents.
2. Discrete and confluent FLAIR-hyperintensity in bihemispheric
subcortical
and periventricular and central pontine white matter, unchanged
since
[**2129-5-18**], and likely representing chronic small vessel ischemic
disease,
perhaps related to underlying hypertension.
3. Unremarkable cranial MRA, with no flow-limiting stenosis.
N.B. The
cervical MRA could not be completed.
Brief Hospital Course:
58F asthma/COPD with recent hospitalization for pneumonia/COPD
exacerbation at [**Hospital1 **] in [**11-26**], sleep apnea,
depression with prior SI, tobacco abuse brought in by ambulance
for altered mental status, found to have pneumonia and
continuing altered mental status thought to be secondary to PRES
syndrome.
ACTIVE ISSUES:
# Hypercarbic and hypoxemic respiratory failure/ COPD with
exacerbation/ Acute bacterial pneumonia (H. Influeza): Pt placed
on BiPAP in ED, but intubated on arrival to the ICU for
respiratory acidosis, hypoxemia and failure of bipap trial,
copious secretions found on intubation. Etiology likely
multifactorial: ? COPD/asthma exacerbation with pneumonia. PE
thought unlikely. CXR showed RLL PNA. Bronchoscopy showed
significant mucous production with airway mucous plugs
occasionally. Patient was started on cefepime, vanco,
levofloxacin (D1= [**2-9**]) for PNA coverage and given Prednisone
60mg for 3 day course with standing MDIs for possible COPD
exacerbation. H. influenza came back positive in the sputum.
Patient was continued on cefepime and levofloxacin (Vanc d/c'd
[**2-12**]) until sensitivities returned and then converted to
levofloxacin alone and finished 10 days of therapy for acute
bacterial pneumonia. She still had considerable wheezing so
standing bronchodilators continued. Prednisone was stopped on
[**2130-2-18**] after development of PRES and patient was started on
fluticasone inhaler for better control of COPD/Asthma.
- Pt ambulating with 02 saturations to 88% on room air that
promptly return to >90% upon rest.
# Sepsis secondary to Bacterial PNA: Patient met SIRs criteria
on admission (fever, tachycardia, leukocytosis) with suspected
pulmonary source (pneumonia). CXR showed RLL PNA. Affected
organs are lungs (respiratory failure) and altered mental
status. Urine output initially poor but Cr remained stable.
Lactate remained WNL. No other apparent sources ?????? UA not
suggestive of infection, does not seem to have any pain w
abdominal palpation, no diarrhea. Had initially questioned
meningitis, however this seemed less likely given her clear
pulmonary source. Continued antibiotics for PNA as above and
septic physiology resolved.
# Acute Encephalopathy: Per reports, patient had gait
instability and was "groggy." There is some concern for ?
toxidrome given numerous psychiatric medications. Other
considerations include septic encephalopathy, hypercarbia,
primary CNS process such as SDH or meningitis. Toxicology
consulted re: possible trazadone ingestion ?????? recommended benzos
for agitation and monitoring of ECG for QRS/QTc prolongation, as
patient is also on effexor. CT scan showed findings concerning
for some hypoxic injury, however unclear if this was acute or
chronic. TSH and Vit B12 normal and on arrival to the floor pt
no longer acutely encephalopathic
.
# Posterior reversible encephalopathy Syndrome/Seizures: On the
day after transfer out of the MICU the patient intially appeared
well and respiratory status was stable. She then developed a
sudden episode of unresponsiveness where she was noted to have
choking sounds but no abnormal movements were noted. She began
to respond in less than a minutes but was unable to speak and
could only follow commands on left side of the body. A code
stroke was called. Head CT benign but already exam had returned
to nearly baseline suggesting more likely seizure. Prior to
going for MRI patient had an additional seizure, which was
convulsive and consisted of face and eye clonic movements to the
right. This lasted less than three minutes and resolved on its
own with post ictal period following. The patient received
lorazepam and went to MRI where imaging consistent with PRES
thought likely contributed to by relative hypertension (SBPs in
170's from baseline of normotensive) and possibly prednisone.
As it was day 8 of prednisone taper this was stopped and patient
was loaded with levetiracetam.
.
***She had no further seizures. She was discharged with plan to
follow up with neurology in one month and repeat MRI in two
months to document resolution. She should be seizure free for
six months prior to driving again, which was emphasized by the
primary team and neurology***
- Final EEG still pending at the time of discharge
- Patient discharged on Keppra 1000mg [**Hospital1 **]
- Pt to follow-up with neurology in 1 month time. She will need
a repeat MRI to evaluate PRES in ~ 2 months.
.
# Hypertension: Patient with hypertension noted in the ICU and
thought likely secondary to prednisone. Captopril was started
but SBPs still running in 150s-170s on transfer out of the MICU.
Dose increased after PRES diagnosis but later when SPB in 90's
was decreased back to 6.25 mg po tid.
**At discharge she was transitioned to lisinopril 10mg with SBPs
in the 110s-120s (based on Captopril dosing)
.
# OSA: She was continued on CPAP after extubated with no acute
issues.
.
# Depression: Held home effexor while intubated, as this cannot
be crushed. Concern for trazadone overdose contributing to AMS
on presentation but then concern for empty pill bottles appears
to have been inappropriate as report of empty bottle actually
referred to another patient. Patient was re-initiated on her
home psychiatric medication regimen with normal mental status
prior to discharge. Psychiatry followed her throughout the
admission. Although remeron and clonazepam were recommended
being discontinued on discharge, the patient stated that she had
these medications at home and would likely take them for sleep
and anxiety once at home. A message was left with the patients
outpatient prescribing physician (Dr. [**First Name (STitle) 6164**] to call back the
Hospitalist pager at [**Telephone/Fax (1) 9472**] and was pending at the time of
discharge. A ECG was checked prior to d/c with the pt's QTC <400
prior to d/c.
.
Transitional Issues:
- Coordination was made with the [**Company 191**] transitions team on
discharge
- A visiting nurse was set up to provide medication teaching,
orthostatic checks and pulmonary evaluation on discharge.
- The patient is to follow-up with Dr. [**Last Name (STitle) **] on [**2130-2-28**]
- A medication reconcillation was attempted over the phone with
the [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **], but the staff member stated the medication
list was a "few years old" ([**2130-2-21**])
- A medication reconcillation was performed with the [**Company 4916**]
on [**Location (un) **] St in [**Location (un) 745**] over the phone on ([**2130-2-21**]). Attempts
were made to reconcile the above list as best possible.
Potential issues include pt prescribed 2 B-agonists (albuterol
and pivoablbuterol), addition of Keppra, low SBPs with
Lisinopril 10mg.
-Patient should not drive until seizure free for six months
-She will need close monitoring of her depression while on
levetiracetam as this medication can worsen depression
-She should follow up with Dr. [**Last Name (STitle) **] in neurology in one month
-She should have repeat head MRI in two months to document
resolution of PRES
Medications on Admission:
- risperdal 2 mg PO qAM
- baclofen 10 mg PO TID
- oxybutynin ER 15 mg PO BID (Pt reported takes 20 mg QAM and 10
mg QPM)
- remeron 45 mg PO qHS
- trazadone 200 mg PO qHS
- [**Doctor First Name 130**] 60 mg 2 tab PO qD
- ibuprofen 800 mg [**1-16**] tab PO prn
- Gabapentin 600 mg PO qHS
- singulair 10 mg PO qD
- doc-q-lace 100 mg PO 2 tab qD
- Effexor XR 75 mg PO qD
- Effexor XR 150 mg 2 tab PO qD
- Protonix 40 mg PO BID
- topamax 200 mg PO BID
- albuterol sulfate INH prn SOB
- prednisone taper [**1-20**] Tablet(s) by mouth daily as directed 60
mg daily x 3 days then 40 mg daily x 3 days then 20 mg daily x 2
days then 10 mg daily x 2 days (unclear if started)
Discharge Medications:
1. risperidone 1 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
2. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. oxybutynin chloride 5 mg Tablet Extended Rel 24 hr Sig: Three
(3) Tablet Extended Rel 24 hr PO twice a day.
4. trazodone 100 mg Tablet Sig: Two (2) Tablet PO at bedtime as
needed for insomnia.
5. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Five (5)
Capsule, Ext Release 24 hr PO DAILY (Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. topiramate 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
10. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO once
a day.
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for shoulder pain or fever.
12. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
13. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Remeron 45 mg Tablet Sig: One (1) Tablet PO once a day.
15. clonazepam 2 mg Tablet Sig: One (1) Tablet PO once a day.
16. Advair Diskus 500-50 mcg/dose Disk with Device Sig: One (1)
Inhalation once a day.
17. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day.
18. Astelin 137 mcg Aerosol, Spray Sig: One (1) Nasal once a
day.
19. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
20. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: [**1-16**]
Inhalation every 4-6 hours.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary Diagnoses:
-Hemophilus Influenza Pneumonia
-Chronic obstructive Pulmonary Disease Exacerbation
-Hypercarbic and Hypoxemic Respiratory Failure
-Posterior Reversible Leukoencephalopathy
Secondary Diagnoses:
-Depression
-Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with shortness of breath and found to have a
severe pneumonia as well as a worsening of your chronic
obstructive pulmonary disease. You were treated with
antibiotics and medicines to help open your lungs but you still
required a machine to support your breathing. You were
eventually weaned off this machine.
You also developed a condition called posterior reversible
leukoencephalopathy (PRES), likely related to relatively high
blood pressures and the prednisone medicine used to treat your
chronic obstructive pulmonary disease. This caused you to have
seizures. You were treated with an anti-seizure medicine and
your blood pressure controlled **and you had no further
seizures.** This should completely resolve but you will need to
follow up with neurology and should not drive for six months.
Your medications have been changed. Please take all medications
as prescribed.
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2130-2-28**] at 10:00 AM
With: DR [**First Name (STitle) **] [**First Name (STitle) **]/[**Company 191**] POST [**Hospital 894**] CLINIC
Phone: [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.**
Department: NEUROLOGY
When: WEDNESDAY [**2130-4-5**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,343
| 180,144
|
13438+56456
|
Discharge summary
|
report+addendum
|
Admission Date: [**2176-8-5**] Discharge Date: [**2176-8-28**]
Date of Birth: [**2134-9-23**] Sex: F
Service: MEDICINE
Allergies:
Trileptal
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Fevers, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
41 yo F w/ hx pineal germ cell tumour s/p XRT and chemo & s/p
VPS for non-communicating hydrocephalus, C. diff,
hypopituitarism, seizure d/o on keprra, HL, HTN, who p/f [**Hospital1 **]
w/ fevers x2wks and declining mental status. Recent BCx have
been negative, UCX w/ pan-resistant pseudomonas, sputum Cx w/
serratia & stenotrophomonas. She also has hx C diff and was
recently on Cefepime and Vanc. Reportedly she has been sleepier
than usual and has occasional R-sided tremor. She is non-verbal
at baseline, with chronic trach and peg.
.
Pt was admitted to [**Hospital1 18**] from [**Date range (1) 40761**] for fevers. During that
admission, she was tx for asp PNA w/ Cefepime and tx for C diff
w/ vancomycin. Her hospital course was complicated by GI bleed
and ARF. She had presentation for exposed hardward w/ removal of
VPA and replacemnet on [**6-19**].
.
In ED, VS: T 99.3 BP: 138/75 HR: 100 RR: 28 SaO2: 92% on 35%
trach mask. Labs were remarkable for WBC 22K, ALT 64, AST 52, Na
128, plt 670, lactate 2.8. U/A w/ mod leuk, (+) nitrites, WBC
21-50, few bacteria. CXR unremarkable. CT: new sulcal effacement
of mostly L-occipital and parietal lobes w/ relative sparing of
frontal and tempral lobes which might be c/w cerebritis.
Neurosurg evaluated pt in ED and tapped VPS to eval for
infeciton. They rec'd empiric Abx to tx infection w/ no role for
surgical intervention. Pt given tylenol and IVF in ED along w/
Vanc/Zosyn/Cefepime/Acyclovir. On arrival to floor, pt
incontinent of loose stool.
Past Medical History:
- Pineal germ cell tumor s/p radiation and chemotherapy at age
14
- s/p VP shunt for noncommunicating hydrocephalus [**2148**] with
frequent falls and several revisions
- s/p fall with depressed skull fracture in [**2174-9-10**],
underwent cranioplasty
- Complex partial seizure disorder
- Bilateral hearing loss
- Pan-hypopituitarism, with reported history of a prolactinoma
and adrenal insufficiency
- Dyslipidemia
- Hypertension
- Osteopenia
- Reported history of SDH in [**2156**] s/p evacuation, and
complicated by stroke with left sided weakness and slurred
speech that completely resolved
- Dysphagia/Aspiration
- PEG placement [**3-18**]
- MRSA UTI
- Colonized by VRE in urine
Social History:
Currently resides at [**Hospital3 105**]. Current baseline is
bed-bound, deaf, and nonverbal.
Family History:
NC
Physical Exam:
Vitals - T: 101.2 BP: 116/61 HR: 118 RR: 23 02 sat: 100% on 50%
trach mask
GENERAL: Patient lying in bed, no apparent distress. Patient
does not follow commands. Diaphoretic.
HEENT: No conjunctival pallor. No scleral icterus. Pupils are
only minimally reactive. MMM. OP with thrush.
CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**].
LUNGS: Scattered rhonchi, no wheezing.
ABDOMEN: NABS. Soft, NT, ND. No HSM. PEG in place.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
NEURO: Non-verbal, withdraws to pain in b/l LE, less so in upper
extremities.
Pertinent Results:
LABORATORY DATA ON ADMISSION:
[**2176-8-5**] 05:00PM BLOOD WBC-22.9* RBC-3.26* Hgb-8.9* Hct-27.6*
MCV-85 MCH-27.2 MCHC-32.1 RDW-19.2* Plt Ct-670*
[**2176-8-5**] 05:00PM BLOOD Neuts-89* Bands-0 Lymphs-4* Monos-5 Eos-1
Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-1*
[**2176-8-5**] 05:00PM BLOOD PT-11.3 PTT-23.4 INR(PT)-0.9
[**2176-8-5**] 05:00PM BLOOD Glucose-306* UreaN-15 Creat-0.8 Na-128*
K-4.7 Cl-92* HCO3-25 AnGap-16
[**2176-8-5**] 05:00PM BLOOD ALT-64* AST-52* AlkPhos-151* TotBili-0.2
[**2176-8-5**] 05:00PM BLOOD Albumin-3.3* Calcium-9.7 Phos-3.6 Mg-1.6
[**2176-8-6**] 12:03PM BLOOD calTIBC-202* Ferritn-201* TRF-155*
[**2176-8-6**] 09:30PM BLOOD Type-ART pO2-86 pCO2-42 pH-7.38
calTCO2-26 Base XS-0
[**2176-8-5**] 05:27PM BLOOD Lactate-2.8*
[**2176-8-5**] 05:27PM URINE RBC-0 WBC-21-50* Bacteri-FEW Yeast-NONE
Epi-0
[**2176-8-5**] 05:27PM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2176-8-5**] 05:27PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2176-8-6**] 12:00AM CEREBROSPINAL FLUID (CSF) WBC-8 RBC-310*
Polys-5 Lymphs-71 Monos-18 Atyps-2 Macroph-4
[**2176-8-6**] 12:00AM CEREBROSPINAL FLUID (CSF) TotProt-102*
Glucose-99
[**2176-8-28**] 05:49AM CALCIUM 10.9
[**2176-8-28**] 05:49AM Dilantin 10.1
[**2176-8-24**] 05:00PM Dilantin 4.6*
[**2176-8-16**] 07:00AM Dilantin 15.6
[**2176-8-13**] 10:33PM Dilantin 20.0
.
MICROBIOLOGY:
1. CSF:
8 WBC, 310 RBCs 5 percent polys; 71 percent lymphs
Gram stain 1+PMNs, no organisms.
Tot protein 102, glucose 99
Cultures and HSV PCR negative
.
2. Blood cultures [**2176-8-5**]: Negative
.
3. Urine cultures 7/28
PSEUDOMONAS AERUGINOSA |
AMIKACIN-------------- 8 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 4 S
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
.
4. Sputum cultures 7/28
PSEUDOMONAS AERUGINOSA
| STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
| |
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 4 S
MEROPENEM------------- 8 I
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
5. Stool negative for C. diff toxin x3
.
STUDIES:
1. CT HEAD W/O CONTRAST ([**2176-8-5**]): New sulcal effacement of the
left occipital and parietal lobes with relative sparing of the
temporal and frontal lobes. Given short interval development
from [**2176-6-29**] in addition to the complete opacification of
the mastoid air cells, this favors an infectious etiology such
as cerebritis. Further evaluation with MRI is recommended.
.
2. CT CHEST/ABDOMEN/PELVIS ([**2176-7-3**]): 1. Bilateral pleural
effusions with bibasilar atelectasis, and airspace opacification
in the right upper lobe, could be due to pneumonia. Correlate
with clinical symptoms. Low lung volumes. 2. Indeterminate
nodule in the left adrenal gland. 3. Multiple subcentimeter
hypodensities in the liver, too small to characterize. 4.
Multiple compression deformities of vertebral bodies, with old
healed fractures in the ribs, old fracture of the sternum, old
fracture at the coccyx.
.
3. CHEST PORTABLE AP ([**2176-8-5**]): New area of opacity in the
right mid lung may represent an area of infection or increased
atlectesis in setting of decreased lung volumes. Otherwise,
bibasilar atelectasis is stable.
.
4. MRI/MRV HEAD: Scattered foci of high signal intensity
indicating restricted diffusion on the left parietal and left
occipital lobe and also on the right occipital lobe, likely
consistent with acute/subacute ischemic changes. There is no
evidence of ventriculitis or cerebritis. Limited examination
secondary to motion artifact and metal artifact, ventricular
shunt noted on the left frontal ventricular [**Doctor Last Name 534**] via right
frontal burr hole. Unchanged areas of encephalomalacia, chronic
pachymeningeal enhancement with small subdural collections
bilaterally, unchanged since the prior examinations. Bilateral
opacities in the mastoid air cells.
.
5. EEG: Five pushbutton activations were captured in this
telemetry without electrographic or clinical correlate. Routine
sampling shows a polymorphic delta activity background rhythm
with decreased voltage over the left hemisphere. There are
epileptiform discharges in the left
mid-temporal region and periodic lateralized epileptiform
discharges in
the right hemisphere. Seizure detection files showed two
electrographic
seizures without clinical correlate on video.
Brief Hospital Course:
Ms. [**Known lastname 40754**] is a 41F with a PMH s/f a pineal germ cell tumer
s/p chemotherapy and radiation many years ago complicated by
hydrocephalus requiring a VP shunt, and complex partial
seizures. In the recent past, her clinical status has
deteriorated after having had multiple VP shunt revisions, and
CNS infections. Currently she is Tracheostomy, PEG tube, and
foley dependent, bed-bound, and with severe cognitive
impairment. She was admitted on [**2176-8-5**] with fevers, altered
mental status, and worsening seizure control. The following
issues arose during her hospitalization from [**0-0-0**]
.
1. Fevers: Prior to arrival to [**Hospital1 18**], she had had multiple
cultures taken at her long term care facility. Her sputum was
growing serratia and stenotrophomonas, and urine was growing
pan-resistant pseudomonas. She also had an ongoing c. difficle
infection. On arrival to the hospital, she was febrile, and
tachycardic with stable blood pressures. A CT scan of her head
showed possible cerebritis. Samples of her CSF, sputum, urine,
blood, and stool were taken to look for a fever source, and with
the help of an infectious disease consultation, she was
empirically treated with vancomycin, cefepime, colistin, PO
vancomycin, and acyclovir- given concern for VPS associated
encephalitis, ventilator associated pneumonia, pan-resistant
foley associated UTI, and c. diff colitis. An MRI was performed
to further evaluate the findings on CT scan, which showed
multiple embolic strokes. Cultures returned negative in the CSF
for bacterial or HSV infection, and highly resistant pseudomonas
species grew in both sputum and urine. Blood cultures remained
negative. Her antimicrobials were pared down to cefepime and
colistin, which she completed a course of for her concurrent
infections, ending on [**2176-8-20**]. She defervesced on this
regimen, and remained hemodynamically stable.
.
2. Altered mental status: Her recent baseline, per her family
and longitudinal care providers was quite limited, with only the
ability to track with her eyes when stimulated. On admission,
she was unresponsive to visual stimulus. Her MRI did not
confirm any evidence of encephalitis, and in fact showed
multiple acute/subacute embolic strokes. Her EEG showed
evidence of seizure activity. Taken together, her decline in
mental status was taken to be multifactorial: related to shower
emboli, increased seizure activity, and delirium from multiple
infections. Unfortunately, this did not improve with treatment
of her seizures or infections.
.
3. Increased seizure activity: Her father had noticed that her
arms were shaking with increased frequency. A 24hour video EEG
was performed, which confirmed the presence of seizure activity,
which correlated to the images captured on video. Initially,
the neurosurgery team recommended titrating her keppra dose.
She initially seemed to respond to this, only to later develoop
further seizure activity despite making these adjustments.
Neurology was consulted, and per their recommendations, dilantin
was started and is being titrated for better seizure control.
Ativan was used as need for seizure control, then later replaced
with daily scheduled Valium.
.
4. Respiratory distress: Early during her admission, she
developed periods of tachypnea, coughing, and desaturations,
which required a brief ~12 hour stay in the MICU. This was
reversed with deep suctioning, and felt to be secondary to
mucous plugging. She requires deep suctioning ~2 times per
nursing shift.
.
5. Hypercalcemia/Elev BUN: During the latter days of her
hospitalization, she started having elev BUN in 30-40 range.
She was also noted to have elev Ca in [**10-20**] range, unable to
assess if she is symptomatic from it. She was given IVF, which
improved these levels mildly. Her tube feeds and free water
flushes were also adjusted to maximize her free water intake.
.
6. Panhypopituitarism: During the first two days of her
admission, she was given a stress dose of hydrocortisone, and
once her tachycardia and fevers resolved, she was switched back
to her usual prednisone dose. She was maintained on
levothyroxine as well.
.
7. Diabetes: She was maintained on an insulin sliding scale
throughout her hospitalization. Her sugars were mostly in
100-200 range.
.
8. Sinus tachycardia: This is chronic for her, baseline 100-110.
She was maintained on her metoprolol.
.
9. Multidisciplinary family meeting: Given her poor prognosis,
the decision was made to hold a family meeting with her
neurosurgeon, parents, and the primary team. The family was
informed about her current status, and poor prognosis. The
family also met with our palliative care team to further explore
[**Known firstname 40762**] options after leaving the hospital. After further
discussions, the code status was changed to DNR/DNI. The family
is however not ready to move to palliative care/hospice, were
wanting the entire family to be able to gather prior to making
that decision.
Medications on Admission:
MEDICATIONS: (per OMR, need to confirm with father)
Heparin 5,000 unit/mL TID
Levetiracetam 1000 mg [**Hospital1 **]
Docusate Sodium 100 mg [**Hospital1 **]
Gabapentin 400 mg Capsule 2 Capsule PO Q12H
Insulin Lispro 100 unit/mL
Lansoprazole 30 mg Tablet daily
Levothyroxine 75 mcg Tablet daily
Metoprolol Tartrate 50 mg Q6H
Multivitamin 1 tablet daily
Senna 8.6 mg Tablet PO BID PRN: constipation
Modafinil 100 mg Tablet daily
Ferrous Sulfate 325 mg daily
Prednisone 5 mg daily
.
ALLERGIES: Trileptal
Discharge Medications:
1. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: One (1)
Subcutaneous ASDIR (AS DIRECTED).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Levothyroxine 75 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
5. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for consipation.
6. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO BID (2 times
a day).
7. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
8. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for [**Female First Name (un) **] on buttocks, back.
9. Keppra 500 mg Tablet [**Female First Name (un) **]: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
10. Prednisone 20 mg Tablet [**Female First Name (un) **]: 1.25 Tablets PO QAM (once a day
(in the morning)).
Disp:*40 Tablet(s)* Refills:*2*
11. Prednisone 2.5 mg Tablet [**Female First Name (un) **]: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet [**Female First Name (un) **]: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
13. Diazepam 5 mg Tablet [**Female First Name (un) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Phenytoin 50 mg Tablet, Chewable [**Female First Name (un) **]: Two (2) Tablet,
Chewable PO NOON (At Noon).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
15. Phenytoin 50 mg Tablet, Chewable [**Female First Name (un) **]: Two (2) Tablet,
Chewable PO QAM (once a day (in the morning)).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
16. Phenytoin 50 mg Tablet, Chewable [**Female First Name (un) **]: Three (3) Tablet,
Chewable PO QPM (once a day (in the evening)).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - Twin Oaks - [**Location (un) 4047**]
Discharge Diagnosis:
Pan-resistant Psuedomonal UTI
Pseudamonal VAP
Seizure d/o
Discharge Condition:
fair
Discharge Instructions:
You were admitted to [**Hospital1 18**] for fevers and change in mental
status. You were found to have a urinary tract infection, as
well as a pneumonia in your lungs. These infections were
treated with the appropriate IV antibiotics. You were also
having increased movements in your arms, raising the concern
about seizures. A video EEG was done which confirmed that you
were indeed having seizures. Your Keppra dose was optimized and
you were also started on a second medication, Dilantin, to
prevent seizures. Additionally, we started daily Valium to
further help with seizure control.
Please make the following changes to your medications:
1. Start Keppra 1500 mg twice a day
2. Stop Keppra 1000mg twice a day
3. Start Dilantin 100 mg in morning and at noon, then 150 mg in
the evening
4. Start Valium 5 mg daily
5. Stop Heparin 5,000 unit/mL three times a day
6. Start Metoprolol Tartate 37.5 mg three times a day
7. Stop Metoprolol Tartate 50 mg every 6 hours
8. Stop Multivitamin 1 tablet daily
9. Stop Modafinil 100 mg Tablet daily
10. Stop Ferrous Sulfate 325 mg daily
11. Start Prednisone 25 mg in morning and 2.5 mg at night
12. Stop Prednisone 5 mg daily
Seek medical attention immediately if patient has uncontrollable
bleeding, continuous seizure activity, fevers or any other
concerning symptoms.
Followup Instructions:
Your doctors at the [**Name5 (PTitle) **] nurse facility with follow you
closely.
.
Your Dilantin and albumin levels need to be checked in 5 days
([**2176-9-2**]). Corrected Dilantin level needs to be in the 15-20
range.
Corrected Phenytoin = Measured Phenytoin Level / ( (adjustment x
albumin) + 0.1); Adjustment = 0.2; In patients with Creatinine
Clearance < 20, adjustment = 0.1.
.
If corrected Dilantin level is higher than 20, then reduce the
evening dose to 100 mg. If corrected Dilantin level is lower
than 15, then increase the noon dose to 150 mg. Dilantin levels
need to be checked again in 5 days.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2176-8-28**] Name: [**Known lastname 7338**],[**Known firstname 194**] R. Unit No: [**Numeric Identifier 7339**]
Admission Date: [**2176-8-5**] Discharge Date: [**2176-8-28**]
Date of Birth: [**2134-9-23**] Sex: F
Service: MEDICINE
Allergies:
Trileptal
Attending:[**First Name3 (LF) 839**]
Addendum:
Corrected dose: Gabapentin 800 mg Tablet Sig: One (1) Tablet PO
twice a day. Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7340**] - Twin Oaks - [**Location (un) 4186**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 841**]
Completed by:[**2176-8-28**]
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
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333, 1839
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|
2564, 2660
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,139
| 174,761
|
42560
|
Discharge summary
|
report
|
Admission Date: [**2186-4-5**] Discharge Date: [**2186-5-1**]
Date of Birth: [**2126-1-11**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Ciprofloxacin / Ertapenem / Meropenem
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Acute renal failure, urinary tract infection
Major Surgical or Invasive Procedure:
Bedside HD line placement, IR guided HD line placement, IR
guided tunnelled HD line placement, PICC line placement,
paracentesis, central line placement, intubation, NG tube
placement
History of Present Illness:
Ms [**Known lastname 92101**] is a 60 year old woman with cirrhosis [**3-13**] methotrexate
(for psoriatic arthritis) and hepatitis C who initially
presented with acute on chronic renal failure; her course has
been complicated by UTI, bacteremia, respiratory distress
requiring ICU transfer as well as worsening ARF requiring HD who
is now stable for call out of the ICU to the floor.
.
The patient was recently admitted to [**Hospital1 18**] from [**3-8**] to [**2186-3-14**]
for an infected bullae. The patient was then discharged to
rehab, where she was feeling well and had no specific
complaints. The patient had routine labs drawn on [**4-3**], which a
Cr of 3.0 (baseline 1.8-2.0).
.
On admission she was found to have a UTI which grew Pseudomonas,
Klebsiella, and ESBL E. coli on straight cath. She was initially
treated with first with Unasyn but developed a diffuse rash. She
was then switched to aztreonam due to allergies to
cephalosporins, penicillins, and fluoroquinolones but the
culture ultimately grew resistent ESBL Ecoli and Pseudomonas.
She was switched to meropenem but developed diffuse erythroderma
with eosinophilia after 3 days. The meropenem was stopped but a
repeat UA and Cx was notable only for yeast and no signs of
ongoing infection. She then became increasingly encephalopathic
and developed a fever. Her blood cultures grew coag negative
Staph x3 bottles and she was started on vancomycin. She also
being treated for hepatorenal syndrome with albumin, midodrine,
and octreotide. Unfortunately her renal function continued to
decline and it was felt that she would need HD. The renal team
was unable to place an HD cath at the bedside on Friday [**2186-4-14**].
She has some post procedure bleeding and was transfused 2U pRBC
the following day. She developed respiratory distress thought to
be due to volume overload on Sat [**4-15**]. ABG on RA 7.36/27/63. She
did not respond to lasix 80 IV, and was therefore transferred to
the ICU.
.
In the ICU a nitro gtt was initiated with relief of her
distress. On [**4-16**], the patient self d/c'd her PICC line. An IR
guided temporary HD cath with a VIP port was placed. She
underwent her first dialysis session on [**2186-4-17**]. She developed a
large hemorrhagic bulla at the site of her HD cath. DDAVP was
given. Hemolysis labs were difficult to interpret in the setting
of ESLD. Wound care was consulted. Her O2 was weaned to 2L NC
(from 4L). Blood culture from [**2186-4-15**] grew VRE and her
antibiotics were changed to Dapto. She also was noted to have AM
hypoglycemia so her evening glargine was decreased to 10U from
20U. Her course has further been complicated by ongoing
encephalopathy which responded to lactulose.
.
On the floor now she is comfortable on 2L NC but remains
encephalopathic. She has no particular complaints but is A&O x
1. She continues to require HD with poor UOP.
Past Medical History:
Hepatitis C, Genotype 1: Diagnosed in [**2185-1-8**] with last
VL 263,000 in [**8-/2185**]
Cirrhosis (Methotrexate and Hepatitis C Induced) s/p TIPS,
complicated by hepatic encephalopathy and ascites
Chronic Kidney Disease with baseline Cr 1.8-2.0
Diastolic CHF: Grade I diastolic dysfunction [**7-17**], EF 75%
Esophageal Varices per report; however, EGD [**7-/2185**] reports
normal esophagus
Psoriasis with Arthropathy - s/p Methotrexate x 15 years (MTX
d/c in 12.07 when patient developed ascites and now uses
halobetasol cream)
Anemia with baseline Hct 25-30
Thyroid nodule 2.2cm identified on ultrasound [**9-16**]
Foot drop from peroneal nerve injury during TIPS procedure (per
DC summary)
Social History:
Quit smoking in [**2184**]. No alcohol problems, no drugs. Formerly
taught hairdressing. Had been living with her son and father
until recent admission after which she went to [**Hospital1 **]. Uses a
walker but has a very difficult time getting around.
Family History:
No known history of liver disease
Physical Exam:
GENERAL: Elderly, pleasant woman 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. Harsh 3/6 systolic murmur.
Nl S1 and S2
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft. Diffusely distended. Non-tender.
EXTREMITIES: 3+ edema bilaterally. Bullae on lower extremities
bilaterally, covered with gauze.
SKIN: Diffusely dry skin with multiple skin tears.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-10**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred. No
asterixis
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
(From NH)
Hct 26
Na 129
K 5.8
Creat 3.03 (baseline 2.0-2.4)
Admission labs:
[**2186-4-5**] 12:23PM BLOOD WBC-19.6*# RBC-2.90* Hgb-8.8* Hct-26.3*
MCV-91 MCH-30.4 MCHC-33.6 RDW-16.7* Plt Ct-126*
[**2186-4-5**] 12:23PM BLOOD PT-19.6* PTT-47.4* INR(PT)-1.8*
[**2186-4-5**] 12:23PM BLOOD Glucose-127* UreaN-40* Creat-3.4*#
Na-130* K-5.4* Cl-103 HCO3-20* AnGap-12
[**2186-4-5**] 12:23PM BLOOD ALT-31 AST-43* LD(LDH)-216 AlkPhos-159*
TotBili-1.0
[**2186-4-5**] 12:23PM BLOOD Albumin-2.3* Calcium-9.1 Phos-3.9 Mg-1.9
.
Discharge labs:
[**2186-4-28**] 05:15AM BLOOD WBC-11.2* RBC-1.93* Hgb-6.2* Hct-18.1*
MCV-94 MCH-32.4* MCHC-34.5 RDW-21.0* Plt Ct-89*
[**2186-4-28**] 05:15AM BLOOD PT-20.9* PTT-50.9* INR(PT)-2.0*
[**2186-4-28**] 05:15AM BLOOD Glucose-50* UreaN-15 Creat-3.5*# Na-139
K-3.5 Cl-100 HCO3-29 AnGap-14
[**2186-4-28**] 05:15AM BLOOD ALT-20 AST-26 LD(LDH)-175 AlkPhos-111
TotBili-1.9*
[**2186-4-28**] 05:15AM BLOOD Albumin-3.2* Calcium-9.8 Phos-4.3# Mg-1.6
.
Culture data:
[**2186-4-5**] 2:15 pm URINE Source: Catheter.
**FINAL REPORT [**2186-4-9**]**
URINE CULTURE (Final [**2186-4-9**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. WARNING! This isolate is an
extended-spectrum beta-lactamase (ESBL) producer and should be
considered resistant to all penicillins, cephalosporins, and
aztreonam. Consider Infectious Disease consultation for serious
infections caused by ESBL-producing species. AZTREONAM = R.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML. AZTREONAM = <=1
MCG/ML = S. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.
SENSITIVITIES: MIC expressed in MCG/ML
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| | PSEUDOMONAS
AERUGINOSA
| | |
AMIKACIN-------------- 8 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S 8 S
CEFAZOLIN------------- R <=4 S
CEFEPIME-------------- R <=1 S 32 R
CEFTAZIDIME----------- R <=1 S 32 R
CEFTRIAXONE----------- R <=1 S
CEFUROXIME------------ 32 R 2 S
CIPROFLOXACIN--------- =>4 R <=0.25 S =>4 R
GENTAMICIN------------ <=1 S <=1 S =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S 4 S
NITROFURANTOIN-------- <=16 S 32 S
PIPERACILLIN---------- R =>128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S =>128 R
TOBRAMYCIN------------ <=1 S <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
.
[**2186-4-6**] 8:40 am BLOOD CULTURE
**FINAL REPORT [**2186-4-9**]**
Blood Culture, Routine (Final [**2186-4-9**]): STAPHYLOCOCCUS,
COAGULASE NEGATIVE.
Anaerobic Bottle Gram Stain (Final [**2186-4-7**]): GRAM POSITIVE
COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2186-4-7**]): GRAM POSITIVE COCCI
IN PAIRS AND CLUSTERS.
.
[**2186-4-11**] 10:35 am URINE Source: Catheter. **FINAL REPORT
[**2186-4-12**]** URINE CULTURE (Final [**2186-4-12**]): YEAST. 10,000-100,000
ORGANISMS/ML.
.
[**2186-4-11**] 1:56 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2186-4-18**]**
Blood Culture, Routine (Final [**2186-4-18**]): STAPHYLOCOCCUS,
COAGULASE NEGATIVE. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in MCG/ML
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final [**2186-4-13**]): GRAM POSITIVE
COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2186-4-13**]): GRAM POSITIVE COCCI
IN CLUSTERS.
.
[**2186-4-13**] 11:06 am URINE Source: Kidney. **FINAL REPORT
[**2186-4-14**]** URINE CULTURE (Final [**2186-4-14**]): YEAST.
10,000-100,000 ORGANISMS/ML.
.
[**2186-4-15**] 6:00 am BLOOD CULTURE **FINAL REPORT [**2186-4-21**]** Blood
Culture, Routine (Final [**2186-4-21**]): ENTEROCOCCUS FAECIUM. FINAL
SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500
mcg/ml of gentamicin. Screen predicts possible synergy with
selected penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of
streptomycin. Screen predicts NO synergy with penicillins or
vancomycin. Consult ID for treatment options. Daptomycin =
3MCG/ML, Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final [**2186-4-16**]): GRAM POSITIVE
COCCI. IN PAIRS AND CHAINS.
.
[**2186-4-17**] 3:18 pm URINE Source: Catheter. **FINAL REPORT
[**2186-4-19**]** URINE CULTURE (Final [**2186-4-19**]): YEAST. 10,000-100,000
ORGANISMS/ML.
.
[**2186-4-21**] 6:00 am BLOOD CULTURE Source: Line-vip. **FINAL REPORT
[**2186-4-27**]** Blood Culture, Routine (Final [**2186-4-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SENSITIVITIES PERFORMED ON
REQUEST. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 2ND STRAIN.
SENSITIVITIES PERFORMED ON REQUEST.
Anaerobic Bottle Gram Stain (Final [**2186-4-23**]): GRAM POSITIVE
COCCI IN PAIRS AND CLUSTERS.
.
IMAGING:
CHEST (PA & LAT)[**2186-4-18**]
[**4-16**] ECG: Sinus rhythm. Low precordial lead voltage. Compared to
the previous tracing of [**2186-4-5**] the precordial voltage is
diminished. Otherwise, no diagnostic interim change.
Brief Hospital Course:
60F with ESLD [**3-13**] HCV and MTX for psoaritic arthritis who
presented initially for ARF then developed a UTI which was
treated. The renal failure persisted consistent with HRS and she
was started on HD. She then developed coag neg Staph bacteremia
and ?VRE bacteremia versus contaminated BCx. Of note, she has
severe skin break down [**3-13**] unknown etiology (?psorasis and
cirrhotic edema and chronic steroid use). She had completed
treatment for bacteremia with vancomycin but the bacteremia with
coag neg Staph recurred almost as soon as the vancomycin was
stopped. She was againe treated with vancomycin for this. She
did poorly clinically with severe skin breakdown, ongoing
recurrent infections, and encephalopathy. She has been de-listed
for liver trasnplant. After long discussion on [**2186-4-29**] with
patient and family, it has been agreed that there the goals of
care will be palliation. She continues to suffer from skin
breakdown and hemorrhage.
.
#. Goals of care: Given inability to treat her infections [**3-13**]
skin breakdown and severe bleeding from heparin at HD, as well
as the reality that [**Known firstname **] will never be eligible for liver or
kidney [**Known firstname **], she and here family agreed to comfort care.
.
#. Anemia / bleeding: Pt with ongoing bleeding from skin with
minor trauma. She continues to lose blood at HD from
heparinization. She has required 1-2U pRCB per HD session for
seepage from her multiple wounds. Previously got epogen at HD.
Less bleeding on exam [**4-30**] and [**5-1**] off heparin for HD.
Transfusions discontinued given focus on comfort. Continue
multivitamins.
.
#. Skin breakdown: She has a large hemorrhagic bulla at the site
of her HD cath. She has two bullae on her legs bilaterally for
which she was recently hospitalized, which are much improved
now. She has skin tears on both arms and her back. She continues
to have extensive skin breakdown of unknown etilogy but presumed
to be from edema and psorasis. It seems likely that her skin
breakdown is etiologic to her recurrent bacteremia. Discontinued
Triamcinolone as psoriasis does not seem to be an active issue.
Minimized dressing changes and adhesives. Per derm, cover entire
skin surface with hydrated petrolatum [**Hospital1 **] for barrier protection
and enhanced moisturization. Per derm, apply bactroban to
erosions daily and cover with adaptic dressings. Continue
multivitamins. Was vitamin A def, which was repleted.
.
# Bacteremia: BCx positive coag neg Staph starting on [**4-11**] for
which she was initially on vancomycin. Then developed VRE
bacteremia x1 BCx and was switched to daptomycin on [**4-17**]. ID felt
this was a contaminant and DCed her daptomycin. She completed
treatment for coag neg Staph bacteremia on [**2186-4-21**] with
vancomycin. However a screening BCx from her HD line taken on
[**2186-4-21**] again grew GPCs. Her skin fragility/breakdown seems like
the most likely source for her recurrent bacteremia. There is
always the possibility that her multiple line placements
recently played a role (s/p PICC, HD attempt at beside, and HD
line at IR). The PICC and HD lines were both pulled and the HD
line was replaced at IR. In addition, urine Cx from [**3-/2106**] grew
ESBL Ecoli, pan-sensitive Klebsiella, and MDR Pseudomonas. She
had initially been treated with Unasyn, then aztreonam but
changed to meropenem once cultures grew out. She developed a
drug reaction with eosinophilia to meropenem, which was then
DCed. Repeat UA was positive only for yeast x 2. Appreciate
prior ID consult. Repeat UCx with yeast only so DC'd foley as
only small amount of urine produced. Discontinued Bactrim PCP
SBP [**Name9 (PRE) 5**] per comfort measures. Continue Rifaximin for bowel
decontamination. BCx from HD line on [**2186-4-21**] grew coag neg Staph
in [**3-13**] bottles. Restarted vancomycin and pulled line on [**2186-4-24**].
New line was placed on [**2186-4-26**] by IR. Subsequent cultures
negative. Status post 7 day course of treatment with vanco from
[**4-24**]. Pus noted on R forearm [**2186-4-27**]. Culture growing yeast.
Holding treatment for comfort measures. No further antibiotics
planned.
.
#. Acute on Chronic Kidney Injury: Patient's baseline Cr PTA was
1.8-1.9. She now seems to have HRS. Her Cr did no respond to
increasing doses of octreotide, midorine, and albumin and she
was unable to manage her volume status with a Cr around 3. She
was ultimately started on HD for respiratory distress [**3-13**]
hypervolemia. She is now essentially anuric. Discontinued
octreotide once on HD to preserve skin integrity. Discontinued
midodrine as hypertensive. Discontinued albumin as ineffective.
Goals of care are palliative at this point, discontinuing HD for
ongoing severe hemorrhage from heparin from lines.
.
#. Encephalopathy: Ongoing hepatic encephalopathy likely
complicated by delirium. Continue Lactulose and rifaximin with
goal to keep patient lucid, may refuse if she wants.
.
# Respiratory Distress: Patient transferred to ICU with
respiratory distress on [**4-15**], thought to be [**3-13**] volume overload.
Her respiratory symptoms improved with initiation of HD.
.
#. HCV and MTX Cirrhosis: MELD rising now that on HD, but not a
candidate for [**Month/Day (2) **] give poor clinical status and risks of
surgery and immune suppression in this patient. Continue
management of hepatic encephalopathy as above. Discontinued
bactrim given focus on comfort.
.
#. Type II Diabetes Mellitus: Lantus only with QAM fingersticks.
.
ICU course: Was transferred to the MICU on HOD 11 ([**2186-4-16**]) for
worsening respiratory distress and fatigue with tachypnea to
30's, hypoxemia requiring 4L NC (previously on RA). CXR c/w
volume overload and team requesting ICU transfer. The patient
received 2U PRBCs and it was thought that fluid overload and
renal failure played a role in the respiratory distress. The
patient pulled out her PICC line, so IR placed a VIP port.
Lactulose was started with good effect of large BMs. Blood
cultures were positive for VRE and the patient was started on
daptomycin. She received hemodialysis on HOD 12 ([**2186-4-18**]). Was
transferred back to the floor after O2 supplementation was
weaned to room air.
Medications on Admission:
Rifaximin 400 mg TID
Metoclopramide 5 mg TID
Prochlorperazine Maleate 5 mg q6h prn for nausea
Triamcinolone Acetonide 0.1 % Cream [**Hospital1 **]
Famotidine 20 mg daily
Lactulose 30 mL qid
Glargine Insulin 20 U daily
RISS
Albuterol nebulizations q4h prn
Ascorbic Acid 500 mg [**Hospital1 **]
Zinc Sulfate 220 mg daily
Bacrim SS daily
Midodrine 5 mg TID
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
4. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO TID (3
times a day).
5. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical DAILY
(Daily): To erosions on chest, legs, and arms daily and cover
with telfa gauze and tegaderm.
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thrombin (Bovine) 5,000 unit Recon Soln Sig: One (1) Recon
Soln Topical PRN (as needed): apply to bleeding areas for
hemostasis.
9. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q2H (every 2
hours) as needed.
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
15. Simethicone 80 mg Tablet, Chewable Sig: [**2-10**] Tablet,
Chewables PO BID (2 times a day) as needed for gas.
16. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] Nursing and Rehabilitation Center
Discharge Diagnosis:
Primary diagnosis: Urinary tract infection, recurrent
bacteremia, hepatorenal syndrome, cirrhosis, hepatic
encephalopathy
.
Secondary diagnosis: Diabetes, depression
Discharge Condition:
Stable vital signs, tolerating POs, alert and oriented x 2, poor
skin integrity
Discharge Instructions:
It has been a pleasure taking care of you at [**Hospital1 771**].
.
You were admitted for renal failure and a urinary tract
infection. You ultimately needed to start dialysis for your
renal failure. Your hospital course was complicated by multiple
infections attributed to your skin problems. Dermatology
consulted on your skin problems but despite our best efforts you
continue to have skin breakdown. You have had several infections
of your blood which have been treated with antibiotics. Because
of your ongoing bleeding we cannot continue with dialysis.
.
At this point the goal of your care is comfort. Given that, you
have the right to refuse any treatments we offer. We have
thinned your medication list to those things which will make
your life more comfortable.
Followup Instructions:
None
Completed by:[**2186-5-1**]
|
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"428.0",
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icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95",
"96.6",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
19276, 19384
|
11060, 17288
|
349, 535
|
19594, 19676
|
5297, 5358
|
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|
265, 311
|
563, 3439
|
19550, 19573
|
5374, 5809
|
19424, 19529
|
3461, 4160
|
4176, 4432
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,980
| 156,397
|
47260
|
Discharge summary
|
report
|
Admission Date: [**2194-11-3**] Discharge Date: [**2194-11-5**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 12303**] is a 94 with history of HTN, HLD, diastolic CHF (last
EF 55% in [**11/2193**]), atrial fibrillation on coumadin s/p
cardioversion x2, most recently in [**Month (only) 958**], IBS with intermittent
rectal bleeding, osteoarthritis, who is presenting with bright
red blood per rectum. The patient and patient's son report that
the night prior to admission, the patient had an episode of
BRBPR. Denies any associated abdominal pain. Has never had
this happen to her in the past. She reports that she was trying
to pass gas and when she did, there ended up being blood all
over the bathroom. As per the patient's son, he reports that
there were about ten drops of blood in the toilet bowl. She
reports that these episodes happened througout the night, at one
hour intervals. She often has frequent episodes of stool at her
baseline because of her IBS; intermittent diarrhea and
constipation type. As per report, however, the patient reports
having crampy abdominal pain associated with her frequent bowel
movements overnight, with tenesmus.
.
Of note, the patient has been on coumadin since [**2193-11-30**] for
atrial fibrillation. She has her INR checked once every two
weeks; denies any new medications. Denies any fevers/chills.
Reports some nausea, but has a history of Schatkzi's ring s/p
esophageal dilation. Reports some dizziness and
lightheadedness, but reports that she has history of vertigo;
not sure if dizziness was consistent with past vertigo. Denies
any chest pain, trouble breathing, shortness of breath, no
vomiting. Last colonoscopy in system in [**2188**]; normal.
.
In the ED, initial VS were: 97.5 70 148/63 22 99%. 2 BRBPR in
the ED. She was given 2 units of FFP. EKG was unchanged. HCT
has remained stable. She was subsequently transferred to MICU.
The patient has two peripherals and is type and crossed for 2
units.
.
On arrival to the unit, vital 98.4 96 132/81 18 99%RA. The
patient reports feeling well. Denying any n/v/d, no abdominal
pain, no rectal pain. No weakness, lightheadedness or
dizziness.
Past Medical History:
afib on coumadin
Prior MI [**2182**]--declined statins
BPPV
Venous stasis
Irritable bowel syndrome
s/p cataract surgery, bilaterally
s/p TAH
Pelvic prolapse
Shatzki ring
Social History:
She lives with her son. She is able to do many of her ADL's at
her home. She has 4 grown children, whom she is close with.
-Tobacco history: denies
-ETOH: denies
-Illicit drugs: denies
Family History:
Great-granddaughter with "missing left ventricle at birth, born
2lbs"
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 95.5 163 78 19 95% on RA
General: Alert, oriented, NAD, pleasant elderly woman, laying
comfortably in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to angle of mandible
CV: Regular rate and rhythm, normal S1 + S2, loud P2, no
murmurs, rubs, gallops appreciated
Lungs: bibasilar crackles, good air movement, no wheezes/rhonchi
Abdomen: + BS, slight lower abdominal tenderness, soft,
nondistended
Ext: warm, well perfused, 2+ pulses, 2+ pitting LE edema b/l
DISCHARGE PHYSICAL EXAM:
General: pleasant, oriented, NAD, elderly woman, laying
comfortably in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP elevated to the jaw
CV: Bradycardic and regular rhythm, loud P2, no murmurs, rubs,
or gallops appreciated
Lungs: bibasilar crackles, good air movement, no wheezes/rhonchi
Abdomen: + BS, Soft, nontender, nondistended, no masses
appreciated
Ext: warm, well perfused, 2+ pitting LE edema b/l
Neuro: Oriented x3, appropriate, moving all 4 extremities.
Pertinent Results:
LABS:
ADMISSION LABS:
[**2194-11-3**] 12:25PM BLOOD WBC-7.5 RBC-3.91* Hgb-11.4* Hct-36.0
MCV-92 MCH-29.2 MCHC-31.8 RDW-14.2 Plt Ct-342
[**2194-11-3**] 12:25PM BLOOD Neuts-67.5 Lymphs-22.9 Monos-6.0 Eos-2.7
Baso-1.0
[**2194-11-3**] 12:25PM BLOOD PT-21.6* PTT-39.0* INR(PT)-2.1*
[**2194-11-3**] 12:25PM BLOOD Glucose-80 UreaN-27* Creat-1.1 Na-141
K-4.7 Cl-106 HCO3-27 AnGap-13
[**2194-11-3**] 08:23PM BLOOD Calcium-9.0 Phos-2.8 Mg-1.9
DISCHARGE LABS:
[**2194-11-5**] 07:40AM BLOOD WBC-9.6 RBC-3.40* Hgb-10.1* Hct-31.2*
MCV-92 MCH-29.6 MCHC-32.3 RDW-14.5 Plt Ct-280
[**2194-11-5**] 07:40AM BLOOD PT-13.5* PTT-31.3 INR(PT)-1.3*
IMAGING:
[**11-3**] CXR COMPARISON: [**2194-8-15**].
IMPRESSION:
1. Cardiomegaly and minimal pulmonary vascular congestion.
Blunting of the right costophrenic angle may be due to overlying
soft tissue, although a trace effusion cannot be excluded.
2. Hiatal hernia.
[**11-5**] Sigmoidoscopy
Diverticulosis of the sigmoid colon
Grade 1 internal hemorrhoids
Otherwise normal sigmoidoscopy to splenic flexure
Brief Hospital Course:
Ms. [**Known lastname 12303**] is a [**Age over 90 **] year old female with history of hypertension,
diastolic heart failure (CHF, last EF 55% in [**11/2193**]), atrial
fibrillation on coumadin status post cardioversion x2, most
recently in [**Month (only) 958**], irritable bowel syndrome (IBS) with
intermittent rectal bleeding, osteoarthritis, who is presenting
with bright red blood per rectum (BRBPR).
ACTIVE ISSUES BY PROBLEM:
# Lower GI bleed: Initially admitted to the ICU for monitoring.
GI was consulted and they recommended a CT scan of the abdomen
and an inpatient colonoscopy. However, the patient declined
both of these studies since her bleeding resolved and she was
claustophobic. Also, she reported that she already had 2
colonoscopies which she did not think had ever been helpful.
Her hematocrit dropped from 36 to 30 initially, however, it then
remained stable at 30 and she did not have further bloody bowel
movements while in the ICU. She did not require blood
transfusions since she was not symptomatic from blood loss. She
did agree to have a flexible sigmoidoscopy which showed
diverticulosis and grade 1 internal hemorrhoids but no active
bleeding. Given these findings, she most likely had a
self-resolving diverticular bleed. As these are prone to recur,
the risk of continuing coumadin therapy did not seem worth the
benefit, so she was told to stop this on discharge. Will defer
to her PCP and cardiologist for further management and
discussion of risk vs benefit of coumadin therapy.
# Atrial fibrillation: status post cardioversion in [**2194-1-28**]
with CHADS score of 3, on coumadin at presentation. She was
given 2 units FFP to reverse here INR, and her aspirin and
warfarin were held due to active bleeding. She was continued on
her home amiodarone. She was not restarted on her aspirin or
warfarin at discharge given her recent bleed, however will defer
to outpatient PCP and cardiologist for further management.
CHRONIC ISSUES BY PROBLEM:
# Diastolic heart failure (dCHF): The patient has a history of
diastolic CHF. Not on daily diueretic regimen, but takes PRN.
Her diuretics and metoprolol were held due to potential GI bleed
and hypovolemia.
TRANSITIONAL ISSUES:
- Anticoagulation: will need to determine if she should restart
warfarin and/or aspirin
Medications on Admission:
lorazepam 0.5 mg [**Hospital1 **] PRN
metoprolol succinate 50 mg [**Hospital1 **]
Warfarin 2.0 mg daily, except Tues/Friday 1 mg)
amiodarone 200 mg qday
fish oil
Prilosec 20 mg daily
MVI
ASA 81
Furosemide 20 mg PRN for leg swelling
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. multivitamin Tablet Sig: One (1) Tablet PO once a day.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY DIAGNOSIS
lower GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 12303**],
You were admitted to the hospital because you were having
bleeding in your stool. You were monitored in the ICU to check
the level of your blood every few hours. You had an initial
drop, however, it stabilized and you did not have any more
bleeding. The GI specialits saw you and they recommended a CT
scan and a colonoscopy to try to look for the source of
bleeding. However, you chose not to undergo these tests because
you had already improved. They did do a test called a
sigmoidoscopy to look at the last half of your colon, and they
saw diverticula (outpouchings of colon) and internal hemorrhoids
but no bleeding. Because your bleeding stopped, it was decided
that you were safe to go home.
The following changes were made to your medications:
STOP warfarin
STOP aspirin
Both these medications are being stopped because they put you at
higher risk for bleeding. Please do not re-start these
medications or take ibuprofen unless your doctor says to do so.
It is very important that you keep all of the follow-up
appointments listed below. Also, because of your history of
heart failure, you should weigh yourself every morning, [**Name8 (MD) 138**] MD
if weight goes up more than 3 lbs.
It was a pleasure taking care of you in the hospital!
Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
When: MONDAY [**2194-11-10**] at 3:45 PM
With: DR. [**First Name8 (NamePattern2) 132**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS Best Parking: On Street Parking
|
[
"455.0",
"562.10",
"428.0",
"E934.2",
"V58.61",
"428.33",
"412",
"578.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
8281, 8339
|
5151, 7352
|
279, 286
|
8417, 8417
|
4091, 4098
|
9920, 10258
|
2809, 2994
|
7746, 8258
|
8360, 8396
|
7489, 7723
|
8600, 9897
|
4542, 5128
|
3034, 3544
|
7373, 7463
|
212, 241
|
314, 2396
|
4114, 4526
|
8432, 8576
|
2418, 2590
|
2606, 2793
|
3569, 4072
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,214
| 133,198
|
1683+55305
|
Discharge summary
|
report+addendum
|
Admission Date: [**2152-2-15**] Discharge Date: [**2152-2-18**]
Date of Birth: [**2089-9-17**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
large L frontal lesion w/ hemorrhagic extension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
62 M widely metastatic prostate CA now with large frontal bleed
(probably tumor). had nausea/HA/blurry vision/aphasia/mild
confusion x 24 hours and new onset fever. neuro exam nonfocal
Past Medical History:
PMH:
1. Prostate cancer
- s/p radical prostatectomy
- s/p hormonal therapy with lupron, casodex,
ketoconazole/hydrocort
- taxotere/extramustane/decadron
- most recently mitoxantrone/prednisone with cross over to
epothilone
2. Right knee surgery
Social History:
Retired, lives with wife in [**Name (NI) 9708**] etoh, tob, drugs
Family History:
Sister with breast cancer
Father with liver cancer (unsure of wheter primary or mets to
liver)
Meds: oxycontin 60mg [**Hospital1 **], Multivitamin, Senna, Oxycodone 5mg
prn, Promethazine 25 mg prn
Allergies: NKDA
Physical Exam:
O: Tc: 101.4 BP: 169/92 HR: 102 RR: 16 O2Sat. 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Left frontal cranial deformity present nontender,
nonerythematous . Anicteric. MMM.
Neck: supple. b/l diffuse LAD
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative, normal affect.
Somewhat slow to respond
Orientation: Oriented to person, place, and date.
Registration intact.
Language: Speech fluent with good comprehension. Aphasic for
basic words during conversation
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light. Visual fields
are
full to confrontation
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-2**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, bilaterally.
Reflexes: +[**3-4**] patellar
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger,
Gait: not tested
Pertinent Results:
[**2152-2-15**] 12:10AM BLOOD WBC-4.5 RBC-2.65* Hgb-8.6* Hct-23.7*
MCV-90 MCH-32.5* MCHC-36.2* RDW-19.5* Plt Ct-32*
[**2152-2-16**] 01:35AM BLOOD WBC-3.8* RBC-3.16* Hgb-9.5* Hct-27.1*
MCV-86 MCH-30.2 MCHC-35.2* RDW-20.3* Plt Ct-116*
[**2152-2-16**] 01:35AM BLOOD Glucose-148* UreaN-20 Creat-0.8 Na-136
K-4.3 Cl-102 HCO3-24 AnGap-14
[**2152-2-15**] 12:10AM BLOOD ALT-7 AST-47* AlkPhos-495* Amylase-49
TotBili-0.9
[**2152-2-16**] 01:35AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.2
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2152-2-15**] 12:49 AM
CT HEAD W/O CONTRAST
Reason: assess for mets, bleed, prior to tap
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with fever, ha, n-v, and met prostate ca
REASON FOR THIS EXAMINATION:
assess for mets, bleed, prior to tap
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Metastatic prostate cancer, presenting with fever,
headache, nausea, vomiting. Evaluate prior to tap.
COMPARISONS: Head CT of [**2151-4-18**].
TECHNIQUE: Axial MDCT images through the brain without IV
contrast.
CT HEAD FINDINGS: There is a large infiltrative sclerotic lesion
in the left frontal calvarium, with an extensive extracranial
soft tissue component, likely representing a metastatic lesion
from the patient's known prostate cancer, more extensive than
the prior study of [**4-2**]. Adjacent to this legion in the
parenchyma of the left frontal lobe, there is an approximately
3cm ovoid region of hemorrhage. This may represent hemorrhage
into the metastatic lesion extending into the left frontal lobe,
or focal hemorrhage in the left frontal parenchyma itself.
Additionally, there may be a small subarachnoid component both
at this level and higher up towards the vertex on the left, seen
best on series 2, image 22-24. There is a small adjacent left
parafalcine subdural hematoma. There is no discernible midline
shift of the adjacent falx. There is at least one other
suspicious area in the right superior parietal calvarium for an
additional metastatic lesion, with an adjacent convex
hypersenity, possibly a small extraaxial hematoma. This has also
increased from the prior study. There is extensive vascular
calcification in the cavernous carotids and vertebro-basilar
arteries.
IMPRESSION:
1) Large left frontal calvarium based metastatic lesion with
hemorrhagic extension into the left frontal parenchyma, and
extracranial soft tissue extension. There is mild surrounding
vasogenic edema, but no shift of the adjacent midline falx.
There appears to be a small component of subarachnoid blood
within a sulcus adjacent to the metastatic lesion, and also
higher up near the left vertex. Mild surrounding vasogenic
edema, without shift of the midline falx.
2) Second metastatic lesion in the right superior frontoparietal
calvarium, with probable adajcent small extraxial hematoma.
RADIOLOGY Final Report
MR HEAD W & W/O CONTRAST [**2152-2-15**] 10:15 AM
MR HEAD W & W/O CONTRAST; MR CONTRAST GADOLIN
Reason: Need to assess for possible resection
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with history of prostate ca, now with head bleed
underlying mass
REASON FOR THIS EXAMINATION:
Need to assess for possible resection
CLINICAL INFORMATION: Need to assess for possible resection.
MRI OF THE BRAIN WITH GADOLINIUM:
Exam was compared to prior head CT scans from [**2152-2-15**].
The lesion involving the left frontal bone has an extracranial
and intracranial component. That intracranially has a somewhat
irregular interface with the subjacent brain. There is some
associated parenchymal hemorrhage in the subjacent location.
There is also parafalcine subdural hemorrhage and some
subarachnoid hemorrhage in the left frontal lobe. The lesion in
the right parietal region does not clearly have a soft tissue
component either extracranially or intracranially, although
there is a small question whether there are prominent veins or a
small intracranial extension on the medial aspect of the lesion
on the coronal post-gadolinium study. There also appears to be a
small degree of hemorrhage in the brain subjacent to this
lesion. Additional metastatic lesions are not identified. There
is no evidence of abnormal diffusion to suggest the presence of
acute infarction.
IMPRESSION: The lesion in the left frontal lobe has an
intracranial extension which may involve the subjacent brain.
The lesion in the right parietal lobe does not clearly extend
into the brain but there does appear to be some subjacent
hemorrhage.
Brief Hospital Course:
[**Known firstname **], [**Known lastname 780**] is a 62 year-old man presented with 24 hours of
aphasia and mild confusion, 1 day of blurry vision and chills,
sudden onset of severe HA with fever up to 102.2 Patient seen
and evaluated in ED and transferred to ICU for neurologic
monitoring. He was transfused with 1 unit of platelets and 3U
PRBC's for PLT count of 32 and HCT of 23.7, respectively. Was
started on Decadron and dilantin. DPH level 18.7. Code status
was addressed later that day and the decision made to be
DNR/DNI.
Patient was seen by heme-onc team, who recommended to keep
platelets >100, no Heparin, weaned his dilantin over to Keppra
due to possibility of dilantin interference with platelets since
he presented with thrombocytopenia.
MRI of the brain showed left frontal lesion involving the bone
has an extracranial and intracranial component. That
intracranially has a somewhat irregular interface with the
subjacent brain. There is some associated parenchymal hemorrhage
in the subjacent location. There is also parafalcine subdural
hemorrhage and some subarachnoid hemorrhage in the left frontal
lobe. The lesion in the right parietal region does not clearly
have a soft tissue component either extracranially or
intracranially. Patient evaluated by Dr [**Last Name (STitle) 3929**], radiation
oncology, who recommended total body radiation to the lesion,
and patient did not wanted to proceed with surgical treatment.
In conversation with DR [**Last Name (STitle) 3929**] patient kept on Decadron mg
QID until seen in radiation oncology clinic on [**2152-2-22**], then
further dosing will be adjusted by him.
Patient was monitored closely with pain and other symptomatology
improving over the next few days. Was transferred to the step
down unit on hospital day two, on day three patient transferred
to floor. Mr. [**Known lastname 780**] has been seen by Physical Therapy who
recommended home safety eval and Home PT which is arranged by
Case manager.
Patient discharged home with a follow up appointments and
discharge instructions.
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
2. Dilantin 100 mg Capsule Sig: One (1) Capsule PO three times a
day: [**2-24**] dilantin 100mg [**Hospital1 **].
[**2-28**] dilantin 100mg daily.
[**3-3**] stop dilantin comletely.
Disp:*20 Capsule(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: for constipation.
Disp:*60 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours):
Take while on decadron.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): Dr [**Last Name (STitle) 3929**] to adjust your dose on [**2152-2-22**].
Disp:*40 Tablet(s)* Refills:*0*
9. Keppra 500 mg Tablet Sig: One (1) Tablet PO as directed: [**2-18**]
keppra 500mg [**Hospital1 **]
[**2-21**] keppra 500mg am, 1000mg pm for 3 days.
[**2-24**] Keppra 1000mg [**Hospital1 **] .
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Metastatic prostate cancer w/ L frontal intracranial bleed
Discharge Condition:
Neurologically stable.
Discharge Instructions:
Please seek medical attention if you experience fever > 101.5,
severe nausea,vomiting,pain,dizziness, numbness,tingling any and
all changes in neurological status as well as any falls or
excessive bleeding from anywhere.
Please take medications as directed
Please go to your follow-up appointments
Followup Instructions:
Follow-up with [**Hospital 9709**] clinic on Monday [**2152-2-21**] at 8:30am with
Dr. [**Last Name (STitle) 1365**]. Hematology/Oncology office number is [**Telephone/Fax (1) 6161**].
Follow up appt w/ Dr. [**Last Name (STitle) 3929**] re: total brain radiation on
[**2152-2-22**] at 1100 [**Hospital Ward Name 23**] Building [**Location (un) 442**]. Dr [**Last Name (STitle) 3929**] will
adjust your steroid dosing at the same day of treatment.
Dr [**Last Name (STitle) 3929**] office number is [**Telephone/Fax (1) 9710**] for any question or
concerns.
Follow up with Dr [**Last Name (STitle) 9711**] in 6 weeks with a noncontrast Head CT.
Call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 9712**] for an appointment.
Completed by:[**2152-2-18**] Name: [**Known lastname 1114**],[**Known firstname **] F Unit No: [**Numeric Identifier 1284**]
Admission Date: [**2152-2-15**] Discharge Date: [**2152-2-18**]
Date of Birth: [**2089-9-17**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 599**]
Addendum:
correction; Total body radiation should be read as total brain
radiation by Dr [**Last Name (STitle) 1285**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]
Completed by:[**2152-2-18**]
|
[
"285.9",
"197.7",
"287.5",
"198.5",
"198.3",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
12472, 12667
|
7146, 9213
|
367, 374
|
10804, 10829
|
2615, 3231
|
11178, 12449
|
957, 1173
|
9236, 10620
|
5677, 5758
|
10722, 10783
|
10853, 11155
|
1188, 1562
|
280, 329
|
5787, 7123
|
402, 588
|
1828, 2596
|
1577, 1812
|
610, 857
|
873, 941
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,986
| 109,624
|
294
|
Discharge summary
|
report
|
Admission Date: [**2130-4-6**] Discharge Date: [**2130-4-13**]
Date of Birth: [**2054-8-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Acute Paralysis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
75yo Korean gentleman awoke this morning, talked to the bathroom
and felt sudden onset back and abdominal pain after which he
lost functioning of bilateral lower extremeties. Taken to OSH
where abdominal CT scan thought to show dissection of thoracic
AAA, Pt xferred to [**Hospital1 18**] for possible surgical
intervention but on review of outside CT, no aneurismal rupture
noted.
Past Medical History:
GERD
HTN
Social History:
Previously heavy smoker, quit 1.5 yrs ago.
no alcohol
Family History:
non contributary
Physical Exam:
VS: afeb 130/60 72
General: WNWD, NAD
HEENT: Anicteric, MMM without lesions, OP clear
Neck: Supple, no LAD, no carotid bruits, no thyromegaly
CV: RRR s1s2 no m/r/g
Resp: CTAB no r/w/r
Abd: Soft/distended
Ext: No c/c/e, distal pulses intact
Skin: No rashes, petechiae
MS: A&O x 3, interactive, appropriate, following all commands
Speech fluent w/o paraphasic errors, +naming of wholes & parts,
+repetition, +comprehension
No evidence of neglect with visual or tactile stimulation
No apraxia: able to comb hair, screw in light bulb
CN: I - not tested, II,III - PERRL, VFF by confrontation, optic
discs sharp, visual acuity OD, OS; III,IV,VI - EOMI, no ptosis,
no nystagmus; V- sensation intact to LT/PP, responds to nasal
tickle, masseters strong symmetrically; VII - no facial
weakness/asymmetry; VIII - hears finger rub B; IX,X - voice
normal, palate elevates symmetrically, gag intact; [**Doctor First Name 81**] -
SCM/Trapezii [**6-2**] B; XII - tongue protrudes midline, no atrophy
or
fasciculations
Motor: nl bulk and tone, no tremor, rigidity or bradykinesia. No
pronatordrift. No asterixis.
Deltd Bicep Tricp ECR/U ExDig FlDig DorsI OppPB
C5 C5-6 C7 C6-7 C7 C8 T1 C8-T1
L 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5
Ilpso Qufem Hamst TibAn [**First Name9 (NamePattern2) 2778**] [**Last Name (un) 938**]
L1-2 L3-4 L5-S2 L4-5 S1-2 L5
DTRs: [**Name2 (NI) **] (C56) BR (C6) Tri (C7) Pa (L34) Ac (S12) Plantar
L 2 2 2 0 0 mute
R 2 2 2 0 0 mute
Sensory: LT intact throughout; temperature, vibration, pin
decreased from T10 level down.
Coord: FNF intact.
Gait: unable to perform.
Pertinent Results:
[**2130-4-13**]
WBC-7.4 RBC-4.79 Hgb-15.2 Hct-44.7 MCV-93 MCH-31.7 MCHC-34.0
RDW-13.7 Plt Ct-103*
[**2130-4-12**]
PT-14.1* PTT-26.2 INR(PT)-1.2*
[**2130-4-13**]
Glucose-139* UreaN-46* Creat-1.1 Na-139 K-4.3 Cl-107 HCO3-24
AnGap-12
[**2130-4-10**]
ALT-62* AST-20 CK(CPK)-95 AlkPhos-62 TotBili-2.1*
[**2130-4-12**]
Calcium-8.1* Phos-3.2 Mg-2.3
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG
URINE RBC-[**4-2**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2
URINE Hours-RANDOM Creat-43 Na-LESS THAN TotProt-13
Prot/Cr-0.3*
[**2130-4-10**] 11:13 AM
RENAL U.S. PORT
TECHNIQUE: Portable renal ultrasound with Doppler studies.
FINDINGS: The right kidney measures 10.9 cm in length, the left
11.6 cm. Within the upper pole of the right kidney, two simple
cysts, each measuring 2.7 cm in diameter, are visualized, as
well as a 2.1 cm simple cyst in the lower pole of the left
kidney. These correspond to a hypoattenuating foci seen on the
recent CT. In the lateral mid pole of the right kidney, there is
a region of cortical echogenicity, which likely corresponds to
an area of relative perfusion defect on the recent CT. The
appearance may represent a small evolving renal infarct.
Doppler studies show normal flow in the right main renal artery
and vein, as well as normal arterial flow in interlobar arteries
among the upper, middle, and lower poles. The resistive indices
range from 0.63-0.70 on the right.
On the left, the main renal artery and vein are also patent, but
interlobar arteries show slight parvus et tardus waveforms,
particularly when compared to the opposite side. The resistive
indices among the interlobar arteries range from 0.63-0.86. In
the setting of portable technique, the Doppler studies of the
left kidney are somewhat suboptimal, but the findings suggest
that there is likely somewhat decreased perfusion to the left
kidney compared to the right.
IMPRESSION:
1. Small echogenic region involving the cortex in the right mid
pole, which correlates with a region of relative decreased
perfusion on the recent CT. This appearance may represent an
evolving infarct within a portion of the right mid pole.
2. Patency of flow to both kidneys. However, Doppler studies are
suggestive of somewhat decreased perfusion to the left compared
to the right
[**2130-4-9**] 2:01 PM
CHEST (PORTABLE AP)
Single portable chest radiograph demonstrates no interval change
in the cardiomediastinal silhouette. There is increased
perihilar opacity involving the bilateral hila and mild diffuse
increased airspace opacity representing mild-to-moderate
pulmonary edema. There is blunting of the left costophrenic
angle representing a small effusion. The right costophrenic
angle is sharp. The trachea remains in the midline. Cardiomegaly
is unchanged.
IMPRESSION:
Cardiomegaly, unchanged.
Worsening CHF.
Brief Hospital Course:
Pt admitted [**2130-4-6**]
Stat lumbar drain placed - to decrease csf pressure less then 10
/ pt transfered to the SICU
A-line placed
Stroke service consulted / CT - reveals aortic dissection no
acute compression or infarct noted / the diseection and low BP
is thought to be responsible by decreasing the blood flow to the
spinal cord.
It is noticed if pts BP elevated, paralysis improves
Pt BP is kept elevated ( Pt also has ARF on admission ) / The
increase BP is probably due to decreasse blood flow to the
kidneys. / steroids started for ? acute cord infarction.
[**2130-4-7**]
Lumber drain stops working / replaced
troponin is increasing / pt started on beta blockers. The
increase troponin is thought to be due to hypoperfusion
syndrome.
[**2130-4-8**]
echo done
[**2130-4-9**]
Increase creat / BUN - renal consulted
[**2130-4-10**]
stable
[**2130-4-11**]
Diovan added for BP control
creat improves
Pt symptoms gradually improve with BP control
[**2130-4-12**]
Pt consult / fails voiding trial
Foley replaced
[**2130-4-13**]
Pt stable for DC
Medications on Admission:
Protonix
BP med
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 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. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours) as needed for SBP>160: prn.
8. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
paralysis with decrease bp
AA dissection
ARF
Discharge Condition:
stable
Discharge Instructions:
BP control 140-180
Moniter BUN creat
Followup Instructions:
Please follow-up with Neurology (Dr. [**Last Name (STitle) 2779**]
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2780**] [**Name (STitle) 2781**] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2130-5-16**]
3:30
**This appointment is on the [**Location (un) **] of the [**Hospital Ward Name **] building.
You will need to call ahead of time to update your registration.
Please call [**Telephone/Fax (1) **]. Thank you.
Please call Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 2625**]
Completed by:[**2130-4-13**]
|
[
"336.1",
"401.9",
"530.81",
"584.9",
"344.1",
"441.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.09",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
7707, 7779
|
5627, 6699
|
329, 335
|
7868, 7876
|
2668, 5604
|
7963, 8519
|
867, 885
|
6765, 7684
|
7800, 7847
|
6725, 6742
|
7900, 7940
|
900, 2649
|
274, 291
|
363, 747
|
769, 779
|
795, 851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,332
| 112,250
|
11773+56290
|
Discharge summary
|
report+addendum
|
Admission Date: [**2152-10-13**] Discharge Date: [**2152-10-22**]
Date of Birth: [**2110-1-16**] Sex: M
Service: PLASTIC
Allergies:
Amphotericin B / Ambisome / Campath
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
Right facial wound and cervicofacial sarcoma.
Major Surgical or Invasive Procedure:
1. Right anterolateral free flap to right face using the
right facial artery and common facial vein.
2. Repair of orocutaneous fistula.
3. Split thickness skin graft 14 x 20 cm at 0.014 inch.
4. Closure of extensive cervicofacial defect which included
exposed zygoma, exposed maxillary bone, exposed lateral
portion of the frontal bone.
History of Present Illness:
The patient is a 42-year-old male
who is a patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**] with a history of
total body irradiation as well as graft versus host disease
following bone marrow transplant several years ago. The patient
then had subsequently developed lesion of the right facial
region
as well as the left cheek area that was biopsied approximately 1
week ago. He was seen in the operating room at [**Location (un) 37217**]
originally for assessment of the wound. The lesion was fully
excised and margins were sent off and a bolster dressing was
placed. He presents to the office for changes of the dressing
and removal of the bolster and preoperative planning.
Past Medical History:
#. MUD allo BMT [**10-8**] for CML, c/b GVHD, chronic
thrombocytopenia, anemia,
Donor Info: donor #[**Numeric Identifier 37214**]
Sex: female,
Age: 37,
# of pregnancies: 4,
ABO donor: Apos,
ABO recipient: Apos,
CMV donor: (+),
CMV recipient:(+)
#. GVHD--symptoms have included severe skin findings,
thrombocytopenia requiring transfusions, bronchiolitis
obliterans and mouth sores. treatment options are limited, since
the patient has also had HUS to calcineurin inhibitors such as
cyclosporine, FK 506, no response to rapamycin, has had multiple
trials of Rituxan as well as trial of endostatin all without
signficant improvement.
#. BOOP due to GVHD. He unfortunately has had multiple prior
therapies including Rituxan, pentostatin, Campath, steroids, and
CellCept. He has had a significant issue as in the past with
cyclosporin and FK-506. The patient had a repeat chest CT in
[**2150-12-8**] to reassess his lung disease. There were no
significant changes in the few opacities that may represent
underlying BOOP since his last scan several months ago.
#. RSV pneumonitis
#. HTN
#. CRI
#. portacath in place
#. chronic right extremity edema
#. episodic spasm of mouth muscles, unclear etiology.
#. Obstructive airways disease, possibly due to GVDH.
Social History:
no EtOH, tobacco, drugs
Family History:
Non-contributory
Physical Exam:
AOx3
Facial wound:
The wound measures at least 17 cm in greatest dimension by
another 15 cm which includes the entire right side of his face.
His zygomatic arch is exposed and the anterior maxillary wall is
exposed. There are elements of parotid gland that are also
exposed. There is no salivary fistula intraorally that is
noted.
He has cutaneous changes over
his entire body from the graft versus host disease.
Pertinent Results:
[**2152-10-13**] 01:47PM BLOOD WBC-7.9 RBC-2.48* Hgb-8.7* Hct-25.9*
MCV-104* MCH-35.2* MCHC-33.7 RDW-16.0* Plt Ct-378
[**2152-10-18**] 03:12AM BLOOD WBC-7.9 RBC-2.33* Hgb-7.9* Hct-23.6*
MCV-101* MCH-33.8* MCHC-33.4 RDW-17.2* Plt Ct-250
[**2152-10-13**] 01:47PM BLOOD Plt Ct-378
[**2152-10-13**] 09:40PM BLOOD PT-11.3 PTT-23.3 INR(PT)-1.0
[**2152-10-17**] 01:46AM BLOOD PT-11.2 PTT-25.4 INR(PT)-0.9
[**2152-10-18**] 03:12AM BLOOD Plt Ct-250
[**2152-10-13**] 09:40PM BLOOD Glucose-114* UreaN-15 Creat-1.0 Na-139
K-4.9 Cl-107 HCO3-27 AnGap-10
[**2152-10-18**] 03:12AM BLOOD Glucose-94 UreaN-20 Creat-1.0 Na-141
K-4.4 Cl-108 HCO3-24 AnGap-13
[**2152-10-13**] 09:40PM BLOOD Calcium-9.0 Phos-3.0 Mg-2.1
[**2152-10-18**] 03:12AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.6
[**2152-10-13**] 06:50PM BLOOD Type-ART Temp-36.6 Rates-/8 Tidal V-600
FiO2-40 pO2-176* pCO2-43 pH-7.44 calTCO2-30 Base XS-5
Intubat-INTUBATED Vent-CONTROLLED
[**2152-10-14**] 03:30AM BLOOD Type-ART Tidal V-550 pO2-186* pCO2-45
pH-7.40 calTCO2-29 Base XS-2 -ASSIST/CON Intubat-INTUBATED
[**2152-10-16**] 06:05AM BLOOD Type-ART pO2-178* pCO2-40 pH-7.43
calTCO2-27 Base XS-2
[**2152-10-17**] 09:25AM BLOOD Type-ART pO2-86 pCO2-36 pH-7.50*
calTCO2-29 Base XS-4
[**2152-10-13**] 06:50PM BLOOD Glucose-81 Na-137 K-4.3
[**2152-10-13**] 06:50PM BLOOD Hgb-10.1* calcHCT-30
[**2152-10-13**] 06:50PM BLOOD freeCa-1.16
[**2152-10-17**] 01:54AM BLOOD freeCa-1.18
Brief Hospital Course:
Pt. admitted and operation proceded with. Flap applied to face
from R ant. thigh, R ant. thigh covered with STSG from L ant.
thigh. Please see detailed Op Note for full details of this
operation. Pt. in PACU for frequent flap checks for first 24hr
post-procedure. Initial low UOP responded promptly to a 500cc
bolus. Pt.'s intubation continued, and pt. remained sedated and
ventilated due to tenuous nature of flap and prominent facial
edema. Pt. transferred to ICU for further care/ventilation/q2hr
flap checks without incident. Pt. remained hemodynamically
stable with excellent dop tones in the flap throughout this
period. An NG tube was placed and tube feeds were slowly
advanced during this time, begining on [**10-15**]. L thigh donor site
was open to air beginning on [**10-16**]. Nutrition was consulted and
provided excellent assisstance with tube feeding recs. Pt.
extubated without incident on [**10-16**]. Tube feeds were slowly
increased and eventually moved to bolus feeds. Facial/flap
edema slowly decreased and one drain was removed. PT saw the
patient and assissted with post-discharge care. Pt. came out to
floor on [**10-18**]. The Vac was taken off the R ant. thigh and the
STSG was observed to have good take. NGT was removed and the
patient advanced to full liquids. At some point the pt. had
transient dysuria, a U/A was done and was clean, and his
symptoms resolved. When the patient was D/C'd his pain was well
controlled, he was tolerating PO well, and was able to ambulate
and void on his own.
Medications on Admission:
acyclovir
Prednisone 5
metoprolol
Folic Acid
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-8**]
Drops Ophthalmic PRN (as needed).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*250 ML(s)* Refills:*1*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
10. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO twice a day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
11. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 10 days.
Disp:*30 Capsule(s)* Refills:*0*
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Cervicofacial sarcoma of the right
face.
Discharge Condition:
good
Discharge Instructions:
Please return to the hospital if you experience fevers greater
then 101.4, chills, or other signs of infection. Also return to
the hospital if you experience chest pain, shortness of breath,
redness, swelling, or purulent discharge from the incision site.
Return if you experience worsening pain or any other concerning
symptoms.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
Restart taking all your regular medications once you arrive at
home.
-Please do not shower until your follow-up visit.
.
Please do not place any pressure on your face, especially the
surgical site. Please keep track of JP
drain output for your follow-up visit. Please continue to take
antibiotics until your drains are out. If you run out of
antibiotics before your drains are removed, please call us
immediately to get a refill.
.
Please resume previous medications as prior to your surgery.
Please take pain medications and stool softener as prescribed.
.
Please follow-up as directed.
Followup Instructions:
F/u with Dr. [**First Name (STitle) **] as directed, please call monday for an
appointment.
Name: [**Known lastname 6703**],[**Known firstname **] Unit No: [**Numeric Identifier 6704**]
Admission Date: [**2152-10-13**] Discharge Date: [**2152-10-22**]
Date of Birth: [**2110-1-16**] Sex: M
Service: PLASTIC
Allergies:
Amphotericin B / Ambisome / Campath
Attending:[**First Name3 (LF) 1165**]
Addendum:
Pt. was not fully cleared by PT services, but patient refuses
further PT evaluation while inpatient today, and refuses home PT
services at this time. Pt. is otherwise medically clear to go
home, and has demonstrated the ability to ambulate around his
room here without difficulty.
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1167**] MD [**MD Number(2) 1168**]
Completed by:[**2152-10-22**]
|
[
"909.3",
"403.90",
"205.10",
"528.3",
"287.4",
"738.19",
"709.2",
"V10.89",
"V15.3",
"996.85",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.43",
"08.52",
"86.69",
"27.53",
"96.6",
"83.82",
"08.61"
] |
icd9pcs
|
[
[
[]
]
] |
9769, 9933
|
4676, 6216
|
344, 694
|
7695, 7702
|
3244, 4653
|
9004, 9746
|
2774, 2792
|
6311, 7581
|
7631, 7674
|
6242, 6288
|
7726, 8981
|
2807, 3225
|
258, 306
|
722, 1439
|
1461, 2715
|
2731, 2758
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,083
| 160,226
|
14278+56525
|
Discharge summary
|
report+addendum
|
Admission Date: [**2170-7-16**] Discharge Date: [**2170-7-26**]
Date of Birth: Sex: F
Service:
I assumed the care of [**Known firstname **] [**Known lastname **] on [**2170-7-26**] from
Dr. [**First Name (STitle) **] [**Name (STitle) **].
HISTORY OF PRESENT ILLNESS: In brief, Ms. [**Known lastname **] is a 75-
year-old woman with a history of hepatic cirrhosis secondary
to hepatitis C who presented to [**Hospital1 188**] for evaluation of a potential TIPS procedure in the
context of worsening ascites.
PAST MEDICAL HISTORY: Additionally, her past medical history
is significant for hepatitis C cirrhosis, hypothyroidism,
history of E. coli septicemia, degenerative joint disease,
mitral valve prolapse, as well as status post TAH/BSO and
lumpectomy of the right breast.
HOSPITAL COURSE: Her hospital course was complicated by
acute renal failure which was felt to be secondary to
hepatorenal syndrome. Nephrology and hepatology followed
throughout her hospital course. Her hepatorenal syndrome was
managed with Octreotide, midodrine, and albumin.
Additionally, she was started on propranolol 10 mg t.i.d. to
decrease her portal pressures. An ultrasound study was
performed to evaluate for ascites for paracentesis. This was
not performed as there was only 500 cc of fluid assessed by
ultrasound. For her hepatic encephalopathy she was continued
on lactulose 45 mL p.o. q.i.d. For her spontaneous bacterial
peritonitis prophylaxis she was continued on Bactrim double
strength 1 tablet 5 times per week. Concerning her
hyponatremia, this improved over her hospital course from
initially the 110s while in the intensive care unit, then
ultimately up to the mid 120s, and then finally her sodium
was 133 on the day of discharge.
DISCHARGE DISPOSITION: Ultimately, she was discharged to a
skilled nursing facility for further care.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
Dictated By:[**Last Name (NamePattern1) 42406**]
MEDQUIST36
D: [**2171-6-6**] 15:10:00
T: [**2171-6-6**] 15:52:50
Job#: [**Job Number 42407**]
Name: [**Known lastname **], [**Known firstname 634**] Unit No: [**Numeric Identifier 7671**]
Admission Date: [**2170-7-16**] Discharge Date: [**2170-7-24**]
Date of Birth: [**2095-6-30**] Sex: F
Service: MED
ADDENDUM: This is an addendum to the discharge summary which
should be present from the MICU Service when the patient was
in the MICU Service. This is a Discharge Summary for when
the patient was transferred to the floor.
In summary, the patient is a 75 year old female with hepatic
cirrhosis secondary to hepatitis C who presented for
evaluation of TIPS procedure in the setting of worsening
ascites. She usually got weekly taps. The TIPS procedure
was postponed and also the EGD procedure that was planned to
actually to be done was also postponed since the patient has
been on the floor. Meanwhile, the [**Hospital 1325**] hospital course
has been complicated by and present with thoracentesis that
was done in the MICU service and a paracentesis which failed
in the MICU service and an interventional radiology based
ultrasound paracentesis was done since. Patient also
receiving a second paracentesis today, on [**2170-7-24**]. Patient
doing better in terms of shortness of breath since being
transferred to the floor.
PAST MEDICAL HISTORY: Hepatitis C.
Status post TAH/BSO.
Status post lumpectomy right breast.
Hypothyroidism.
History of right ureter calculus.
History of E.coli septicemia secondary to obstructed right
ureteral calculus.
DJD.
Mitral valve prolapse.
ALLERGIES: The patient is allergic to ciprofloxacin and
Prilosec.
HOSPITAL COURSE: The patient, since being admitted to the
medicine service, in terms of the patient's shortness of
breath, it has improved. She has gone down from 5 liters
nasal cannula down now to room air on [**7-24**] and doing much
better also with less shortness of breath. In terms of her
liver functions, her total bilirubin has elevated each day
and it has gone up from the high 2s to 3s and now to 5.7, but
per renal service since she had developed hepatorenal
syndrome, she was started on octreotide and midodrine and her
kidney function has actually improved since being on the
floor. Her kidney function has gone from mid-2 to about 2.3,
to now 1.8 on [**7-24**] and doing much better. Also her sodium
has gone from mid-120s, initially on the unit in the 110s,
and now it is in the low 130s.
In terms of her hypothyroidism, she was continued on her
thyroid replacement.
In terms of the patient's renal function, Renal is following
closely. She was receiving also albumin and she also had
some hyperkalemia which has resolved since.
In terms of prophylaxis, she was on Pneumo boots. In
addition, she had some asterixis on exam which has improved
since her bowel movements have increased over four bowel
movements per day.
The patient is being discharged to a rehab facility.
Her current medications while in-house have been albuterol
neb, albumin, erythromycin eyedrops q.i.d., guaifenesin 5 to
10 mg p.o. q.six hours p.r.n., ipratropium, lactulose 45 mg
p.o. q.i.d. to be titrated to four to five bowel movements
per day which she has received. Also she is on levothyroxine
100 mcg p.o. q.d., Midodrine 15 mg p.o. t.i.d., octreotide
200 mcg subcu q.eight.
Followup discharge summary to be done by discharging intern.
It was a privilege taking care of this patient and very
pleasant family.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7672**], MD [**MD Number(2) 7673**]
Dictated By:[**Name8 (MD) 1902**]
MEDQUIST36
D: [**2170-7-24**] 15:09:51
T: [**2170-7-24**] 15:53:33
Job#: [**Job Number 7674**]
|
[
"572.4",
"276.1",
"518.0",
"789.5",
"511.8",
"070.44",
"571.5",
"424.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"34.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
1793, 3395
|
3739, 5797
|
299, 540
|
3418, 3721
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,560
| 118,505
|
6764
|
Discharge summary
|
report
|
Admission Date: [**2133-4-15**] Discharge Date: [**2133-4-21**]
Date of Birth: [**2086-12-16**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2133-4-15**] - CABGx3 (Left internal mammary artery->left anterior
decending artery, Saphenous vein graft->Obtuse marginal artery,
Saphenous vein graft->Posterior left ventricular artery).
History of Present Illness:
[**Known firstname **] is a 46-year-old patient of Dr. [**First Name8 (NamePattern2) 1446**] [**Last Name (NamePattern1) 5263**]. She has a
history of diabetes, CAD, status post MI, and renal
insufficiency. She states she has had on and off dizziness for
a month and on [**2133-4-9**] when getting ready for work suddenly felt
dizzy and nauseous and actually vomited. She made her way down
the stairs into the kitchen and within about two minutes, she
felt better. She was very concerned because these are the same
symptoms she had when she had an MI [**36**] years ago.
She is high risk for an MI with her CAD and diabetes and
actually recently had a stress test, which showed an increased
area of concern. She has had no diarrhea, no fever or chills,
and no other obvious explanation for her symptoms.
Past Medical History:
1. CAD status post MI [**2119**] (presented with nausea, vomiting,
syncope) status post RCA PTCA. Subsequent MRI [**2122**],
asymptomatic
with RCA total occlusion and collaterals from the LAD.
Subsequent cardiac catheterizations in 12/99, [**11-24**], and [**8-27**],
[**10-30**]:
with last catheterization demonstrating mid LAD 70% lesion, mid
circ 80% stenosis, with an 80% narrowing at the bifurcation of
the OM and a 40% proximal OM lesion, RCA is occluded
2. Hypertension
3. Type 1 diabetes diagnosed [**2096**], age 10 complicated by
neuropathy, retinopathy, chronic kidney disease, gastroparesis
4. Asthma
5. GERD.
6. Prior tobacco use, quit [**9-29**].
7. Obesity
8. Depression on medications.
9. Carpal tunnel surgery in the [**2113**] bilaterally.
10. Recurrent rhinitis.
11. Bilateral cataract surgery.
12. Chronically elevated CPK levels
13. ORIF of the right ankle with removal of hardware and
subsequent repeat surgery.
14. Hyperprolactinemia, negative MRI, presumed medication
induced.
15. Axillary abscess [**9-4**] and right groin abscess in the recent
past, status post I&D.
16. Chronically elevated CPK levels
Social History:
Patient has worked as a paralegal for the last 25 years. She
lives by herself with her Golden Retriever, [**Doctor Last Name 25699**]. 10 pack
year history (quit), one drink/week.
Family History:
Father with HTN, mother with breast CA in remission. No family
history of early MI, arrhythmia, cardiomyopathies, or sudden
cardiac death; otherwise non-contributory.
Physical Exam:
Pulse: 50 Resp: 18 O2 sat: 98%
B/P Right: 107/58 Left:
Height: Weight:
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
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: Left:
Carotid Bruit: none Right:+2 Left:+2
Pertinent Results:
Pre-op:
[**2133-4-15**] 09:27AM HGB-12.4 calcHCT-37
[**2133-4-15**] 09:27AM GLUCOSE-206* LACTATE-1.1 NA+-139 K+-4.3
CL--102
[**2133-4-15**] 11:04AM GLUCOSE-170* LACTATE-1.4 NA+-138 K+-3.5
CL--105
[**2133-4-15**] 01:50PM PT-13.0 PTT-35.9* INR(PT)-1.1
[**2133-4-15**] 01:50PM PLT COUNT-202
[**2133-4-15**] 01:50PM GLUCOSE-113* LACTATE-1.4 NA+-137 K+-3.2*
CL--108
[**2133-4-15**] 03:24PM WBC-14.6*# RBC-3.61* HGB-9.6* HCT-28.7*#
MCV-79* MCH-26.6* MCHC-33.6 RDW-12.9
[**2133-4-15**] 03:24PM UREA N-28* CREAT-1.3* CHLORIDE-115* TOTAL
CO2-20*
Discharge:
[**2133-4-21**] 05:36AM BLOOD WBC-9.1 RBC-3.26* Hgb-8.9* Hct-27.3*
MCV-84 MCH-27.4 MCHC-32.7 RDW-13.9 Plt Ct-266
[**2133-4-21**] 05:36AM BLOOD Plt Ct-266
[**2133-4-17**] 03:44AM BLOOD PT-12.6 PTT-31.6 INR(PT)-1.1
[**2133-4-21**] 05:36AM BLOOD Glucose-120* UreaN-19 Creat-1.1 K-4.5
HCO3-27
[**2133-4-21**] 05:36AM BLOOD Calcium-8.2* Mg-2.1
[**2133-4-15**] 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. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. 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 and no aortic
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Physiologic mitral regurgitation
is seen (within normal limits). There is a trivial/physiologic
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is being a paced. There is normal
biventricular systolic function. The thoracic aorta appears
intact. No changes from the prebypass study.
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2133-4-18**]
Final Report
HISTORY: CABG. PICC line placement.
There is increased density in the retrocardiac area consistent
with
atelectasis or consolidation. The costophrenic sulci are
blunted.
Mediastinal structures are unchanged. A right internal jugular
sheath remains in place. A PICC line has been inserted on the
left and terminates at the level of the cavoatrial junction.
Compared with the previous study
retrocardiac density has increased and blunting of the
costophrenic sulci is new or more apparent.
IMPRESSION: PICC placement as described. Increased atelectasis
or
consolidation in the lower left lung. Evidence for small pleural
effusions.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**]
Brief Hospital Course:
Ms. [**Known lastname 111**] was a same day admission to the [**Hospital1 18**] on [**2133-4-15**] for
coronary artery bypass grafting. She was taken to the operating
room where she underwent coronary artery bypass grafting to
three vessels. Please see operative note for details.
In summary she had: Coronary artery bypass grafting x3 with left
internal mammary artery to the left anterior descending coronary
artery; reverse saphenous vein single graft from the aorta to
the first obtuse marginal coronary artery; reverse saphenous
vein single graft from the aorta to the posterior left
ventricular coronary artery.
Endoscopic left greater saphenous vein harvesting.
Her bypass time was 78 minutes with a crossclamp time of 63
minutes.
She tolerated the operation well and post-operatively she was
transferred to the intensive care unit for monitoring. In the
immediate post-op period she remained hemodynamically stable,
she awoke neurologically intact and was extubated.
Because the patient is a type 1 diabetic followed by the [**Last Name (un) 387**]
diabetes service they were consulted for assistance in her care
and insulin management. The patient stayed in the ICU for 3
additional days because she required a Phenylephrine infusion to
support her blood pressure. On POD4 she transferred out of the
ICU to the stepdown floor for continued care and recovery from
her surgery. Beta blockade, aspirin and a statin were resumed.
She was seen by physical therapy and her activity was advanced.
The remainder of her hospital course ws uneventful. On POD6 the
patient was discharged home with visiting nurses. she is to
follow-up with Dr [**Last Name (STitle) 914**] in 4 weeks.
Medications on Admission:
Acetaminophen-Codeine [**Hospital1 **] prn
Albuterol Sulfate [ProAir HFA]
Atenolol 25 mg Tablet QD
Bupropion HCl 200 mg Tablet Sustained Release QD
Clobetasol [Olux] 0.05 % Foam apply to affected area once a day
Esomeprazole Magnesium [Nexium] 40 mg QD
Fexofenadine 180 mg Tablet QD
Folic Acid 1 mg QD
Furosemide 80 mg Tablet QD
Insulin pump
Isosorbide Mononitrate 120 mg Tablet SR
Losartan 50mg QD
Metoclopramide [Reglan] 10 mg Tablet with meals and at bedtime
Montelukast [Singulair] 10 mg Tablet QD
Sertraline 200mg QD
Simvastatin 40 mg Tablet QD
Topiramate [Topamax] 25 mg Tablet
Aspirin 325 mg Tablet QD
Calcium Carbonate-Vitamin D3
Cyanocobalamin [Vitamin B-12] 250 mcg Tablet QD
Flaxseed Oil 1,000 mg Capsule
Multivitamin QD
Pyridoxine [Vitamin B-6] 100 mg Tablet
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
6. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
7. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24)
hours for 10 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**4-28**]
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
11. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a
day.
13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
14. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: 15-30
MLs PO Q6H (every 6 hours) as needed for cough.
Disp:*360 mls* Refills:*0*
15. Insulin Pump Cartridge Cartridge Sig: as directed units
Subcutaneous infusion: resume preop schedule.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
1. CAD s/p CABGx3 [**2133-4-15**]
2. Hypertension
3. Type 1 diabetes diagnosed [**2096**], age 10 complicated by
neuropathy, retinopathy, chronic kidney disease, gastroparesis
4. Asthma
5. GERD.
6. Prior tobacco use, quit [**9-29**].
7. Obesity
8. Depression on medications.
9. Carpal tunnel surgery in the [**2113**] bilaterally.
10. Recurrent rhinitis.
11. Bilateral cataract surgery.
12. Chronically elevated CPK levels
13. ORIF of the right ankle with removal of hardware and
subsequent repeat surgery.
14. Hyperprolactinemia, negative MRI, presumed medication
induced.
15. MRSA forehead
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with Dilaudid prn
Sternal wound healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, 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 follow-up with Dr. [**Last Name (STitle) 914**] [**2133-5-19**] 1:00PM
Please follow-up with Dr. [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 5263**] [**Telephone/Fax (1) 250**]
Date/Time:[**2133-6-1**] 11:10.
Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**]
Date/Time:[**2133-4-29**] 3:20
[**Hospital 409**] Clinic in 2 weeks, nurses to schedule appt befoer
discharge
Completed by:[**2133-4-21**]
|
[
"411.1",
"530.81",
"357.2",
"414.01",
"V15.82",
"414.2",
"362.01",
"403.90",
"278.00",
"250.51",
"311",
"250.61",
"585.9",
"250.41",
"276.2",
"V58.67",
"285.9",
"V12.04",
"253.1",
"493.90",
"536.3",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11001, 11060
|
6649, 8332
|
332, 526
|
11696, 11844
|
3556, 6626
|
12469, 12926
|
2752, 2921
|
9154, 10978
|
11081, 11675
|
8358, 9131
|
11868, 12446
|
2936, 3537
|
282, 294
|
554, 1367
|
1389, 2536
|
2552, 2736
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
902
| 137,798
|
44538
|
Discharge summary
|
report
|
Admission Date: [**2165-4-18**] Discharge Date: [**2165-4-23**]
Date of Birth: [**2111-12-6**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Penicillins
Attending:[**First Name3 (LF) 9554**]
Chief Complaint:
ventricular fibrillation
Major Surgical or Invasive Procedure:
1. Cardiac catheterization
2. AICD placement.
History of Present Illness:
53yo M with no known heart disease, history of narcotic and
alcohol abuse on methodone presented to [**Hospital3 4107**] with
syncope. He had had recurrent syncopal events over the last 4
days prior to admission but refused medical attention. He was
found to be in ventricular fibrillation. He was defibrillated
and intubated. He awoke with conversion to sinus rhythm. was
agitated. (initial K 2.7, Initial ABG at [**Hospital3 4107**]
7.40/47/326.)He pulled out his ET tube, became progressively
obtunded with more ventricular ectory and was reintubatd. He was
treated for recurrent bouts of ventricular tachycardia with IV
amiodarone, magnesium and potassium, as well as ativan and
Pavulon. Drug screen was positive for benzodiazepine,
tetrahydrocannabinol and was negative for ETOH. He developed VF
again on amiodarone and with K 3.0 requiring another
defibrillation. He had subsequent addition of lidocaine with
stabilization of ventricular ectopy. Weaning was attempted next
am when he began to develop ventricular ectopy. Echo showed
anterior septal hypokinesis with EF 30-40%. His peak CK was
5675 post defibrillation
Past Medical History:
1. GERD
2. Hypothyroidism
3. Hepatitis B and C positive
4. PVD
5. Partial gastrectomy in [**2138**]
6. Appendectomy in [**2138**].
Social History:
marijuana use
significant ETOH use
prior heroin use
Family History:
nc
Physical Exam:
PHYSICAL EXAMINATION:
GEN: short obese male with long unkempt hair asleep but easily
arousable, NAD. Pt conversing in full sentences without
accessory muscle use.
HEENT: EOMI, anicteric, mmm, op clear
CV: RRR, S1, S2, distant heart sounds, no murmurs, rubs, gallops
appreciated
Chest: improved but persistent bilateral wheezing. right
subclavian line in place without significant erythema,
induration or tenderness on palpation. Large white abd pad over
left chest, clean dry intact. Minimal tenderness over site.
Abd: obese, soft, NT, ND
Ext: wwp, +1 non-pitting edema with some tenderness, ?trace PT.
multiple areas of echymosis (pt unclear how he got them) without
skin breakdown.
Pertinent Results:
[**2165-4-18**] 05:51PM WBC-9.9 RBC-4.49* HGB-12.9* HCT-40.5 MCV-90
MCH-28.7 MCHC-31.7 RDW-15.4
[**2165-4-18**] 05:51PM PLT COUNT-173#
[**2165-4-18**] 05:51PM GLUCOSE-114* UREA N-7 CREAT-0.6 SODIUM-138
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-9
[**2165-4-18**] 05:51PM ALT(SGPT)-78* AST(SGOT)-258* LD(LDH)-639*
CK(CPK)-8324* TOT BILI-2.5*
[**2165-4-18**] 05:51PM CK-MB-61* MB INDX-0.7 cTropnT-0.03*
[**2165-4-18**] 05:51PM TSH-9.6*
[**2165-4-18**] 05:51PM HBsAg-NEGATIVE HBs Ab-POSITIVE
[**2165-4-18**] 05:51PM HCV Ab-POSITIVE
[**2165-4-18**] 05:51PM TRIGLYCER-62 HDL CHOL-28 CHOL/HDL-2.7
LDL(CALC)-35
[**2165-4-18**] 05:55PM PT-14.7* PTT-32.1 INR(PT)-1.4
[**2165-4-18**] 07:14PM [**Doctor First Name **]-NEGATIVE
[**2165-4-18**] 07:58PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2165-4-18**] 07:58PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-TR
[**2165-4-18**] 07:58PM URINE RBC->50 WBC-0 BACTERIA-0 YEAST-NONE
EPI-0
[**2165-4-18**] 09:29PM TYPE-ART PO2-152* PCO2-43 PH-7.43 TOTAL
CO2-29 BASE XS-4
.
.
[**2165-4-19**] Abd US:
"Echogenic liver consistent with fatty infiltration. Other forms
of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on the
basis of this study. No focal liver lesions are identified. The
additional finding of splenomegaly is suggestive of intrinsic
liver disease."
.
.
[**2165-4-19**] TTE:
"1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Regional left
ventricular wall
motion is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
3. The aortic root is mildly dilated."
.
.
[**2165-4-21**] Hip X-ray:
"1) Status post right femoral head resection with acetabular
screws as described. No significant change.
2) Degenerative disease of the left hip, no obvious fracture but
due to osteopenia, subtle fractures may be missed and if
clinical suspicion persists, an MRI could be helpful."
.
.
[**2165-4-22**] Cardiac Cath:
"1. Coronary arteries had no flow limiting disease.
2. Severe diastolic ventricular dysfunction."
.
.
[**2165-4-23**] CXR:
"Status post ICD placement with single lead in the right
ventricle. No evidence of pneumothorax"
.
.
Brief Hospital Course:
A/P: 53yo M with significant alcohol use, narcotic abuse and no
significant cardiac history presents with recurrent ventricular
arrhythmia s/p VF arrest in the setting of positive tox screen,
hypokalemia and hypomagnesemia. He is transferred for EP
evaluation s/p VF cardiac arrest and EF 30-40%.
.
1. CV:
A). Coronaries: Pt was without prior history of CAD, however he
had a high CK on admission which was most likely due to his
repeated cardioversions. However with VF and new CHF, ischemic
causes were ruled out with cardiac catheterization. The cath
demonstrated clean coronaries confirming our suspicion regarding
the origin of the high CK. The patient was continued on ACEI
(Lisinopril 5mg once daily), and BB (Atenolol 50mg once daily)
and was started on ASA.
.
B). Pump: On admission, the patient was clinically found to
have significant CHF. TTE at [**Hospital3 4107**] showed EF 30-40%.
Cardiac cath demonstrated clean coronaries, making ischemic
causes unlikely. This is possibly due to alcohol induced,
infectious (HIV pending, HCV positive), narcotic induced,
familial, infiltrative or idiopathic or his arrhythmia. This is
unlikely to be due to thyroid (TSH of 11 but normal free T4), or
hemochromoatosis (normal iron studies). Sarcoidosis also can
not be excluded but is unlikely given the rest of his clinical
history, exam and normal Ca. [**Doctor First Name **] and ESR also were wnl. Pt was
continued on ACEI and BB during his hospital stay as above.
After correction of his electrolytes, and repeated DCCV, he was
back in NSR and his CHF appeared to resolve as well.
.
C). Rhythm: Pt presented with VFib arrest in setting of
positive THC, BZD with hypokalemia and hypomagnesemia. This is
most likely secondary to electrolyte imbalance from substance
abuse. His electrolytes were repleted and the pt was started on
amiodarone 400mg TID. He also received an AICD after his
cardiac catheterization without any complications. He wa
monitored on telemetry during his hospital stay and remained in
NSR to Sinus Tach. At time of discharge, the amiodarone was
discontinued as he now had an AICD implanted. In addition,
given his hx of thyroid disorder and unknown pulmonary function
(but requiring fluticasone and albuterol), amiodarone was deemed
unsafe/unnecessary in this setting. At time of discharge he was
sent home on clindamycin QID for 6days for prophylaxis (the
patient has an allergy to PCN).
.
.
2. Pulm: Pt was intubated at OSH after his episodes of vfib
arrest. He was acutely agitated after conversion to NSR and self
extubated himself. He progressively became obtunded with more
ventricular ectopy requiring re-intubation at OSH. At [**Hospital1 18**], he
was extubated without complication. After extubation, he was
found to have significant wheezing on exam but improved with IH
and nebulizers. The patient was continued on Fluticasone [**Hospital1 **]
with albuterol nebulizers. In addition, he was given
guaifenesin PRN for mucous secretions. At time of discharge, he
was given additional prescriptions for the Fluticasone and
albuterol IH and given explicit instructions to both him and his
wife on how to use the IH and spacers effectively. The patient
was also instructed to follow up with his PCP regarding [**Name9 (PRE) 1570**] and
sleep study.
.
.
3. Substance abuse: The patient has a significant substance
abuse history and was admitted with positive BZD and THC
(cannabinoids) on tox screen. Pt also was found to have LFT
changes consistent with chronic alcohol disease. He was
continued on his standing valium 5mg [**Hospital1 **] as well as methadone
120mg QD with oxycodone for break through pain (outpatient
regimen). His wife and the methadone clinic was contact[**Name (NI) **]
regarding this regimen which was confirmed. He was monitored on
a CIWA scale but did not require additional BZD or additional
pain control.
.
.
4. ID: Pt had occasional temperature spikes earlier in hospital
course and was started on azithromycin for bronchitis. This was
switched to cipro 500mg [**Hospital1 **] on [**4-20**]. He finished a 5day course
of abx and was afebrile, without any focal signs of sx of
infections. He was discharged on clindamycin QID for 6days (for
prophylaxis s/p AICD placement).
.
.
5. Hypothyroidism: continued synthroid dose.
.
.
6. MS: The patient experienced an episode of vfib arrest with ?
period of anoxia. Secondary to this significant event, he was
found to have some short term memory loss. However at time of
discharge, he was found to be fuctional with all ADL and IADL.
After evaluation by PT and OT, he was cleared to go home with
outpatient PT and services. His wife reports there is still
some baseline disturbances, but believes he is improving slowly
with time.
.
.
7. FEN: Folate, thiamine, MVI supplements. Replete lytes as
above.
.
.
8. PPx: Pt was continued on heparin sub Q TID for DVT
prophylaxis throughout his hospital course. Colace and senna
was also given for bowel regimen given opiate use with dulcolax
PRN.
.
.
9. Code: Full code.
.
Medications on Admission:
synthroid 0.05mg QD
Valium 2mg [**Hospital1 **]
protonix 40 [**Hospital1 **]
methadone 120 QD
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Methadone HCl 40 mg Tablet, Soluble Sig: Three (3) Tablet,
Soluble PO QD ().
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Alprazolam 1 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day)
as needed.
8. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*10 Tablet(s)* Refills:*0*
11. Colace 100 mg Capsule Sig: [**1-27**] Capsules PO twice a day.
Disp:*30 Capsule(s)* Refills:*2*
12. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two
(2) puffs Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
13. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-27**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
14. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four
times a day for 6 days.
Disp:*24 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. Ventricular fibrillation cardiac arrest
2. Sleep apnea
3. Sick euthyroid
4. Hypertension
5. History of polysubstance abuse
6. Hepatitis B and C postive
Discharge Condition:
Good
Discharge Instructions:
Please take all your medications as listed on the following
page.
Please follow up with your doctors.
Please call your doctor or return to the hospital if you have
chest pain/lightheadedness/shortness of breath or if there are
any concerns at all
Please do NOT drive for at least 6 months.
Followup Instructions:
PCP: [**Name10 (NameIs) **] your PCP: [**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 68961**] for an
appointment within 2 weeks. You need to be evaluated with a
outpatient sleep study for sleep apnea. Please also have your
PCP arrange for an outpatient PFTs as well as repeat thyroid
studies.
Cardiology:
1. DEVICE CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2165-4-30**] 3:00
2. Please call ([**Telephone/Fax (1) 2037**] to shedule an appointment with
Dr. [**Last Name (STitle) **], the cardiologist, within one month of your
discharge
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]
Completed by:[**2165-4-24**]
|
[
"305.00",
"425.5",
"443.9",
"070.30",
"070.70",
"304.31",
"275.2",
"427.41",
"276.8",
"244.9",
"428.0",
"780.57",
"304.41",
"490"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"89.49",
"88.56",
"37.94",
"37.22",
"38.93",
"94.65",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11378, 11433
|
4824, 9892
|
307, 356
|
11637, 11643
|
2487, 4801
|
11985, 12758
|
1760, 1764
|
10036, 11355
|
11454, 11616
|
9918, 10013
|
11667, 11962
|
1779, 1779
|
1801, 2468
|
243, 269
|
387, 1514
|
1536, 1675
|
1691, 1744
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,439
| 161,768
|
41133
|
Discharge summary
|
report
|
Admission Date: [**2179-5-26**] Discharge Date: [**2179-6-9**]
Date of Birth: [**2093-8-17**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Headaches.
Major Surgical or Invasive Procedure:
[**2179-5-28**]: Right occipital brain biopsy.
History of Present Illness:
[**Known firstname **] [**Known lastname 56636**] is an 85-year-old right-handed woman, with history
of B cell lymphoma, who complains of nightly headaches waking
her from her sleep, difficulty walking and word-finding
difficulty. She has been followed by neuro-onc and was sent for
an MRI which revealed a right occipital lesion. She
denies fevers, chills, nightsweats, nausea, vomiting, or loss of
consciousness.
Past Medical History:
B-cell lymphoma
HTN
CAD
PVD: s/p 2 stents
hypercholesterolemia
s/p splenectomy, cholecystectomy, hysterectomy
Social History:
She has a heavy smoking history. She is a social drinker. She
lives with daughter and grandson.
Family History:
Her mother died at age 85 from coronary artery disease. Her
father also died from coronary artery disease. She had 3
brothers who are deceased; they all had coronary artery disease
and one also had a cerebral aneurysm. She had 3 sisters who are
deceased; one died as an infant, one had Peutz-Jeghers
syndrome, and a third had coronary artery disease. She has 4
daughters and 3 sons and they all have coronary artery disease,
hypertension, and hyperhcolesterolemia.
Physical Exam:
On admission:
PHYSICAL EXAM:
Vital Signs: Temperature: afebrile, blood pressure 90/60, pulse
60, respiration 14.
General: WD/WN, comfortable, NAD.
HEENT: Pupils: 2.5->2mm bilat EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiovascular: RRR, S1/S2, positive systolic murmur.
Abdomen: Soft, NT, BS+
Extremities: Warm and well-perfused.
Neurological Examination:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light bilaterally.
There is a homonymous left visual field cut.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-13**] throughout. She has slight
left pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin.
Pertinent Results:
ADMISSION LABS:
[**2179-5-26**] 08:25PM BLOOD WBC-7.9 RBC-3.98* Hgb-12.9 Hct-37.3
MCV-94 MCH-32.4* MCHC-34.6 RDW-14.1 Plt Ct-371
[**2179-5-26**] 08:25PM BLOOD Glucose-117* UreaN-11 Creat-0.7 Na-135
K-4.3 Cl-98 HCO3-29 AnGap-12
[**2179-5-26**] 08:25PM BLOOD Calcium-9.0 Phos-4.1 Mg-2.2
DISCHARGE LABS:
[**2179-5-26**] ECG:
Sinus rhythm. Left atrial abnormality. Diffuse non-diagnostic
repolarization abnormalities. No previous tracing available for
comparison.
[**2179-5-26**] MRI Brain:
IMPRESSION:
1. Marked interval enlargement of gyriform right occipital
enhancing mass
with marked worsening of adjacent vasogenic edema. The gyriform
pattern and associated restricted diffusion are most suspicious
for "metastatic" lymphoma from the patient's known systemic
lymphoma.
2. The other foci of enhancement in the left posterior temporal
lobe and left cerebellar hemisphere show continued decrease in
prominence.
[**2179-5-27**] ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with
akinesis/aneurysm of the basal inferior and inferolateral
segments. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are mildly thickened (?#).
There is severe aortic valve stenosis (valve area 0.8-1.0cm2).
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild focal LV systolic dysfunction. Diastolic dysfunction.
Likely severe calcific aortic stenosis (low-output, low-gradient
AS).
[**2179-5-28**] Head CT:
IMPRESSION: Right occipital lobe parenchymal hemorrhage
following biopsy.
[**2179-5-29**] Head CT:
IMPRESSION: Increase in size of right parietal intraparenchymal
hemorrhage, with increase in associated leftward midline shift.
[**2179-5-29**] Head CT:
IMPRESSION: Stable appearance of right parietal intraparenchymal
hemorrhage with associated mass effect.
Brief Hospital Course:
This is an 85-year-old woman with history of lymphoma,
presenting with headaches and left visual cut, now s/p brain
biopsy showing CNS lymphoma, with course complicated by post-op
left sided weakness and hemorrhage at biopsy site now C1D4 MTX.
(1) CNS lymphoma: Patient has known lymphoma diagnosed in [**2176**]
and found to have intracranial masses in [**2179-1-9**] but
symptoms had been stable and she was being monitored clinically.
She now presented with headaches and left visual field cut, and
was subsequently admitted to the neurology service.
Neurosurgery was consulted and the patient underwent a brain
biopsy on [**2179-5-28**] consistent with CNS lymphoma.
Post-operatively, the patient developed a new left hemiparesis,
a CT head showed a hemorrhage in the post-op tumor bed with
cerebral edema. She received Mannitol x1 and Decadron 10mg x1.
Her repeat Head CTs showed stability of the bleed, and her left
sided weakness slowly improved. She also had a restaging torso
CT on [**6-3**] concerning for malignant nodules within a background
of infectious/inflammatory process. She was transferred to the
oncology floor where methotrexate was initiated which she
tolerated well. She was continued on leucovorin until her blood
methotrexate levels cleared. Her urine pH was monitored to
ensure alkalotic urine. She was continued on dexamethasone
during treatment which was tapered to 4mg q12 hours. Of note,
patient was seen by ophthalmology who felt that she did not have
ocular lymphoma contributing to her visual symptoms. She was
maintained on IV morphine and oxycodone in-house for her
headaches. Patient was discharged with appropriate oncology
follow up. Plans for next round of MTX will be done at [**Hospital1 4494**] under the supervision of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
(2) UTI: Urinalysis drawn for very slightly elevated
temperature to 99.1 F. Urinalysis borderline with cultures
growing Klebsiella sensitive to ciprofloxacin. She was treated
with 3 day course of ciprofloxacin starting [**2179-6-8**], last day
[**2179-6-10**].
(3) Depression: Clinically stable. She continued on sertraline
200mg daily.
(4) Hyperlipidemia: Continued atorvastatin 80mg daily.
Medications on Admission:
- ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - [**1-10**] Tablet(s) by
mouth every 6 hours headaches
- ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth
HS (at bedtime)
- FUROSEMIDE - 20 mg Tablet - 0.5 (One half) Tablet(s) by mouth
DAILY (Daily)
- PHENYTOIN SODIUM EXTENDED - 100 mg Capsule - 1 Capsule(s) by
mouth three times a day
- POTASSIUM CHLORIDE 10 mEq Tablet Extended Release - 1
Tablet(s) by mouth every other day
- SERTRALINE - 100 mg Tablet - 2 Tablet(s) by mouth once a day
- TEMAZEPAM [RESTORIL] - 15 mg Capsule - 1 Capsule(s) by mouth
nightly
- TOLTERODINE [DETROL LA] 4 mg Capsule, Ext Release 24 hr - 1
Capsule(s) by mouth once a day
- ASPIRIN 81 mg Tablet Chewable - 1 Tablet(s) by mouth DAILY
(Daily)
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
7. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. tolterodine 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO three times a
day.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Oragesic Solution Sig: One (1) Mucous membrane four times a
day as needed for oral sore pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
-Central Nervous System Lymphoma
-Right occipital brain mass - with associated left sided
hemineglect
-Right occipital hemorrhage
-Oral stomatitis - secondary to methotrexate
-Uncomplicated UTI - with Klebsiella sensitive to ciprofloxacin
-Depression
-Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 56636**],
You were admitted to the hospital for vision changes and
headaches. A biopsy of your brain was done which showed
lymphoma. You were transferred to the oncology service and
started on Methotrexate chemotherapy which you tolerated well.
You also developed weakness of your left side while in the
hospital. We did a scan of your head and you were found to have
a hemorrhage where your biopsy was done. Your weakness improved
overadmission and the hemorrhage remained stable.
You cleared the chemotherapy out of your system and we feel you
are safe for discharge.
We made the following changes to your medications:
- STOP acetaminophen-codeine
- START oxycodone 2.5mg every 4-6 hours as needed for headache
- START acetaminophen 650mg three times daily for headache
- START dexamethasone 4mg oral twice daily, please continue this
until Dr. [**Last Name (STitle) 724**] instructs you to stop
- START omeprazole 20mg daily, please continue this as long as
you are taking dexamethasone to prevent stomach ulcers
- START colace 100mg twice daily as needed for constipation
- START senna 8.6 mg twice daily as needed for constipation
- START oragesic mouth wash as needed for oral sore pain
- STOP potassium chloride
Dr. [**Last Name (STitle) 724**] is going to talk to your local medical oncologist, Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], and will coordinate your next round of chemotherapy
and follow up appointment.
Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Location: [**Hospital1 18**] DEPT OF NEUROLOGY
Address: [**Location (un) **], TCC 8, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1844**]
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**] is going to talk to your outpatient oncologist
and will coordinate your next round of chemotherapy and follow
up appointment. We are working on a follow up appointment for
you with Dr. [**Last Name (STitle) 724**] in the next 4-8 days. You will be called at
home with the appointment. If you have not heard within 2
business days or have questions, please call the number above.
Completed by:[**2179-6-9**]
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Discharge summary
|
report+addendum
|
Admission Date: [**2204-11-14**] Discharge Date: [**2204-11-19**]
Date of Birth: [**2154-5-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 3853**]
Chief Complaint:
"lethargy."
Major Surgical or Invasive Procedure:
intubation/extubation
History of Present Illness:
Patient is a 50 M with a past history of diabetes, chronic lower
leg pain, COPD, obesity-related hypoventilation syndrome, past
history of respiratory failure, chronic pain on opiates, DMII
who presents with decreasing and fluctuating mental status per
his mother. [**Name (NI) **] is also complaining of leg pain and weakness
that is similar to prior. He has been feeling somewhat more
short of breath particularly with exertion. He is using his
albuterol and ipratroprium inhalers slightly more than baseline.
He also states that he has had some non-productive cough, chills
but no fevers. His mother controls his medications, and she is
fairly certain that he has not overdosed on his pills.
In the ED, his initial VS were 97.5 116 146/81 8 100% ra. He
then triggered for hypoxia to 88% on RA. His exam was
significant for lethargy, moving all extremities but not
compliant with full neuro exam [**12-20**] drowsiness. He had wheezing
on pulmonary exam. His ABG showed pCO2 63. Lactate 1.4. Tox
screen was positive for benzos. His EKG showed sinus 116, NANI,
no STE. CXR showed LLL infiltrate and he was given levoquin. He
was also given solumedrol and azithro for COPD flare. Vitals
prior to transfer: P 94, 140/82, O2 sat 93% on 4 L via biPAP
.
On arrival to the MICU, patient was requesting food.
Past Medical History:
- Type 2 DM has been followed at [**Last Name (un) **] (last A1c 8.0 [**2204-10-8**])
- OSA on CPAP at home
- Hepatits C - s/p aborted course of interferon
- Major depressive disorder, ? of schizophrenia and bipolar
disorder
- Hypertension
- Bilateral avascular necrosis of femoral heads s/p hip
replacements in '[**79**] and '[**85**]
- s/p L1/L2 kyphoplasty after fall [**6-25**]
- s/p left distal radius fracture after fall [**6-25**]
- Bilateral lower extremity edema, thought to be secondary to
venous stasis
- DJD of his back
- Osteoporosis
- Morbid Obesity
- Schatski's ring
Social History:
On disability, lives with his mother, attends a day program.
- Tobacco: Smokes [**12-21**] ppd for > 10yrs
- Alcohol: no EtoH for 15 years
- Illicits: Stopped IVDA in [**2186**] after 3 years of use, did take
cocaine with heroine. Has not used since then.
Family History:
father with DM and CAD
Physical Exam:
Vitals: T: 97.2 BP: 160/72 P: 106 R: 17 O2: 94% on 2L NC
General: Obese, AAOx3, closes eyes during interview but easily
arousable
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: diminished breath sounds throughout, no wheezes, rales,
ronchi
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no organomegaly
Ext: hypertrophic toenails
Neuro: CNII-XII intact, moving all extremities, 3/5 strength in
LE limited by pain, sensation intact throughout
Discharge PE:
General: Obese, flat affect, in NAD
HEENT: CN 2-12 grossly intact, MMM
CV: distant HS, RRR, no RMG
Lungs: CTAB, no WRR, distant BS
Abdomen: obese, soft, NTND, bowel sounds present
Extremities: decreased strength in hip flexion and extension [**1-21**]
and knee extension/flexion 4+/5 and ankle plantar flexion and
extension 4+/5, sensation in grossly intact
Pertinent Results:
Admission:
[**2204-11-14**] 11:30AM BLOOD WBC-4.5 RBC-3.88* Hgb-12.1* Hct-37.1*
MCV-96 MCH-31.2 MCHC-32.7 RDW-13.9 Plt Ct-127*
[**2204-11-14**] 11:30AM BLOOD Neuts-69.1 Lymphs-21.7 Monos-6.6 Eos-2.1
Baso-0.4
[**2204-11-14**] 11:30AM BLOOD Glucose-161* UreaN-33* Creat-1.0 Na-135
K-4.9 Cl-99 HCO3-29 AnGap-12
[**2204-11-14**] 11:30AM BLOOD Calcium-9.0 Phos-4.4 Mg-1.5*
[**2204-11-14**] 01:09PM BLOOD Type-ART pO2-109* pCO2-59* pH-7.34*
calTCO2-33* Base XS-4 Comment-GREEN TOP
[**2204-11-14**] 11:48AM BLOOD Glucose-150* Lactate-1.4
Discharge:
[**2204-11-17**] 06:10AM BLOOD WBC-5.5 RBC-3.86* Hgb-11.9* Hct-35.2*
MCV-91 MCH-30.9 MCHC-33.9 RDW-13.9 Plt Ct-139*
[**2204-11-19**] 06:00AM BLOOD Glucose-327* UreaN-23* Creat-0.9 Na-134
K-4.4 Cl-93* HCO3-32 AnGap-13
[**2204-11-19**] 06:00AM BLOOD Calcium-9.6 Phos-4.1 Mg-1.6
CXR [**2204-11-14**]
IMPRESSION: Mild pulmonary edema. Repeat imaging after diuresis
is
recommended to evaluate for concomitant pneumonia.
ECHO [**2204-11-15**]
IMPRESSION: Suboptimal image quality. Normal global and regional
biventricular function. Mildly dilated aortic arch. Mild
pulmonary artery hypertension.
Brief Hospital Course:
50M with h/o OSA, COPD and chronic pain on narcotics, who was
admitted with hypercarbic respiratory failure.
#. AMS: Patient presented with increased lethargy for week. He
was oriented on arrival to the MICU but was falling asleep
intermittently during the interview. Patient had been taking
seroquel 600 mg po qHS and xanax 4 mg po BID, oxycontin SR 100
mg po TID, oxycodone IR 10 mg po q3-4h which are likely
contributing to his AMS. He has not been taking risperdal. Held
all pysch meds while lethargic discontinued seroquel. Decreased
xanax dose and continue lower dose seroquel once more awake.
Treated medical comorbities as below. His AMS improved and he
was transferred to the floor. His AMS was thought to be
multifactorial. His BiPAP settings were adjusted, psych was
consulted and adjusted his medications to seroquel 300mg PO
daily, risperidone 3mg Daily and diazepam 1mg PO QID. Pain was
also consulted and we were able to lower his pain regiment to
oxycontin 40mg PO Q8H and oxycodone 10mg PO Q6H:PRN and Topomax
25mg PO Daily. We discussed with the patient and his mother the
fine balance needed between symptom control and maintaining his
normal mental state and respiratory integrity. He will follow
up with psych in the outpatient setting for eventual weaning off
of the seroquel and diazepam.
.
#Shortness of breath: likely multifactorial - obesity
hypoventilation, pulmonary HTN from OSA, COPD exacerbation, in
the setting of taking multiple sedating medications. Patient was
originally admitted to the ICU for respiratory failure requiring
BiPAP in the ED. On arrival to the MICU, he was on 2 L NC and
while minimal shortness of breath and wheezing. He also also
evidence of pulmonary edema on CXR but no sign of pna.Continued
prednisone 60 mg po daily and azithromycin 250 mg po daily . He
was intubated for brief period of time and successfully
extubated. Continued home BIPAP at night and albuterol and
ipratroprium nebs. Home BiPAP settings are Nasal CPAP with PSV,
inspiratory pressure 18cm/H20, expiratory pressure 10 cm/H20,
supplemental oxygen 2-6 L/min to maintain SpO2 to >92%. He was
diuresed 6.4L and was satting well at his goal O2 of 88-92% on
RA at the time of transfer to the floor. He remained stable on
the floor.
.
# Chronic pain: He has severe, debilitating chronic pain [**12-20**]
bilateral hip avascular necrosis. His home narcotics and benzos
were tapered and he was transferred to the floor with CIWA
protocol. Psychiatry consulted and recommended continuation of
xanax during taper period with ativan for CIWA. Pain service
was also consulted and recommended new regimen of standing
oxycontin 40mg PO Q8H with oxycodone 10mg Q6H:PRN as well as
Topomax 25mg Daily. On this new regiment, we were able to
achieve his baseline pain of [**2-26**]. He was discharged on this
new regiment.
.
# schizophrenia: pt denied AH/VH. psych was consulted and
recommended starting risperidal alongside seroquel and slowly
tapering seroquel, because of its sedative effects. He will
also continue diazepam 1mg QID for now with plan to taper off of
benzodiazepines in the future.
.
# Diabetes: Patient was continued on home insulin 70/30 [**Hospital1 **]
regiment with a sliding scale that was higher than normal
because he was on steroids during his stay for possible COPD
exacerbation. His sugars were high while on the steroids, but
manageable with his ISS. His metformin and glyburide were
restarted at the time of discharge.
.
# Hypertension: continued home metoprolol, lisinopril, and
losartan, hctz, amlodipine with holding parameters
===================================
TRANSITION OF CARE:
-Patient's BiPAP settings are: Nasal CPAP w/PSV (BIPAP)
----Inspiratory pressure: 18 cm/h2O
----Expiratory pressure: 10 cm/h2O
----Supplemental oxygen: 2-6 L/min to maintain SpO2 to >92
- patient needs follow up with psychiatry
Medications on Admission:
-buspirone 15 mg PO BID
-glipizide ER 10 PO twice a day.
-metformin 850 mg PO three times a day with meals.
-lisinopril 40 mg PO once a day.
-metoprolol succinate 100 mg PO DAILY
- quetiapine 600 mg PO QHS
- oxycodone ER 80 mg TID
- oxycodone 10 mg PO q3-4h
- losartan-hydrochlorothiazide 100-12.5 mg PO once a day
- alprazolam 2 mg PO QID prn (takes 4 mg qAM and qPM)
- albuterol sulfate 90 mcg 2 Puffs Q6H prn SOB/ wheezing.
- ipratropium bromide 17 mcg 2 Puffs Q6H prn SOB/ wheezing.
- risperidone 1 mg PO qAM and 2 mg Tablet PO HS (NOT TAKING)
- multivitamin PO once a day. (not taking)
- insulin NPH & regular human 100 unit/mL (70-30)- 40 units [**Hospital1 **]
- Vitamin D 50,000 units PO once a week (not taking)
- Amlodipine 5 mg po daily
- Tamzepam 30 mg po qHS
- Atorvastatin 40 mg po daily
Discharge Medications:
1. buspirone 15 mg Tablet Sig: as directed Tablet PO twice a
day: Please take one pill (15mg) in AM, and two pills (30mg) in
PM .
Disp:*90 Tablet(s)* Refills:*2*
2. glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO twice a day.
3. metformin 850 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals.
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. quetiapine 300 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO HS (at bedtime).
7. losartan-hydrochlorothiazide 100-25 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
9. Outpatient Physical Therapy
Patient has difficulty ambulating [**12-20**] pain, would benefit from
outpatient PT.
10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day.
Disp:*30 * Refills:*2*
11. ipratropium bromide 0.02 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
12. risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Extended Release 12 hr(s)* Refills:*0*
16. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for pain.
17. topiramate 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
20. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
21. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
Disp:*1 bottle* Refills:*2*
22. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Forty (40) units Subcutaneous twice a day.
23. alprazolam 1 mg Tablet Sig: One (1) Tablet PO four times a
day.
Disp:*120 Tablet(s)* Refills:*0*
24. quetiapine 100 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Health Systems
Discharge Diagnosis:
obesity hypoventilation syndrome
narcotic/benzo overdose
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 14323**],
It was a pleasure participating in your care at [**Hospital1 771**]. You came to the hospital because you
were confused. Your oxygen levels were found to be low so you
were admitted to the ICU. You are on many medications that can
reduce your respiratory drive, or urge to breathe. Notably,
narcotics (oxycontin and oxycodone) and benzodiazepines (xanax)
can do this, so these medications were reduced for your safety.
You were also given medications to treat a possible COPD
exacerbation and reduce extra fluid in your lungs.
Please attend the follow-up appointment listed below with your
primary care doctor to help determine a pain management regimen
that does not cause as many respiratory side effects. You should
also follow up with your psychiatrist to figure out how to best
treat your anxiety.
We made the following changes to your medications:
1. INCREASED buspirone (Buspar) to 15mg in the AM, and 30mg in
the PM
2. DECREASED quetiapine (Seroquel) to 300mg before bedtime, plus
an extra 100-200mg if needed for insomnia
3. DECREASED oxycontin to 40mg by mouth three times daily
4. DECREASED oxycodone to 10mg by mouth every 6 hours as needed
for breakthrough pain
5. DECREASED alprazolam (Xanax) to 1 mg by mouth four times
daily
6. CHANGED risperidone (Risperdal) to 3mg by mouth at bedtime
7. INCREASED losartan-hydrochlorothiazide to 100-25mg by mouth
once daily
8. STOPPED temazepam (Restoril)
9. STARTED docusate (Colace) 100mg by mouth twice daily
10. STARTED senna 1 tab by mouth twice daily
11. STARTED polyethylene glycol (Miralax) 17 gram/dose powder by
mouth daily
Followup Instructions:
Please call your psychiatrist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 27181**]) to
schedule a follow-up appointment as soon as possible (within the
next 1-2 days).
Please call [**Hospital 6549**] Medical Care (1-[**Telephone/Fax (1) 27182**]): this
company will help to optimize your home BiPAP settings and make
sure they are correct.
Department: [**State **] SQUARE, PRIMARY CARE DOCTOR
When: TUESDAY [**2204-11-27**] at 11:20 AM
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Name: [**Known lastname 2797**],[**Known firstname **] J Unit No: [**Numeric Identifier 4664**]
Admission Date: [**2204-11-14**] Discharge Date: [**2204-11-19**]
Date of Birth: [**2154-5-25**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 4665**]
Addendum:
Per the request of Health Information Management:
1) Polypharmacy from taking multiple medications as perscribed
(confirmed from mother and son)
2) acute on chronic non cardiac pulmonary edema
Discharge Disposition:
Home With Service
Facility:
[**Hospital 1896**] Health Systems
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4666**] MD [**MD Number(2) 4667**]
Completed by:[**2204-12-28**]
|
[
"275.2",
"733.00",
"338.29",
"295.90",
"V58.67",
"729.5",
"276.2",
"E937.0",
"491.21",
"564.09",
"070.54",
"278.03",
"518.81",
"296.24",
"518.4",
"278.01",
"416.8",
"348.31",
"250.00",
"E935.2",
"530.85",
"305.1",
"327.23",
"305.51",
"401.9",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15389, 15612
|
4727, 8599
|
282, 306
|
12264, 12264
|
3566, 4703
|
14101, 15366
|
2535, 2560
|
9456, 12061
|
12166, 12243
|
8625, 9433
|
12447, 13315
|
2575, 3173
|
13344, 14078
|
3187, 3547
|
231, 244
|
334, 1640
|
12279, 12423
|
1662, 2245
|
2261, 2519
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,925
| 153,661
|
41014+58415
|
Discharge summary
|
report+addendum
|
Admission Date: [**2177-5-7**] Discharge Date: [**2177-5-12**]
Date of Birth: [**2110-5-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Allopurinol / Sulfa (Sulfonamide Antibiotics) /
Indocin / Gentamicin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2177-5-7**] Aortic Valve Replacement (25mm St. [**Male First Name (un) 923**] Tissue)
History of Present Illness:
66 year old patient with a history of hypertension,
dyslipidemia, aortic regurgitation, aortic stenosis (peak
gradient 70mmHg; mean gradient 45mmHg). He reports exertional
chest pain and dyspnea when walking up an incline over the past
several months. He saw his PCP for [**Name Initial (PRE) **] routine physical and was
subsequently referred to his cardiologist. He was referred for
cardiac catheterization which showed no coronary disease and an
aortic valve area of 0.9.
Past Medical History:
Aortic stenosis and regurgitation
Dyslipidemia (noted in Dr.[**Last Name (un) **] [**2177-3-26**] office note)
Sleep Apnea - does not use CPAP
Glucose intolerance (noted in Dr.[**Last Name (un) **] [**2177-3-26**] office
note)
GERD
Gout
s/p Tonsillectomy as a child
Social History:
Race:Caucasian
Last Dental Exam: 1 month ago, ([**Location (un) **] Family Dentist,
[**Telephone/Fax (1) 89457**] in [**Location (un) **] MA)
Lives with:wife
Occupation:currently unemployed
Tobacco:denies
ETOH:denies
Family History:
Maternal grandfather had an MI and died at age 54. His father
had heart valve replacement surgery [**96**] years ago and also has a
defibrillator. His mother has a heart arrhythmia and
hypertension.
Physical Exam:
Pulse:58 Resp:13 O2 sat:98/RA
B/P 136/62
Height:5'[**76**]" Weight:210 lbs
General: awake alert oriented
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 systolic ejection
murmur
with 2/6 diastolic murmur.
with radiation to the left carotid area
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds +
Extremities: Warm [x], well-perfused [x] no Edema
Varicosities:
no
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: soft murmur likely related
to AS
Pertinent Results:
[**2177-5-7**] Echo: PRE-CPB: The left atrium is markedly dilated. No
thrombus is seen in the left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The ascending aorta is mildly
dilated. The descending thoracic aorta is mildly dilated. There
are simple atheroma in the descending thoracic aorta. No
thoracic aortic dissection is seen. The aortic valve is bicuspid
with a horizontal commissure. The aortic valve leaflets are
severely thickened/deformed. There is moderate aortic valve
stenosis (valve area 1.0-1.2cm2). Mild to moderate ([**1-5**]+) aortic
regurgitation is seen. The aortic regurgitation jet is
eccentric, directed toward the anterior mitral leaflet. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen.
POST-CPB: A bioprosthetic valve is seen in the aortic position.
The valve is well seated and the leaflets appear to be normally
mobile. Two small paravalvular leaks were seen after initial
separation from bypass but are no longer seen after
administration of protamine. The peak gradient across the aortic
valve is 14mmHg and the mean gradient is 7mmHg with a CO of
3.7L/min. There is no AI. The MR appears to be trace. The LV
systolic function remains normal. There is no evidence of aortic
dissection.
.
[**2177-5-8**] WBC-9.5 RBC-3.15* Hgb-9.8* Hct-27.3* RDW-13.0 Plt
Ct-117*
[**2177-5-9**] WBC-12.7* RBC-3.20* Hgb-10.0* Hct-28.4* RDW-13.0 Plt
Ct-100*
[**2177-5-11**] WBC-8.2 RBC-3.00* Hgb-9.3* Hct-26.6* RDW-13.1 Plt
Ct-158#
[**2177-5-12**] WBC-8.2 RBC-3.02* Hgb-9.4* Hct-26.7* RDW-13.2 Plt
Ct-205
[**2177-5-8**] Glucose-132* UreaN-16 Creat-1.1 Na-137 K-4.2 Cl-106
HCO3-25
[**2177-5-9**] Glucose-133* UreaN-25* Creat-1.3* Na-135 K-5.0 Cl-103
HCO3-25
[**2177-5-10**] Glucose-118* UreaN-25* Creat-1.0 Na-135 K-4.5 Cl-100
HCO3-30
[**2177-5-11**] Glucose-126* UreaN-21* Creat-1.2 Na-136 K-4.3 Cl-98
HCO3-32
[**2177-5-12**] Glucose-120* UreaN-23* Creat-1.0 Na-135 K-4.2 Cl-99
HCO3-30
[**2177-5-11**] Calcium-8.4 Phos-2.5* Mg-2.5
[**2177-5-12**] 05:40AM BLOOD WBC-8.2 RBC-3.02* Hgb-9.4* Hct-26.7*
MCV-88 MCH-31.0 MCHC-35.2* RDW-13.2 Plt Ct-205
[**2177-5-12**] 05:40AM BLOOD Glucose-120* UreaN-23* Creat-1.0 Na-135
K-4.2 Cl-99 HCO3-30 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 12598**] was as same day admit after undergoing all
pre-operative work-up as an outpatient. On [**2177-5-7**] he was brought
directly to the operating room where he underwent an aortic
valve replacement. Please see operative note for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring. Within 24 hours, he was weaned from
sedation, awoke neurologically intact and extubated without
incident. On post-op day one he was started on beta-blockers and
diuretics. He was then transferred to the step-down floor for
further care. Chest tubes and epicardial pacing wires were
removed per protocol. He did have a small-moderate right
pneumothorax seen on CXR after chest tubes were pulled and this
was stable on subsequent chest x-rays. He remained stable from
a respiratory status saturating 95-100% on room air. On
postoperative day three, he went into rapid atrial fibrillation
and converted back to normal sinus rhythm after receiving
Amiodarone. Over the next several days, he continued to make
clinical improvements and transitioned to PO Amiodarone. He
remained in a normal sinus rhythm and no further episodes of
atrial fibrillation were noted. He was medically cleared for
discharge to home with VNA services on postoperative day five.
At discharge, his blood pressure was 124/74, with regular heart
rate of 64 beats per minute with oxygen saturations of 99% on
room air. Discharge chest x-ray showed persistent small right
apical pneumothorax - which was stable. This will be monitored
with repeat CXR next week prior to wound check on [**5-20**]. All
follow up instructions were scheduled and advised.
Medications on Admission:
ASPIRIN 81 mg Tablet daily, OMEPRAZOLE 20 mg Capsule daily
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 6 days: 400 mg [**Hospital1 **] through [**5-17**]; then 400 mg(2 tabs)
daily [**Date range (1) 70309**]; then 200 mg(1 tab) daily ongoing.
Disp:*80 Tablet(s)* Refills:*0*
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day for 10 days.
Disp:*10 Tablet, ER Particles/Crystals(s)* Refills:*0*
9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Aortic stenosis and regurgitation s/p Aortic valve replacement
Postop Atrial Fibrillation
Dyslipidemia
Sleep Apnea - does not use CPAP
Glucose intolerance
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - healing well, no erythema or drainage
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
.
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] on [**6-5**] at 1:00 PM
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7526**] on [**6-3**] at 10:30 AM
**Wound Check [**5-20**] at 10:30 AM [**Hospital Ward Name **] 2A **
CHECK CXR to assess Right PTX prior to wound check - go to
Radiology [**Hospital Ward Name **] clinical center [**Location (un) 470**] prior to wound
check
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) 12395**] [**Last Name (NamePattern1) 13013**] in [**4-8**] weeks [**Telephone/Fax (1) 21640**]
**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:[**2177-5-12**] Name: [**Known lastname 4016**],[**Known firstname 77**] Unit No: [**Numeric Identifier 14179**]
Admission Date: [**2177-5-7**] Discharge Date: [**2177-5-12**]
Date of Birth: [**2110-5-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Allopurinol / Sulfa (Sulfonamide Antibiotics) /
Indocin / Gentamicin
Attending:[**First Name3 (LF) 741**]
Addendum:
The cardiac echo preformed [**2177-5-7**]- before surgery has the
finding of:
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Moderate AS (area 1.0-1.2cm2) Mild to
moderate ([**1-5**]+) AR. Eccentric AR jet directed toward the
anterior mitral leaflet.??????
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 6688**]
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2177-6-9**]
|
[
"327.23",
"427.31",
"E878.2",
"424.1",
"790.29",
"274.9",
"E849.7",
"272.4",
"746.4",
"997.1",
"512.1",
"416.8",
"401.9",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10897, 11092
|
4970, 6643
|
363, 453
|
8386, 8551
|
2475, 4947
|
9321, 10874
|
1496, 1696
|
6752, 8091
|
8208, 8365
|
6669, 6729
|
8575, 9298
|
1711, 2456
|
304, 325
|
481, 957
|
979, 1246
|
1262, 1480
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,436
| 179,614
|
20510
|
Discharge summary
|
report
|
Admission Date: [**2143-7-6**] Discharge Date: [**2143-7-20**]
Date of Birth: [**2073-7-21**] Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Shortness of breath, nausea
Major Surgical or Invasive Procedure:
cardiac cath [**2143-7-15**]
cardiac cath [**2143-7-18**]
cardiac biopsy [**2143-7-18**]
History of Present Illness:
69 y/o w/ HTN, CAD (Lcx 99%, 40% mLAD, 40% r PDA), systolic CHF
EF 30-35% w/ significant LVH, recent NSTEMI, presented with
generalized weakness, mild confusion, nausea and vomitting. She
was just discharged from [**Hospital 26580**] hospital where she was admitted
from [**Date range (3) 54882**]. Per obtained discharge summary, she
presented with progressive SOB and LE edema and ruled in for
NSTEMI with trop 0.38, 0.48, 0.98. She subsequently had cardiac
cath completed on [**2143-7-1**] which showed mid LAD 40% stenosis, mid
Lcx 99% unfavorable total occlusion, rPDA 40% stenosis,
pulmonary hypertension, mod-severe MR, depressed LVEF ~45% and
LVH. She then had TEE to better evaluate MR on [**2143-7-2**] which
showed 3+ MR [**First Name (Titles) 15015**] [**Last Name (Titles) **] hitting back wall with probably mild
mitral stenosis and LVEF 30-35% with dilated atria b/l, elevated
wedge pressure and significant LVH. She was diuresed with lasix
(-10L per patient), and started on metoprolol and losartan. She
was discharged on lasix 100mg [**Hospital1 **] and she reports improvement in
SOB and edema with diuresis throughout hospital stay.
.
Upon discharge home, she was initially feeling well, but then
became weak, more SOB and LE persisted and may have slightly
worsened. No reported weight gain. No PND, +orthopnea (sleeps w/
2 pillows nightly). The morning of admission she became nauseous
and vomitted ~5 times (bilious w/ food non-bloody), was unable
to take POs and thus re-presented to [**Hospital1 46**]. Per her
cardiologist Dr. [**Last Name (STitle) 3321**], she was transferred to [**Hospital1 18**] for
cardiac MRI and evaluation for MV repair/replacement.
.
At OSH, she was A&O x3, vitals prior to transfer were afebrile,
HR 74 BP 86/61, 20 99% 4L. Upon arrival to the floor she has
mild SOB and c/o LE edema. Nausea/vomitting much improved. Was
feeling "spacy" earlier, but now feels lucid. Feels generalized
weakness. Denies F/C, HA, vision changes, cough, CP,
palpitations, abd pain, diarrhea, constipation, melena,
hematochezia, dysuria or hematuria.
Past Medical History:
Recent NSTEMI admitted [**Hospital 26580**] hosp [**Date range (1) 54883**]
CATH: [**2143-7-1**]: LMCA normal, mid LAD 40% stenosis, mid Lcx 99%
unfavorable total occlusion, rPDA 40% stenosis, pulmonary
hypertension, mod-severe MR, depressed EF ~45%
CABG: none
HTN
DM2
systolic and diastolic CHF
Peripheral vascular disease
COPD - not on home O2
B12 deficiency
Hypothyroidism
H/o DVT [**2142-10-8**] - on coumadin
Insominia
Osteoporosis
cholecystectomy
hysterectomy
appendectomy
h/o thyroidectomy and parathyroidectomy
exploratory laporotomy [**2142-10-8**] (for possible gut ischemia but
none seen)
h/o diverticulitis s/p partial colectomy w/ temp colostomy and
reanastamosis
Social History:
lives w/ husband, independent in all ADL and iADLs, recently
walking on treadmill at cardiac rehab, h/o 45 pack years quit
tob 10 years ago, no ETOH or IVDA.
Family History:
mother w/ CVA, no known MI, HTN, malignancy or DM.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: 98.4 100/66 85 16 98% RA 55.3kg
GENERAL: NAD, A&Ox3
HEENT: PERRLA, EOMI, sclerae anicteric, oral MM dry, no OP
lesions.
NECK: Supple, no thyroid gland, JVP 13cm
HEART: RRR, nl S1, nl S2, cannot appreciate murmurs
LUNGS: mild crackles bilateral bases R>L, no rh/wh, resp
unlabored.
ABDOMEN: Soft/NT/ND, no rebound/guarding, +BS.
EXTREMITIES: 2+ pitting edema to knee b/l w/ venous stasis skin
changes, decreased sensation in feet b/l, callus (? non-healing
ulcer) left foot plantar surface, pulses diminished DP/PT b/l,
2+ peripheral pulses in UE b/l
Pertinent Results:
ADMISSION LABS:
[**2143-7-7**] 06:24AM BLOOD WBC-7.2 RBC-5.83*# Hgb-15.8# Hct-50.0*#
MCV-86# MCH-27.1# MCHC-31.6# RDW-19.1* Plt Ct-231
[**2143-7-7**] 06:24AM BLOOD Neuts-70.2* Lymphs-19.8 Monos-7.4 Eos-1.8
Baso-0.8
[**2143-7-7**] 08:40AM BLOOD PT-14.4* PTT-31.0 INR(PT)-1.2*
[**2143-7-7**] 06:24AM BLOOD Glucose-98 UreaN-43* Creat-1.6* Na-137
K-4.0 Cl-97 HCO3-23 AnGap-21*
[**2143-7-7**] 06:24AM BLOOD ALT-39 AST-50* LD(LDH)-364* CK(CPK)-41
AlkPhos-108* TotBili-1.1
[**2143-7-7**] 06:24AM BLOOD TotProt-6.6 Albumin-3.9 Globuln-2.7
Calcium-9.2 Phos-5.3*# Mg-2.4 Iron-PND
[**2143-7-7**] 06:24AM BLOOD CK-MB-4 cTropnT-0.30*
[**2143-7-19**] 01:55AM BLOOD WBC-12.1*# RBC-5.63* Hgb-15.3 Hct-47.1
MCV-84 MCH-27.1 MCHC-32.4 RDW-19.4* Plt Ct-190
[**2143-7-19**] 10:45AM BLOOD PT-16.8* PTT-115.7* INR(PT)-1.5*
[**2143-7-19**] 01:55AM BLOOD Glucose-119* UreaN-51* Creat-1.8* Na-130*
K-4.1 Cl-91* HCO3-23 AnGap-20
[**2143-7-19**] 01:55AM BLOOD Calcium-9.2 Phos-5.8*# Mg-2.3
[**2143-7-20**] 03:15AM BLOOD WBC-22.5*# RBC-5.99* Hgb-16.2* Hct-51.5*
MCV-86 MCH-27.0 MCHC-31.4 RDW-19.7* Plt Ct-292#
[**2143-7-20**] 03:15AM BLOOD Neuts-90* Bands-0 Lymphs-3* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2143-7-20**] 03:15AM BLOOD PT-19.3* PTT-90.8* INR(PT)-1.7*
[**2143-7-20**] 03:15AM BLOOD Glucose-77 UreaN-66* Creat-3.0*# Na-131*
K-4.8 Cl-87* HCO3-21* AnGap-28*
[**2143-7-20**] 03:15AM BLOOD Calcium-9.5 Phos-7.0* Mg-2.3
Pertinent studies:
Cardiac MRI ([**2143-7-8**])-
1. Normal left ventricular cavity size with segmental wall
motion
abnormalities (see above) and mildly reduced systolic function
with the LVEF of 41%. The effective forward LVEF was severely
depressed at 19%. There are multiple areas of hyperenhancement
as described above consistent with myocardial infarction/scar.
2. Moderately to severely increased LV wall thickness.
3. Severely increased LV mass index.
4. Normal right ventricular cavity size with abnormal global
systolic
function. The RVEF was moderately depressed at 23%.
5. Severe mitral regurgitation. There is leaflet tethering
consistent with
"ischemic" (post-infarction) mitral regurgitation.
6. The indexed diameters of the ascending and descending
thoracic aorta were normal. The indexed diameter of the main
pulmonary artery was mildly enlarged.
7. Mild right and left atrial enlargement.
8. Normal coronary artery origins with no evidence of anomalous
coronary
arteries.
9. A note is made of moderate to severe right pleural effusion
and small left pleural effusion.
CXR ([**2143-7-10**])- Interval increase in a now moderate right effusion
with associated atelectasis. New small left effusion.
Spirometry ([**2143-7-11**])- Mild restrictive ventilatory defect with a
severe gas exchange defect. The DLCO is reduced out of
proportion to the reduction in TLC which is consistent with an
interstitial or pulmonary vascular process. The reduced FEV1/SVC
ratio (62.4, 87% of predicted) indicates a coexisting
obstructive ventilatory defect. There are no prior studies
available for comparison.
TEE ([**2143-7-11**])- No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is low normal (LVEF
50-55%). There is borderline normal free wall function of the
right ventricle. There are complex (>4mm) atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened with no aortic valve stenosis or regurgitation.
The mitral valve leaflets are structurally normal with mild (1+)
mitral regurgitation. The tricuspid valve leaflets are mildly
thickened. There is a small pericardial effusion with no
echocardiographic signs of tamponade.
Dobutamine stress echo ([**2143-7-12**])- Resting images were acquired at
a heart rate of 85 bpm and a blood pressure of 84/60 mmHg. These
demonstrated near-akinesis of the inferior wall with mild
hypokinesis elsewhere (EF 35%). There is a small pericardial
effusion. Doppler demonstrated mild mitral regurgitation with no
aortic stenosis, aortic regurgitation or significant resting
LVOT gradient. At low dose dobutamine [5mcg/kg/min; heart rate
84 bpm, blood pressure 84/58 mmHg), there was failure to augment
systolic function of the inferior wall, with mild augmentation
of all other segments. At mid-dose dobutamine [10 mcg/kg/min;
heart rate 88 bpm, blood pressure 76/50 mmHg), there was failure
to augment systolic function of the inferior wall, with mild
augmentation of all other segments.
.
Cardiac cath ([**2143-7-15**])-
1. Two vessel coronary artery disease.
2. Moderate diastolic ventricular dysfunction.
3. Moderate pulmonary hypertension.
4. Successful PTCA and stenting of the distal Cx with a BMS.
.
Right Heart cardiac cath ([**2143-7-18**])
1. Moderately elevated biventricular pressures.
2. Severe pulmonary hypertension.
3. Depressed cardiac index.
4. Successful RV biopsy.
.
Cardiac biopsy [**2143-7-18**]:
Myocardial tissue with extensive amyloid deposition (confirmed
with [**Country **] red stains) primarily subendocardial and associated
with blood vessels.
Urine culture [**2143-7-20**]:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS
Blood culture [**2143-7-20**]:
Blood Culture, Routine (Final [**2143-7-26**]): NO GROWTH.
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] is a 69 yo w/ HTN, CAD (Lcx 99%, 40% mLAD, 40% r
PDA), systolic CHF EF 30-35% w/ significant LVH, ruled in for
NSTEMI, 3+ MR, LVEF 30-35% with dilated atria b/l, elevated
wedge pressure and significant [**Hospital 54884**] transferred to [**Hospital1 18**] for
cardiac MRI and evaluation for MV repair/replacement, but only
mild MR on repeat TEE, now s/p BMS of LCx, and cardiac biopsy
positive for cardiac amyloidosis.
--For a summary of her hospital course, please refer to accept
note dated [**2143-7-19**].
After Pt was transferred to [**Hospital1 1516**], she had SBP in 80s/50s,
remained asymptomatic, but at ~9pm, had one measurement to
60s/40s, although remeasurement was high 70s/50s. Pt was
completely asymptomatic, even when sitting up, and remained
talkative and was joking with MDs. The 60s/40s was felt to be
due to measurement error due to Pt's very thin body habitus,
even when using small adult cuff. Cardiology fellow and resident
were both consulted, who felt that Pt was very stable. Pt
remained afebrile and HR was in 70s-80s throughout. Pt did not
have any discomfort or pain and was not dyspnic. She had O2 sat
~97% on 2L nc.
The following morning ([**7-20**]) at 0700, Pt was found to tachypnic
to 25 but still sat 95% on 2L nc. She was working harder to
breathe but stated that she did not feel short of breath when
questioned. When morning lab results returned at ~0830, Pt was
noted to have leukocytosis to ~22k and Cr jumped to 3.0 from 1.8
the day prior. Stat blood cultures, urine analysis, and urine
cultures, and chest XR were send. Her foley cath was
discontinued. She was started on IV vancomycin and cefepime. Pt
was never febrile, though she had one oral temp to 35.5C at ~
midnight that was ~36.1C four hours later. Pt was never
tachycardic and her BP remained in 80s/50s, consistent with her
prior BPs on the floor. Pt began to feel very short of breath at
this time (0830), was tachypnic to 30s-40s, and put on
non-rebreather mask. She looked very and her family was notified
to come to the hospital given her rapidly deteriorating state.
After the arrival of family and in discussion with the Pt, who
was still lucid, Pt decided to be made comfort measures only
with the exception of antibiotics, declined intubation and
declined transfer to the CCU. Pt was given lorazepam and
morphine to help with dyspnea, which was initially difficult to
control. Palliative care was consulted who recommended IV
morphine, which was provided, and Pt appeared to respond. Pt
became less and less responsive by 1300, received Eucharist at
1400 and expired at 1440.
Pt's family consented to autopsy.
------------
#Acute on chronic congestive heart failure: Mrs. [**Known lastname **] was
admitted for CHF most likley due to MR but possibly secondary to
ischemic cardiomyopathy versus infiltrative cardiomyopathy. She
has evidence of diffuse coronary disease, but only significant
single vessel disease (Lcx 99% stenosed) that likely does not
explain her global hypokinesis. Additional contributing factors
include MR (see below) and diastolic dysfunction (significant
LVH seen) raising suspicion for potential infiltrative
cardiomyopathy as well. Infiltrative etiologies to consider
include amyloid, multiple myeloma, sarcoid, hemachromotosis, HIV
or myocarditis, but have so far been negative. In the workup so
far, serum protein electrophoresis, ACE, TSH, and iron levels,
were all normal. Infiltrative disease was further supported by
echo findings and a cardiac MRI. Given the negative work-up thus
far this was highly concerning for specific cardiac amyloid
without systemic involvement. Therefore the patient underwent a
endocardial biopsy on [**2143-7-18**]. Results of the biopsy were
consistent with cardiac amyloidosis ([**Country **] red stainin
positive). Final stains and studies are still pending.
Symptomatically, she initially had lower extremity edema, a
stable right lower lobe pleural effusion, inspiratory crackles
on exam and dyspnea. She initially responded well to diuresis
with furosemide up to 80mg IV BID which was then decreased to 80
daily. However she continued to dyspnea and chest xray findings
consistent with volume overload in the setting of low blood
pressure which made further diuresis difficult. On HD8, patient
had a right sided catheterization which showed elevated PA and
PCWP pressures consistent with class II pulmonary artery
hypertension resulting form left ventricular overload.
Following cardiac catheterization with placement of BMS to the
LCx, the patient was transferred to the CCU for diuresis with
lasix gtt with pressure support initially with dopamine gtt.
She did not have a good response to diuresis and was changed
from dopamine to milrinone with improvement in urine output.
Additionally, metolazone was added to augment diuresis. In the
CCU she was diuresed 3 L in 4 days with improvement in her
respiratory status. Milrinone was stopped with inital
maintenance of blood pressure. Repeat right heart catherization
on [**2143-7-18**], done for endocardial biopsy, showed continued
elevation of right heart pressures as well as a persistent low
cardiac index of 1.28. Though she was still volume overloaded
lasix gtt was stopped due to hypotension and rising creatinine
with improvement in blood pressure. The plan was to establish
her on a home oral regimen as her congestive heart failure is
end stage and the patient has expressed desire to go home. She
was transferred to [**Hospital1 1516**].
.
On further review of EKG and echocardiogram, it was noted that
patient had a left bundle branch block causing a dyssynchronous
rhythm. It was felt that cardiac output may improve with BiV
pacing. However in further evaluation of the echocardiogram it
was felt that BiV pacing would likely not be helpful as the
patients right heart dysfunction was more significant than her
left heart dysfunction.
#Acute Respiratory Distress: see above
.
#Mitral regurgitation: On her outside hospital TEE, Pt was
thought to have moderate to severe mitral regurgitation. Pt was
transferred here for a cardiac MRI, which showed a normal left
ventricular cavity size with segmental wall motion abnormalities
and mildly reduced systolic function with the LVEF of 41% with a
severely depressed calculated effective forward LVEF of 19%.
Multiple areas of hyperenhancement were observed and interpreted
as being consistent with myocardial infarction/scar. She also
had moderately to severely increased LV wall thickness, severely
increased LV mass index, a normal right ventricular cavity size
with abnormal global systolic function and moderately depressed
RVEF at 23%. Also observed on the cardiac MRI was severe mitral
regurgitation with leaflet tethering consistent with "ischemic"
(post-infarction) mitral regurgitation. Given these findings,
cardiac surgery was consulted regarding the possiblility of
mitral repair versus replacement and suggested a repeat TEE at
[**Hospital1 18**], which surprisingly showed mild symmetric left ventricular
hypertrophy, an overall low normal left ventricular systolic
function is (LVEF 50-55%) and structurally normal mitral valve
leaflets with only mild (1+) mitral regurgitation. Complex
(>4mm) atheroma in the descending thoracic aorta were also
observed. The Pt therefore did not require surgery, and
attention re-centered on the known left circumflex stenosis (see
below).
.
#Coronary artery disease: Pt had a diagnostic cardiac cath
performed by Dr. [**Last Name (STitle) 3321**] just prior to admission showing
stenosis of the Lcx 99%, 40% mLAD, 40% r PDA of unknown age,
with no intervention at the time. To determine whether any of
the affected areas were salvagable, the patient had a dobutamine
viability echo, which showed minimal viability in the inferior
wall but apparently-viable myocardium elsewhere. She was taken
to cardiac cath on [**2143-7-15**] and a bare metal stent was placed in
the left circumflex artery. Catherization also showed elevated
filling pressures, pulmonary HTN and a cardiac index of 1.23.
Following the procedure, patient was started on aspirin, plavix
and heparin. Her catheterization site was c/d/i and no bruits
or hematomas were appreciated. Right heart catherization for on
[**7-18**] demonstrated continued poor cardiac index.
.
#Acute kidney injury: On admission her creatinine was noted to
be 1.6 (1.0 on discharge two days before). This was thought to
be pre-renal from poor kidney persusion from CHF, poor PO intake
and nausea, and she had recently started losartan on her prior
admission. Losartan was held during this admission. Because she
was still volume overloaded she was gently diuresed. As above
the patient did require additional diuresis with inotropic
support. She was started on a lasix gtt with resultant increase
in her creatinine. Furosemide was held due to decreased kidney
function.
.
# Atrial Fibrillation: On HD # 8 the patient was noted to be in
atrial fibrillation with RVR associated with nausea and
vomiting. She was initally rate controlled with metoprolol.
However, during her endocardial biopsy she was noted to have HR
to the 130s and a drop in her systolic blood pressure to the
70s. She was given IV metoprolol and fluids with spontaneous
conversion to sinus rhythm. She was then given a PO amiodarone
load and started on a heparin drip. Given her CHADS2 score of 3
she was started on warfarin. This was discontinued on [**Hospital1 1516**].
.
# RLL infiltrate: Patient noted to have possible RLL infiltrate
vs atelectasis on chest xray and white count to 12. She
remained afebrile and noted only a scant sputum. X ray also
showed a R sided pleural effusion. Therefore it was felt
changes likely represented atelectasis and antibiotics were not
started.
.
#Nausea: Pt was reported significant nausea and vomiting on
admission, was given PO zofran PRN which effectively controlled
her nausea and she had only one episode of vomiting throughout
the remainder of her hospital course. Nausea was always
associated with volume overload or atrial fibrillation.
.
# Code Status: The poor prognosis of both her poor cardiac
function and cardiac amyloid was discussed in depth with the
patient and her family. She expressed understanding that her
congestive heart disease was likely end stage. She additionally
decided that she would not want intubation or CPR and was made
DNR/DNI. Pt was made comfort measures only on [**7-20**] and expired
at 1440 (see above).
# COPD: no evidence of acute exacerbation. Pt was continued on
her home albuterol and tiotropium.
.
# Diabetes: well controlled, on sliding scale
# Hypothyroidism: stable on home levothyroxine, TSH normal
# peripheral neuropathy: stable, vicodin PRN pain
Medications on Admission:
albuterol 1puff q4H PRN
aspirin 81mg daily
conjugated estrogens 1 vag application PRN
furosemide 100mg [**Hospital1 **]
hydrocodone/acetaminophen 5/500 1-2 tabs q4H PRN
levothyroxine 75mcg daily
oxazepam 15-30mg qHS PRN
tiotropium 18mcg daily
vitamin B12 IM
coumadin 1mg daily
zoledronic acid administered in clinic
zolpidem 10mg qHS
losartan 25mg daily
metoprolol succinate 25mg daily
KCL 20meQ daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary Diagnosis:
Cardiac amyloidosis
Congestive heart failure
Coronary artery disease
Secondary Diagnoses:
Mild mitral regurgitation
Hypothyroidism
Diabetes mellitus, type 2
Chronic obstructive pulmonary disease (COPD)
Discharge Condition:
Pt expired on [**2143-7-20**].
Completed by:[**2143-7-28**]
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icd9cm
|
[
[
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[
"37.23",
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"00.40",
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icd9pcs
|
[
[
[]
]
] |
20549, 20558
|
9330, 20097
|
298, 389
|
20824, 20885
|
4061, 4061
|
3392, 3444
|
20579, 20579
|
20123, 20526
|
3459, 3473
|
20689, 20803
|
231, 260
|
417, 2500
|
4077, 9307
|
20598, 20668
|
3487, 4042
|
2522, 3201
|
3217, 3376
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,955
| 134,136
|
28464
|
Discharge summary
|
report
|
Admission Date: [**2140-10-30**] Discharge Date: [**2140-11-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with stenting of the LAD
History of Present Illness:
Pt is an 87 yo woman with h/o HTN, hypercholesterolemia who
presented to OSH with chest pain. The patient was in her USOH
the day prior to admission when she started feeling R-sided
chest pain, rated [**11-22**], as well as nausea. Pain developed
while she was doing her laundry. Pain persisted throughout the
night with minimal improvement. Then this AM due to persistent
pain she decided to go to hospital. She denied any SOB,
diaphoresis, vomiting, LH, syncope, or palpitations. At the
OSH, her vitals were T 98.7, HR 72, BP 178/93, O2 sat 96% RA.
EKG was notable for ST elevation in anterolateral leads. She
received SL nitroglycerin, heparin, ASA 325, metoprolol 5 mg IV
x 2, Integrillin bolus and drip, atorvastatin 80 mg PO x 1,
Plavix 600 mg PO x 1, and morphine. On arrival to [**Hospital1 18**], her ABG
was 7.37/45/107. She underwent cath with stenting of LAD.
Past Medical History:
HTN
Hyperlipidemia
Vestibular dysfuntion- Vertigo
Social History:
Lives with husband. 4 children. Denies any T/A/D use.
Family History:
NC
Physical Exam:
T BP 127/75 HR 85 RR 16 O2sats 96% Wt 64kg
Gen: Elderly female in NAD
HEENT: PERRL, EOMI, anicteric, dry mm
Neck: No JVD
Lungs: CTAB anteriorly
Heart: Irregular due to multiple PVC's seen on tele, S1/S2, no
m/r/g
Abd: Soft, NT, ND, normoactive
Ext: No edema, 2+ DP bilaterall, no bruit in right groin
Neuro: A&O times 3, grossly intact
Pertinent Results:
Admission Labs:
[**2140-10-30**] 12:34PM GLUCOSE-176* LACTATE-1.5 K+-4.1
[**2140-10-30**] 12:34PM TYPE-ART O2 FLOW-4 PO2-107* PCO2-45 PH-7.37
TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**]
[**2140-10-30**] 12:35PM PT-13.2* PTT-100.7* INR(PT)-1.2*
[**2140-10-30**] 12:35PM CK-MB-49* MB INDX-13.3* cTropnT-0.49*
[**2140-10-30**] 12:35PM CK(CPK)-369*
[**2140-10-30**] 12:35PM GLUCOSE-181* UREA N-12 CREAT-1.0 SODIUM-138
POTASSIUM-5.0 CHLORIDE-108 TOTAL CO2-19* ANION GAP-16
[**2140-10-30**] 01:15PM PLT COUNT-311
[**2140-10-30**] 01:15PM WBC-10.2 RBC-3.69* HGB-11.2* HCT-32.3* MCV-88
MCH-30.4 MCHC-34.8 RDW-15.2
[**2140-10-30**] 08:51PM PLT COUNT-297
[**2140-10-30**] 08:51PM HCT-36.1
[**2140-10-30**] 08:51PM MAGNESIUM-1.7
[**2140-10-30**] 08:51PM CK-MB-348* MB INDX-14.6*
[**2140-10-30**] 08:51PM CK(CPK)-2380*
[**2140-10-30**] 08:51PM UREA N-13 CREAT-0.7 POTASSIUM-4.5
.
DISCHARGE LABS:
[**2140-11-3**] 07:12AM BLOOD WBC-8.1 RBC-3.46* Hgb-10.5* Hct-30.8*
MCV-89 MCH-30.4 MCHC-34.2 RDW-15.5 Plt Ct-310
[**2140-11-3**] 07:12AM BLOOD Plt Ct-310
[**2140-11-3**] 07:12AM BLOOD Glucose-87 UreaN-20 Creat-0.8 Na-139
K-4.1 Cl-104 HCO3-27 AnGap-12
[**2140-11-3**] 07:12AM BLOOD Calcium-8.3* Phos-3.1 Mg-1.9
.
STUDIES:
EKG [**10-30**] (OSH): NSR @ 68 bpm, ST elevation in I, aVL, V2-V5; ST
depression in II, III, aVF
EKG [**10-30**] ([**Hospital1 18**]): 87 bpm, ST elevations in V2-V6, TWI in aVL,
V1, V2, Q waves in I, II, aVF, V1-V6.
.
[**2140-10-30**] Cardiac Cath:
1. Selective coronary angiography of this left dominant system
demonstrated single vessel coronary artery disease. The LMCA
revealed no
angiographically apparent coronary artery disease. The LAD had
40%
ostial stenosis at its origin. There was further 95% stenosis in
the
proximal vessel. This was followed by serial 70-80% stenoses
throughout
the mid and distal vessel. The LCX was a large vessel and widely
patent.
The RCA was a small non-dominant vessel with no angiographically
apparent coronary artery disease.
2. Resting hemodynamics were performed. The right sided filling
pressures were elevated (mean RA pressure was 13 mmHg and RVEDP
was 15
mmHg). The pulmonary artery pressures were elveated (PA pressure
was
39/18 mmHg). The left sided filling pressures were elevated
(mean PCW
pressure was 21 mmHg). The cardiac index was depressed measuring
1.7
l/min/m2).
3. Successful primary PTCA and stenting of the proximal LAD with
a 3.0
Cypher DES. There was no residual stenosis at the stent site,
however
70-80% stenoses in the mid and distal LAD were left untreated.
The final
angiography showed TIMI III flow in the distal vessel and no
evidence of
dissection, embolization or peforation.
.
[**2140-11-2**] ECHO: LVEF 35%; [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**] dilated; nl LV wall thickness;
nl LV cavity size; tissue velocity imaging E/e' is elevated
(>15) suggesting increased LV filling pressure (PCWP>18mmHg);
mid to distal anterior, anteroseptal and apical
akinesis/hypokinesis; AV leaflets(3) are mildly thickened; no
AR; MV leaflets mildly thickened; mild MR; mod pulmonary artery
systolic hypertension
Brief Hospital Course:
INITIAL IMPPRESSION: 87 yo F with h/o HTN, hyperlipidemia p/w
chest pain, EKG c/w anterolateral STEMI, now s/p LAD stenting.
.
HOSPITAL COURSE BY SYSTEM:
.
* Cardiovascular: The patient underwent stenting of her LAD. She
was started on ASA 325 qd, Plavix 75 qd, atorvastatin 80,
metoprolol 12.5 mg q6h and captopril 12.5 q8h. With her BP and
HR stable, metoprolol was titrated up to metoprolol XL 200 mg qd
and captopril to lisinopril 5 mg qd. Her echocardiogram
suggested increased LV filling pressure; therefore, furosemide
10 mg qd was started. Telemetry revealed frequent PVCs. She was
asymptomatic and clinically stable during the CCU course. She
did not experience any more chest pain or other symptoms during
admission.
.
* Psych: The patient experienced confusion and agitation during
the first night in the CCU. She was started on olanzapine 5 mg
qhs and had no more periods of confusion or agitation.
.
* Code: DNR/DNI per patient
.
Medications on Admission:
Reports no medications at home
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*11*
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*11*
6. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnsois:
1. Coronary Artery Disease s/p ST Elevation Myocardial
Infarction, s/p cardiac cath with stent to Left Anterior
Descending coronary artery
.
Secondary Diagnoses:
1. Hypertension
2. Hyperlipidemia
3. Vestibular dysfuntion- Vertigo
Discharge Condition:
Stable, pain free, stable on medication regimen, appropriate
followup arranged.
Discharge Instructions:
Take all medications as prescribed. It is especially important
to take the Plavix and aspirin to protect your heart. You have
also been started on medications for your blood pressure.
Please keep all follow up appointments.
Please return to the hospital if you develop chest pain,
shortness of breath, or any other symptoms that concern you.
Followup Instructions:
An appointment has been made for you with your PCP/Cardiologist
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10543**] on Monday, [**11-14**], at 4:00 PM ([**Telephone/Fax (1) 40360**]
|
[
"414.01",
"401.9",
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"410.11",
"293.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.66",
"37.23",
"00.45",
"00.40",
"99.20",
"88.56",
"36.07"
] |
icd9pcs
|
[
[
[]
]
] |
6752, 6810
|
4967, 5094
|
275, 325
|
7103, 7185
|
1775, 1775
|
7575, 7783
|
1399, 1403
|
5993, 6729
|
6831, 6991
|
5938, 5970
|
7209, 7552
|
2727, 4944
|
5121, 5912
|
1418, 1756
|
7012, 7082
|
224, 237
|
353, 1235
|
1791, 2711
|
1257, 1309
|
1325, 1383
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,530
| 117,990
|
10309+10310
|
Discharge summary
|
report+report
|
Admission Date: [**2155-4-21**] Discharge Date: [**2155-5-9**]
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 85 year-old
man who underwent coronary artery bypass grafting x2 as well
as aortic valve replacement on [**2155-4-7**] by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 70**]. His postoperative course was uneventful except for
atrial fibrillation for which he was discharged on Coumadin.
The patient was doing well at home until the day before
admission when he developed increasing chest pain and fever.
EMS was called and he was taken to [**Hospital3 3583**] where he
was noted to be febrile to 203 in rapid atrial fibrillation
with a ventricular response in the 120s and an increased
white blood cell count to 18,000 with an INR of 4.2,
otherwise unremarkable. His chest x-ray was reportedly
negative and he was transferred to the [**Hospital1 190**] for further work up and care.
PAST MEDICAL HISTORY: Is significant for coronary artery
bypass graft x2 as well an aortic valve replacement and
tissue valve, coronary artery disease, aortic stenosis,
prostate carcinoma, paroxysmal atrial fibrillation, rectal
bleeding, status post cauterization, cholelithiasis, status
post abdominal aortic aneurysm repair in [**2145**], status post
bilateral hernia repairs, status post right lung surgery,
chronic renal insufficiency with a baseline creatinine of
1.1, chronic obstructive pulmonary disease.
MEDICATIONS AT HOME: Included aspirin 81 mg daily, Colace
100 mg b.i.d., Flovent 110 2 puffs b.i.d., Percocet 5/325 1
to 2 tablets p.o. q 4 to 6 hours p.r.n., Atrovent 2 puffs
q.i.d., Protonix 40 mg daily, Lopressor 25 mg b.i.d., Lipitor
20 mg daily, Bacitracin ointment to air lesions, Celexa 10 mg
daily and Warfarin which is held from [**4-18**] on due to an
elevated INR.
ALLERGIES: Patient states no known drug allergies.
PHYSICAL EXAMINATION: At time of admission temperature 99.9,
pulse 94, blood pressure 124/70, respiratory rate 24, O2
saturation 94% on 3 liters by nasal cannula. Neurologic
grossly intact, moves all extremities without difficulty.
Pulmonary with scattered rhonchi, diminished breath sounds at
the bases. Cardiovascular: Irregularly irregular with no
murmur. Abdomen is soft and nontender, nondistended.
Extremities are warm with no edema. Sternum is stable with
Steri-Strips. No erythema or drainage.
Patient was admitted to CT surgery. He was scheduled for a
chest CT as well as a chest x-ray and echocardiogram. He was
begun on Vancomycin and levofloxacin pending the results of
blood and wound cultures. Chest CT showed a suspicious for
small subcutaneous fluid collection. Also a deep infected
fluid collection. Superficial exploration relieved the small
fluid collection. Culture was sent. The bone appeared to be
intact at that time and it was decided to treat the patient
conservatively with frequent dressing changes plus or minus
the operating room for debridement if there was no
significant improvement. Over the next several days the
patient's wound showed significant improvement with
decreasing amounts of drainage and beginnings of granulation
tissue in the wound margins. A PICC line was placed on
hospital day #4 for anticipated long term Vancomycin
infusions. However, on hospital day 8 it was noted that the
patient's sternal drainage had again increased with the wound
appearing less stable and at this time decision was made to
bring him to the operating room for surgical incisions and
drainage of the wound with plus or minus sternal debridement.
The patient did indeed undergo sternal debridement once in
the operating room. Please the operating room report for full
details. He tolerated the operation well and was transferred
from the operating room to the Cardiothoracic Intensive Care
Unit. At the time of transfer the patient's chest was open
with packed sternal wound. He was also seen by plastic
surgery at that time. Over the next several days the patient
remained in the Cardiothoracic Intensive Care Unit. During
that period he was chemically paralyzed and sedated with an
open chest wound. He remained hemodynamically stable
throughout that period and on [**5-1**] the patient was brought
to the operating room once again for bilateral pectoralis
advancement flaps and sternal wound closure. He tolerated
this operation well. Please seen the operating room report
for full details.
Following wound closure he was transferred from the operating
room to the Cardiothoracic Intensive Care Unit without
complications. Following wound closure the patient's
paralytics were discontinued. On postoperative day #1 he was
weaned from the ventilator and successfully extubated. He was
begun on oral beta blockade and his diet was advanced as
tolerated and on postoperative day #3 he was transferred to
floor for continuing postoperative care and activity
advancement. Over the next week the patient had an uneventful
hospital course. His activity was increased with the
assistance of nursing and physical therapy. The [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drains in his chest were removed by plastic surgery service
and on postoperative day #11 and #8 it was decided that the
patient was stable and ready to be transferred to
rehabilitation. At the time of this dictation the patient's
physical is as follows: Temperature 98.3, heart rate 74 in
atrial fibrillation, blood pressure 116/60, respiratory rate
20, O2 saturation 95% on room air. Weight preoperatively 80
kilos, at discharge is 82.5 kilos.
LABORATORY DATA: White count 7.3, hematocrit 33.8, platelets
266, sodium 140, potassium 4.0, chloride 101, CO2 32, BUN 13,
creatinine 1.1, glucose 97, PT is 18.2 with an INR of 2.1.
PHYSICAL EXAMINATION: Neurologically alert and oriented
times three, moves all extremities, follows commands,
nonfocal examination. Pulmonary: Diminished at the bases with
scattered rhonchi, otherwise clear. Cardiac: Irregularly
irregular, S1 and S2 with no murmurs. Sternum with running
sutures, is open to air, clean and dry. Bilateral deltoid
incisions open to air, clean and dry with one [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drain draining serosanguineous fluid. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm and well perfused with 1 to 2+ edema.
Additionally the patient has a PICC in the left antecubital
space, slight without erythema.
Patient is to be discharged to rehabilitation. He is to have
follow up with Dr. [**Last Name (STitle) **] in the plastic surgery clinic one
week following transfer for assessment of [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drain. Follow up with Dr. [**Last Name (STitle) 70**] in four to six weeks and
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] four weeks after discharge
from rehabilitation.
CONDITION AT TIME OF DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Aortic sclerosis - status post aortic valve replacement.
2. Coronary artery disease - status post coronary artery
bypass graft times two on [**2155-4-7**].
3. Status post sternal debridement on [**4-28**].
4. Status post pectoralis flap advancement and sternal wound
closure on [**5-1**].
5. Prostatic carcinoma.
6. Abdominal aortic aneurysm repair in [**2145**].
7. Status post right lung surgery.
8. Chronic renal insufficiency with baseline creatinine of
1.1.
9. Chronic obstructive pulmonary disease.
10. Status post bilateral hernia repairs.
11. Status post right lung surgery.
DISCHARGE MEDICATIONS: Include Combivent 1 to 2 puffs q 6
hours p.r.n., zinc sulfate 220 mg daily times one month,
Percocet 5/325 1 to 2 tablets q 4 to 6 hours p.r.n. for pain,
ascorbic acid 500 mg b.i.d. x one month, Colace 100 mg b.i.d.
while taking Percocet, aspirin 81 mg daily, pantoprazole 40
mg daily, metoprolol 50 mg b.i.d., Lasix 20 mg daily,
multivitamin 1 tablet daily, warfarin as directed to maintain
the target INR of 2 to 2.5, Vancomycin 750 mg q 24 hours x 2
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2155-5-9**] 13:16:41
T: [**2155-5-9**] 14:08:13
Job#: [**Job Number 34280**]
Unit No: [**Numeric Identifier 34281**]
Admission Date: [**2155-4-21**]
Discharge Date: [**2155-5-9**]
Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 85 year-old
man who underwent coronary artery bypass grafting x2 as well
as aortic valve replacement on [**2155-4-7**] by Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 70**]. His postoperative course was uneventful except for
atrial fibrillation for which he was discharged on Coumadin.
The patient was doing well at home until the day before
admission when he developed increasing chest pain and fever.
EMS was called and he was taken to [**Hospital3 3583**] where he
was noted to be febrile to 203 in rapid atrial fibrillation
with a ventricular response in the 120s and an increased
white blood cell count to 18,000 with an INR of 4.2,
otherwise unremarkable. His chest x-ray was reportedly
negative and he was transferred to the [**Hospital1 190**] for further work up and care.
PAST MEDICAL HISTORY: Is significant for coronary artery
bypass graft x2 as well an aortic valve replacement and
tissue valve, coronary artery disease, aortic stenosis,
prostate carcinoma, paroxysmal atrial fibrillation, rectal
bleeding, status post cauterization, cholelithiasis, status
post abdominal aortic aneurysm repair in [**2145**], status post
bilateral hernia repairs, status post right lung surgery,
chronic renal insufficiency with a baseline creatinine of
1.1, chronic obstructive pulmonary disease.
MEDICATIONS AT HOME: Included aspirin 81 mg daily, Colace
100 mg b.i.d., Flovent 110 2 puffs b.i.d., Percocet 5/325 1
to 2 tablets p.o. q 4 to 6 hours p.r.n., Atrovent 2 puffs
q.i.d., Protonix 40 mg daily, Lopressor 25 mg b.i.d., Lipitor
20 mg daily, Bacitracin ointment to air lesions, Celexa 10 mg
daily and Warfarin which is held from [**4-18**] on due to an
elevated INR.
ALLERGIES: Patient states no known drug allergies.
PHYSICAL EXAMINATION: At time of admission temperature 99.9,
pulse 94, blood pressure 124/70, respiratory rate 24, O2
saturation 94% on 3 liters by nasal cannula. Neurologic
grossly intact, moves all extremities without difficulty.
Pulmonary with scattered rhonchi, diminished breath sounds at
the bases. Cardiovascular: Irregularly irregular with no
murmur. Abdomen is soft and nontender, nondistended.
Extremities are warm with no edema. Sternum is stable with
Steri-Strips. No erythema or drainage.
Patient was admitted to CT surgery. He was scheduled for a
chest CT as well as a chest x-ray and echocardiogram. He was
begun on Vancomycin and levofloxacin pending the results of
blood and wound cultures. Chest CT showed a suspicious for
small subcutaneous fluid collection. Also a deep infected
fluid collection. Superficial exploration relieved the small
fluid collection. Culture was sent. The bone appeared to be
intact at that time and it was decided to treat the patient
conservatively with frequent dressing changes plus or minus
the operating room for debridement if there was no
significant improvement. Over the next several days the
patient's wound showed significant improvement with
decreasing amounts of drainage and beginnings of granulation
tissue in the wound margins. A PICC line was placed on
hospital day #4 for anticipated long term Vancomycin
infusions. However, on hospital day 8 it was noted that the
patient's sternal drainage had again increased with the wound
appearing less stable and at this time decision was made to
bring him to the operating room for surgical incisions and
drainage of the wound with plus or minus sternal debridement.
The patient did indeed undergo sternal debridement once in
the operating room. Please the operating room report for full
details. He tolerated the operation well and was transferred
from the operating room to the Cardiothoracic Intensive Care
Unit. At the time of transfer the patient's chest was open
with packed sternal wound. He was also seen by plastic
surgery at that time. Over the next several days the patient
remained in the Cardiothoracic Intensive Care Unit. During
that period he was chemically paralyzed and sedated with an
open chest wound. He remained hemodynamically stable
throughout that period and on [**5-1**] the patient was brought
to the operating room once again for bilateral pectoralis
advancement flaps and sternal wound closure. He tolerated
this operation well. Please seen the operating room report
for full details.
Following wound closure he was transferred from the operating
room to the Cardiothoracic Intensive Care Unit without
complications. Following wound closure the patient's
paralytics were discontinued. On postoperative day #1 he was
weaned from the ventilator and successfully extubated. He was
begun on oral beta blockade and his diet was advanced as
tolerated and on postoperative day #3 he was transferred to
floor for continuing postoperative care and activity
advancement. Over the next week the patient had an uneventful
hospital course. His activity was increased with the
assistance of nursing and physical therapy. The [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drains in his chest were removed by plastic surgery service
and on postoperative day #11 and #8 it was decided that the
patient was stable and ready to be transferred to
rehabilitation. At the time of this dictation the patient's
physical is as follows: Temperature 98.3, heart rate 74 in
atrial fibrillation, blood pressure 116/60, respiratory rate
20, O2 saturation 95% on room air. Weight preoperatively 80
kilos, at discharge is 82.5 kilos.
LABORATORY DATA: White count 7.3, hematocrit 33.8, platelets
266, sodium 140, potassium 4.0, chloride 101, CO2 32, BUN 13,
creatinine 1.1, glucose 97, PT is 18.2 with an INR of 2.1.
PHYSICAL EXAMINATION: Neurologically alert and oriented
times three, moves all extremities, follows commands,
nonfocal examination. Pulmonary: Diminished at the bases with
scattered rhonchi, otherwise clear. Cardiac: Irregularly
irregular, S1 and S2 with no murmurs. Sternum with running
sutures, is open to air, clean and dry. Bilateral deltoid
incisions open to air, clean and dry with one [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drain draining serosanguineous fluid. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm and well perfused with 1 to 2+ edema.
Additionally the patient has a PICC in the left antecubital
space, slight without erythema.
Patient is to be discharged to rehabilitation. He is to have
follow up with Dr. [**Last Name (STitle) **] in the plastic surgery clinic one
week following transfer for assessment of [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drain. Follow up with Dr. [**Last Name (STitle) 70**] in four to six weeks and
follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] four weeks after discharge
from rehabilitation.
CONDITION AT TIME OF DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Aortic sclerosis - status post aortic valve replacement.
2. Coronary artery disease - status post coronary artery
bypass graft times two on [**2155-4-7**].
3. Status post sternal debridement on [**4-28**].
4. Status post pectoralis flap advancement and sternal wound
closure on [**5-1**].
5. Prostatic carcinoma.
6. Abdominal aortic aneurysm repair in [**2145**].
7. Status post right lung surgery.
8. Chronic renal insufficiency with baseline creatinine of
1.1.
9. Chronic obstructive pulmonary disease.
10. Status post bilateral hernia repairs.
11. Status post right lung surgery.
DISCHARGE MEDICATIONS: Include Combivent 1 to 2 puffs q 6
hours p.r.n., zinc sulfate 220 mg daily times one month,
Percocet 5/325 1 to 2 tablets q 4 to 6 hours p.r.n. for pain,
ascorbic acid 500 mg b.i.d. x one month, Colace 100 mg b.i.d.
while taking Percocet, aspirin 81 mg daily, pantoprazole 40
mg daily, metoprolol 50 mg b.i.d., Lasix 20 mg daily,
multivitamin 1 tablet daily, warfarin as directed to maintain
the target INR of 2 to 2.5, Vancomycin 750 mg q 24 hours x 2
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2155-5-9**] 13:16:41
T: [**2155-5-9**] 14:08:13
Job#: [**Job Number 34280**]
|
[
"998.59",
"V42.2",
"593.9",
"V45.81",
"427.31",
"V10.46",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"77.11",
"38.93",
"77.61",
"96.6",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
15486, 16093
|
16117, 16850
|
9966, 10375
|
14249, 15465
|
8561, 9429
|
9452, 9944
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,153
| 150,883
|
29653
|
Discharge summary
|
report
|
Admission Date: [**2201-1-29**] Discharge Date: [**2201-2-19**]
Date of Birth: [**2167-12-20**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 16920**]
Chief Complaint:
Right arm crush injury
Major Surgical or Invasive Procedure:
mechanical ventilation
1/24 exploration by ortho
[**1-29**] angiogram
[**1-29**] 1. Debridement of skin, subcutaneous tissue and muscle of
the right upper extremity.
2. Pulse lavage washout of the right upper extremity.
3. Muscle transposition of the biceps brachii.
4. Complex adjacent tissue transfer and local tissue
rearrangement of the right upper extremity.
[**1-30**] debridement
[**2-2**] 1. Debridement of skin and subcutaneous tissue from the
right upper extremity.
2. Adjacent tissue transfer and local tissue rearrangement
of the right upper extremity.
3. Vacuum assisted closure (VAC) dressing placement.
4. Right lateral chest wall hematoma evacuation.
5. Biceps muscle flap transposition.
[**2-6**] Closed reduction right elbow dislocation.
Application multiplanar external fixator.
Exploration radial nerve.
debridement and vac drain placed
[**2-11**] debridement w/wound vac drain change
[**2-13**] debridement w/ wound vac removed
History of Present Illness:
33 YO M presents to ED s/p getting arm caught in a roller press
at work. The press rolled up his R arm all the way to the
shoulder and caused a degloving injury to the proximal portion
of
the R arm. There was prolonged extrication (up to 15 minutes).
Medflighted from OSH to [**Hospital1 18**]. Difficulty Breathing in the ED,
and subsequently intubated.
Past Medical History:
none
Social History:
married, two kids, RHD, smoker x 1ppd
Family History:
non-contributory
Physical Exam:
T 100.1 P 114 BP 144/70 R 18 99% on 2L
Gen: NAD, A&Ox3, pale
Neck- c-collar in place
Chest: CTAB
CV: tachy reg rythym.
Abd: NT +BS, neg FAST exam
Ext: R shoulder deformity, TTP. degloving injury of proximal
aspect of RUE encompassing approx 270 degrees of arm with
exposed
underlying tissue, biceps defect, palpable brachial artery.
Olecreanon visible. Forearm deformity with ganglion cyst on the
radial apsect of anterior forearm. Dopplerable ulnar and radial
arteries. slow capillary refill in digits. decreased strength
in RUE, unable to assess strength due to bandages and pain.
decreased sensation in hand and forearm.
Pertinent Results:
[**2201-1-28**] 09:26PM WBC-42.7* HCT-31.0*
[**2201-1-28**] 09:26PM PLT SMR-NORMAL PLT COUNT-350
[**2201-1-28**] 09:26PM PT-13.3* PTT-25.6 INR(PT)-1.2*
[**2201-1-28**] 09:26PM FIBRINOGE-213
[**2201-1-28**] 09:26PM GLUCOSE-198* UREA N-20 CREAT-1.0 SODIUM-140
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-19* ANION GAP-15
[**2201-1-28**] 09:26PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Imaging:
-[**2201-1-28**] shoulder/elbow xrays: No clear evidence of fracture.
Large subcutaneous edema and emphysema.
-[**2201-1-29**] angiogram: evidence of occlusion of the
ulnar artery near its take off. There was faint opacification
of the brachial artery. There was good opacification of the
interosseous artery which reconstituted distal ulnar artery
as well as a distal brachial artery. The palmar arch was intact
-[**2201-2-11**] cxr: No evidence of acute cardiopulmonary process.
[**2201-2-16**] MRI
Brief Hospital Course:
Pt was admitted to [**Hospital1 18**] after a traumatic injury - industrial
injury - got his arm caught in wood press resulting in degloving
of right forearm after 10-15 min extraction time. In the ED, the
patient was found to have dopplerable pulses, but weak. Pt.
taken to the OR w/plastics/vascular. Angiogram in OR showed
occlusion of radial/ulnar, but reconstitution distal [**Last Name (un) **]
anterior intraosseous. Wound debridement and VAC placement
occured. Pt. w/dislocated shoulder reduced, and unstable elbow
injury that was splinted. Received 6 L IVF and had ~700 cc EBL.
- [**1-29**]: Pt was intubated in EDangiogram showed evidence of
occlusion of the ulnar artery near its take off. There was faint
opacification of the brachial artery. There was good
opacification of the
interosseous artery which reconstituted distal ulnar artery as
well as a distal brachial artery. The palmar arch was intact. In
addition, the patient underwent debridement of skin,
subcutaneous tissue and muscle of the right upper extremity.
Pulse lavage washout of the right upper extremity.Muscle
transposition of the biceps brachii. Complex adjacent tissue
transfer and local tissue rearrangement of the right upper
extremity. With ortho, he underwent a R elbow exploration.
- [**1-30**]:Extubated in TSICU. To OR for Debridement, I and D with
vac drain change
- [**2-1**]: The patietn had brief episode of fever, tachycardia and
rapidly increasing swelling of R clavicular area/chest. LAter
in the day, went to the OR for Drainage of anterior chest
hematoma. Cultures were negative for organisms.
- [**2-2**]: Debridement of skin and subcutaneous tissue from the
right upper extremity. Adjacent tissue transfer and local tissue
rearrangement of the right upper extremity. Vacuum assisted
closure (VAC) dressing placement Right lateral chest wall
hematoma evacuation. Biceps muscle flap transposition.
- [**2-4**]: Left subclavian central line removed.
- [**2-5**]: Further non-invasive studies by Vascular surgery.
Determined that pt does not need revascularization procedure of
forearm. Will conservatively manage
- [**2-6**]: Closed reduction right elbow dislocation. Application
multiplanar external fixator. Exploration radial nerve.
Debridement and vac drain placed. elbow hinged Ex-Fix placement
by Orthopedics.
-[**2-10**]: developed fever to 101.2 of unknown source. WBC count of
22. Responded to tylenol and improved over course of 3 days.
- [**2-11**]: debridement w/wound vac drain change
- [**2-12**]: Received 2 units of pRBC for a decreased Hct. fever
improved. WBC count 10. PCA discontinued at patient's request.
Good pain control with PO dilaudid, with occasional need for IV
dilaudid for breakthrought pain. Pt and wife continued
discussions with social work regarding coping skills and
caregiver [**Last Name (Titles) 16089**].
- [**2-13**]: [**Name2 (NI) 71067**]t w/ wound vac removed; patient transfered to
Plastic Surgery
- [**2-14**]: Began [**Hospital1 **] wet to dry dressing changes at the bedside by
Plastic Surgery. pt tolerates the dressing changes with
baseline pain meds only.
- [**2-16**]: Ex-fix unlocked by Orthopedics. Continues to work with
PT/OT on ROM, fine motor movements. Has severe pain with ROM.
Medications on Admission:
none
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
R Arm Crush Injury
Discharge Condition:
good
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 3228**]
Please see a occupational hand therapist for treatment and
further strengthening of your hand
|
[
"881.20",
"305.1",
"E919.8",
"832.00",
"903.3",
"780.6",
"285.1",
"927.8",
"998.12",
"903.2",
"831.01",
"880.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.01",
"86.74",
"79.82",
"04.49",
"99.07",
"88.49",
"86.22",
"78.12",
"83.45",
"83.79",
"38.93",
"84.72",
"79.71",
"99.04",
"99.06"
] |
icd9pcs
|
[
[
[]
]
] |
6758, 6831
|
3455, 6703
|
339, 1321
|
6894, 6901
|
2495, 3432
|
7866, 8021
|
1808, 1826
|
6852, 6873
|
6729, 6735
|
6925, 7843
|
1841, 2476
|
277, 301
|
1349, 1708
|
1730, 1736
|
1752, 1792
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,078
| 168,732
|
53675
|
Discharge summary
|
report
|
Admission Date: [**2148-2-24**] Discharge Date: [**2148-3-4**]
Date of Birth: [**2077-1-23**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
s/p unwitnessed fall
Major Surgical or Invasive Procedure:
[**2148-2-25**] Intramedullary rod fixation of right intertrochanteric
hip fracture with open bone biopsy.
[**2148-2-27**] IVC filter placement
History of Present Illness:
This is a 83 year old man with dementia when and chronic low
platelets that was at home suffered an unwitnessed fall.
There was unknown loss of consciousness. The patient has
baseline dementia and is unable to relay the events of his
injury. He presented to an outside hospital where a head CT was
consistent with small subdural hematoma and SAH as well as right
interotrochanteric fracture. The patient was transferred to
[**Hospital1 18**] [**Location (un) 86**] for further evaluation and care
Past Medical History:
PMH: bipolar, dementia, chronic thrombocytompenia of unknown
etiology
PSH: none
Social History:
Lives with wife. Ambulates with cane. Recently moved here from
NY. No EtOH or tobacco.
Family History:
Noncontributory
Physical Exam:
On admission:
O: T: BP: 127/60 HR: 60 R: 14 O2Sats; 100%
Gen: comfortable, NAD.
HEENT:NO BATTLE/raccoon SIGN- NO otorrhea/NO rhinorrhea. right
eye edema ecchymosis. Pupils: 4-3mm bilaterally EOMs:
grossly intact
Neck: ridgid- but patient does not participate
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert,baseline dementia-does not
participate in detailed neurological exam
Orientation: NOT Oriented to person, place, and date.
Recall:pt does not participate
Language: Speech fluent spontaneously- but when asked questions
the patient repeats himself- non sensical
On discharge:
T 98.0 BP 100/55 HR 55 R 18 O2 sat 99% RA
GEN: Alert and conversant, NAD
NEURO: PERRLA, alert, oriented x [**12-4**], +MAE, follows commands and
responds appropriately to questions, speech clear, 5/5 strength
B/L UE, [**4-6**] LLE, [**2-5**] RLE
HEENT: Right periorbital and forehead large echymosis, skin
intact.
CV: RRR, no m/r/g
PULM: CTAB
ABD: Soft, nontender, nondistended
EXTR: RLE with surgical dressings x 2 to lateral thigh intact
with small sang staining, right hip with lg echymosis, soft,
+DP/TP pulses
Pertinent Results:
CT spine [**2148-2-24**] - No evidence of acute fracture or malalignment
CTA head [**2148-2-24**] - On the maximum intensity images are presented
for interpretation and show no evidence of stenosis, occlusion
or an aneurysm greater than 3 mm in size.
CT head [**2148-2-24**] - Increasing and new areas of intracranial
hemorrhage as described above.
CT head [**2148-2-25**] - Compared to recent preceding exam, there
appears to be slight increase in size and number of multiple
scattered hemorrhagic contusions without significant increase in
mass effect or shift of normally midline structures.
2. Overall stable distribution of multicompartmental hemorrhage
within the
brain, subarachnoid space, subdural, subependymal, and
intraventricular
spaces.
3. Large right frontoparietal subgaleal hematoma.
4. Unchanged hemorrhage distending the right maxillary sinus.
CT head [**2148-2-25**] - Overall similar appearing exam with extensive
intracranial hemorrhage.
CT head [**2148-2-26**] - Overall, little change in comparison to prior
study from the night before with a similar appearance of
extensive intracranial hemorrhages as described above.
CT head [**2148-2-27**] - No appreciable change since the study on [**2-26**], [**2147**] with multiple foci of hemorrhagic contusion, most
prominent in the right frontal region; small bilateral subdural
hematomas; small intraventricular hemorrhage; and blood products
within the right maxillary sinus. No new hemorrhage or mass
effect.
FEMUR (AP & LAT) RIGHT, PELVIS (AP only) [**2148-2-25**]:
Intertrochanteric fracture without displacement.
TTE [**2148-2-26**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
[**2148-2-26**]:
Right ICA no stenosis.
Left ICA no stenosis.
Labs on admission:
[**2148-2-24**] 05:42PM WBC-12.2* RBC-4.60 HGB-15.5 HCT-46.9 MCV-102*
MCH-33.7* MCHC-33.0 RDW-14.2
[**2148-2-24**] 05:42PM PLT COUNT-77*
[**2148-2-24**] 05:42PM PT-11.3 PTT-30.7 INR(PT)-1.0
[**2148-2-24**] 05:42PM FIBRINOGE-226
[**2148-2-24**] 05:42PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2148-2-24**] 05:42PM CK-MB-8
[**2148-2-24**] 05:42PM cTropnT-0.20*
[**2148-2-24**] 05:42PM LIPASE-59
[**2148-2-24**] 05:42PM CK(CPK)-100
[**2148-2-24**] 05:50PM GLUCOSE-130* LACTATE-2.6* NA+-140 K+-4.1
CL--105 TCO2-21
[**2148-2-24**] 05:42PM UREA N-24* CREAT-1.2
[**2148-2-24**] 06:47PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-7.5 LEUK-NEG
[**2148-2-24**] 06:47PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
Labs at discharge:
[**2148-3-4**] 04:47AM BLOOD WBC-7.7 RBC-2.46* Hgb-7.7* Hct-25.4*
MCV-103* MCH-31.5 MCHC-30.5* RDW-17.9* Plt Ct-118*
[**2148-3-4**] 04:47AM BLOOD Glucose-137* UreaN-26* Creat-1.2 Na-145
K-3.6 Cl-114* HCO3-24 AnGap-11
[**2148-3-3**] 04:46AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.7
Brief Hospital Course:
Mr. [**Known lastname **] was admitted under the Acute Care Surgery Service on
[**2148-2-24**] for management of his injuries s/p fall which included
right interotrochanteric fracture as well as SAH and SDH. He was
admitted to the Trauma ICU for close monitoring and hourly neuro
checks and transferred to the surgical floor on [**2148-2-27**] with a
stable neurologic exam. Below details his hospital course by
system:
Neuro: Neurosurgery was consulted for his SAH and SDH. He was
started on keppra 500 mg [**Hospital1 **] for seizure prophylaxis for a total
course of 7 days which is completed at discharge. He had
multiple head CT's to monitor his intra-cranial hemorrhage,
which stabilized on [**2148-2-25**]. He had serial neuro exams which
improved throughout his hospitalization and he became
increasingly alert and appropriately responsive to questions,
with ability to follow commands.
His pain was well-controlled with IV and oral medications. At
discharged his pain was well controlled on tylenol and prn
oxycodone.
CV: His troponin in the ED was elevated to 0.2, though his EKG
was normal at that time. He had serial cardiac enzymes checked,
which normalized. He never had any chest pain, shortness of
breath, or other symptoms concerning for acute cardiac event.
His heart rate and blood pressure were routinely monitored. He
also had an echo and carotid US as part of a syncope work up
given unknown cause of his fall. Both of these tests were within
normal limits (see pertinent results section for details). His
vital signs were routinely monitored and he remained
hemodynamically stable.
Resp: No issues. IS and good pulmonary toilet were encouraged.
O2 saturations were monitored regularly with vital signs, and
remained within normal limits.
GI/GU: He was initially kept NPO with IVF. On attempt to advance
his diet, he was noted to have some coughing with swallowing and
a speech and swallow evalation was performed, which recommended
ground diet with thin liquids. He was also started on a bowel
regimen, and was having bowel movements prior to discharge.
A foley catheter was placed to monitor urine output. This was
removed on [**2148-2-28**], however he was unable to void and his foley
was replaced for urinary retention. He was subsequently started
on flomax.
Heme: He was thrombocytopenic on admission (and has a history of
chronic thrombocytopenia) with a platelet count of 77. He was
transfused 1 unit of platelets for this on admission given his
injuries and risk for increased bleeding. He had serial
hematocrits checked. He had a drop in his Hct on [**2-26**] to 25.4,
associated with a significant amount of bruising of his right
hip as well as thrombocytopenia. This was evaluated by
orthopedics, who did not feel intervention was needed, and felt
this drop was expected post-operatively. His Hct dropped to 22
that evening, and he was transfused 2u PRBC, with a
post-transfusion Hct of 26.4. His hct remained stable thereafter
and is 25.4 at discharge on [**2148-3-4**]. His thrombocytopenia remains
stable at 118 at discharge, with neurosurgery recommendations to
keep platelet count >80. His PCP was notified of his admission
and thrombocytopenia and will follow as a the pt after
discharge. A HIT panel was sent to rule out heparin induced
thrombocytopenia which was negative. His is being discharged
with plan for continued CBC monitoring and has been instructed
to follow up with his primary care provider after discharge from
rehab to continue to follow his thrombocytopenia.
A PICC line was placed on [**2-26**] as the patient had poor
peripheral venous access for medications and blood draws. It
remains in place upon discharge to rehab as access for lab
draws.
An IVC filter was placed on [**2-27**] given the patient's
thrombocytopenia and concerns with anticoagulation. The decision
was made to hold SC heparin at the time of discharge.
MSK: He went to the operating room on [**2148-2-25**] for repair of his
right hip fracture. He tolerated the procedure well. He was
weightbearing as tolerated on his RLE postoperatively. PT and OT
were consulted to assess his mobility, and it was recommended
that he be discharged to a rehab facility to continue physical
therapy after discharge from the hospital.
On [**2148-3-4**] he is afebrile and hemodynamically stable. His
neurological status is improving. His pain is well controlled.
He is being discharged to a rehab facility to continue his
recovery.
Medications on Admission:
depakote 1250am, 1000pm , topamax 25 mg daily, citalopram 10 mg
daily
Discharge Medications:
1. topiramate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. oxycodone 5 mg Tablet Sig: 0.5-5 Tablets PO Q6H (every 6
hours) as needed for pain.
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. valproic acid (as sodium salt) 250 mg/5 mL Solution Sig:
Fifteen (15) mL PO Q8H (every 8 hours).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. insulin regular human 100 unit/mL Solution Sig: One (1) per
insulin sliding scale Injection ASDIR (AS DIRECTED).
11. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
12. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
13. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] TCU - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
s/p fall
Injuries:
1. Bilateral fronto-temporal SAH
2. Right fronto-temporal SDH
3. Right intertrochanteric femur fracture, non-displaced
Secondary:
Thrombocytopenia
Acute blood loss anemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after suffering a fall. You
sustained multiple injuries including bleeding and bruising in
your brain as well as a broken hip. Your platelets were also low
and so your received platelets because of concern for bleeding
from your injuries. You also received a blood transfusion
because you lost some blood due to your injuries.
You were taken to the operating room and had your hip fracture
repaired. You may now bear weight on your right leg as
tolerated.
You also had a filter placed in your inferior vena cava to
prevent clots in you lungs.
You had multiple repeat head CT scans which have showed no
further changes recently in your head bleeds.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining, or
excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (colace)
while taking narcotic pain medication.
Unless directed by your doctor, DO NOT take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen, etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
New onest of tremors or seizures.
Any confusion, lethargy or changes in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not relieved
by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Follow up appointment instructions:
Please follow up with the neurosurgery team at the appointment
listed below. You will need a CT scan of the brain without
contrast prior to your appointment.
Also please follow up with the orthopedic surgeon at the
appointment listed below for your hip.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: Primary Care
Location: FAMILY PRACTICE GROUP, P.C.
Address: [**Street Address(2) 53051**] STE 1A, [**Location (un) **],[**Numeric Identifier 53052**]
Phone: [**Telephone/Fax (1) 35561**]
*Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: ORTHOPEDICS
When: TUESDAY [**2148-3-12**] at 7:40 AM
With: ORTHO XRAY on SCC2
Phone: [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*Scheduled X-Ray prior to appointment
Department: ORTHOPEDICS
When: TUESDAY [**2148-3-12**] at 8:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 4974**]: [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2148-3-14**] at 3:15 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**]
At: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: THURSDAY [**2148-3-28**] at 1:30 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: [**Hospital Ward Name 517**] CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
*Scheduled Ct Scan prior to appointment
Department: NEUROSURGERY
When: THURSDAY [**2148-3-28**] at 2:30 PM
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
Completed by:[**2148-3-4**]
|
[
"788.20",
"780.2",
"851.86",
"E885.9",
"294.20",
"285.1",
"820.21",
"287.5",
"296.80",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.35",
"77.45",
"38.7",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11831, 11905
|
5976, 10439
|
324, 470
|
12150, 12150
|
2412, 4809
|
14190, 16257
|
1224, 1241
|
10560, 11808
|
11926, 12129
|
10465, 10537
|
12325, 14167
|
1256, 1256
|
1877, 2393
|
264, 286
|
5678, 5953
|
498, 1000
|
4823, 5658
|
12165, 12301
|
1022, 1103
|
1119, 1208
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,435
| 191,407
|
17604
|
Discharge summary
|
report
|
Admission Date: [**2195-12-29**] Discharge Date: [**2196-1-22**]
Date of Birth: [**2117-2-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
resp distress, COPD, rapid atrial fibrillation
Major Surgical or Invasive Procedure:
Exploratory laparotomy, right colectomy and wash out, ileal
transverse anastomosis
Central line placement
Arterial line
History of Present Illness:
78 yo female with COPD, Afib on Coumadin, CHF presents with 2-3
day history of SOB, cough, and chest congestion along with some
fever and chills and decrease po appetite. Denies any other
associated symptoms and did receive the flu shot couple of weeks
ago. In the ED, patient did not get her Ca channel and B blocker
and so went into rapid Afib with RVR and so being ruled out. Had
some EKG changes. Back to normal rate after meds.
Past Medical History:
PMHx:
1. Chronic AFib
2. HTN
3. COPD
4. CHF (dx'd in setting of RVR)
5. MIBI [**7-4**]: negative
6. TTE [**5-3**]: 55%, 2+MR
Social History:
Long, heavy smoking history. Quit 9 years ago.
no EtOH, drugs.
Lives at home alone
retired lawyer
Family History:
NC
Physical Exam:
100.0 71 113/88 18 96% RA
Gen: NAD, sleeping but easily arousable
HEENT: PERRL, EOMI
neck: no JVD
CV: irreg, irreg, no M/R/G
lungs: expiratory wheezes
Abd: soft, NT/ND, NABS
Ext: warm, no edema
Pertinent Results:
[**2195-12-28**] 08:44PM GLUCOSE-110* UREA N-18 CREAT-1.3* SODIUM-140
POTASSIUM-3.1* CHLORIDE-96 TOTAL CO2-30* ANION GAP-17
[**2195-12-28**] 08:44PM PT-20.6* PTT-42.0* INR(PT)-2.7
[**2195-12-28**] 08:44PM PLT COUNT-162
[**2195-12-28**] 08:44PM NEUTS-75.1* LYMPHS-16.5* MONOS-8.0 EOS-0.1
BASOS-0.3
[**2195-12-28**] 08:44PM WBC-6.6 RBC-5.09 HGB-15.3 HCT-45.9 MCV-90
MCH-30.2 MCHC-33.4 RDW-14.4
[**2195-12-28**] 08:44PM CK-MB-2 cTropnT-<0.01
[**2195-12-28**] 08:44PM GLUCOSE-110* UREA N-18 CREAT-1.3* SODIUM-140
POTASSIUM-3.1* CHLORIDE-96 TOTAL CO2-30* ANION GAP-17
[**2195-12-29**] 03:50AM CK-MB-2
[**2195-12-29**] 03:50AM cTropnT-<0.01
[**2195-12-29**] 03:50AM CK(CPK)-115
[**2196-1-20**] 07:40AM BLOOD WBC-9.3 RBC-3.52* Hgb-10.9* Hct-32.8*
MCV-93 MCH-31.0 MCHC-33.2 RDW-16.5* Plt Ct-176
[**2196-1-12**] 01:10PM BLOOD Neuts-91* Bands-2 Lymphs-3* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 Hyperse-1*
[**2196-1-22**] 07:55AM BLOOD PT-13.0 INR(PT)-1.1
[**2196-1-22**] 07:55AM BLOOD Glucose-121* UreaN-31* Creat-0.7 Na-140
K-4.0 Cl-99 HCO3-34* AnGap-11
[**2196-1-22**] 07:55AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.1
[**2196-1-19**] 09:00AM BLOOD Vanco-32.0
[**2196-1-19**] 04:48AM BLOOD Vanco-20.5*
[**2196-1-17**] 07:47AM BLOOD Vanco-30.1
[**2196-1-17**] 05:04AM BLOOD Vanco-18.5*
Brief Hospital Course:
The [**Hospital 228**] hospital course was significant for the following
issues:
In the Emergency Department, the patient's EKG revealed atrial
fibrillation at a rate of 127 with 2.5mm ST depressions in leads
V3-V5, II, AvF. Given the patient's history, she was placed on
droplet precautions and a nasopharyngeal aspirate was performed
to evaluate for influenza. Her EKG changes were attributed to
demand ischemia in the setting of a rapid rate. She was
continued on metoprolol and diltiazem. On hospital day #2, the
patient's heart rate increased to the 160s and she became
increasingly short of breath and developed significant
respiratory distress. An arterial blood gas was performed and
revealed: 7.15/88/125. The patient was placed on mask
ventilation and transferred to the intensive care unit where she
was intubated.
MICU COURSE:
*Respiratory failure: The patient's respiratory failure was
likely secondary to influenza, COPD exacerbation and flash
pulmonary edema due to AF with rapid ventricular rate.
The patient had a DIRECT INFLUENZA A ANTIGEN TEST which was
Positive for Influenza A viral antigen. The viral culture
revealed HEMADSORPTION POSITIVE VIRUS. She was treated with
amantadine for a total of 5 days.
The patient was treated aggressively for COPD flare with
Solu-Medrol and frequent nebulizer treatments. She was
transitioned to 60mg po prednisone on [**2196-1-8**]. This should be
tapered slowly over the course of [**2-4**] weeks as tolerated.
The patient developed a new CXR opacity while in the MICU and
was treated for a superimposed bacterial pneumonia with
Vancomycin and levofloxacin. The patient developed a rash on her
trunk and extremities. The etiology of rash was not clear but
the possibility that this was an adverse reaction to Vancomycin
or Levaquin has been entertained. Skin eruption responded to
Benadryl IV and resolved by the time of transfer out of the MICU
after Abx were discontinued. She completed a course of
levofloxacin.
The patient was extubated on [**2196-1-7**] and O2 was weaned.
*AF with RVR: The patient was initially started on a diltiazem
drip but continued to require boluses of iv metoprolol with
sub-optimal rate control. She was loaded with digoxin on [**1-6**] and
continued on digoxin. Her rate did decrease somewhat with this
regimen. Her coumadin was continued initially but then held for
elevated INR likely from Coumadin interaction with levofloxacin.
*Hypotension: The patient was transiently hypotensive in the
MICU and required pressor support and multiple IVF boluses.
With treatment of her infection and weaning of sedation, the
patient's blood pressure normalized.
*Colonic pseudo-obstruction: The patient had severe constipation
while in the ICU likely secondary to Fentanyl effect on
intestinal motility. She was given neostigmine with good result
and then was continued on an aggressive bowel regimen and
Reglan.
*Hyperglycemia: The patient was started on an insulin gtt for
tight glucose control. She was transitioned to a regular
insulin sliding scale prior to transfer from the MICU.
*FEN: The patient was started on tube feeds while intubated.
After extubation, she underwent a swallowing study which
revealed no signs of aspiration but swallowing was a respiratory
demand for her and she could easily desat if feed to quickly.
Recommendations included: 1. Diet of thin liquids and pureed
solids. Straws are okay. 2. Please feed slowly with rest
between bites/sips trying to keep sats in low 90's.
Pt was transferred to medical floor on [**2196-1-9**]. The remainder of
her hospital course was significant for the following issues.
AF with RVR: The patient was transitioned to po diltiazem,
metoprolol and digoxin. The patient's rate was consistently in
the 105-120 range with occasional bursts to 150-160. She was
asymptomatic and hemodynamically stable. She will need to
follow up with cardiology as an outpatient and it might be worth
consider whether she is a candidate for AV node ablation with PM
placement.
The patient's INR was elevated upon transfer from the MICU.
This elevation was thought to be due to interaction of coumadin
and levofloxacin. The patient's Coumadin was held and should
continue to be held until her INR reaches goal of [**2-4**].
CHF: The patient has a known EF of 50%. She had some evidence
of diastolic dysfunction. She was total body overloaded (> 10
liter positive) upon transfer from the MICU but diuresed well
with lasix. She will need continued diuresis of 750-1L of fluid
per day until euvolemic.
COPD: She was transitioned to 60mg po prednisone on [**2196-1-8**]. This
should be tapered slowly over the course of [**2-4**] weeks as
tolerated.
Colonic pseudo-obstruction: The patient was continued on Reglan
and an aggressive bowel regimen. She had several bowel
movements and her abdominal distention was improving.
Hyperglycemia: continued on RISS
FEN: Prior to discharge, speech and swallow were re-consulted
for evaluation
Oral Candidiasis: The patient received nystatin for mild oral
thrush.
[**1-12**] patient taken to OR
diagnosis: Perforated cecum with ileal necrosis with feculent
perforation secondary to cecal necrosis secondary to
dilatation with ischemia.
Procedure: Exploratory laparotomy, right colectomy and wash
out, ileal transverse ileocolostomy. There were no complications
and patient was extubated without trouble. EBL 100cc
Post operatively she was kept NPO, IVF, NG, foley, Vanc, Levo,
Flagyl
POD 1 pain was well controlled. Physical therapy was consulted.
POD 2 she continued to do well and the NG was taken out. In the
evening she felt worse and had one episode of emesis, so a NG
was placed again.
POD 3 The patient felt better again. Cardiology continued to
follow.
POD 5 She was started on clears.
POD 7 She was started on a regular diet. +flatus Foley was
placed secondary to retension.
POD 8 Foley was taken out at midnight.
POD 9 Patient was discharged in good condition to rehab.
tolerating a regular diet and moving her bowels without
difficulty
Medications on Admission:
see below
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation [**Hospital1 **] (2 times a day).
2. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: One (1) ML
Inhalation Q6H (every 6 hours).
3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
6. Diltiazem HCl 60 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day)
for 3 days: [**1-22**] is first day.
9. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) for 3
days.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Terazosin HCl 2 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours) as needed for pain control.
13. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO ONCE
(once) as needed for atrial fibrillation for 1 doses.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
16. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
17. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8 for 4 days.
18. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous once a day for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Perforated cecum with feculent
perforation secondary to cecal necrosis secondary to
dilatation with ischemia.
Chronic obstructive pulmonary disease
Influenza A
Bacterial Pneumonia
Atrial Fibrillation
Ileus
Hyperglycemia
oral thrush
Diastolic heart failure
Discharge Condition:
Good
Discharge Instructions:
1. Please monitor for the following: fever, chills, nausea,
vomiting, inability to tolerate food/drink. If any of these
occur, please contact your physician [**Name Initial (PRE) 2227**].
2. Staples need to come out in about two weeks.
Followup Instructions:
Please call Dr.[**Name (NI) 11471**] office for a follow up appointment.
([**Telephone/Fax (1) 6347**]
Follow up with Dr. [**Last Name (STitle) 931**] within 1-2 weeks.
Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5543**]. Call for appointment.
Completed by:[**2196-1-22**]
|
[
"428.0",
"569.83",
"427.31",
"491.21",
"E932.0",
"569.5",
"112.0",
"560.1",
"518.81",
"401.9",
"251.8",
"487.0",
"428.30",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.93",
"38.93",
"96.72",
"99.15",
"45.73",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10443, 10522
|
2745, 8800
|
319, 445
|
10823, 10829
|
1424, 2722
|
11114, 11428
|
1187, 1191
|
8860, 10420
|
10543, 10802
|
8826, 8837
|
10853, 11091
|
1206, 1405
|
233, 281
|
473, 907
|
929, 1056
|
1072, 1171
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,583
| 189,695
|
6409
|
Discharge summary
|
report
|
Admission Date: [**2138-3-17**] Discharge Date: [**2138-4-19**]
Date of Birth: [**2065-8-1**] Sex: M
Service: SURGERY
Allergies:
Sulfonamides / Lipitor / Naprosyn / Penicillins / Amoxicillin /
Chocolate Flavor / Crestor / Morphine / Ativan
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Operation 1: Repair of ventral hernia.
Small bowel resection.
Operation 2: Exploratory laparotomy.
Lysis of adhesions, extensive.
Partial resection of omentum.
Drainage of multiple abdominal abscesses.
Drainage of right upper quadrant hematoma.
Small bowel resection with primary reanastomosis
Operation 3: Tracheostomy.
Endoscopic placement of post pyloric feeding tube.
History of Present Illness:
72 yo man with ventral hernia for greater than 10 years, noted
abdominal pain and hard mass at site of hernia 2 days ago. HAs
never had pain with the hernia. +nausea and vomiting today. No
fevers.
Past Medical History:
1. CAD - s/p LAD and OM1 stent in [**8-2**], s/p RCA PTCA in '[**28**]
2. DM 2
3. HTN
4. PVD s/p bilat LE bypass surgeries (Dr.[**Last Name (STitle) 24688**])
5. CRI - baseline Cr 1.6-2.0
6. cataracts
7. gout
8. BPH
9. Abd hernia
10. s/p CCY, ex-lap w/abd hernia resulting
Social History:
Worked as head [**Doctor Last Name 7051**]. Hx Etoh abuse x 20 yrs, but quit [**2124**]. 86
ppy tob.
Multiple family memebrs live nearby
Family History:
Fa: died secondary to colon ca
Mo: died secondary to PNA
Siblings: Etoh abuse, HTN
Physical Exam:
GA: in pain
HEENT: PERRLA sclera nonicteric
CV: rrr no m/r/g
Lungs CTA bilat no w/r/r
abd: hard, tender mass midline, no erythema
extrem: no c/c trace edema
Pertinent Results:
ADMISSION LABS:
[**2138-3-17**] 02:20AM BLOOD WBC-8.8 RBC-3.59* Hgb-11.0* Hct-32.8*
MCV-91 MCH-30.7 MCHC-33.7 RDW-16.2* Plt Ct-231
[**2138-3-17**] 02:20AM BLOOD Neuts-92.8* Bands-0 Lymphs-4.1* Monos-2.9
Eos-0.1 Baso-0.1
[**2138-3-17**] 02:20AM BLOOD PT-12.0 PTT-24.3 INR(PT)-1.0
[**2138-3-17**] 02:20AM BLOOD Glucose-212* UreaN-97* Creat-2.8* Na-141
K-4.9 Cl-104 HCO3-24 AnGap-18
[**2138-3-17**] 06:57AM BLOOD ALT-17 AST-23 LD(LDH)-211 AlkPhos-101
Amylase-87 TotBili-0.3
[**2138-3-17**] 06:57AM BLOOD Lipase-62*
[**2138-3-17**] 06:57AM BLOOD Albumin-4.1 Calcium-9.2 Phos-5.3* Mg-2.5
US guided absess drain: IMPRESSION: Successful ultrasound-guided
placement of an 8 French pigtail catheter into pelvic/abdominal
fluid. A total of 500 cc of sanguinous feculent-smelling fluid
was aspirated. A portion of the fluid was sent for microbiology,
Gram stain, cell count and bilirubin as ordered by the surgeons
taking care of the patient. The case was then discussed with the
primary surgical team.
Brief Hospital Course:
Mr. [**Known lastname **] was transferred to [**Hospital1 18**] on [**3-17**] for an incracerated
ventral hernia and acute renal failure. He was taken to the OR
on [**3-17**] for repair of ventral hernia and a small bowel resection
without complications. Please see the operative report for
further details. He did well initially and was transferred to
the floor. He did require 4 units of blood in the first 4 post
operative days but was always hemodynamically stable. While on
the floor he developed a post-operative ileus and a CT was
obtained on POD 7 which revealed multiple fluid collections and
contrast through to the colon. He did have a fair amount of
free air on that CT possibly consistent with post-op changes.
He also had a troponin leak with out EKG changes.
A percutaneous drain was placed on POD8 and his abdominal pain
improved. This grew out multiple organisms. He was stable.
However he subsequently developed increased distension and his
WBC count was elevated on POD 11. He also had a worsening
respiratory status and increased fluid requirement and the
decision was made to take him back to the OR for exploration.
A small bowel leak was identified and his intestine was
re-resected. He was taken to the ICU and extubated. However
his respiratory status was borderline and he required
reintubation and tracheostomy for airway protection. He was
treated for ventilatory associated pneumonia and subsequently
transferred to the floor.
At this time neurologically he requires small amounts of
haldol and ativan for agitation. He is responsive and follows
commands. He is cardiovascularly stable in a first degreee AV
block. He is on Lipitor and lopressor and aspirin. He is not
in CHF. From a respiratory perspective he is a trach mask
saturating well in the high nineties. He is tolerating goal
tube feed via a post-pyloric dobhoff tube and having formed
stools on a regular basis. His renal function is at his
baseline and he requires daily lasix. He is only mildly fluid
overloaded which should imporve over the next few weeks. He has
a indwelling foley. He is off all antibiotics.
He should continue to recieve DVT prophylaxis.
Medications on Admission:
Lopressor 50mg [**Hospital1 **], Hydralazyne 100 mgTID, Zetia 10mg QD,
Lipitor 10mg QD ASA 81mg, Diovan 40mg QD, Allopurinol 100mg [**Hospital1 **],
Lasix 40mg QD, Nifedipine ER 90 mg QD,
Prilosec 20', colchicine 0.6 QD, Plavix 75mg QD
Discharge Medications:
1. Epoetin Alfa 4,000 unit/mL Solution [**Hospital1 **]: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
3. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Albuterol Sulfate 0.083 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
5. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 325-650 PO Q4-6H
(every 4 to 6 hours) as needed.
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Zinc Oxide-Cod Liver Oil 40 % Ointment [**Last Name (STitle) **]: One (1) Appl
Topical PRN (as needed).
8. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical PRN
(as needed).
9. Clonidine 0.1 mg/24 hr Patch Weekly [**Last Name (STitle) **]: One (1) Patch Weekly
Transdermal QFRI (every Friday).
10. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
11. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
12. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed.
13. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day).
14. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed.
15. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
16. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours).
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: 10ml
NS followed by 1ml of 100 units/ml heparin (100 units heparin)
each lumen QD and PRN. Inspect site every shift MLs Intravenous
DAILY (Daily) as needed.
18. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day): Hold for SBP<100 or HR<60.
19. Insulin Regular Human Subcutaneous
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Discharge Worksheet-Discharge Diagnosis-Last Updated by:
[**Last Name (LF) 17353**],[**Name8 (MD) **], MD on [**2138-4-19**] @ 1113
Primary: Incarcerated strangulated ventral hernia, Small bowel
resection with primary reanastomosis, multiple abdominal
abscesses, respiratory failure, myocardial infarction
Secondary: PMH: CAD s/p LAD and OM1 stent in [**8-2**], s/p RCA PTCA
in '[**28**]
DM 2
HTN
PVD
CRI (Cr 1.6-2.0)
cataracts
gout
BPH,
h/o EtOH abuse (quit 13 yrs ago), h/o heavy tobacco use
Discharge Condition:
stable
Discharge Instructions:
Take your medications as directed. You will be seen by doctors
[**Name5 (PTitle) 1028**] in rehab.
Call your doctor or go to the ED for:
-chest pain or shortness of breath
-fever>102
-significant drainage or blood from your wound
-or any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 12637**], M.D. on [**2138-5-16**]
10:20am
You will need an repeat echo in [**2-2**] months, please see Dr.
[**First Name (STitle) **] to arrange this.
Please follow up with Dr. [**Last Name (STitle) **] on [**5-6**]-call [**Telephone/Fax (1) 24689**] to
make the appointment
|
[
"585.9",
"600.00",
"557.0",
"V45.82",
"410.71",
"274.9",
"428.0",
"551.20",
"426.10",
"998.11",
"997.4",
"401.9",
"560.1",
"608.86",
"568.0",
"584.9",
"250.00",
"567.21",
"285.1",
"518.5",
"557.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.91",
"99.15",
"45.13",
"54.4",
"54.59",
"54.91",
"45.91",
"45.62",
"33.24",
"53.59",
"38.93",
"00.17",
"96.72",
"31.1",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7364, 7447
|
2749, 4926
|
384, 758
|
7985, 7994
|
1730, 1730
|
8308, 8679
|
1454, 1538
|
5213, 7341
|
7468, 7964
|
4952, 5190
|
8018, 8285
|
1553, 1711
|
330, 346
|
786, 987
|
1747, 2726
|
1009, 1283
|
1299, 1438
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,941
| 170,429
|
39562
|
Discharge summary
|
report
|
Admission Date: [**2184-9-29**] Discharge Date: [**2184-10-1**]
Date of Birth: [**2106-4-10**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Nsaids /
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Common bile duct transection, admission for IR-guided
cholangiogram
Major Surgical or Invasive Procedure:
[**2184-9-30**] cholangiogram by interventional radiology
History of Present Illness:
78F s/p lap cholecystectomy [**2184-6-4**] for gangrenous
cholecystitis c/b CBD transection. Drains were placed and she
subsequently underwent Roux en Y hepaticojejunostomy [**2184-7-9**]
c/b respiratory failure with mechanical ventilator dependence
requiring open tracheostomy with J tube and G tube placement
[**2184-8-2**]. She was discharged to rehabilitation facility on
[**2184-9-7**] and returns now for elective cholangiogram.
Past Medical History:
HTN
- DMII
- GERD
- multiple sclerosis since age 29
- rheumatic heart disease w/ aortic stenosis (moderate aortic
stenosis & diastolic dysfunction noted on echo [**2183-11-3**]) with an
aortic valve area of 0.8cm2
- arthritis of the cervical and lumbar spine
Social History:
Retired homemaker/housewife, lives at home with husband, no
children. Smoked briefly when she was in her 20s. Denies alcohol
or recreation/illicit drug use.
Family History:
Strong family history of DM, CAD and HTN
Physical Exam:
Admission exam
VS T 98.5 HR 69 BP 131/41 RR 16 SAT 100% CMV 30% 400/16 5
Gen: A and O x 3, NAD
Card: RRR II/VI SEM LUSB
Pulm: scattered rhonchi B. No rales or wheeze. R chest pigtail
catheter capped.
Abd: Soft healing open right subcostal incision. G tube, Jtube,
Transhepatic catheter, roux tube
Ext: no edema. warm. palpable distal pulses
GU: foley
Pertinent Results:
[**2184-9-30**] 01:00AM BLOOD WBC-8.9 RBC-3.51* Hgb-10.8* Hct-32.2*
MCV-92 MCH-30.7 MCHC-33.5 RDW-18.0* Plt Ct-187
[**2184-9-30**] 01:00AM BLOOD Neuts-83.5* Lymphs-9.3* Monos-3.9 Eos-2.8
Baso-0.5
[**2184-9-30**] 01:00AM BLOOD PT-13.5* PTT-25.8 INR(PT)-1.2*
[**2184-9-30**] 01:00AM BLOOD Plt Ct-187
[**2184-9-30**] 01:00AM BLOOD Glucose-125* UreaN-89* Creat-1.4* Na-148*
K-3.6 Cl-111* HCO3-23 AnGap-18
[**2184-9-30**] 01:00AM BLOOD ALT-287* AST-127* AlkPhos-937*
TotBili-0.7
[**2184-10-1**] 02:10AM BLOOD ALT-241* AST-87* AlkPhos-931* Amylase-44
TotBili-0.7
[**2184-10-1**] 02:10AM BLOOD Glucose-176* UreaN-88* Creat-1.7* Na-145
K-3.6 Cl-109* HCO3-26 AnGap-14
Brief Hospital Course:
Patient was admitted from rehab for elective cholangiogram. She
was maintained on her ventilation via tracheostomy. On [**2184-9-30**]
she underwent a cholangiogram via her T-tube by interventional
radiology. It demonstrated flow into the R and L intrahepatic
ducts and flow into the anastamosis without evidence of leak.
There was a filling defect of the R and L ducts questionable for
inspisated bile that resolved. The biliary drain was replaced
with a 6 French catheter and capped. The Roux drain was removed
after the procedure. Patient had 2 episodes of hypotension to
SBP 70s that responded both times to 250 mL boluses. Pressure
remained stable at 91/43 with a heartrate of 77. PEEP was
increased to 10. [**10-1**] AM CXR showed increase in size of
bilateral moderate pleural effusions. Of note, patient has had
chronic bilateral pleural effusions, was not noted to be in
respiratory distress, and was saturating 98%. Patient was
discharged back to [**Hospital1 700**] on ventilator as
on admission.
Medications on Admission:
Miconazole Nitrate 2 % Powder Topical TID, Lisinopril 20 daily,
Omeprazole 20 mg Delayed Release [**Hospital1 **], Heparin 5,000 TID,
Morphine 5 IV Q4H prn pain, Ondansetron HCl 4 prn nausea,
Humulin 70/30 30 units sc bid, RISS qid, Bisacodyl 10 daily
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day).
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for skin irritation.
3. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Humulin 70/30 100 unit/mL (70-30) Suspension Sig: Thirty (30)
units Subcutaneous twice a day.
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection three times a day.
10. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for constipation.
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO Q8H
(every 8 hours).
13. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-22**]
Drops Ophthalmic PRN (as needed) as needed for dry eye.
14. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for sob,
wheeze.
16. torsemide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
17. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**]
Discharge Diagnosis:
common bile duct transection s/p cholangiogram
Discharge Condition:
Mental Status: intubated via tracheostomy
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you have any of
the warning signs listed below:fever greater than 101,redness
that is spreading,pain not adequately relieved with
medication,drainage from wound,opening of
incision,tachypnoea,wheezing,blood in stool,black stool.
Wound care:Change abdominal wound dressings with wet to dry
dressing twice a day.
Blood sugar:Finger sticks QID
Ventillation settings:The patient is ventillator dependant.Keep
the patient on CPAP during day and CMV during night.
CPAP settings:Mechanical Ventilation: CPAP w/ & w/o PS
Consult Respiratory Therapy
Pressure support level: 18 cm/h2o PEEP: 10 cm/h2o FIO2: 40 %
CMV settings: AC 30% 400x16+10 @ 2000h
Followup Instructions:
Follow up appointment in1 weeks time would be set up by [**First Name4 (NamePattern1) 698**]
[**Last Name (NamePattern1) 699**] (Ph:[**Numeric Identifier 87345**],coordinator for Dr [**Last Name (STitle) **]
She will set up a follow-up cholangiogram if necessary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
|
[
"E878.6",
"530.81",
"V44.1",
"458.9",
"997.4",
"340",
"V44.0",
"511.9",
"401.9",
"395.0",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"97.55",
"96.6",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5457, 5503
|
2541, 3550
|
429, 489
|
5594, 5594
|
1858, 2518
|
6476, 6870
|
1429, 1471
|
3852, 5434
|
5524, 5573
|
3576, 3829
|
5736, 6039
|
1486, 1839
|
322, 391
|
6050, 6453
|
517, 954
|
5609, 5712
|
977, 1238
|
1254, 1413
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,319
| 160,866
|
7621
|
Discharge summary
|
report
|
Admission Date: [**2178-6-18**] Discharge Date: [**2178-6-22**]
Date of Birth: [**2134-12-26**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Fevers, chills, abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placement
History of Present Illness:
43 yo F, neurologist at [**Hospital1 18**] with PMH of systemic lupus
erythematosus with leukopenia, positive anticardiolipin
antibodies, recurrent UTIs, who presents with fever, rigors, and
abdominal pain.
.
Patient reports that two nights prior to admission, she
developed a diffuse left lower abdominal pain at dinner time.
She initially thought it was due to constipation. The pain did
not radiate anywhere. However, she then developed subjective
fever, shaking chills, nightsweats, dizziness, fatigue, and
nausea. The pain improved somewhat by the following morning and
she went to work, only to realize that she was feeling more ill
and thus presented to the ED. Patient denied dysuria, hematuria,
blood in the stool. No cough, headache, vomiting, or diarrhea.
Of note, she had similar abdominal pain two weeks ago which
spontaneously resolved.
.
In the ED, initial vs were: T:103.5 HR:116 BP:137/88 RR:20
O2at:98% RA. Labs were notable for a marked leukocytosis to 7.2
(baseline wbc 1.5-2 from SLE) with 51% bands, mild hyponatremia
of 132, lactate of 2.9, and anemia with Hct of 34.8 compared to
recent baseline of ~37. Urinanalysis notable for large leuks,
125 wbc, and few bacteria. CT abdomen/pelvis showed left
proximal ureteric stone with mild hydronephrosis on ultrasound.
Patient was given Levofloxacin 750 mg x1, zosyn 4.5 g x1,
acetaminophen 1000 mg x2. Received a total of 3 liters of IVF.
Urology was consulted and recommended percutaneous nephrostomy
tube versus ureteral stent, and patient chose the former.
Interventional radiology was consulted and patient taken to OR
for placement of nephrostomy tube. Prior to leaving the ED, Tm
was 103.5 with BP 138/80.
.
Patient arrived at the ICU shortly after palcement of the
percutaneous nephrostomy tube. She was alert and oriented,
expressing [**4-26**] pain, tachycardic to the 120s, hypertensive to
the 160s, and in some mild discomfort.
Past Medical History:
- Systemic lupus erythematosus: leukopenia main symptom
- Positive anticardiolipin antibodies with postpartum DVT (off
coumadin for years)
- Mastitis
- Recurrent UTIs (Proteus: pan-sensitive, E. Coli: sensitive to
Zosyn)
- Mild depression
Social History:
Neurologist at [**Hospital1 18**]. Married with two kids and lives with
family.
- alcohol: none
- tobacco: none
- illicits: none
Family History:
The patient's grandfather had a diagnosis of rheumatoid
arthritis. There is a paternal aunt with a history of mixed
connective tissue disease.
Physical Exam:
Vitals: T: 100.6 BP:167/103 P:112 R:26 O2:98% RA
General: Alert, oriented, notably uncomfortable
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, no LAD
Lungs: Bibasilar crackles, no wheeze
CV: Tachycardic and regular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +bs, soft, tender on palpation, non-distended, slight
guarding
GU: left percutaneous nephrostomy tube with bag attached,
draining clear serosanguinous fluid
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2- 12 grossly intact. Alert and oriented.
Physical exam on Day of Discharge
VS T99.8F, BP 157/106, HR 101
General: Alert, oriented, sweaty, sitting up in chair working on
computer
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, no LAD
Lungs: Moving air appropriately, bibasilar crackles
CV: Tachycardic and regular, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +bs, soft, minimal tenderness to palpation,
non-distended
GU: left percutaneous nephrostomy tube with bag attached,
draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
1. Labs on admission:
[**2178-6-18**] 03:23PM BLOOD WBC-7.2# RBC-4.03* Hgb-11.9* Hct-34.8*
MCV-86 MCH-29.5 MCHC-34.2 RDW-12.5 Plt Ct-169
[**2178-6-18**] 03:23PM BLOOD Neuts-71* Bands-6* Lymphs-12* Monos-6
Eos-0 Baso-0 Atyps-5* Metas-0 Myelos-0
[**2178-6-18**] 03:23PM BLOOD PT-13.9* PTT-27.9 INR(PT)-1.2*
[**2178-6-18**] 03:23PM BLOOD Glucose-113* UreaN-14 Creat-1.1 Na-132*
K-3.5 Cl-96 HCO3-25 AnGap-15
[**2178-6-18**] 03:23PM BLOOD ALT-29 AST-30 AlkPhos-60 TotBili-0.5
[**2178-6-18**] 03:23PM BLOOD Lipase-16
[**2178-6-18**] 03:23PM BLOOD Albumin-4.2 Calcium-8.9 Phos-3.2 Mg-1.7
[**2178-6-19**] 09:41AM BLOOD PTH-125*
.
2. Labs on discharge:
[**2178-6-20**] 01:16AM BLOOD Fibrino-911*#
[**2178-6-20**] 01:16AM BLOOD Ret Aut-1.4
[**2178-6-20**] 01:16AM BLOOD Hapto-330*
[**2178-6-19**] 09:41AM BLOOD PTH-125*
.
3. Imaging/diagnostics:
- CXR ([**2178-6-18**]): No acute intrathoracic process.
.
- Renal ultrasound ([**2178-6-18**]): Mild left hydronephrosis, source
not identified on this study.
.
- CT abdomen/pelvis ([**2178-6-18**]): 7 x 4 mm proximal to mid left
ureteral stone with mild to moderate left hydronephrosis and
left perinephric stranding. 2-3 mm stone in the inferior pole of
the left kidney.
.
- Interventional radiology ([**2178-6-18**]): 1. Mild-moderate-left-sided
hydronephrosis. 2. Only a small amount of contrast was injected
confirming location, and to minimize distension given the
patient's symptoms. However, no obvious contrast flow was seen
beyond the proximal ureter, corresponding to the site of
ureteral calculus obstruction seen on the CT scan. 3. Successful
placement of an 8 French locking pigtail nephrostomy catheter
within the left renal pelvis.
IMPRESSION: Successful placement of an 8 French locking
nephrostomy catheter within the left renal pelvis. The catheter
was attached to external bag drainage.
MICROBIOLOGY
[**2178-6-18**]
- URINE CULTURE (Final [**2178-6-20**]):
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
- Blood Culture, Routine (Final [**2178-6-21**]):
PROTEUS MIRABILIS. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2178-6-19**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 27795**] (4I) @
8:06AM [**2178-6-19**].
Aerobic Bottle Gram Stain (Final [**2178-6-19**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by PEI [**Doctor Last Name **] ([**Numeric Identifier 27796**]) [**2178-6-19**]
@1600.
Brief Hospital Course:
43 yo F with systemic lupus erythematosus with leukopenia,
recurrent UTIs, presents with high fevers and abdominal pain,
found to have infected ureteral calculus, now s/p percutaneous
nephrostomy tube placement, hemodynamically stable.
# Pyelonephritis/sepsis: On admission, patient had high fevers,
chills, leukocytosis with bandemia. CT abdomen showed left
proximal ureteric stone with mild hydronephrosis. Urology was
consulted and IR placed a percutaneous nephrostomy tube. Blood
cultures grew out pan-sensitive Proteus and urine culture grew
pan-sensitive Proteus. Patient initially treated with
Pipercillin-tazobactam and then transitioned to ciprofloxacin
after sensisitivities came out. She remained hemodynamically
stable throughout. Urology plans on stone removal 1-2 weeks
after resolution of fevers. She will continue with
ciprofloxacin in the outpatient setting for a total of 14 days.
# Anemia: Hct 34.8 on admission compared to recent baseline of
39.5. No obvious hematuria and signs or symptoms to suggest
hematoma around the nephrostomy site. This can be followed in
the outpatient setting.
# Thrombocytopenia: Platelet count dropped from 169 k -> 59 k
during the first two days of admission. Unlikely to be HIT but
heparin stopped nevertheless and patient placed on fondaparinux
given positive anticardiolipin antiboties. DIC labs were
negative. Platelet count recovered prior to discharge.
# Systemic lupus erythematosus: Diagnosed in [**2171**] when she
presented with repeated bounts of leukopenia (baseline WBC 1.5 -
2) during pregnancy as well as spontaneous DVTs. Followed
closely by Dr. [**First Name5 (NamePattern1) 9619**] [**Last Name (NamePattern1) 9620**] in Rhematology at [**Hospital1 18**].
Continued on hydroxxhloroquine 400 mg po qd while inpatient.
# Depression: Stable. Continue home medication Citalopram 10 mg
po qd.
Medications on Admission:
- Citalopram 10 mg po qd
- Hydroxychloroquine 400 mg po qd
- Imipramine 25 mg po qd
- Vitamin D2 1000 units capsule qd
- Kenalog in orabase 0.1 % Paste - apply thin layer to affected
areas three times a day
Discharge Medications:
1. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: to
reduce risk of constipation while also using narcotics.
Disp:*60 Capsule(s)* Refills:*2*
5. citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Pyelonephritis
Nephrolithiasis (infected stone)
Anemia
Thrombocytopenia
Hyponatremia
SECONDARY DIAGNOSES:
Systemic lupus erythematosus
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. [**Known lastname 6817**], you were admitted to the [**Hospital3 **] Medical
Center because you had fevers, chills, and abdominal pain. We
found that you had a kidney stone which was infected. We placed
a nephrostomy tube to decompress the kidney. You got antibiotics
to treat the infection in your blood and urine.
Please also see the additional NEPHROSTOMY TUBE CARE
INSTRUCTIONS provided by nursing AND the instructions provided
by interventional radiology for you and VNA.
DISCHARGE INSTRUCTIONS
--No vigorous physical activity for 2 weeks AND while tube is in
place
-Expect to see occasional blood in your urine and to experience
some minimal urgency and frequency over the next month.
-The kidney stone/fragments may still be in the process of
passing.
-You may experience some pain associated with spasm of your
ureter. This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Tylenol should be your first line pain medication, a narcotic
pain medication has beenprescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Make sure you drink plenty of fluids to help keep yourself
hydrated and facilitate passage of stone fragments.
-You may shower but do NOT bathe or immerse in water.
-Do not drive or drink alcohol while taking narcotics or operate
dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related tonarcotic pain medication. Discontinue
if loose stool or diarrhea develops. Colace is a stool
softener, NOT a laxative
-Resume your pre-admission medications, unless otherwise noted.
-DO NOT use ASPIRIN or NSAIDs unless cleared by Dr. [**Last Name (STitle) 770**]
-Call your urologist??????s office for follow-up AND if you have any
questions.
-You may have been given a course of antibiotics--please
complete the course as instructed (two week course of
Ciprofloxacin)
Followup Instructions:
Please make an appointment and follow-up with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 770**],MD, who Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] recommended in his absence. Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] may be reached via [**First Name8 (NamePattern2) 2147**] [**Last Name (NamePattern1) **], administrative
assistant, at [**Telephone/Fax (1) 164**]. He will gladly speak with you by
telephone and has informed Ms. [**Name13 (STitle) **] of such.
You must make arrangements to have your stone treated and tube
managed. This should arranged within the next 1-2 weeks time.
Dr. [**Last Name (STitle) **] [**First Name (STitle) **] be reached at [**Telephone/Fax (1) 921**].
You also have the following appointment listed as upcoming:
Department: RHEUMATOLOGY
When: THURSDAY [**2178-9-3**] at 9:30 AM
With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2178-6-22**]
|
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"591",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.03"
] |
icd9pcs
|
[
[
[]
]
] |
10937, 10995
|
8097, 9961
|
332, 373
|
11205, 11205
|
4034, 4042
|
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2737, 2882
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4056, 4659
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11220, 11332
|
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|
2590, 2721
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,787
| 165,954
|
9269
|
Discharge summary
|
report
|
Admission Date: [**2124-3-31**] Discharge Date: [**2124-4-6**]
Date of Birth: [**2044-4-18**] Sex: M
Service: MEDICINE
Allergies:
Calcium / Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
FEVER
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79 year old male with a history of hypertension, type II DM,
systolic heart failure (with EF of 45%) and CVA ([**2101**],[**2121**]) with
residual right hemiplegia and dysarthria who is presenting with
fever from his nursing home. He developed a fever to 104. He
was brought to the ED for this reason. In the ED, he was
tachycardic to the 140s, however this resolved after fluid
resuscitation. A Foley was placed and frank pus was noted. He
was also noted to be in acute renal failure with a creatinine of
2.0 compared to a baseline of 0.7. Chest x-ray was
unremarkable. Blood pressures were initially in the 90s
systolic but improved with fluid administration. He was started
on broad spectrum antibiotics (vancomycin, meropenem and flagyl)
given the frank pus and history of Clostridium difficile on
prior hospitalizations. His vitals at time of transfer were:
temp 98.3, pulse of 97, respirations of 28, BP of 101/64, and O2
sat of 96% on RA.
He has a history of hypertension, type II DM, systolic heart
failure (with EF of 45%) and CVA ([**2101**],[**2121**]) with residual right
hemiplegia and dysarthria. He had a prior hospitalization in
[**Month (only) 958**] after presenting with somnolence and found to have a left
sided pneumonia - he was started on levaquin and required
transfer to MICU where ; also in [**Month (only) 956**] of this year for a
clogged G-tube and IR replacement and in [**Month (only) 404**] for hypoxic
respiratory failure in setting of H. influenza pneumonia
complicated by an upper GI bleed from G-tube site and
Clostridium difficile infection.
At time of transfer, his vitals were normalized - his
temperature was 98, his heart rate was 90, SBP was 90/70, RR 12,
98% on RA.
Past Medical History:
1. multiple strokes: 1)old remote left frontal stroke in [**2101**]
that per NH notes purportedly left him with R-hemi and
dysarthria
(per son, able to think of words he wants to say and makes
grammatically intact sentences, but is often unintelligible)
2. DM2
3. HTN
4. Systolic heart failure with EF of 45%
Social History:
Lives at rehab. Remote history of alcohol and smoking cigarettes
(quit 1 year ago.)
Family History:
Unable to obtain as patient is nonverbal and not documented in
OMR.
Physical Exam:
On admission:
VS: temp 98, RR 12, O2 sat 98%, BP 90/70, HR 90
Gen: Chinese male, in no apparent distress
Neuro: nonverbal, tracks to movement, grimacing and moans
intermittently, intact reflexes
Cardiac: Nl s1/s2 RRR no murmurs appreciable, no appreciable JVD
Resp: lungs clear bilaterally
Abd: soft, nontender and nondistended with normoactive bowel
sounds
Ext: no edema noted
Discharge
Tmc 98.6 127/57, 85-104, 20 99RA
Gen: Ill appearing male, non-verbal, does not appear acutely
distressed. Patient can track with eyes. Non-verbal despite
[**Last Name (un) **]-interpreter (baseline)
Cardiac: S1S2, RRR, tachycardic, no JVD, no m/r/g
Resp: CTA b/l, no w/r/r, but not cooperative with exam
Abd: soft, ND, NT, +BS
Ext: 1+ pedeal edema. trace + UE edema, 2+ peripheral pulses
Neuro: nonverbal, tracks to movement, grimacing and moans
intermittently, will wave tremulously if engagaged. Can make
occasionally make purposeful movements and. Aphasic.
Pertinent Results:
1) Admission Labs:
[**2124-3-31**] 12:16PM BLOOD WBC-15.6*# RBC-3.83* Hgb-12.4* Hct-39.2*
MCV-102* MCH-32.4* MCHC-31.7 RDW-13.8 Plt Ct-389
[**2124-3-31**] 12:16PM BLOOD Neuts-85.7* Lymphs-10.0* Monos-3.2
Eos-0.8 Baso-0.3
[**2124-3-31**] 01:20PM BLOOD PT-12.3 PTT-28.3 INR(PT)-1.1
[**2124-3-31**] 12:16PM BLOOD Glucose-339* UreaN-75* Creat-2.0*# Na-144
K-4.9 Cl-103 HCO3-27 AnGap-19
[**2124-4-1**] 04:16AM BLOOD Glucose-128* UreaN-51* Creat-1.3* Na-152*
K-3.9 Cl-117* HCO3-29 AnGap-10
[**2124-3-31**] 12:16PM BLOOD Calcium-8.4 Phos-3.5 Mg-2.8*
Micro:
[**2124-3-31**] 12:30PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2124-3-31**] 12:30PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2124-3-31**] 12:30PM URINE RBC-15* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0 TransE-7
[**2124-3-31**] 12:30PM URINE CastHy-37*
[**2124-3-31**] 12:30PM URINE WBC Clm-MANY
Blood cultures NEGATIVE.
URINE CULTURE (Final [**2124-4-4**]):
THIS IS A CORRECTED REPORT [**2124-4-2**], 11:55AM.
Reported to and read back by DR. [**Last Name (STitle) **] [**Numeric Identifier 30972**], [**2124-4-2**],
11:55AM.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
PREVIOUSLY REPORTED AS <10,000 organisms/ml ON [**2124-4-1**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ 8 S
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 128 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2124-3-31**] 9:16 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2124-4-2**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
CXR [**2124-3-31**] IMPRESSION: No acute cardiopulmonary process.
Labs upon discharge:
[**2124-4-6**] 06:15AM BLOOD WBC-8.9 RBC-3.02* Hgb-9.7* Hct-31.1*
MCV-103* MCH-32.1* MCHC-31.1 RDW-14.5 Plt Ct-353
[**2124-4-5**] 05:55AM BLOOD WBC-9.1 RBC-3.12* Hgb-10.0* Hct-32.4*
MCV-104* MCH-31.9 MCHC-30.8* RDW-14.7 Plt Ct-319
[**2124-4-6**] 06:15AM BLOOD Glucose-206* UreaN-17 Creat-0.6 Na-138
K-4.4 Cl-108 HCO3-24 AnGap-10
[**2124-4-1**] 04:16AM BLOOD ALT-11 AST-14 LD(LDH)-130 AlkPhos-67
TotBili-0.3
[**2124-4-6**] 06:15AM BLOOD Calcium-8.0* Phos-2.8 Mg-2.1
Pending results: None
Brief Hospital Course:
79 year old male with a history of hypertension, type II DM,
systolic heart failure (with EF of 45%) and CVA ([**2101**],[**2121**]) with
severe residual right hemiplegia and dysarthria who presented
from his skilled nursing facility with VRE urosepsis.
1. VRE Urosepsis
2. Acute Kidney Injury
3. Hypotension
4. Hypernatremia
5. Decubitus ulcers
Chronic problems:
1. Type 2 diabetes.
2. S/P CVA
# VRE Urosepsis: Mr [**Known lastname **] presented from rehab with high fever to
104, leukocytosis, tachycardia, tachypnea, with an indwelling
foley catheter. His foley catheter was removed and it was
grossly purulent. He was initially started on vancomycin for
the possibility of enterococcus, along with meropenem for gram
negatives (he has a penicillin and cephalosporin allergy). He
continued to have low grade fevers and leukocytosis on the
vanc/meropenem combination. His urine cultures were finalized on
[**2124-3-31**] and were sensitive to ampicillin and linezolid. He has a
reported allergic history to penicillin. However, on review of
his medical records, he has received Unasyn for 3 days in the
past as well as augmentin for 3 days in the past without any
mention of adverse reaction. On the ampicillin, he has remained
afebrile for 48 hours and he is without leukocytosis. Given that
he has a complicated, catheter related urinary tract infection,
we are treating with ampicillin (500mg q6h via Gtube) for a two
week course, to end on [**2124-4-20**].
#Acute Kindey Injury: The patient was admitted with a serum Cr
of 2. This was most likley in the setting of dehydration,
hypovolemia, and urosepsis. He was given 2L IV fluids and his
hypotension as well as his serum creatinine improved to 1.3.
Over the duration of his hospital course as the patient was no
longer hypotensive or intravascularly depleted, his renal
function returned to his baseline of 0.8.
# Hypotension: Given his initial presentation of hypotension.
The patients metoprolol and hctz-triameterene were held. He has
not been hypertensive during this admission, therefore we
remained to hold these medications during inpatient
hospitalization.
#Hypernatremia: When the patient presented to the floor he was
hypernatremia to 150. The patient is strict NPO after his stroke
and has limited access to free water. He was given free water
flushes as well as D5W. His serum sodium stayed at 150 and then
decreased to the low 130's. His tubefeeds were continued with at
75cc/hr without free water flushes which returned him to
normonatremia. We suggest rechecking his CHEM 7 on [**2124-4-8**] and
then every 72 hours. His free water flushes might need to be
increased pending his serum sodium.
#Wound care: Patient has stage two decubitus ulcers. Wound care
recommendations are included within the page one of the
discharge paperwork.
# s/p CVA: - Patient is s/p two CVA's. He has severe residual
deficits from his CVAs. He can track with his eye movements and
is aware of people in the room. He can recognize familiar faces
and occasionally say one word. According to his son, he has not
spoken a complete sentence in a "very long time."
# Type II DM. Glyburide was held and he was maintained on
insulin sliding scale.
Transitional Issues:
1. Continue Ampicillin for enterococcal UTI for 14 days (last
day of antibiotics [**2124-4-20**])
2. Outpatient Lab Work
Please check CHEM 7 and CBC on [**2124-4-8**] and then q72h. Please
notify [**Name8 (MD) **] MD of results. 599.0
3. Please alter the amount of free water patient receives in
flushes if patient becomes hypernatremic.
4. Please follow up wound care recommendations as listed in
paperwork for decubitus ulcers.
5. Please restart metoprolol 50 mg TID and HCTZ-Triamterene
37.5/25 mg daily as blood pressure tolerates
Medications on Admission:
MVA PG daily
Omeprazole 20 mg PG qdaily
Plavix 75 mg PG qdaily
Triamterene-HCTZ 37.5/25 mg PG qdaily
Pravastatin 20 mg PG qdaily
Ferrous sulfate liquid 300 mg PG [**Hospital1 **]
Glyburide 3 mg PG [**Hospital1 **]
Vitamin C 500 mg PG [**Hospital1 **]
Albuterol prn
metprolol 50 mg PG TID
Tamsulosin 0.4 mg PG daily
Levaquin 500 mg PG daily x 10 days (started [**2124-2-10**]) day 4
today
Citalopram 20 mg PG daily
Glucerna 1.0 cal @ 75 cc/hr PG
Humalog sliding scale (received 6-12 units every other day)
Discharge Medications:
1. clopidogrel 75 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
2. pravastatin 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY
(Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr [**Year (4 digits) **]: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. citalopram 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).
5. heparin (porcine) 5,000 unit/mL Solution [**Year (4 digits) **]: One (1)
Injection TID (3 times a day).
6. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. ampicillin 125 mg/5 mL Suspension for Reconstitution [**Last Name (STitle) **]:
Five Hundred (500) mg PO Q6H (every 6 hours) for 14 days: Last
day [**4-8**].
8. omeprazole 2 mg/mL Suspension for Reconstitution [**Month/Day/Year **]: Twenty
(20) mg PO once a day.
9. Outpatient Lab Work
Please check CHEM 7 and CBC on [**2124-4-8**] and then q72h. Please
notify [**Name8 (MD) **] MD of results. 599.0
10. insulin aspart 100 unit/mL Solution [**Name8 (MD) **]: as dir units
Subcutaneous please see sliding scale: per sliding scale .
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare Center - [**Location (un) **]
Discharge Diagnosis:
Active:
1. VRE Urosepsis
2. Urinary tract infection, complicated, cathetered related.
3. Stage 2 decubitus ulcers
4. Acute Kidney Injury
5. Hypernatremia
Chronic:
1. Cerebrovascular accident
2. Type 2 diabetes
3. Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted for a very bad infection in your bladder which
was most likely caused by an indwelling catheter. As a result of
this infection, you became extremely ill and required monitoring
overnight in the ICU. Initially you were on very broad spectrum
antibiotics but once the urine cultures came back we put you on
a more specific antibiotic focused on treating your complicated
urinary tract infection.
We have started you on the following antibiotic.
1. Ampicillin 500mg every six hours through your feeding tube
for 2 weeks.
Your blood pressure was initially low so we held some of the
following blood pressure medications:
1. Holding Triameterene-hctz
2. Holding metoprolol
Since you had acute kidney injury we held your glyburide. This
has now resolved and it is between you and your outpatient
providers if you would like this medication restarted.
1. Holding glyburide.
Followup Instructions:
When you are discharged from rehab please call [**Last Name (LF) **],[**First Name3 (LF) **]
[**Telephone/Fax (1) 10349**] for a follow up appointment.
|
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[
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[
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29,506
| 154,435
|
33231
|
Discharge summary
|
report
|
Admission Date: [**2191-1-26**] Discharge Date: [**2191-2-3**]
Date of Birth: [**2129-6-28**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Heparin Agents
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
severe COPD who was transferred from an OSH for evaluation by IP
and vascular surgery. She has thoracoabdominal aneurysms and
tracheobronchial malacia.
Major Surgical or Invasive Procedure:
1. Retroperitoneal repair of abdominal aortic aneurysm using 16
mm Dacron tube graft.
2. PROCEDURE: Flexible bronchoscopy
History of Present Illness:
HPI: 61F w/ severe COPD who was transferred from an OSH for
evaluation by IP and vascular surgery. She has thoracoabdominal
aneurysms and tracheobronchial malacia.
She was originally admitted to an OSH on [**1-17**] for a COPD
exacerbation, which resolved on BIPAP, steroids, and
antibiotics. During that admission, a CTA was done to rule out
PE, and this showed a 4.2 cm distal thoracic aortic aneurysm
that extends to the celiac and the origin of the celiac is
aneurysmal. The neck
below the renals is only about 1 cm. The AAA is about 5.8 cm,
with a distorted ovoid appearance just above the bifurcation
that is about 7.3 cm. The aneuysm extends to the bifurcation.
There is also a R CIA aneurysm 3.6 cm. There is also a R
adnexal mass.
The pt has had a vague abdominal pain for about a week PTA, but
this is very difficult to interpret in the setting of her
expressive aphasia. The pain is diffuse, radiating to the back.
No nausea ior vomiting, but she is constipated (last BM
today-small). She denies any Hx of claudication, rest pain, or
ischemic ulcers.
Past Medical History:
PMH: severe COPD (FEV1 890ml, 30% predicted on home O2), SAH/CVA
w/ subsequent sz disorder '[**73**], residualr R hemiparesis and
expressive aphasia, bipolar disorder,
.
PSH: ? C-section
Social History:
SH: She is disabled, formerly worked at daycare, quit cigarettes
over 20 yrs ago, denies EtOH or drugs
Family History:
FH: N/C, no aneurysms
Physical Exam:
PE: T 99.0, P 76, BP 108/75, RR 20, O2 95% (4l)
gen- NAD, alert and pleasant
noticable expressive aphasia
neck- no bruits
heart- RRR
lungs- dimished BS throughout
abd- lower midline scar, Inc C/D/I, pos BS
ext- unable to move on the R
pulses- Femoral (2+ b/l), [**Doctor Last Name **] (2+ b/l), DP (1+ L, 2+ R), PT
(triphasic b/
Pertinent Results:
[**2191-2-2**] 06:45AM BLOOD
WBC-7.8 RBC-3.49* Hgb-10.8* Hct-31.9* MCV-91 MCH-30.9 MCHC-33.8
RDW-14.3 Plt Ct-243
[**2191-1-28**] 02:18AM BLOOD
PT-12.0 PTT-23.6 INR(PT)-1.0
[**2191-2-3**] 06:35AM BLOOD
Glucose-98 UreaN-12 Creat-0.7 Na-145 K-4.4 Cl-110* HCO3-23
AnGap-16
[**2191-2-3**] 06:35AM BLOOD
Calcium-8.6 Phos-3.6 Mg-2.2
[**2191-2-2**] 1:32 PM
CHEST (PA & LAT)
Following bronchoscopy, there is no evidence of pneumothorax or
pneumomediastinum. Marked improved aeration in the right lower
lobe is present. However, there is worsening atelectasis within
the left lower lobe accompanied by an enlarging
small-to-moderate left pleural effusion. Small right pleural
effusion is also demonstrated.
IMPRESSION:
1. Marked improvement in right lower lobe atelectasis following
bronchoscopy with no pneumothorax.
2. Worsening left lower lobe atelectasis and increasing left
pleural effusion.
[**2191-1-26**] 3:29 PM
PELVIS, NON-OBSTETRIC; PELVIS U.S., TRANSVAGINAL
INDICATION: 61-year-old female with a history of right adnexal
mass seen on CT. Further characterization requested.
COMPARISONS: Outside hospital CT examination dated [**2190-1-24**].
FINDINGS: Transabdominal and transvaginal scanning is performed,
the latter to more closely assess the endometrium and ovaries.
The patient is post- menopausal. Per the patient the patient had
a remote possible removal of the left ovary. Transabdominal
imaging demonstrates an unremarkable appearing uterus measuring
8.3 x 3.5 x 5.0 cm. The endometrium is mildly heterogeneous and
measures 8 mm in thickness. No fibroid masses are identified.
Within the right adnexa there is a complex, multiseptated cystic
mass with several mural nodules measuring 9.2 x 3.6 x 5.8 cm
which corresponds to the previously seen right adnexal mass on
the recent CT examination. No definite vascular flow is
identified within these septae or nodules. No definable right
ovary is identified. A hyperechoic 4-cm mass just superior to
this area corresponds to a right iliac artery aneurysm seen on
the recent CT evaluation. The left ovary is not visualized.
There is no left adnexal mass.
There is no free fluid or hydronephrosis.
IMPRESSION: Complex right adnexal cystic mass containing mural
nodules. Differential diagnosis favors ovarian cystadenoma but
malignancy cannot be excluded.
[**2191-1-26**] 6:07 PM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
TECHNIQUE: Low-dose MDCT axial images of the chest were
acquired. Following the administration of 100 cc of Optiray
intravenous contrast MDCT axial images were acquired from the
thoracic inlet to the pubic symphysis. Coronal and sagittal
reformatted images were then obtained. Reconstructed, volume
rendered and multiplanar reformatted images were also acquired.
CT OF THE CHEST WITH IV CONTRAST: The heart is normal in size.
The thoracic aorta is normal in caliber and contour with
exception of the most distal aspect (see below). There is no
significant calcification of the coronary arteries. There is no
pericardial effusion. There are no pathologically enlarged
mediastinal, hilar or axillary lymph nodes. Lung windows
demonstrate centrilobular lucencies particularly at the bases
consistent in appearance with emphysema. There are areas of
linear atelectasis present at the right lung base.
CT OF THE ABDOMEN WITH IV CONTRAST: The liver, gallbladder,
adrenal glands, kidneys, pancreas, stomach, and abdominal
portions of the large and small bowel are unremarkable. A small
wedge-shaped hypoattenuating focus along the posterior margin of
the spleen likely represents perfusion abnormality versus a
small focus of infarction (3:70). The spleen is unremarkable in
appearance otherwise. There is no free fluid or free air within
the abdomen. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are identified.
At the level of the diaphragmatic hiatus there is a right-sided
crescentic vertically oriented mural thrombus just superior to
the celiac artery takeoff. The aorta at this level measures 3.8
x 3.8 cm (3:65). The aorta is normal in caliber at the level of
the superior mesenteric artery takeoff. The celiac artery,
superior mesenteric artery, left renal artery and right renal
artery originate from the abdominal aorta without evidence of
narrowing or atherosclerotic disease. The normal anatomic
configuration is maintained of these vessels. There is a small
left accessory left renal artery. There is a second area of
aneurysmal dilatation below the renal arteries measuring 5.6 x
5.2 cm (3:83). Linear areas of hyperdensity along the anterior
margin of this mural thrombus likely represents [**Last Name (un) 74186**] of
calcification when examined on the coronal and sagittal
reformatted images. A third area of aneurysmal dilatation is
noted just inferior and proximal to the iliac bifurcation. This
aneurysmal dilatation contains a protuberant portion that
extends anteriorly close to the anterior abdominal wall and
measures 7.7 cm in maximal dimension. Once again, a few linear
foci of hyperdensity within the mural thrombus are probably
consistent in appearance with calcification. A patent inferior
mesenteric artery is not definitely visualized. There is
extensive mural thrombus involving the right common iliac artery
with aneurysmal dilatation measuring a maximal dimension 3.6 cm
which extends to the iliac bifuraction. Dilation of the right
superficial femoral artery to 1.2 cm is also noted.
CT OF THE PELVIS WITH IV CONTRAST: The bladder, rectum, sigmoid
colon, uterus and intrapelvic loops of small bowel are
unremarkable. A complex right adnexal mass was better evaluated
on the concurrent pelvic ultrasound examination. Please refer to
that exam for further details. There is no left adnexal mass.
There are no pathologically enlarged inguinal or retroperitoneal
lymph nodes. There is no free fluid within the pelvis.
OSSEOUS STRUCTURES: There are no suspicious lytic or blastic
lesions.
IMPRESSION:
1. Large predominantly infrarenal abdominal aortic aneurysm with
a focal area of dilatation measuring 7.5 cm in maximal
dimension. The maximal height of the mural thrombus of this
aneurysm is approximately 13 cm. A short segment of aneurysmal
dilatation measuring 3.8 cm is noted at the level of the
diaphragmatic hiatus, encompassing the distal thoracic aorta.
Note is again made of a large right common iliac aneurysm with
associated mural thrombus. The main branching abdominal vessels
are patent with take-offs separate from the abdominal aortic
aneurysm.
2. Probable centrilobular emphysema.
3. Right adnexal complex mass better evaluated on the concurrent
pelvic ultrasound examination.
Brief Hospital Course:
HPI: 61F w/ severe COPD who was transferred from an OSH for
evaluation by IP and vascular surgery. She has thoracoabdominal
aneurysms and tracheobronchial malacia.
GYN did se the patient for 9 cm right complex adnexal mass
visualized on CT Abd/Pelvic and Pelvic U/S. They were unable to
do a full cansult, because the pt was rushed to the OR for
emergent surgery on her AAA. This need to be worked up as an
outpt.
[**1-26**] - pt seen by vascular surgery - Pt seen and examined. 7cm
aneurysm of infrarenal aorta, 3.7cm above celiac, 3.5cm R CIA,
aorta tapers to normal at SMA / Renals. Aneurysm is tender.
Urgent repair needed. Plan to repair only infrarenal aorta w
tube graft to minimize duration / extent of surgery in hope of
avoidiing pulmonary complications. Iliac aneurysm may be dealt
with in future via endograft under local or regional anesthesia.
thoracic aneurysm unlikely to rupture in near future if she
tolerates cross clamping at renals. Pt understands risks and
wishes to procede w repair.
[**1-27**] - pt began to have increased abdominal pain consistent with
a rupturing AAA.
Vascular surgery transported the pt to the OR for emergent
repair.
She agreed to have an elective surgery. Pre-operatively, he was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preperations were made.
Pt did require prophylactic AB for COPD exacerbation
She was prepped, and brought down to the operating room for
surgery. Intra-operatively, she was closely monitored and
remained hemodynamically stable. She tolerated the procedure
well without any difficulty or complication.
Post-operatively, she was extubated and transferred to the [**Month/Year (2) 42137**]
for further stabilization and monitoring.
IN the [**Name (NI) 42137**] pt was weaned from pressure and vent support. When
she was stable
She was then transferred to the VICU for further recovery. While
in the VICU she recieved monitered care. When stable she was
delined. Her diet was advanced. A PT consult was obtained. When
she was stabalized from the acute setting of post operative
care, she was transfered to floor status.
Pt did have some respiratory issues. She has a history of severe
COPD with tracheal malacia. She required lasix to help
respiratory staus. She did become alkalotic with the lasix. Her
diuretic was changed to diamox. She also could not clear her
secretions.Muculitics were used. Interventional Pulmonary
consulst was obtained. They did perform a bedside bronch.
Pt also required steroids for her COPD. She is currently on a
taper.
Pt with history of seizure disorder. PCP was [**Name (NI) 653**] wanted
Dilantin level to be [**5-13**]. Pt did require bolus of dialntin. ON
DC level is 5.6
On the floor, she remained hemodynamically stable with his pain
controlled. She progressed with physical therapy to improve her
strength and mobility. She continues to make steady progress
without any incidents. She was discharged to a rehabilitation
facility in stable condition.
Medications on Admission:
[**Last Name (un) 1724**]: Dilantin 100mg PO BID, Singulair 10mg PO daily, Advair 500
INH [**Hospital1 **], Atrovent 2 puffs QID, proventil 90 mcg 2 puffs [**Hospital1 **] anf
q 4 prn, nebulizer prn, Albuterol INH PRN, actonel 35 mg 1
weekly, calcium / vit 600/200 [**Hospital1 **], tylenol prn
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4-6H () as needed.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q3H (every 3 hours) as needed.
12. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day).
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
16. Hydrocortisone 10 mg Tablet Sig: Five (5) Tablet PO twice a
day for 6 days: then switch to 25 mg PO BID x 6 days
.
then 25 mg po QD x 6 days
.
then prednisone taper as scheduled untill off steroids
.
[**Month (only) **] HAVE TO ADJUST ACCORDING TO BP
.
17. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days: START AFTER HYDROCORTISONE TAPER
.
then taper as follows:
10 mg po qd x 6 days
then 5 Mg qd x 6 days
then 1 mg po x 6 days
.
then DC
[**Month (only) **] HAVE TO ADJUST ACCORDING TO BP .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Contained rupture abdominal aortic aneurysm.
Severe COPD and tracheobronchial malacia
Sz disorder '[**73**],
Bipolar disorder
Discharge Condition:
good
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-12**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-6**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Call Dr [**Last Name (STitle) 23782**] office and schedule an appointment for 2
weeks. His office can be reached at ([**Telephone/Fax (1) 9393**].
[**Last Name (LF) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 74780**], You should call your PCP. [**Name10 (NameIs) **]
have some tests which showed a Complex right adnexal cystic mass
containing mural nodules. Differential diagnosis favors ovarian
cystadenoma but malignancy cannot be excluded. Your PCP can make
an appointment to see a GYN specialist.
Completed by:[**2191-2-3**]
|
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"296.80",
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"438.20",
"519.19",
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"276.3",
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icd9cm
|
[
[
[]
]
] |
[
"33.22",
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
14319, 14366
|
9091, 12102
|
440, 566
|
14537, 14544
|
2403, 9068
|
17283, 17825
|
2015, 2039
|
12447, 14296
|
14387, 14516
|
12128, 12424
|
14568, 16830
|
16856, 17260
|
2054, 2384
|
248, 402
|
594, 1667
|
1689, 1878
|
1894, 1999
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,398
| 105,262
|
40876
|
Discharge summary
|
report
|
Admission Date: [**2192-4-9**] Discharge Date: [**2192-4-18**]
Date of Birth: [**2141-1-4**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2758**]
Chief Complaint:
transfer from outside hospital for treatment of PE
Major Surgical or Invasive Procedure:
IVC filter placement on [**2192-4-9**]
History of Present Illness:
51 year-old Russian speaking F transferred from [**Hospital1 **] Needman with
concerns of GI bleed and new PE. She was admitted on [**2192-4-7**] to
OSH after 1 week of daily rectal bleeding with each bowel
movement. She also started noticing clots of blood from the
rectum as well. She gradually started experiencing dizziness but
denies syncope. Symptoms also associated with left sided chest
pressure, palpitations, and mild pleuritic chest pressure not
worse with bleeding. Of note, patient had a left ankle in cast
from recent ankle fracture in late [**Month (only) 956**]. She has been less
mobile as a result. Also, she flew here from [**Location (un) 3156**] in early
[**Month (only) 956**]. She denies a previous history of bleeding or clotting.
AT OSH, she was found to have a hematocrit of 14.8 and received
7 units PRBCs for GIB. An EGD showed mild gastritis without
active bleeding and a colonoscopy was normal. A CT chest showed
PE. CT abd/pelvis was normal except for large fibroid. An echo
was also within normal limits.
Upon arrival to ICU, the patient was feeling fatigued and
endorsed left sided chest pressure. She described the chest
pressure as a burning, [**5-8**] pain, that was worse with breathing.
Denied dizziness, fever/chills, abd pain, vaginal bleeding,
rectal bleeding but endorsed some mild nausea.
Past Medical History:
-uterine fibroids
-iron defiency anemia
Social History:
From [**Location (un) 3156**], recently returned to US in [**2192-1-31**]. Denies
smoking, alcohol, or drug use. Previously worked as an
accountant.
Family History:
mother died of breast ca at 42, father died of liver cancer NOS
Physical Exam:
Admission Physical Exam:
Vitals: T:98.6 BP:110/73 P:97 R:20 18 O2:98% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dryMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, 1/6 SEM best heard
at llsb, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
REctal: per surgery note, internal and external hemorrhoids
Ext: left ankle in cast below knee, well perfused, 2+ pulses, no
clubbing, cyanosis or edema
DISCHARGE
Pertinent Results:
ADMISSION LABORATORY STUDIES:
[**2192-4-9**] 04:47PM BLOOD WBC-10.2 RBC-4.49 Hgb-13.5 Hct-38.6
MCV-86 MCH-30.1 MCHC-35.0 RDW-13.7 Plt Ct-179
[**2192-4-9**] 04:47PM BLOOD PT-12.3 PTT-25.7 INR(PT)-1.0
[**2192-4-9**] 04:47PM BLOOD Glucose-71 UreaN-8 Creat-0.7 Na-137 K-3.5
Cl-107 HCO3-18* AnGap-16
[**2192-4-9**] 04:47PM BLOOD LD(LDH)-199 CK(CPK)-81 TotBili-2.2*
[**2192-4-9**] 04:47PM BLOOD Calcium-7.6* Phos-2.8 Mg-1.9
DISCHARGE LABORATORY STUDIES:
[**2192-4-18**] 05:45AM BLOOD WBC-4.5 RBC-4.19* Hgb-12.5 Hct-37.4
MCV-89 MCH-29.8 MCHC-33.4 RDW-14.1 Plt Ct-221
[**2192-4-14**] 06:15AM BLOOD Glucose-90 UreaN-16 Creat-0.9 Na-137
K-3.9 Cl-104 HCO3-25 AnGap-12
[**2192-4-18**] 05:45AM BLOOD PT-13.0 PTT-59.0* INR(PT)-1.1
CTA from [**Hospital1 **] [**Location (un) 620**]
IMPRESSION:
1. RIGHT-SIDED PULMONARY EMBOLUS AT JUNCTION OF RIGHT MIDDLE AND
LOWER LOBE PULMONARY ARTERIES AND EXTENDING INTO LOWER AND
MIDDLE LOBE BRANCHES,
2. SMALL AREA OF DEPENDENT DENSITY IN THE DESCENDING COLON OF
UNCERTAIN SIGNIFICANCE ON THIS SINGLE PHASE EXAM. REPEAT
DEDICATED GI-BLEEDING PROTOCOL. INCLUDING PRE-CONTRAST AND
DELAYED POST CONTRASTPHASES THROUGH THE ABDOMEN COULD BE
PERFORMED IF CLINICALLY INDICATED.
3. BILATERAL SMALL EFFUSIONS.
4. SMALL AREA OF LOBULATED SOFT TISSUE IN THE LEFT BREAST [**Month (only) **]
REFLECT AN INTRAMAMMARY LYMPH NODE BUT IS NONSPECIFIC.
CORRELATION WITH CLINICAL HISTORY IS ADVISED.
5. LEFT NINTH RIB ANTERIOR FRACTURE.
6. MULTIPLE ARTERIAL PHASE ENHANCING LESIONS WITHIN THE LIVER.
WHILE NONSPECIFIC, THESE ARE LIKELY TO REFLECT HEMANGIOMAS.
FURTHER ASSESSMENT WITH ULTRASOUND COULD BE OBTAINED.
7. MULTIPLE UTERINE FIBROIDS.
[**2192-4-12**] Ultrsounds of Lower Extremities:
- No evidence for DVT in right or left lower extremity.
Brief Hospital Course:
Ms. [**Known lastname 89278**] presented with profound anemia and an acute pulmonary
embolus after recovering from a recent ankle fracture. On
presented to [**Hospital1 **] [**Location (un) 620**] and to [**Hospital1 18**] it was a bit unclear why
she was so anemic. However, on review of her history and lab
studies she had evidence of chronic blood loss anemia worse over
the few days prior to presentation. Upper, lower, and capsule
endoscopies revealed no source of bleeding other than internal
hemorrhoids. The best estimate at her presentation included
worsening constipation/hemorrhoids and a DVT/PE while recovering
from her recent ankle fracture. Fortunately, she improved with
treatments for each of these conditions and is being discharged
to follow-up with her new PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**4-20**]. Management of
specific medical problems outlined below:
1. Acute pulmonary embolism:
- thought to be provoked from immobility with cast on left leg
and recent plane flight from [**Location (un) 3156**].
- given the bleeding and anticoagulation a retrievable IVC
filter (OptEase IVC filter) was placed on admission. As outlined
below, she will probably do well on anticoagulation but the
filter was left in place while this is being determined. If she
does not have any complications on anticoagulation this should
be removed. This can be arranged by calling [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**] in the
Radiology Care Unit at [**Telephone/Fax (1) 6747**].
- despite profound anemia on presentation she was treated with
many days of anticoagulation while hospitalized and had no drop
in her hematocrit. She was discharged on Lovenox and warfarin
and should have a 3 month warfarin course for a provoked DVT/PE.
She was started on warfarin 5mg on [**4-17**], 5mg on [**4-18**], and will
see Dr. [**Last Name (STitle) **] on [**4-20**] for repeat check. Her last INR was 1.1 on
[**4-18**].
2. Chronic blood loss anemia
- thought to be from a slow bleed internal hemorrhoids
- she was advised to take water, fiber, and stool softeners as
needed to avoid constipation. If the hemorrhoids continue to
bleed she may need referral to a surgeon for consideration of
banding or surgery.
3. Ankle fracture
- cast removed while hospitalized and placed in a walking boot.
She will follow-up with the Orthopedic Surgery Team on [**5-10**].
Contact information: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP. Phone:
[**Telephone/Fax (1) 1228**].
4. Breast lymph node
- at [**Hospital1 **] [**Location (un) 620**] she was noted to have an abnormal left breast
lymph node on her CT angiogram (description under the results
section of this discharge summary). She should have routine
mammogram with mention of the lymph node while ordering as she
may need a breast ultrasound.
TRANSITION ISSUES:
- check hematocrit and INR at 4/22 visit
- arrange for evaluation of breast lymph node at 4/22 visit
Medications on Admission:
Medications prior to admission:
- none
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO as directed.
Disp:*30 Tablet(s)* Refills:*2*
3. warfarin 1 mg Tablet Sig: Thirty (30) Tablet PO as directed.
Disp:*30 Tablet(s)* Refills:*2*
4. Lovenox 60 mg/0.6 mL Syringe Sig: Fifty (50) mg Subcutaneous
twice a day.
Disp:*10 syringes* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Multifactorial anemia, acute on chronic, GI bleeding,
hemorrhoids, gastritis
Acute pulmonary embolism
Iron deficiency
Left ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 89278**],
You were admitted with severe anemia. We think this was from a
slow bleed from your hemorrhoids. As we discussed you should
take water, fiber, and stool softeners as needed to avoid
constipation. If your hemorrhoids continue to bleed or you need
more transfusions you may need to see a surgeon for
consideration of surgery for your hemorrhoids.
While here you were also noted to have a blood clot in your
lungs. We are discharging you on warfarin (Coumadin) and
Lovenox. Please take 5mg of warfarin (Coumadin) daily and have
Dr. [**Last Name (STitle) **] adjust these medicines at your appointment on Friday.
In case you need to come off your blood thinners, you also have
an IVC filter in place to prevent further blood clots from
travelling to your lungs. You will need to have this removed in
the next few weeks. Dr. [**Last Name (STitle) **] can help you get this removed by
calling [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**] in the Radiology Care Unit at
[**Telephone/Fax (1) 6747**].
You will also need to use your boot while walking until seen by
the Orthopedic Surgery Team on [**5-10**] as below.
The only other change to your medications was that we started
you on vitamin D for your bone health.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Appointment: Friday [**4-20**] at 3:20PM
**Please arrive 30 minutes early to finish your registration
process**
Department: ORTHOPEDICS
When: THURSDAY [**2192-5-10**] at 8:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: THURSDAY [**2192-5-10**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**Please call registration to update your information. Their
number is [**Telephone/Fax (1) 10676**] and they are open Monday thru Friday,
7:30AM-6:00PM.**
To have your IVC filter removed, please call Call the Radiology
Care Unit at [**Telephone/Fax (1) 6747**]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**] can you help arrange
this.
|
[
"E943.0",
"218.9",
"V16.3",
"280.0",
"V54.9",
"693.0",
"564.00",
"793.89",
"276.2",
"535.50",
"285.1",
"455.2",
"V16.0",
"415.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7"
] |
icd9pcs
|
[
[
[]
]
] |
8091, 8097
|
4546, 7562
|
353, 393
|
8279, 8279
|
2764, 4523
|
9729, 10985
|
2004, 2071
|
7652, 8068
|
8118, 8258
|
7588, 7588
|
8430, 9706
|
2111, 2745
|
7621, 7629
|
263, 315
|
421, 1757
|
8294, 8406
|
1779, 1821
|
1837, 1988
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,968
| 148,141
|
25792
|
Discharge summary
|
report
|
Admission Date: [**2124-12-12**] Discharge Date: [**2125-1-19**]
Date of Birth: [**2066-12-31**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Readmitted from rehabiliatation facility with hypotension,
diarrhea, and elevated white blood cell count.
Major Surgical or Invasive Procedure:
[**2124-12-18**]: Total abddominal colectomy and ileostomy with Hartmann
procedure
[**2124-12-20**]: Nasoduodenal tube placement
[**2124-12-25**]: Nasoduodenal tube placement
[**2124-12-25**]: PICC line placement
[**2124-12-26**]: Tracheostomy
[**2125-1-3**]: Nasoduodenal tube placement
[**2125-1-12**]: Tunneled hemodialysis Line placement under fluoro
History of Present Illness:
The patient is a 57-year-old male with a history of HCV
cirrhosis who underwent an orthotopic deceased donor liver
[**Month/Day/Year **] in [**2123-12-24**], complicated by hepatic artery
thrombosis requiring retransplantation on [**2124-10-25**]. He
was recently admitted to the [**Year (4 digits) **] service with failure to
thrive. He was started on tube feeds via [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-intestinal tube,
which he tolerated well. He was then discharged to rehab for
further care. However, he returned shortly thereafter with
diarrhea, hypotention, and a rising white blood cell count.
Past Medical History:
-History of UGIB ([**2120**])
-Hepatitis C cirrhosis - s/p OLT [**12-31**] in the setting of
decompensated liver failure [**12-25**] infection. Hepatitis thought to
be from blood transfusions vs tattoos, noticed on random LFTs.
Genotype 1, treated with Peg-IFN and ribavirin several times
with no response. He has three Grade II varices with portal
gastropathy s/p banding. Last EGD in [**5-29**] showed Varices at the
lower third of the esophagus w/ scarring from previous banding,
portal hypertensive gastropathy.
-hx L leg cellulitis, necrotizing fascitis, osteomyelitis and
group A strep sepsis [**11/2123**], requiring skin graft
-Chronic thrombocytopenia
-Hypersplenism
-Cellulitis [**2119**]
-MVA [**2101**], surgery to R leg, multiple fractures to L leg
-Failure to thrive after liver [**Year (4 digits) **]
-Multiple episodes of acute renal failure with unclear baseline
creatinine (was as low as .8 in [**12-31**], range .8-4.5)
Social History:
Denies tobacco use. No alcohol x 18 years. Denies ever using IV
drugs. Lives with wife, has 6 children, 5 grandchildren. Owns
his own towing/auto body repair business.
Family History:
Son died of colon cancer, grand father died of colon cancer. No
history of liver disease
Physical Exam:
T 94 P 106 BP 100/59 R 20 SaO2 100% RA
General: Cachectic, frail appearing older than stated age.
HEENT: mucous membranes dry, an-icteric
Card: RRR
Lungs: CTA bilaterally
Abd: Incision well healed. Roux tube remains in place, capped
under dressing. Soft, non-tender, nondistended.
Extr: warm, well-perfused
Skin: Has stage 2 decubitus on coccyx
Pertinent Results:
On Admission: [**2124-12-12**] 10:48PM LACTATE-2.8*
GLUCOSE-140* UREA N-108* CREAT-4.3* SODIUM-130* POTASSIUM-5.8*
CHLORIDE-102 TOTAL CO2-13* ANION GAP-21*
ALT(SGPT)-14 AST(SGOT)-11 ALK PHOS-122* TOT BILI-0.2
ALBUMIN-2.1* CALCIUM-9.2 PHOSPHATE-5.6*# MAGNESIUM-2.4
WBC-31.4* RBC-3.55* HGB-10.7* HCT-31.1* MCV-88 MCH-30.1
MCHC-34.4 RDW-19.8* PLT COUNT-544*
.
[**2124-12-13**] Liver U/S: patent vasculature, no ductal dilatation
.
[**2124-12-12**] Abdominal CT:
1. Pancolitis is most likely infectious in origin with
appearances highly
suggestive of pseudomembranous colitis.
2. Diffuse anasarca.
.
[**2124-12-13**] CT abdomen: pancolitis
.
Labs on Discharge: [**2125-1-19**]
WBC-4.5 RBC-3.20* Hgb-10.2* Hct-29.1* MCV-91 MCH-31.9 MCHC-35.1*
RDW-18.3* Plt Ct-160
Glucose-132* UreaN-32* Creat-1.9* Na-141 K-3.6 Cl-103 HCO3-31
AnGap-11
ALT-18 AST-22 AlkPhos-221* TotBili-0.3
Calcium-8.5 Phos-2.4* Mg-1.5*
PT-16.0* PTT-47.5* INR(PT)-1.4*
calTIBC-124* Ferritn-Greater than [**2115**] TRF-95*
[**2125-1-16**] PTH-51
[**2125-1-19**] tacroFK-5.2
[**2125-1-18**] calTIBC-124* Ferritn-GREATER than [**2115**] TRF-95*
Brief Hospital Course:
On [**2124-12-12**], Mr. [**Known lastname 64239**] was admitted to the [**Known lastname **] service.
He was put on a host of antibiotics, including PO Vancomycin and
IV Flagyl for coverage of culture-demonstrated C. Difficile
colitis after colonic inflammation was noted on CT scan. On
[**2124-12-13**], he was transferred to the SICU for close monitoring. He
was noted to be hypotensive and had declining urine output,
suggestive of worsening renal function. He was started on
pressors for blood pressure support. He was transfused pRBCs for
a falling hematocrit and given FFP for INR correction.
On [**12-14**], he was started on Nitazoxanide on the recommendation of
the infectious disease service as this drug is currently being
used investigationally for treatment of C.difficile colitis. He
also received one dose of IVIG on this date. On [**12-15**], he had
another CT scan which showed pan colitis and pneumatosis. On
[**12-16**], he became progressively more unstable, requiring increased
fluids, vasopressors, with increasing acidosis. He was then
intubated for mechanical ventilation and correction of the
acidosis. He was started on TPN. Overnight on [**12-17**] to the early
morning of [**12-18**], he was taken emergently to the operating room
for a total abdominal colectomy and ileostomy with [**Doctor Last Name 3379**]
procedure. He then returned to the SICU still intubated.
His renal function started to slowly improve after surgery and
he was weaned off pressors within 48 hours. A nasointestinal
tube was placed and tube feeds were started. On [**12-22**], TPN was
stopped as tube feeds were at goal. Continuous [**Last Name (un) **]-venous
hemodialysis was begun on [**12-21**] because although renal function
was slowly returning, it was inadequate to mobilize the large
amount of fluid he was retaining. He had been tried on a Lasix
drip for 24 hours prior to CVVH but had shown an inadequate
response to Lasix. He continued upon therapy for C. Difficile
colitis.
Over the weekend of [**3-12**], he continued on CVVHD and tube
feeds were advanced to goal. He began having bloody rectal
discharge, and it was thought that the best course of action
would be supportive care and observation. We refrained from
anoscopy/proctoscopy for fear of disrupting what is sure to be a
fragile anastomosis. Because of his continued vent dependence,
it was decided to perform tracheostomy, which was done by Dr.
[**Last Name (STitle) **] and the ICU team on [**12-26**]. He tolerated the procedure
well.
On [**12-28**], he tolerated trach mask ventilation. He initially was
having to go back to CMV as he tired easily, but this improved
over time and he was on Trach mask continuously. A Passy-Muir
valve was evaluated and placed on [**2124-12-29**].
He was continuing on CVVHD per renal recommendations through [**12-30**]
when he was discontinued off renal replacement therapy and
assessed daily. On [**2125-1-1**] he underwent hemodialysis using a
temporary line.
He was transferred to the surgical floor on [**1-7**]. At that time
he was deemed to not need dialysis. He was continuing with tube
feeds, trach, and ostomy care.
He was transferred back to the SICU on [**1-12**] secondary to
respiratory distress. He did not respond to lasix and the
decision was made to place a permanent cuffed HD catheter and
start intermittent hemodialysis on him. He received several
short treatments and is now undergoing hemodialysis three times
weekly. This will continue to be followed upon discharge.
He was able to be transferred back to the surgical floor. He
continues on Heparin drip and Coumadin therapy for DVT with
subtotal thrombosis of right common femoral vein. He will
require hemodialysis for renal failure to be evaluated during
clinic visits. He remains on tube feedings via [**Last Name (un) **]-duodenal
tube. Patient has very poor PO intake which has been an ongoing
issue even prior to this admission. He is s/p colostomy for c
diff colitis and need for ostomy which has been functioning
well. He has a PICC line in place for infusions and blood draws.
He has been evaluated by OT and PT and is found to need
continued therapy, patient malnourished and profoundly weak from
prolonged and eventful hospitalization.
Medications on Admission:
Prograf 1/0.5, Cellcept [**Pager number **]'', Bactrim SS daily, Metoprolol
25'', Ambien 5', Oxycodone 5 prn, CaCO3 500, ZnSO4 220, Valcyte
450 q48hr, fluconazole 200, Protonix 40', Warfarin 2.5,
prednisone 15, lispro sliding scale
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable [**Pager number **]: One (1)
Tablet, Chewable PO DAILY (Daily).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet [**Pager number **]: One (1)
Tablet PO DAILY (Daily).
3. Fluconazole 200 mg Tablet [**Pager number **]: One (1) Tablet PO Q24H (every
24 hours).
4. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution
[**Pager number **]: 2.5 ml PO BID (2 times a day).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: [**4-1**] ml PO Q4H (every 4
hours) as needed.
7. Valganciclovir 450 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO 2X/WEEK
(TU,FR).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: One (1) Inhalation Q6H (every 6 hours) as
needed.
9. Metoprolol Tartrate 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID
(3 times a day).
10. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: per sliding
scale Injection ASDIR (AS DIRECTED).
11. Prednisone 2.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily): Per [**Month/Year (2) **] clinic taper.
12. Epoetin Alfa 10,000 unit/mL Solution [**Month/Year (2) **]: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday): [**Month (only) 116**] give at hemodialysis.
13. Warfarin 2 mg Tablet [**Month (only) **]: Two (2) Tablet PO Once Daily at 4
PM.
14. Tacrolimus 1 mg Capsule [**Month (only) **]: One (1) Capsule PO twice a day.
15. Folic Acid 1 mg Tablet [**Month (only) **]: One (1) Tablet PO DAILY (Daily).
16. Cyanocobalamin 100 mcg Tablet [**Month (only) **]: 0.5 Tablet PO DAILY
(Daily).
17. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month (only) **]: One (1) Cap
PO DAILY (Daily).
18. Lorazepam 2 mg/mL Solution [**Month (only) **]: 0.25 ml Injection [**Hospital1 **] PRN as
needed for anxiety.
19. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Hospital1 **]: Nine Hundred (900) units Intravenous ASDIR (AS
DIRECTED): 900 units hourly.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
C diff colitis now s/p total colectomy with ostomy
Tracheostomy with Passy Muir Valve
Acute on chronic renal failure requiring hemodialysis
s/p second liver [**Hospital1 **] [**2125-10-25**] (due to Hep C and HA
thrombus)
Femoral DVT requiring anticoagulation
Malnutrition: receiving tube feeds via [**Last Name (un) 1372**]-duodenal
(post-pyloric) feeding tube
Discharge Condition:
Stable/Fair
Discharge Instructions:
Please call the [**Last Name (un) **] clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, problems with ostomy, issues with
tube feeding (intolerance defined by profuse diarrhea or nausea)
or other concerning symptoms.
Remains on Heparin drip. Please keep PTT goal between 60-80. He
will need daily labs draws for PT/INR/PTT. Continue Comadin and
checl PT/INR/PTT daily until therapeutic. [**Hospital 1326**] clinic will
manage anticoagulation and immunosuppressives. PLease page
coordinator at [**Telephone/Fax (1) 673**] and page the On call [**Telephone/Fax (1) **]
coordinator with results daily starting [**1-20**] (Saturday)
Followup Instructions:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, Phone [**Telephone/Fax (1) 673**] Date/Time [**2125-1-24**] Time:
please call [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 23170**] for appointment time
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2125-1-30**] 1:00
Daily PT/INR/PTTs call to [**Telephone/Fax (1) 673**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2125-1-19**]
|
[
"V12.51",
"995.92",
"276.7",
"557.0",
"V42.7",
"585.9",
"287.5",
"276.2",
"789.59",
"518.81",
"008.45",
"263.9",
"584.9",
"785.52",
"038.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"39.95",
"99.15",
"96.72",
"38.93",
"46.23",
"38.95",
"38.91",
"45.82",
"31.1",
"99.14",
"33.21",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10886, 10965
|
4207, 8454
|
421, 778
|
11371, 11385
|
3075, 3075
|
12093, 12660
|
2600, 2690
|
8736, 10863
|
10986, 11350
|
8480, 8713
|
11409, 12070
|
2705, 3056
|
276, 383
|
3734, 4184
|
806, 1435
|
3089, 3715
|
1457, 2398
|
2414, 2584
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,751
| 182,511
|
31327
|
Discharge summary
|
report
|
Admission Date: [**2191-1-30**] Discharge Date: [**2191-2-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Tremors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **]yoM h/o alzheimers dementia, presenting with fevers and
shaking. Per report the patient lives in an independent living
facility with a daily aide. He is reported to have been in his
usual state of good physical health, eating, walking, sleeping
normally yesterday. This morning his son noted him to be
"shaking", his entire upper body was shaking to the point that
he could not eat and he needed two people to assist him with
walking.
He was brought to the [**Hospital1 18**] emergency room where he was noted to
be somewhat fatigued and confused though this may be his
baseline. He complained only of nasal congestion.
In the ED his vitals were T101.5, hr92, bp157/69, 15, 98%ra. He
spiked to a maximum temperature of 104.3 with tachycardia to
115. He had an elevate white count to 12.5 and an elevated
lactate to 4.4. He received 2L or NS and his lactate trended
down to 2.1 then 1.6. He received tylenol. A UA was negative.
Urine and blood cultures were sent. A CXR showed a possible "new
R pneumonia". He was given a dose of vanco and zosyn for
nosocomial pneumonia and he was transferred to the ICU for
concern of sepsis.
The patient complains only of a "stuffy nose" leading to
occasional difficulty breathing. His ROS is otherwise negative
in detail. In particular he denies CP/SOB, abdominal pain,
nausea/vomiting, diarrhea or constipation, headache, dizziness,
change in vision, or weakness.
Past Medical History:
-Alzheimer's disease: Per the son's report, the pt's dementia
has slowly progressed over the past couple of years but his
functioning has become noticeably more impaired within the past
6 mos. Six months ago he could balance his checkbook but is no
longer able. He also has been more disoriented over the past
few months in terms of place and time. He has been treated with
Aricept.
-Depression: Per son's report, has had a long history of
depression but only sought treatment after his wife passed away
several years ago. Currently tx with Celexa.
-Urinary frequency: Saw a urologist several years ago in [**Location (un) 73711**]. Unclear whether dx with BPH or other underlying
etiology.
Social History:
Lives at [**Hospital1 100**] Senior Life in an independent facility ([**Street Address(2) 73867**] ) with daily aide from 6am-10pm. Able to walk w/o
walker or caneand eat. Walks without walker or cane. Needs
assistance with other ADLs and IADLS. Retired podiatrist 30
years ago. Quit tobacco 35 years ago. No alcohol use. WWII
veteran. Civial podiatrist in the army. He lived in [**Location (un) 11177**]
until 3 years ago. Widowed x 6 years feom 2nd wife. [**Name (NI) **] brought
him to [**Location (un) **] after he was unable to cope at home in [**Location (un) 73711**] 3 years ago. He has wandered off the property in the past.
He has gotten disoriented in the dining room. Fell last [**Month (only) 216**]
[**2189**]. The social workers at his building have advocated for 24
hour care and they have suggested that he move from the building
but the patient's son does not think that they are credible
sources.
Family History:
Sister with dementia and another sister with lung cancer and
smoking history died in her 80s.
Physical Exam:
on discharge
Vitals: 96.5 145/64 60 18 99%RA
Pain: denies
Access: PIV
Gen: nad, more awake
HEENT: mm dry
CV: RRR, no m
Resp: CTAB, no crackles, no wheezing
Abd; soft, mild distended, nontender, +BS
Ext; no edema
Neuro: A&OX1, more awake today, following commands, not
cooperating with full exam
Skin: no changes
psych: calm
.
Pertinent Results:
wbc 12.5->7.3
hgb 12->10->11, HCT 31->32
Chem panel: bun 21->16, Creat 1.3->1.1
INR 1.2
lactate 4.4->1.6
.
viral screen negative
.
blood cx [**1-30**] X2 NTD
UA, UCx [**1-30**] negaive
.
.
Imaging/results:
CT head [**1-30**]: VENTRICULOMEGALY OUT OF PROPORTION TO THE SULCAL
EMLARGEMENT WHICH [**Month (only) **] REPRESENT NORMAL PRESSURE HYDROCEHALUS.
STABLE ATROPHY AND ISCHEMIA. NO ACUTE INTRACRANIAL PROCESS
.
CXR [**1-31**]; In comparison with the study of [**1-30**], there is little
change for slightly better degree of inspiration. Calcified
pleural plaques from asbestos-related disease persists.
Continued prominence of interstitial markings could reflect
chronic pulmonary disease or some elevated pulmonary venous
pressure. No evidence of acute focal pneumonia.
.
CXR [**2-1**]: Since yesterday, lung volumes are much lower,
increasing bibasilar opacity, could be atelectasis or chronic
interstitial lung disease. Calcified pleural plaques from prior
asbestos exposure are unchanged. Volume overload improved. The
cardiomediastinal silhouette and hilar contours are unchanged
.
KUB [**1-30**]; No evidence of ileus or bowel obstruction.
Brief Hospital Course:
[**Age over 90 **] year old male with mod-severe AD, CKD, BPH, admitted from ILF
with rigors/fevers to 104. Initially with leukocytosis, elevated
lactate, concerning for sepsis. admitted to MICU. Rapid
improvement and transfered to Gen Med shortly after. As for
source, No localized symptoms. UA neg. CXR initially ?PNA, final
read negative. Blood cx negative. No focal neuro symptoms, head
CT negative. Empiric 5days Levo. Likely was viral syndrome.
Recieved seroquel for agitation, caused excess sedation and was
sleeping most of hospital day 2.
More awake by hospital day 3. Decreased appeite/PO intake, added
ensure and started remeron 7.5mg qhs (low dose as also on
celexa)
Given concerns for lack of 24hour supervision at home in setting
of severe dementia and reports of wandering, reccommended [**Hospital1 1501**].
son finally accepted and pt transfered to [**Hospital1 **] [**Hospital1 1501**] on
discharge.
.
.
See progress note below for details by problem:
.
Fevers/Viral syndrome: infectious w/u negative (CXR no PNA, UA
negative, blood Cx NTD, no diarrhea, no abdominal discomfort).
Most likely this is viral syndrome given recent URI symptoms and
very high fever that rapidly resolved. His neurologic exam shows
no photophobia, neck stiffness, or focal neurologic signs. Head
CT shows no intracranial process or sinusitis. s/p vanc/zosyn in
ICU, currently on levaquin for possible PNA. Afbrile now, no
more rigors.
-given his age and degree of illness, got 5day levaquin course
-per nursing, ?cough with PO intake, speech did not feel at risk
for aspiration when awake.
-CIS
.
Decreased PO: per nursing, not taking PO. ?doesnt like
hospital food. Doesnt appear chronically malnourished.
-start ensure supp
-remeron 7.5mg qhs for appetite
-monitor for volume depletion
.
Constipation: KUB full of stool and abdominal distention. not
impacted on exam. Had some BMs with lactulose.
-docusate, senna,
-continue to monitor
.
[**Last Name (un) **] on CKD IV: Creat 1.3 on admission (baseline 1.1). Improved
back to baseline with IVFs, monitor trend closely
-monitor for volume depletion
-renally dose meds, no nephrotoxins
.
Anemia, chronic: normocytic. Appears to be near baseline Hgb
[**10-6**].
-outpt follow up
.
Alzheimers: Severe dementia.
-Hold Memantine (unclear if on this as his [**Name (NI) **] PCP did not have
this listed), continue Donepezil 5mg qd ([**Name8 (MD) **] MD has this dose),
continue Citalopram 20mg qd
-remeron 7.5mg started as above, will help sleep, appeite,
anxiety
-avoid seroquel as caused excess seroquel while here
.
BPH: vesicar nonform, resume on di/c
-consider flomax
.
FEN/proph: HLIV, monitor lytes, encourage gen diet when awake
with aspiration precautions, ensure supp, TEDs, heparin [**Hospital1 **], no
PPI, bowel regimen
.
Dispo: full code per son. Accepted to [**Hospital **] rehab. f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MD.
Medications on Admission:
1. Memantine 10mg qam and 5mg qpm (son reports this, not
2. Donepezil 5mg daily (though son states 10mg)
3. [**Name2 (NI) 73868**] 5mg
4. Citalopram 20mg qd
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for diarrhea.
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. [**Name2 (NI) 73868**] 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Remeron 15 mg Tablet Sig: 0.5 Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Viral syndrome
SEvere Alzheimer's dementia
Decrease PO/appetite [**12-27**] above
Discharge Condition:
STABLE
Discharge Instructions:
Admitted for Rigors, fevers to 104
Infectious w/u negative, likely viral syndrome. Given URI
symptoms, initial concern for PNA, Rx with 5days levaquin
[**Month (only) **] appetite, started remeron 7.5mg qhs
Namenda stopped (not sure if supposed to be on this)
Followup Instructions:
please follow up with your Doctor [**First Name (Titles) **] [**Last Name (Titles) **] in 2weeks
|
[
"564.09",
"788.30",
"079.99",
"331.0",
"585.4",
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"294.10",
"584.9",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8598, 8670
|
5030, 7941
|
269, 275
|
8796, 8804
|
3854, 5007
|
9112, 9211
|
3394, 3489
|
8152, 8575
|
8691, 8775
|
7967, 8129
|
8828, 9089
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3504, 3835
|
222, 231
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303, 1724
|
1746, 2443
|
2459, 3378
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,190
| 184,071
|
43686
|
Discharge summary
|
report
|
Admission Date: [**2155-4-15**] Discharge Date: [**2155-4-24**]
Date of Birth: [**2072-12-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
[**First Name3 (LF) **]
Intubation
History of Present Illness:
82 yo M w/ afib, HTN p/w jaundice and itching. symptoms started
3 wks back. he noticed increased itching all over. yesterday he
had a f/u appt w/ his cards dr [**Last Name (STitle) **] where they noticed that he
was jaundiced. He was sent to the ED where abd US showed 3 cm
pancreatic mass and elevated LFTs (tbili 9.6 with alk phos
>1900). pt also c/o swelling in legs for past 2 wks. he denies
pain in abd/N/V/constipation/abd distention. he has been
suffering from diarrhea for past 6 wks and thought it to be d/t
lactyose intolerance. he says it improved after stopping the
milk products. he he lost 52 lbs and then gained 8 lbs over past
1 yr. the wt loss was intentional. his appetite is fine. no
insomnia. mood fine. denies F/C/C, denies CP, SOB, dizziness,
palpitations. He was admitted to [**Hospital1 **] on [**2155-4-15**]. He had a CT
abd that showed a marked bilary dilation without definitive mass
in the pancreas seen. He was referred for [**Date Range **] on [**2155-4-17**] but
the procedure was not tolerated well. He was brought back to
[**Date Range **] to be done under general anesthesia on [**2155-4-18**]. The
procedure showed irregular malignant appearing high grade
stricture in the distal CBD measuring 1.5 cm. Sphincterotomy and
biliary stent placement were done. Cytology brushings were
taken. In the PACU he developed acute shortness of breath and
hypoxia. Heart rates were 100-114. Per notes, he had mild wheeze
and bronchial breath sounds. He was intubated with
etomidate/succinylcholine. Vital signs post-intubation were
112/67 87 100%RA. He dropped his blood pressure requiring
neosynephrine gtt.
Past Medical History:
CAD, MI in [**2106**] Echo showed old IPMI. stress echo in [**5-7**] showed
no e/o ischemia.
Afib: diagnosed 06. underwent DCCV in [**9-6**]. now back in afib.
HTN
Obesity
Gout
Hypothyroidism
Shrapnel in his face during WWII s/p removal
Social History:
He is a widow with two daughters. [**Name (NI) **] is retired.
quit smoking 42 yrs back. smoked for 1 yr. quit etoh 6 yrs back.
was a social drinker.
Family History:
no h/o Ca, CAD, DM
Physical Exam:
98.2 122/70 86 16 97/RA fs187
NAD
heent: icterus +, no LAD, MM
chest: CTABL
heart: RRR, no M/R/G, nl S1 S2
Abd: soft, NT, obese (but no recent change per pt), BS +
Extr: 2+ pitting edema
Neuro: no focal deficit, no asterixis
Pertinent Results:
see attached lab results and [**Name (NI) **] report
[**Name (NI) **]:
Impression: 1.Normal major papilla
2.Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique.
3.Cholangiogram showed a irregular malignant appearing high
grade stricture in the distal CBD measuring 1.5 cm. The bile
duct proximal to the stricture appeared dilated.
4.A sphincterotomy was performed in the 12 o'clock position
using a sphincterotome over an existing guidewire.
5.Cytology samples were obtained for histology using a brush at
the CBD stricture.
6.A 7cm by 10F Cotton [**Doctor Last Name **] biliary stent was placed
successfully across the biliary stricture.
MICRO:
Stool- c diff negative x 3
All cultures without growth
Cytology of biliary stricture: atypical cells
Brief Hospital Course:
1)Biliary obstruction: Resolved with [**Doctor Last Name **] placement of stent.
Obstruction appears malignant, concerning for possible
pancreatic v cholangiocarcinoma. Cytology inconclusive but CA
[**65**]-9 elevated. GI team is concerned that pt would not likely
tolerate more aggressive biopsy. They are considering doing an
endoscopic ultrasound with biopsy in the future and will take
further brushings which they discuss with daughters.
--- Follow up [**Year (2 digits) **] for biliary stent change in [**Month (only) **], scheduled
2)Hypoxic respiratory failure: Required intubation after [**Month (only) **].
Cause undetermined, no h/o CHF but some improvement with nebs
and diurese. Pt also had episodes of rapid AF and so it was
considered that possibly this had caused acute CHF or aspiration
give occurred just after [**Month (only) **]. Continue nebs, on corgard for
many years at home. CXR without pneumonia, did have small b/l
pleural effusions. Was in the ICU, extubated [**2155-4-21**].
3)AF: Pt has been on corgard for many years which he asked to
continue rather than lopressor which was suggested. Coumadin
restarted [**4-23**] at his home dose. This needs to be held for one
week prior to [**Month (only) **] [**Month (only) **].
4)Hypotension / Shock: This occured shortly after [**Month (only) **] and resp
failure requiring intubation. Sepsis was considered given [**Month (only) **]
manipulation. Cultures neg, course of levofloxacin and flagyl.
5) Loose stool: 3 sets c. diff toxin negative.
Medications on Admission:
Cozaar 50mg daily
Nadolol 60mg daily (was on lopressor in past but d/c'ed as
fatigue was A/E.)
Aspirin 81mg daily
Warfarin 5mg daily
Lovastatin 10mg daily
Niaspan 1 tablet at bedtime
triamterene MWF
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) u
Injection TID (3 times a day): UNTIL INR > 2.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed.
3. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16): CHECK DAILY INR, ADJUST AS NEEDED.
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
6. Corgard 20 mg Tablet Sig: One (1) Tablet PO once a day: Pt
was on 60mg per day at home, titrate up as possible.
7. Cozaar 50 mg Tablet Sig: One (1) Tablet PO once a day: Hold
for sbp < 110.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
9. Niaspan 750 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO at bedtime.
10. Triamterene 50 mg Capsule Sig: One (1) Capsule PO every
other day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) **]
Discharge Diagnosis:
biliary obstruction, stricture on bile duct
CAD
AF
HTN
Hypothyroid
Discharge Condition:
stable
Discharge Instructions:
Please contact the doctor at the rehab with any worsening
abdominal pain, fevers, or other concerning symptoms.
Followup Instructions:
Pt needs to return to have his biliary stent replaced in [**Month (only) **].
Also, the pathology of the biliary stricture was inconclusive
and so he may need further biopsy, this will be discussed by Dr. [**Name (NI) 93908**] team with the family.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2155-6-20**] 3:00
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2155-6-20**] 3:00
Dr. [**Last Name (STitle) **] office will contact your daughters regarding
additional follow up if needed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
Completed by:[**2155-4-24**]
|
[
"998.59",
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"157.0",
"274.9",
"038.9",
"401.9",
"244.9",
"412",
"518.81",
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"51.85",
"51.10",
"96.71",
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icd9pcs
|
[
[
[]
]
] |
6296, 6366
|
3566, 5106
|
324, 360
|
6477, 6486
|
2748, 3543
|
6646, 7394
|
2467, 2487
|
5356, 6273
|
6387, 6456
|
5132, 5333
|
6510, 6623
|
2502, 2729
|
276, 286
|
388, 2022
|
2044, 2283
|
2299, 2451
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,312
| 136,851
|
44522
|
Discharge summary
|
report
|
Admission Date: [**2193-4-17**] Discharge Date: [**2193-4-26**]
Date of Birth: [**2135-7-11**] Sex: M
Service: [**Company 191**]
CHIEF COMPLAINT: Transfer from outside hospital for
management of bleeding esophageal varices.
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
male with hepatitis B and hepatitis C, cirrhosis with
ascites, and esophageal varices (esophagogastroduodenoscopy
on [**2193-1-7**] showed grade 2 varices in the
lower/middle esophagus which were nonbleeding with
congestion/friability in the stomach consistent with portal
hypertensive gastropathy), intravenous drug abuse, and
bipolar disorder who was transferred from [**Hospital6 3426**] for management of bleeding esophageal varices.
The patient was admitted to the outside hospital on [**4-16**]
with hematemesis of approximately 100 cc. The patient had a
hematocrit of 21 with a systolic blood pressure in the 80s.
He had an esophagogastroduodenoscopy there which revealed
variceal rupture and underwent sclerosis. The patient was
transfused 4 units of packed red blood cells with a rise in
his hematocrit to 28; which subsequently fell to 26. The
patient had increasing lethargy after Versed and had
increased confusion. The patient was treated with lactulose
enemas and transferred to [**Hospital1 188**] for possible transjugular intrahepatic portosystemic
shunt evaluation.
Upon arrival, the patient was unresponsive to painful
stimuli, had mild tachypnea, and a systolic blood pressure in
the 70s to 80s. The patient's initial laboratory results
revealed significant metabolic acidosis, and the patient was
intubated for airway protection, acidosis, and hypotension.
Initially, the patient received an A-line, was started on
dopamine, then Levophed, and Sandostatin. A triple lumen
catheter was placed. A chest x-ray was without pneumothorax
or effusions. The patient was given 3 units of packed red
blood cells, a normal saline bolus of 500 cc, and started on
a bicarbonate drip for severe acidemia with a blood gas
showing a pH of 7.1, a PCO2 of 28, and PO2 of 383. The
patient's systolic blood pressure stabilized around 85 on
Levophed/dopamine drip.
PAST MEDICAL HISTORY:
1. Alcohol abuse.
2. Cirrhosis.
3. Ascites.
4. Depression.
5. Hepatitis B and hepatitis C.
6. Intravenous drug use in the past.
MEDICATIONS ON ADMISSION: Medications at home included
lactulose 15 cc p.o. b.i.d., Aldactone 300 mg p.o. q.d.,
trazodone, lithium, Ambien, nadolol 20 mg p.o. q.d.
MEDICATIONS ON TRANSFER: Medications on transfer included
D-5 normal saline of 60 cc per hour, lactulose 45 cc q.4h.,
vitamin K 10 mg subcutaneous q.d. times three days,
Sandostatin at 100 mcg per hour.
ALLERGIES:
SOCIAL HISTORY: The patient is divorced. He smokes
cigarettes. He has a history of intravenous drug use and
alcohol abuse. He lives with his nephew [**First Name8 (NamePattern2) **] [**Name (NI) 7518**]).
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
temperature was 97, weight was 75 kg, blood pressure
was 106/50 on 10 mcg of dopamine per minute with 5.3 mcg of
Levophed, heart rate was 70 to 90, respiratory rate was 10 to
14 (with ventilator settings of AC/700/12X12/100/5, oxygen
saturation was 91%. In general, the patient was
unresponsive, snoring, and tachypneic. He was intubated and
sedated. Head, ears, nose, eyes and throat showed pupils
were equal, round, and reactive to light. The oropharynx
showed poor dentition, mucous membranes were moist. The neck
showed no jugular venous distention. There was no
lymphadenopathy. The heart was regular in rate and rhythm.
Normal first heart sound and second heart sound. The lungs
had coarse rhonchi throughout. There were no rales of
wheezes. The abdomen was distended, but not tense ascites.
There was a positive fluid wave, positive umbilical hernia.
The extremities were without edema. There were multiple
ecchymoses on the bilateral upper and lower extremities.
PERTINENT LABORATORY DATA ON PRESENTATION: White blood cell
count was 21.8, hematocrit was 27.1, platelets were 162, mean
cell volume was 90. Differential revealed 79% neutrophils,
8% bands, 10% lymphocytes, 3% monocytes). Sodium was 139,
potassium was 5.8, chloride was 106, bicarbonate was 6, blood
urea nitrogen was 74, creatinine was 2, blood glucose
was 128. PT was 19.6, PTT was 39.5, INR was 2.7. ALT
was 151, AST was 196, alkaline phosphatase was 55, ammonia
was 357, total bilirubin was 1.6, albumin was 1.9. Calcium
was 8, phosphorous was 6.7, magnesium was 2.3. Uric acid
was 9.9. Acidic fluid revealed total protein was 1.2, LDH
was 67. Gram stain revealed 1+ polys, no organisms. Acidic
cultures were pending times two. White count of acidic fluid
showed 126 white blood cells, 547 red blood cells.
RADIOLOGY/IMAGING: A chest x-ray showed the right internal
jugular in good position. There was no pneumothorax, no
effusions, no consolidations. The ETT was 2 cm from the
carina. The dropoff was in the esophagus.
ASSESSMENT AND PLAN: In summary, the patient is a
57-year-old male with hepatitis B and hepatitis C, cirrhosis,
and ascites; status post recent esophageal variceal rupture
with severe encephalopathy and metabolic acidosis (likely
secondary to sepsis) who was hypotensive and intubated, on
pressors, at the time of admission.
HOSPITAL COURSE: The patient was felt to possibly be septic
at the time of admission; possibly secondary to spontaneous
bacterial peritonitis. He was started on ceftriaxone
initially.
His hypotension was felt to be multifactorial secondary to
both hypovolemia secondary to blood loss as well as sepsis.
His encephalopathy was felt most likely to be secondary to
his underlying liver disease as well as multiple sedating
medications. His coagulopathy was felt to be secondary to
fulminant liver failure.
Initial management was aimed at treating possible spontaneous
bacterial peritonitis as well as supportive care for the
other problems described.
On hospital day two, the patient's pressors were
discontinued, and he was ultimately transfused 6 units of
packed red blood cells. He also received vitamin K and 4
units of fresh frozen plasma. He developed thrombocytopenia
of unknown cause. He then became alcoholic secondary to the
bicarbonate as well as ventilator settings; and ventilator
adjustments were made as well as bicarbonate drip
discontinued. His INR improved to 1.7 from 2.7, but an
additional 2 units of fresh frozen plasma were given. His
creatinine improved to 1.8 with intravenous fluids.
An abdominal ultrasound was obtained given his elevated
amylase and lipase and elevated liver function tests. This
ultrasound showed liver cysts, normal portal flow, and
gallstones but no evidence of obstruction. The pancreas was
not visualized. There was evidence of cirrhosis and
splenomegaly. He received platelets for his
thrombocytopenia.
On hospital day three, the ascites cultures came back with
4/4 bottles positive for gram-negative rods. The patient was
started on ciprofloxacin and continued on previously
prescribed ceftriaxone. His creatinine continued to improve.
His fractional secretion of sodium was greater than 25%;
consistent with acute tubular necrosis from his hypotension.
On hospital day four, nadolol was started for the patient's
portal hypertension. His antibodies were sent given his
decreasing platelets. These eventually came back negative.
Free water boluses were started for rising sodium.
On hospital day five, total parenteral nutrition was started,
and the patient received his last dose of octreotide.
Ciprofloxacin was discontinued as the gram-negative rods were
found to be sensitive to ceftriaxone.
On hospital day six, the patient's urine culture came back
positive for enterococcus. Vancomycin was started. The
patient was extubated. Tube feeds were started.
On hospital day seven, a paracentesis was done with 6.8
liters of fluid removed.
On hospital day eight, the patient was transferred out to the
general medical floor. At the time of transfer, the patient
was without complaints. He was still very encephalopathic
but stable. After arriving to the floor the patient was
noted to have extremely poor output with less than 50 cc over
four hours. A 500-cc bolus was given without effect. Foley
irrigation was done, and approximately 50 cc of gross blood
and clots were removed. The patient was hemodynamically
stable, and oxygen saturations were within normal limits. He
received 12.5 g of albumin as well as normal saline, and a
three way Foley catheter was inserted with continuous
irrigation. Overnight, his urine output improved.
On hospital day nine, the patient had an
esophagogastroduodenoscopy and banding of his esophageal
varices by Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**]. This procedure was without
complaints, and the patient appeared stable that evening
following the procedure.
On the tenth hospital stay, the patient's diet was slowly be
advanced. His hematocrit was noted to be slowly trending
down, but there was initially no evidence of rebleeding.
However, later that morning the patient developed hematemesis
around 2 p.m. He had eaten lunch and was up in the chair
doing well and then developed 200 cc to 300 cc of
hematemesis. He had no shortness of breath, chest pain, or
abdominal pain at that time. He did have some slight
dizziness, however. A STAT hematocrit was sent. Then the
patient developed a bloody bowel movement, maroon stool,
which was approximately 300 cc. He then had approximately
200 cc of bright red blood per rectum following. His blood
pressure was 94/70 at this time. The patient was still
mentating and feeling "fine."
Given the evidence of what appeared to be massive rebleeding
of his esophageal varices, the patient was transferred back
to the Medical Intensive Care Unit for further management.
Upon transfer back to the Medical Intensive Care Unit, the
patient developed massive upper gastrointestinal hemorrhage;
and despite pressors, fluid resuscitation, blood
resuscitation, and octreotide, the patient was not able to be
resuscitated. The patient passed away later that evening.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed.
2. Esophageal varices; status post banding.
3. Hepatitis B and hepatitis C cirrhosis.
4. Acute tubular necrosis.
5. Thrombocytopenia.
6. Metabolic acidosis.
7. Spontaneous bacterial peritonitis.
8. Sepsis.
9. Acute renal failure.
10. Urinary tract infection.
11. Malnutrition.
12. Hepatic encephalopathy.
13. Hypernatremia.
14. Portal hypertension.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1379**]
Dictated By:[**Last Name (NamePattern1) 6859**]
MEDQUIST36
D: [**2193-8-27**] 12:03
T: [**2193-9-2**] 01:31
JOB#: [**Job Number 95381**]
|
[
"571.2",
"286.9",
"038.49",
"276.0",
"572.3",
"567.2",
"518.81",
"456.20",
"789.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"42.33",
"54.91",
"38.91",
"38.93",
"96.6",
"96.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10238, 10915
|
2362, 2501
|
5359, 10216
|
164, 243
|
272, 2178
|
2527, 2718
|
2200, 2335
|
2735, 5340
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,238
| 103,988
|
4594
|
Discharge summary
|
report
|
Admission Date: [**2132-12-11**] Discharge Date: [**2132-12-17**]
Date of Birth: [**2095-6-17**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
abdominal pain, acute liver failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
37 YOF nurse who presents with nausea/vomiting and RUQ pain x 3
days. Presented initially to OSH where she was found to have ALT
8856 AST 7932 TB 5.9 and INR 3.4. Creat and bicarb normal. She
then revealed that she has been taking upwards of 6G APAP/day
since [**Month (only) 958**] for back pain. Isn't sure exactly how many tablets
she takes, but estimates 10 extra-strength Tylenol tabs and [**2-28**]
Tylenol PM, as well as occasional Vicodin. Denies poor PO in the
days preceeding onset of sx but since then hasn't been eating
well as oral intake has exacerbated her sx. Denies other toxic
habits/ingestions. Feels sleepy now since she has been up all
night but denies changes in mental status or excessive
sleepiness preceeding presentation. Drinks socially (about [**5-3**]
beers in one sitting, once per week or every 2 weeks) including
the night prior to the onset of her sx. Denies any suicidal
intent.
.
Reports that she lives at home w husband and 5 kids. She was
fired from her nursing job becuase of her back/neck pain, she
reports. She feels happy and safe at home and reports a close
family support system. She does admit to a suicide attempt at
age 14 but doesn't remember the details.
.
In speaking with her huband he reports that she also takes
Fioricet and Nyquil occasionally in addition to the other meds,
and agrees that this was not a deliberate attempt to hurt
herself. He corroborates that she does not use street drugs.
Past Medical History:
Body Dysmorphic Disorder
Anxiety
chronic neck/back pain [**1-29**] work-related injury
remote hx of OD suicide attempt as teen
GERD
IBS
Bilateral breast augmentation 00' and 04'
Social History:
Lives w/ husband and 5 kids (age [**4-8**]). Married 4 years. Last
worked as RN but injured back at work and was then laid off.
Parents live on [**Hospital3 **].
-Reports up to 4 drinks 3x a week (2 drinks 4 days a week) per
husband. + blackouts. [**12-31**] CAGE. No previous detoxes.
-Denies IV drugs, tobacco, cocaine
Family History:
No liver dz, AI disease, IBD or cancer
Physical Exam:
PHYSICAL EXAMINATION:
VS - Temp afebrile, BP 91/46, HR 86, R 18, O2-sat 98% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - PERRL, EOMI, sclerae mildly icteric with B/L lateral
conjunctival hemorrhages, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, TTP in RUQ & epigastrium, ND, no masses or
HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-30**] throughout, sensation grossly intact throughout, gait not
observed, no asterixis
Pertinent Results:
[**2132-12-10**] EKG: Sinus tachycardia. Modest diffuse ST-T wave
changes are non-specific. No previous tracing available for
comparison.
.
[**2132-12-11**] ECHO: The left atrium is normal in size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 80%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
.
[**2132-12-11**] CXR: The lungs are well expanded and clear without
focal consolidation, pleural effusion or pneumothorax. The
cardiac and mediastinal silhouette and hilar contours are
normal.
.
[**2132-12-11**] RUQ U/S: Ultrasound of the right upper quadrant
demonstrates no focal liver lesions. The gallbladder is
contracted, accentuating wall thickness. The portal vein is
patent with hepatopetal flow. No ascites is seen. No intra- or
extra-hepatic biliary dilation is seen. The CBD measures 3 mm.
No evidence of cholelithiasis is seen. IMPRESSION: 1. Patent
portal vein with hepatopetal flow. 2. Contracted gallbladder
without specific signs to suggest cholecystitis.
.
Labs:
Brief Hospital Course:
37 yo W with acute hepatitis and liver injury secondary to
chronic acetaminophen use
.
#. Acute hepatitis/liver failure: Determined to be secondary to
chronic, unintentional, overuse of tylenol for control of a
work-related back injury. On presentation the patient had grade
I encephalopathy and a transplant evaluation was initiated. She
was started on the NAC protocol. Her liver function tests
improved obviating the need for urgent transplant. She remained
on the NAC gtt for a total of 5 days, then was monitored for an
additional day, and discharged after it was ensured that her
labs were all improving. We instructed her to abstain from all
alcohol and acetaminophen until she follows up with Dr. [**Last Name (STitle) 497**] in
the Liver Clinic. At that time she will have her ceruloplasm
levels re-checked, as this was found to be low during her
transplant work-up.
.
#. Chronic back pain: secondary to a work-related injury, and
the reason she was taking large amounts of tylenol daily. The
patient has been seeing an Orthopedic Pain Specialist for
steroid injections and plans to continue this treatment. Her
pain was controlled on Tramadol, which we provided a
prescription for at discharge. She will need to follow up with
her Primary Care Physician and [**Name9 (PRE) 1194**] Specialist to develop a plan
to manage her chronic pain. She was instructed to stop all
medications with acetaminophen.
.
#. Adjustment Disorder with Anxious and Depressed Mood: The
patient was evaluated by Psychiatry and Social Work upon
admission. It was determined that her chronic acetaminophen
ingestion was not intentional. She was not currently on an
antidepressant, but has tried some in the past and discontinued
use secondary to bothersome side effects. She would likely
benefit from a SSRI or SNRI, which can be determined by the
patient and her Primary Care Physician on an outpatient basis.
.
#. RUQ abdominal pain and nausea: likely secondary to her liver
injury. The patient remained afebrile, without leukocytosis. She
was started on a daily PPI.
.
#. Urinary Tract Infection: The patient was treated with three
days of Ampicillin for an Enterococcal UTI. Her dysuria
resolved.
.
#. Herpes labialis: The patient was started on Valtrex for
recurrent HSV cold sores.
.
#. Pancytopenia: Unclear etiology, possibly secondary to
acetaminophen or NAC. Also, may have had an element of
hemodilution from the large amount of fluids received during the
admission. She had no evidence of bleeding and remained
hemodynamically stable throughout the admission.
Medications on Admission:
Tylenol
Percocet
Klonopin 5mg PRN
Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 1 weeks.
Disp:*42 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for breakthrough abdominal pain for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. valacyclovir 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 4 days.
Disp:*14 Tablet(s)* Refills:*0*
4. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO as instructed
as needed for anxiety.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
acute hepatitis secondary to chronic acetaminophen overuse
abdominal pain
urinary tract infection
adjustment disorder
pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 19499**],
.
You were recently admitted to the [**Hospital1 1170**] for continued evaluation and management of your abdominal
pain secondary to acute liver failure from chronic overuse of
tylenol. You were initially admitted to the Intensive Care Unit,
and then transferred to the floor. We provided you with
medications and you improved. We also found evidence of a
urinary tract infection and started you on antibiotics. We also
provided you with treatment for herpes labialis (cold sores).
Please continue to see your outpatient therapist, and consider
seeing a Psychiatrist in the future for your anxiety. Also, it
is important that you keep all of your follow up appointments
after discharge.
.
We are also giving you a short course of pain medications that
are safe to take during your liver injury. You will need to
follow up with your Primary Care Physician and [**Name9 (PRE) 1194**] Specialist
to figure out the best regimen for yout to continu on to treat
your chronic neck pain.
.
We are making the following changes to your outpatient
medication regimen:
-Please STOP all products containing acetaminophen (tylenol,
eccedrin, percocet) until you follow up with Dr. [**Last Name (STitle) 497**]. Please
read all of the labels of your over the counter medications to
ensure they do not contain acetaminophen.
-Please START Famotidine twice daily
-Please START Valtrex twice daily until [**2132-12-20**]
-Please take Tramadol every 4 hours as needed for pain
-Please take Oxycodone 5 mg every 6 hours as needed for pain
(please note that this medication can be sedating as well as
cause constipation)
- You may also take colace (a stool softener to prevent
constipation)
.
It was a pleasure taking care of you during this
hospitalization.
Followup Instructions:
Name: [**Name6 (MD) 19500**] [**Name8 (MD) **],MD
Specialty: Internal Medicine
When: Thursday [**12-18**] at 10:30am
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**]
Phone: [**Telephone/Fax (1) 6699**]
** Please note that this appointment is in the [**Location (un) **] office **
.
Department: LIVER CENTER
When: FRIDAY [**2133-1-9**] at 2:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"041.04",
"723.1",
"724.5",
"E850.4",
"599.0",
"338.21",
"309.28",
"054.9",
"573.3",
"284.1",
"789.01",
"348.39",
"965.4",
"799.02",
"570",
"787.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8133, 8139
|
4767, 7324
|
341, 348
|
8314, 8314
|
3245, 4744
|
10265, 10946
|
2380, 2421
|
7408, 8110
|
8160, 8293
|
7350, 7385
|
8465, 10242
|
2436, 2436
|
2458, 3226
|
266, 303
|
376, 1824
|
8329, 8441
|
1846, 2025
|
2041, 2364
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,240
| 111,589
|
53019
|
Discharge summary
|
report
|
Admission Date: [**2183-12-23**] Discharge Date: [**2183-12-25**]
Date of Birth: [**2113-7-19**] Sex: M
Service: NEUROSURGERY
Allergies:
Iodine-Iodine Containing
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
ACOMM Aneurysm
Major Surgical or Invasive Procedure:
Cerebral Angiogram for ACOMM aneurysm stenting
History of Present Illness:
Pt presents for elective coiling of Acomm artery aneurysm
Past Medical History:
CAD 15 heart catheterizations and 3 stents in the past.
knee repair, back surgery, and a cluster of veins in his right
eye. He has diminished vision in the right eye.
Social History:
He is retired and works part-time as a security officer. His
wife works in a medical facility. He is married. He does not
smoke and quit in [**2157**]. He takes alcohol rarely.
Family History:
Family history is significant for cancer in the mother who died
at age 42, heart attack in father who died at age 49. He has a
sister who has a history of cancer and brother with liver
problems.
Physical Exam:
This pt is awake alert and oriented with a non focal
neurological exam. Full motor and sensory throughout. His
right groin angio site is flat and distal pulses are palpable.
Pertinent Results:
Head CT [**2183-12-23**]:
Stent spanning the A1 segment of the left anterior cerebral
artery, the
anterior communicating artery, and the proximal A2 segment of
the right
anterior cerebral artery. No evidence of acute hemorrhage.
his angio report from [**2183-12-23**] is not finalized at this time of
discharge
Brief Hospital Course:
70M with an unruptured ACOMM aneurysm who came for an elective
cerebral angiogram for stenting of the ACOMM aneurysm. No
coiling was done. Post-angio, the patient was placed on a
Heparin drip for a PTT goal of 60-80. His drip was discontinued
late [**12-24**] morning and he was transferred to the floor. He
remained neurologically intact without issue. He was d/c'd to
home with plans to follow up in 6weeks for completion of
coiling. His aneurysm at this time is not secured.
Medications on Admission:
metformin/ glipizide/ tylenol/ omeprazole/ atenolol/ ativan/ asa
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 6 weeks.
Disp:*42 Tablet(s)* Refills:*0*
10. prednisone 20 mg Tablet Sig: Two (2) Tablet PO as directed
for procedure: take 40mg 16 hours prior to test, 40 mg 8 hours
prior and 2 hours prior .
Disp:*6 Tablet(s)* Refills:*0*
11. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO take 50mg one
hour prior to your procedure.
Disp:*2 Capsule(s)* Refills:*0*
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO one hour
prior to your procedure .
Disp:*1 Tablet(s)* Refills:*0*
13. lancets
lancets for fingerstick glucose monitoring.
disp 1 box
Discharge Disposition:
Home
Discharge Diagnosis:
ACOMM Aneurysm (Unruptured)
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? 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 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
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 6 weeks at
[**Telephone/Fax (1) 1669**] for your angiogram with coiling.
[**First Name9 (NamePattern2) 90411**] [**Doctor First Name **] from the office of Dr. [**First Name (STitle) **] will contact you
at home with your time for your procedure .... you will also
receive a packet in the mail regarding the same.
Completed by:[**2183-12-25**]
|
[
"530.81",
"414.01",
"401.9",
"V45.82",
"496",
"437.3",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"88.41",
"00.45",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
3456, 3462
|
1588, 2069
|
304, 353
|
3534, 3624
|
1252, 1565
|
5697, 6128
|
843, 1040
|
2185, 3433
|
3483, 3513
|
2095, 2162
|
3685, 4755
|
4781, 5674
|
1055, 1233
|
250, 266
|
381, 440
|
3639, 3661
|
462, 630
|
646, 827
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,986
| 104,646
|
15472
|
Discharge summary
|
report
|
Admission Date: [**2109-4-1**] Discharge Date: [**2109-4-5**]
Date of Birth: [**2041-10-3**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
headache, confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: [**Known firstname **] [**Known lastname 3123**] is a 67-year-old right-handed man who
presented to the ED after left parietal bleeding. Patient stated
that he was in his usual state of health when he woke up this
morning and went for his doctor appointment due to pain in his
groin. Upon arrival to the front desk he was not feeling right
and he gave a very vague description. He noticed that he was not
able to write his name and his hand writing was not aligned. At
this point he felt confused and inattentive. He was able to
drive
back home, but did no have any recollection of the driving. He
parked the car in the sideway. Next time he remembered he was
lying in the couch with a terrible headache. His wife arrived
between 11am-12pm and found him poorly responsive, mumbling
sounds with very few understandable words,a and not coherent.
She
also mentioned glassy eyes. She decided to bring him to the
closest ED ([**Hospital1 **] Needhan) for evaluation. He had wobbly gait.
Patient underwent a NCHCT which revealed a left parietal
bleeding. He was then transfer to [**Hospital1 18**] [**Location (un) 86**] for further
evaluation.
Patient described his headache as strong left temporal burning
sensation.
ROS:
The pt denied diplopia, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denied focal weakness, numbness,
parasthesiae. The pt 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.
Past Medical History:
Hyperlypidemia- patient was prescribed a statin in the past but
refused to take medicine
Recent admission [**11-2**] to [**Hospital1 **] [**Location (un) 620**] with transient visual
change, thought to be TIA vs migraine
Small MI in [**2085**]
??TIA [**2078**]
Apendicectomy
Tonsillectomy
Bilat arthroscopy knee
right shoulder surgery
Social History:
Married, lives with his second wife.
-EtOh: occasionally
-tobacco: quit smoking 10 years ago, but used to be heavy smoker
-drugs: no IV drugs
Family History:
-mother: heart attack and stroke. Mat GM with heart attack
-father: passed away after heart attack ~68yo. No CA, no
migraines; no epilepsy.
Physical Exam:
Vitals: T:afebrile P:64 R: 15 BP: 150X75mmHg SaO2:
General: Awake, cooperative, NAD.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward with
mild difficulty. Language is fluent with intact repetition and
comprehension. Patient had difficulties in calcualtion: quarters
in $1.75, he first answered wrong and then after thinking hard
he
was able to say 7. Difficulties on [**Location (un) 1131**] the card. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. But clearly had left-right confusion. Finger agnosia.
Abnormal graphesthesia in the right hand. He could not write his
name, clearly inability to write.
CN
I: not tested
II,III: VFF to confrontation, pupils 4mm->2mm bilaterally, fundi
normal
III,IV,VI: EOMI, no ptosis. ??nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**5-29**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; no asterixis or myoclonus.
Right pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 2 Flexor
R 2 2 2 2 2 Flexor
-Sensory: Decreased light touch, pinprick, in the right arm
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
-Gait: not tested
Pertinent Results:
[**2109-4-1**] 05:40PM BLOOD WBC-6.3 RBC-4.76 Hgb-14.7 Hct-41.5 MCV-87
MCH-31.0 MCHC-35.5* RDW-13.7 Plt Ct-167
[**2109-4-1**] 05:40PM BLOOD PT-12.5 PTT-23.9 INR(PT)-1.1
[**2109-4-1**] 05:40PM BLOOD Plt Ct-167
[**2109-4-1**] 05:40PM BLOOD Glucose-84 UreaN-20 Creat-1.1 Na-139
K-3.8 Cl-103 HCO3-28 AnGap-12
[**2109-4-2**] 04:31AM BLOOD ALT-27 AST-25 AlkPhos-67 TotBili-1.4
[**2109-4-2**] 04:31AM BLOOD %HbA1c-PND
[**2109-4-2**] 04:31AM BLOOD Triglyc-100 HDL-39 CHOL/HD-4.8
LDLcalc-129
EKG: Sinus rhythm. Right bundle-branch block with rightward
precordial R wave transition point consistent with right
ventricular strain or hypertrophy. Compared to the previous
tracing of [**2102-11-24**] there is no diagnostic change.
CT head [**2109-4-1**]
1. Left parietal intraparenchymal hemorrhage slightly larger
compared to six
hours prior. Together with moderate surrounding vasogenic edema,
this causes
local sulcal effacement, without shift of normally midline
structures. Again
as etiology of the hemorrhage has not yet been determined, MRI
is recommended
for evaluation of such, if there is no contra-indication.
2. Large polypoid soft tissue in the right nasal cavity and
right maxillary
sinus, incompletely imaged, and previously seen on [**2108-3-13**].
Also, decreased
mineralization of medial wall of right maxillary sinus, with no
history of
such surgery noted on CareWeb. Findings likely due to
antro-choanal polyp
with bony remodeling. Correlation with direct visualization, and
dedicated
imaging if clinically indicated.
MRI brain, MRA head/neck [**2109-4-1**]
1. Large left parietal lobar hematoma with only mild mass
effect. Evaluation
for an underlying mass is limited in the absence of intravenous
contrast.
Evaluation for an underlying vascular malformation is also
limited in the
absence of intravenous contrast, and because the hematoma is not
fully
included in the field of view of the head MRA (which was
targeted for
evaluation of the circle of [**Location (un) 431**]). If the patient can tolerate
intravenous
contrast, then further evaluation is suggested by a CTA of the
head, and a
follow-up MRI with and without contrast after resolution of
blood products.
Otherwise, follow-up MRI without contrast may be performed.
2. Normal appearance of the circle of [**Location (un) 431**]. Unremarkable neck
MRA, with
limited evaluation of the great vessel origins.
3. Probable right antrochoanal polyp again seen.
CT head [**2109-4-2**]
No change in size or appearance of left parietal IP hemorrhage.
No new
hemorrhage or change in mass effect.
TTE [**2109-4-2**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Left
ventricular systolic function is hyperdynamic (EF>75%). 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 left
ventricular inflow pattern suggests impaired relaxation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No obvious cardiac source
of embolism; however, image quality was suboptimal to exclude
shunting via bubble study. Mild concentric LV hypertrophy.
Preserved biventricular systolic function.
CTA head [**2109-4-3**]:
The intracranial vasculature demonstrates no evidence of
stenosis,
thrombosis, occlusion, large aneurysm, or dissection. There is
no evidence of nidus or draining veins adjacent to the left
parietal hematoma or elsewhere to suggest arteriovenous
malformation. No abnormal arterial structures are identified.
There is no evidence of cerebral venous thrombosis.
MRI HEAD W & W/O CONTRAST [**2109-4-3**]
1. No interval change in appearance of the left parietal
hematoma with no
abnormal enhancement to suggest an underlying mass. Followup as
the blood
products resolved is recommended.
2. Polypoid enhancing soft tissue within the right nasal cavity
which should be correlated with direct inspection.
3. Spiculated hypointensity within the subcutaneous tissues
within the
suboccipital region of unclear etiology, present on prior
examinations, and should be correlated with clinical findings.
Brief Hospital Course:
Patient is a 67-year-old male with history of CAD, angioplasty,
possible prior [**Hospital 44881**] transferred from [**Hospital1 **] [**Location (un) 620**] after he was
found to have a left parietal hemorrhage. Repeat CT head upon
arrival to [**Hospital1 18**] revealed a 4.1 x 2.4 cm bleed in the left
parietal region and the patient was admitted to the neurology
ICU. The patient was admitted to the Neuro ICU for q1h
neurochecks. His systolic blood pressure was maintained 120-160
without requiring antihypertensive agents in the ICU. A repeat
CT head was performed 12 hours after admission which was
unchanged from the initial study. The patient was transferred
to the neurology [**Hospital1 **] on [**4-2**] for further care. An MRI brain and
MRA neck were performed which showed a stable large left
parietal hemorrhage. The post-gadolinium study also showed no
interval change in the appearance of the left parietal hematoma.
As a potential etiology included hemorrhagic transformation of
an ischemic infarct, a TTE was performed which showed no obvious
cardiac source of embolism. The patient's LDL was 129 and HgbA1c
was 5.3%. He was started on simvastatin 10 mg daily. While on
the neurology [**Hospital1 **], he had elevated SBP in the 160's so
amlodipine 5 mg daily was started. After initiation of
amlodipine, his blood pressure normalized. The patient was
evaluated by physical and occupational therapy who recommended
that he could be discharged home with outpatient PT and VNA home
safety evaluation. The following were significant findings on
his discharge neurologic exam: Awake, alert, and oriented times
3. Able to recount events well. Improved simple calculation
ability but still with some difficulty. No apraxia. Normal motor
exam. Normal gait.
Medications on Admission:
Motrin PRN
Tramadol PRN
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left parietal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge neurologic exam: Awake, alert, and oriented times 3.
Able to recount events well. Improved simple calculation ability
but still with some difficulty. No apraxia. Normal motor exam.
Normal gait.
Discharge Instructions:
You were admitted with left parietal hemorrhage. Repeat head CT
scan and MRI showed no interval change in size of the bleed. You
were evaluated with a CTA and MRA of the head which showed
normal intracranial vasculature. Your echocardiogram showed no
cardiac source of embolism.
You have a follow-up appointment scheduled with your PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on Wednesday, [**4-17**], at 11:15 AM. He will refer
you to an Atrius neurologist and schedule a repeat MRI of the
brain with and without contrast in [**7-2**] weeks.
A nurse will visit your home for a home safety evaluation.
You have been provided with prescriptions for physical therapy,
occupational therapy, and speech therapy.
Should you develop any symptoms as listed below or concerning to
you, please call your doctor or go to the emergency room.
Followup Instructions:
1. You have a follow-up appointment scheduled with your PCP, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on Wednesday, [**4-17**], at 11:15 AM. He will refer
you to an Atrius neurologist and schedule a repeat MRI of the
brain with and without contrast in [**7-2**] weeks.
2. A nurse will visit your home for a home safety evaluation.
3. You have been provided with prescriptions for physical
therapy, occupational therapy, and speech therapy.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2109-4-5**]
|
[
"V45.82",
"431",
"277.39",
"272.4",
"784.69",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11136, 11194
|
9062, 10646
|
334, 340
|
11263, 11263
|
4800, 9039
|
12537, 13183
|
2550, 2692
|
10917, 11113
|
11215, 11242
|
10869, 10894
|
11616, 12514
|
2707, 3141
|
275, 296
|
368, 2014
|
11278, 11396
|
11413, 11592
|
2036, 2373
|
2389, 2534
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,569
| 111,580
|
46083
|
Discharge summary
|
report
|
Admission Date: [**2121-4-29**] Discharge Date: [**2121-5-3**]
Date of Birth: [**2054-2-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x3 (left internal mammary artery >
left anterior descending artery, saphenous vein graft > RAMUS,
saphenous vein graft > posterior descending artery) mitral valve
repair (30 mm CG future annuloplasty ring [**2121-4-29**]
History of Present Illness:
67 year old male with decreased exercise tolerance for several
months. Then with shortness of breath, underwent cardiac
catherization that revealed coronary artery disease and was
referred for cardiac surgery
Past Medical History:
Diabetes mellitus
MRSA in back [**11-11**]
Arthritis
severed fingers at age 12 - reattached
broken leg at age 20
Social History:
Works as a plumbing and electrical contractor
Tobacco - smoked for 10 years but quit 38 years ago
ETOH denies
Lives with spouse
Family History:
Mother with coronary artery disease at age 55
Physical Exam:
Well appearing male in no acute distress
HR 80, RR 20, b/p 140/89 weight 82.2 kg
Skin excision nasal basal cell cancer with scar
HEENT unremarkable
Neck supple Full range of motion
Chest clear to auscultation bilaterally
Heart RRR
Abdomen soft, nontender, nondistended, + bowel sounds
Extremities warm well perfused no edema pulses palpable
Neuro: grossly intact
Pertinent Results:
[**2121-5-2**] 05:35AM BLOOD WBC-8.1 RBC-2.93* Hgb-8.9* Hct-24.6*
MCV-84 MCH-30.5 MCHC-36.4* RDW-13.9 Plt Ct-138*
[**2121-5-2**] 05:35AM BLOOD Plt Ct-138*
[**2121-5-1**] 05:30AM BLOOD Glucose-157* UreaN-25* Creat-1.0 Na-134
K-4.7 Cl-100 HCO3-24 AnGap-15
Brief Hospital Course:
Mr. [**Known lastname 98064**] was admitted for same day surgery and went to the
operating room for a coronary artery bypass graft and mitral
valve surgery. Please see the operative report for further
details. He received vancomycin for perioperative antibiotics.
He was transfer to the intensive care unit on propofol,
epinephrine, neosynephrine, and amiodarone. Amiodarone was
started due to ventricular arrythmia in the operating room and
was stopped post operative day one due to no further rhythm
issues. In the first twenty four hours he was weaned from
sedation, awoke neurological intact, and was extubated without
complications. He was weaned from all vasoactive medications
and remained hemodynamically stable. He was transfered to the
post operative floor on day one for the remainder of his care.
He remained in a first degree atrioventricular block throughout
his stay, but was placed on beta blockade regardless due to his
intra-operative ventricular arrythmias. Physical therapy worked
with him on strength and mobility. He was gently diuresed and
betablockers titrated for heart rate control. His metformin was
increased as he regained his appetite. By post-operative day
four he was ready for discharge to home.
Medications on Admission:
Aspirin 325 mg daily
Motrin 400 mg twice a day
Metformin 1500 mg qam, 500mg qpm
Glipizide 5 mg twice a day
Lopressor 50 mg twice a day
Lipitor 80 mg at bedtime
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
6. Metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM.
7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
14 days.
Disp:*14 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 14
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
10. Motrin 400 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
11. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Mitral Regurgitation s/p mitral valve repair
Diabetes Mellitus type 2
MRSA
Arthritis
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 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 5456**] in 1 week ([**Telephone/Fax (1) 25798**]) please call for appointment
Dr [**Last Name (STitle) **] [**Name (STitle) 98065**] in [**1-7**] weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2121-5-3**]
|
[
"V15.82",
"E878.2",
"414.01",
"426.11",
"250.00",
"V02.54",
"424.0",
"427.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.12",
"36.15",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
4594, 4651
|
1851, 3089
|
339, 591
|
4813, 4820
|
1573, 1828
|
5331, 5774
|
1128, 1175
|
3299, 4571
|
4672, 4792
|
3115, 3276
|
4844, 5308
|
1190, 1554
|
280, 301
|
619, 830
|
852, 966
|
982, 1112
|
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